Appendicitis

Question 1

In which age group does appendicitis typically occur?

Answer 1

15-59 years

Question 2

List 2 weak risk factors for the development of appendicitis?

Answer 2

Low dietary fibre

Smoking

Question 3

In which sex is appendicitis more common?

Answer 3

Males

Question 4

Describe the aetiology of appendicitis?

Answer 4

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

Question 5

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?

Answer 5

Children

Question 6

Name 2 rare but important causes of obstruction of the appendix which can lead to appendicitis?

Answer 6

Carcinoma of the caecum

Carcinoid tumour

Question 7

Describe the pathophysiology of appendicitis?

Answer 7

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.

Question 8

What are the key symptoms of appendicitis which can be found in the patient history?

Answer 8

Central abdominal pain (colicky in nature) which later localises to RLQ and becomes constant
Anorexia
Nausea (common)
Vomiting (uncommon)

Question 9

What are the key signs of appendicitis which can be found on examiantion?

Answer 9

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

Question 10

Rovsing’s sign may be present in patients with appendicitis. Describe this sign.

Answer 10

Pain can be elicited in the right lower quadrant by compressing the left lower quadrant of the abdomen

Question 11

Why is pain initially poorly localised in appendicitis?

Answer 11

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

Question 12

Why is the pain in appendicitis initially colicky in nature?

Answer 12

Because the essential feature is of an obstructed appendix so the pain will usually be colicky due to peristalsis in the appendicular muscle

Question 13

Why does pain later become more localised in appendicitis?

Answer 13

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

Question 14

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?

Answer 14

Flank or back pain

Question 15

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?

Answer 15

Testicular pain (due to irritation of the spermatic artery or ureter)

Question 16

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?

Answer 16

Suprapubic pain

Question 17

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?

Answer 17

Left lower quadrant (if the inflammation is in the tip of the appendix)

Question 18

What result would you expect to see in appendicitis on FBC?

Answer 18

Raised WCC - predominantly neutrophils

Question 19

Why should a urinalysis be performed in a patient with possible appendicitis?

Answer 19

To rule out UTI or renal colic

Question 20

In a young female patient presenting with symptoms of possible appendicitis, what simple test is vital to perform?

Answer 20

Urinary pregnancy test

Question 21

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?

Answer 21

Enlarged appendix
Appendiceal wall thickening
Peri-appendiceal fat stranding
Possible evidence of abscess

Question 22

List some of the possible differentials of appendicitis?

Answer 22

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

Question 23

How is appendicitis initially managed pre-op?

Answer 23

IV fluids - often ringer lactate is used

Question 24

Laparoscopic appendectomy is most commonly used in cases of appendicitis. However, in which patient group is open appendectomy considered the safest approach?

Answer 24

Pregnant women

Question 25

In an appendectomy, the incision is made at McBurney’s point. Where is this point?

Answer 25

2/3rds the way along an imaginary line drawn between. the umbilicus and ASIS

Question 26

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)?

Answer 26

Acutely unwell with hypotension and tachycardia

Tense, distended abdomen with generalised guarding and absent bowel sounds

Question 27

How would a patient (who is otherwise well) with a peri-appendiceal abscess be managed?

Answer 27

Conservative management with IV fluids and broad spectrum antibiotics
Possible interval appendectomy after 6 weeks if symptoms are not completely resolved

Question 28

What are the signs / symptoms of an appendicular abscess?

Answer 28

Tender right lower quadrant mass
Swinging fever
Leukocytosis

Question 29

How is an appendicular abscess managed?

Answer 29

IV antibiotics and CT guided drainage of the abscess

+/- interval appendectomy 6 weeks later if symptoms have not resolved