Appendicitis

Question 1

Definition

Answer 1

Inflammation of the appendix

Question 2

Aetiology/Risk factors

Answer 2

· Gut organisms invade the appendix wall after lumen obstruction (e.g. by lymphoid hyperplasia, faecolith or filarial worms)

· This leads to oedema, ischaemic necrosis and perforation

Question 3

Epidemiology

Answer 3

· The MOST COMMON surgical emergency

· Can occur at any age

· Most commonly occurs between 10-20 yrs

Question 4

Presenting symptoms

Answer 4

· Periumbilical pain that moves to the right iliac fossa

· Anorexia is an important feature

· Vomiting (may occur after pain)

· Constipation

· Diarrhoea

Question 5

Signs on physical examination (general)

Answer 5

· 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)

Question 6

Signs on physical examination (special signs)

Answer 6

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)

Question 7

Signs on physical examination (variation)

Answer 7

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 8

Investigations

Answer 8

· Bloods
o High WCC (mainly neutrophils)
o High CRP

· Ultrasound may help

· CT - high diagnostic accuracy

Question 9

Management plan

Answer 9

· Prompt appendicectomy

· Antibiotics:
o Cefuroxime
o Metronidazole

· Laparoscopy - diagnostic and therapeutic advantages

Question 10

Possible complications

Answer 10

· 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 11

Prognosis

Answer 11

· Uncomplicated appendicitis - most people recover with no long-term problems

· Ruptured appendix - greater risk of complications/death