Appendicitis

Question 1

Define

Answer 1

Inflammation of the appendix

Question 2

What’s the aetiology?

Answer 2

• Gut organisms invade the appendix wall after lumen obstruction (e.g. by lymphoid hyperplasia, faecolith or filarial worms). Most common organisms E.coli or streptococci.
• This leads to oedema, ischaemic necrosis and perforation

Question 3

Epidemiology?

Answer 3

• The MOST COMMON surgical emergency
• Can occur at any age
• Most commonly occurs between 10-20 yrs

Question 4

What are the presenting symptoms?

Answer 4

• Periumbilical pain that moves to the right iliac fossa
• Anorexia is an important feature
• Vomiting (may occur after pain)
• Constipation
• Diarrhoea

Question 5

What are the signs?

Answer 5

•	General Signs
o	Tachycardia
o	Fever 
o	Furred tongue 
o	Lying still 
o	Coughing hurts 
o	Foetor with/without flushing 
o	Shallow breaths 
•	RIF Signs
o	Guarding 
o	Rebound and percussion tenderness 
o	PR pain on the right side (sign of low-lying pelvic appendix)

Question 6

What other signs can be seen?

Answer 6

o Rovsing’s Sign - palpation of the left iliac fossa causes more pain in the right iliac fossa than the left
o Psoas Sign - pain on extending the hip (caused by retrocaecal appendix)
o Cope Sign - pain on flexion and internal rotation of the hip (occurs if the appendix is in close proximity to the obturator internus)

Question 7

What are the variations in clinical picture?

Answer 7

o Inflammation of retrocaecal/retroperitoneal appendix may cause flank pain or RUQ pain
• The only sign may be tenderness on the right on DRE
o A child may have vague abdominal pain and will not eat their favourite food
o A shocked confused 80+ year old who is not in any pain

Question 8

What are the appropriate investigations?

Answer 8

•	Bloods
o	High WCC (mainly neutrophils) 
o	High CRP 
•	Ultrasound may help 
•	CT - high diagnostic accuracy 
•	Urine pregnancy test – rule out ectopic pregnancy

Question 9

What’s the management plan?

Answer 9

•	Prompt appendicectomy
•	IV Antibiotics:
o	Cefuroxime
o	Metronidazole 
•	Laparoscopy - diagnostic and therapeutic advantages

Question 10

What are the possible complications?

Answer 10

• Perforation
• Appendix mass
o Occurs when the inflamed appendix becomes covered with omentum
• Appendix abscess
o May occur if appendix mass fails to resolve
o Treatment involves drainage and antibiotics

Question 11

What is the prognosis?

Answer 11

• Uncomplicated appendicitis - most people recover with no long-term problems
• Ruptured appendix - greater risk of complications/death