Appendicitis Flashcards
In which age group does appendicitis typically occur?
15-59 years
List 2 weak risk factors for the development of appendicitis?
Low dietary fibre
Smoking
In which sex is appendicitis more common?
Males
Describe the aetiology of appendicitis?
Appendicitis is likely the result of obstruction of the lumen of the appendix. This is commonly obstruction to faecolith, normal stool, infective agents of lymphoid hyperplasia
Lymphoid hyperplasia is likely the result of viral infection and can cause obstruction of the appendix leading to appendicitis most commonly in which patient group?
Children
Name 2 rare but important causes of obstruction of the appendix which can lead to appendicitis?
Carcinoma of the caecum
Carcinoid tumour
Describe the pathophysiology of appendicitis?
The appendix becomes obstructed causing the lumen distal to the obstruction to fill with mucous. The appendix distends and intraluminal and intramural pressure increases. Normal bacteria present in the appendix (e.coli) multiply. As the pressure of the lumen exceeds venous pressure, small venues and capillaries thrombus leading to engorgement and congestion of the appendix. The inflammatory process evolves to involve the serosa, causing inflammation of the parietal peritoneum. Eventually thrombosis of the arterials causes ischaemia, infarction and perforation fo the appendix.
What are the key symptoms of appendicitis which can be found in the patient history?
Central abdominal pain (colicky in nature) which later localises to RLQ and becomes constant
Anorexia
Nausea (common)
Vomiting (uncommon)
What are the key signs of appendicitis which can be found on examiantion?
Localised right iliac fossa tenderness (McBurney’s sign) and guarding with rebound tenderness
Pain in right lower quadrant after compressing the left lower quadrant (Rovsing’s sign)
Bowel sounds may be reduced
Mild fever
Rovsing’s sign may be present in patients with appendicitis. Describe this sign.
Pain can be elicited in the right lower quadrant by compressing the left lower quadrant of the abdomen
Why is pain initially poorly localised in appendicitis?
In the early. stages, inflammation is confined to the wall of the appendix so is felt as a poorly localised visceral pain in the central abdomen as the appendix originates from the embryological midgut
Why is the pain in appendicitis initially colicky in nature?
Because the essential feature is of an obstructed appendix so the pain will usually be colicky due to peristalsis in the appendicular muscle
Why does pain later become more localised in appendicitis?
As the inflammatory process progresses, the surrounding tissues and parietal peritoneum become inflamed and this is felt locally as somatic pain in the right iliac fossa
The exact location of the appendix is variable and so the localisation of pain in appendicitis can be variable. Where might pain be felt in appendicitis if the appendix is retrocaecal?
Flank or back pain
The exact location of the appendix is variable and so the localisation of pain in appendicitis can be variable. Where might pain be felt in appendicitis in male patients if the appendix is retroileal?
Testicular pain (due to irritation of the spermatic artery or ureter)
The exact location of the appendix is variable and so the localisation of pain in appendicitis can be variable. Where might pain be felt in appendicitis if the appendix is pelvicl?
Suprapubic pain
The exact location of the appendix is variable and so the localisation of pain in appendicitis can be variable. Where might pain be felt in appendicitis if the appendix is very longl?
Left lower quadrant (if the inflammation is in the tip of the appendix)
What result would you expect to see in appendicitis on FBC?
Raised WCC - predominantly neutrophils
Why should a urinalysis be performed in a patient with possible appendicitis?
To rule out UTI or renal colic
In a young female patient presenting with symptoms of possible appendicitis, what simple test is vital to perform?
Urinary pregnancy test
If patients present with a typical history of appendicitis they may be taken to theatre without any imaging test. However in patients with appendicitis for whom a CT scan is conducted, what signs would you expect to see?
Enlarged appendix
Appendiceal wall thickening
Peri-appendiceal fat stranding
Possible evidence of abscess
List some of the possible differentials of appendicitis?
Mesenteric adenitis Ruptured ectopic pregnancy Viral gastroenteritis Meckel's diverticulitis Intussusception Chron's disease Peptic ulcer disease Right-sided ureteric stone Cholecystitis UTI Pelvic inflammatory disease Ovarian torsion
How is appendicitis initially managed pre-op?
IV fluids - often ringer lactate is used
Laparoscopic appendectomy is most commonly used in cases of appendicitis. However, in which patient group is open appendectomy considered the safest approach?
Pregnant women
In an appendectomy, the incision is made at McBurney’s point. Where is this point?
2/3rds the way along an imaginary line drawn between. the umbilicus and ASIS
Patients with appendicitis who delay seeking medical attention may incur the complication of perforation. How would such a patient present (in terms of observation and examination findings)?
Acutely unwell with hypotension and tachycardia
Tense, distended abdomen with generalised guarding and absent bowel sounds
How would a patient (who is otherwise well) with a peri-appendiceal abscess be managed?
Conservative management with IV fluids and broad spectrum antibiotics
Possible interval appendectomy after 6 weeks if symptoms are not completely resolved
What are the signs / symptoms of an appendicular abscess?
Tender right lower quadrant mass
Swinging fever
Leukocytosis
How is an appendicular abscess managed?
IV antibiotics and CT guided drainage of the abscess
+/- interval appendectomy 6 weeks later if symptoms have not resolved
