Appendicitis Flashcards
What are the different positions of the appendix? (7)
Pre-ileal Post-ileal Sub-ileal Pelvic Sub-caecal Paracaecal Retrocaecal
What is the most common position of the appendix?
Retrocaecal
What are the classical symptoms of appendicitis?
Periumbilical pain that moves to the RIF (worse on coughing)
Anorexia
Nausea and vomiting
Changes to bowels (constipation or diarrhoea) - not common
What are the signs on examination of appendicitis?
Tachycardia Low-grade fever Guarding and rebound tenderness in RIF McBurney's sign (tenderness in RLQ) Rovsing's sign Reduced bowel sounds
What age is appendicitis most common?
10-20 years old
What is Rovsing’s sign?
When palpate LIF, Pain > in RIF
What are alternative presentations - e.g. older adults, young age, pregnacy?
1) Shock + confusion, no pain or fever
2) Vague abdo pain, anorexia
3) Perforation more common, pain less localised, less obvious signs
Where does pain localise if retrocaecal appendix?
Flank or RUQ
Where does pain localise if pelvic appendix?
Suprapubic
What is appendicits?
Acute inflammation of vermiform appendix, most likely due to obstruction of the lumen of the appendix e.g. by faecolith, stool, infection, hyperplasia
What are the differentials?
Perforated peptic ulcer Acute mesenteric adenitis Meckel's diverticulum Diverticulitis Crohn's Cholecystitis Food poisoning/viral gastroenteritis Gynae - UTI, dysmenorrhoea, PID/salpingitis, ectopic pregnancy
What initial tests and bloods should be done?
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
What imaging?
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!
How does perforated appendicitis present?
generalised peritonitis - severe continuous pain, nausea or vomiting, fever, tachycardia, SOB, distension, tachypnoea
How is appendicitis managed?
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
How to manage patients without peritonitis who have an appendix mass?
NBM
Broad-spectrum abx and consider performing an interval appendicectomy (6-8 weeks later)
Exclude colonic tumour!
Laparoscopic surgery is generally safer and preferred. When is it not considered the safest approach?
Pregnancy
Where do you make incision for open appendicectomy?
1.5-5cm incision at McBurney’s point
Where do you make incision for lap. appendicectomy?
2cm supraumbilical incision
What is McBurney’s point?
2/3rds of the way from the umbilicus to the R ASIS, corresponds to most common location of appendix
What are the complications of appendicectomy?
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
Why does pain move from periumbilical to RIF?
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
Aetiology of appendicitis?
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.
Blood supply of appendix?
appendicular artery
Venous drainage of appendix?
appendicular vein
Nerve supply of appendix?
Ileocolic branch of superior mesenteric plexus
Lymph drainage of appendix?
Upper and lower ileocolic lymph nodes
