Appendicitis

Question 1

Definition

Answer 1

Inflammation of the appendix

Question 2

Epidemiology

Answer 2

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

Question 3

Aetiology/risk factors

Answer 3

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

Question 4

Signs on PE

Answer 4

• 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)
• Special Signs
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)
• Variations in clinical picture
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 5

Investigations

Answer 5

•	Bloods
o	High WCC (mainly neutrophils) 
o	High CRP 
•	Ultrasound may help 
•	CT - high diagnostic accuracy

Question 6

Management

Answer 6

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

Question 7

Complications

Answer 7

• 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 8

Prognosis

Answer 8

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

Question 9

Symptoms

Answer 9

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