Appendicitis

Question 1

What are the different positions of the appendix? (7)

Answer 1

Pre-ileal
Post-ileal
Sub-ileal 
Pelvic 
Sub-caecal
Paracaecal 
Retrocaecal

Question 2

What is the most common position of the appendix?

Answer 2

Retrocaecal

Question 3

What are the classical symptoms of appendicitis?

Answer 3

Periumbilical pain that moves to the RIF (worse on coughing)
Anorexia
Nausea and vomiting
Changes to bowels (constipation or diarrhoea) - not common

Question 4

What are the signs on examination of appendicitis?

Answer 4

Tachycardia
Low-grade fever
Guarding and rebound tenderness in RIF 
McBurney's sign (tenderness in RLQ)
Rovsing's sign
Reduced bowel sounds

Question 5

What age is appendicitis most common?

Answer 5

10-20 years old

Question 6

What is Rovsing’s sign?

Answer 6

When palpate LIF, Pain > in RIF

Question 7

What are alternative presentations - e.g. older adults, young age, pregnacy?

Answer 7

1) Shock + confusion, no pain or fever
2) Vague abdo pain, anorexia
3) Perforation more common, pain less localised, less obvious signs

Question 8

Where does pain localise if retrocaecal appendix?

Answer 8

Flank or RUQ

Question 9

Where does pain localise if pelvic appendix?

Answer 9

Suprapubic

Question 10

What is appendicits?

Answer 10

Acute inflammation of vermiform appendix, most likely due to obstruction of the lumen of the appendix e.g. by faecolith, stool, infection, hyperplasia

Question 11

What are the differentials?

Answer 11

Perforated peptic ulcer
Acute mesenteric adenitis
Meckel's diverticulum
Diverticulitis
Crohn's
Cholecystitis
Food poisoning/viral gastroenteritis
Gynae - UTI, dysmenorrhoea, PID/salpingitis, ectopic pregnancy

Question 12

What initial tests and bloods should be done?

Answer 12

FBC (raised, neutrophils)
CRP (raised)
U+E (rule out cholecystitis)
LFT (rule out hepatitis)
Pregnancy test
Urine dip - can be positive for leucocytes, not nitrites

Question 13

What imaging?

Answer 13

USS - rule out differentials e.g. ectopic, presence of free fluid should raise suspicion

Don’t always need imaging! Hx, exam, bloods can be enough!

Question 14

How does perforated appendicitis present?

Answer 14

generalised peritonitis - severe continuous pain, nausea or vomiting, fever, tachycardia, SOB, distension, tachypnoea

Question 15

How is appendicitis managed?

Answer 15

ABCDE - history, exam, tests, bloods, imaging
NBM + IV fluids
Appendicectomy (laparoscopic is 1st choice)
Prophylactic IV abx - pip/taz 4.5g/8h, 1-3 doses starting pre-op
Abdo lavage if perforated

Question 16

How to manage patients without peritonitis who have an appendix mass?

Answer 16

NBM
Broad-spectrum abx and consider performing an interval appendicectomy (6-8 weeks later)
Exclude colonic tumour!

Question 17

Laparoscopic surgery is generally safer and preferred. When is it not considered the safest approach?

Answer 17

Pregnancy

Question 18

Where do you make incision for open appendicectomy?

Answer 18

1.5-5cm incision at McBurney’s point

Question 19

Where do you make incision for lap. appendicectomy?

Answer 19

2cm supraumbilical incision

Question 20

What is McBurney’s point?

Answer 20

2/3rds of the way from the umbilicus to the R ASIS, corresponds to most common location of appendix

Question 21

What are the complications of appendicectomy?

Answer 21

Bleeding
Injury to nearby organs
Conversion to open surgery
Removal of ovary/tubes if pathology is originating from here
Stoma
Anaesthetic risks
Early post-op – pain, bleeding, infection, scarring, VTE, stroke, MI, kidney failure, death
Late post-op – hernia, adhesions, reintervention

Question 22

Why does pain move from periumbilical to RIF?

Answer 22

The appendix or visceral peritoneum has no somatic innervation and so the brain attributes the pain to a location whose dermatome corresponds to the same entry level in the spinal cord - this is periumbilical for midgut.
As the inflammation progresses and irritates the parietal peritoneum, the pain settles at McBurney’s point

Question 23

Aetiology of appendicitis?

Answer 23

Acute inflammation, most likely due to obstruction of the lumen of the appendix (by faecolith, normal stool, infective agents, or lymphoid hyperplasia). Gut organisms invade the appendix wall after lumen obstruction, leading to oedema, ischaemic necrosis, and perforation.

Question 24

Blood supply of appendix?

Answer 24

appendicular artery

Question 25

Venous drainage of appendix?

Answer 25

appendicular vein

Question 26

Nerve supply of appendix?

Answer 26

Ileocolic branch of superior mesenteric plexus

Question 27

Lymph drainage of appendix?

Answer 27

Upper and lower ileocolic lymph nodes