Appendicitis

Question 1

Summerise the Epidemiology of Appendicitis:

Answer 1

Most common surgical emergency

Most common 10-20 yrs

Question 2

Define Appendicitis:

Answer 2

Sudden inflammation of the Vermiform Appendix usually initiated by obstruction of the lumen

Question 3

What are the common causes of Appendicitis?

Answer 3

Lumen Obstruction by:

Faecolith

Filarial Worms

Lymphoid hyperplasia (growth of Lymphoid follicles in the walls of the appendix - often in adolescence - that can obstruct the lumen)

Leading to:

Oedema, Ischaemic necrosis and perforation

Question 4

Describe the Pathophysiology of Appendicitis:

Answer 4

1. Lumen Obstructed
2. Appendix wall continues to secrete mucous
3. Gut Flora thrive
4. Immune response to this - pus
5. Appendix expands - pain
6. If continues, vascular supply compromised
7. Bacteria invade the appendix wall
8. Appendix may rupture and leak pus into peritoneum - peritonitis

Question 5

How might Appendicitis present?

(5 symptoms)

Answer 5

Left-lower quadrant pain

Anorexia

Vomiting (may occur after pain)

Constipation

Diarrhoea

Question 6

What general signs might you see on examination of someone with acute Appendicitis?

Answer 6

Acute Abdomen

Tachycardia

Fever

Furred tongue

Lying still

Coughing hurts

Shallow breathing

Question 7

Describe the pattern of pain in Appendicitis:

Answer 7

Early periumbilical pain - moves to Right Illiac Fossa as peritoneum becomes involved

Most commonly seen over McBurney’s Point - 1/3 of distance from ASIS to umbilicus

Question 8

What signs may you see on abdominal examination of someone with Appendicitis?

(Include general signs and special signs)

Answer 8

RIF: Guarding, Rebound Tenderness

Rovsing’s sign: +ve if pain in the RIF is greater than the LIF when the LIF is pressed. (As the pressure stretches the entre peritoneum lining so causes pain where the peritoneum is irritating the muscle)

Psoas sign: Pain when extending hip - seen when retrocaecal appendix (leg goes backwards)

Cope sign: Pain on flexion and internal rotation of right hip (if appendix is in close proximity to Obturator internus)

Question 9

Describe three abnormal presentations of Appendicitis:

Answer 9

1. Inflammation of retrocaecal/retroperitoneal appendix may cause flank pain or RUQ pain
2. A child may have vague abdo pain and not eat their favourite food
3. A shocked confused 80+ yo who is not in any pain

Question 10

What three investigations may you perform when you suspect Appendicitis?

Answer 10

Bloods: (high WCC - mainly neutrophils)

Ultrasound

CT - high diagnostic accuracy

Question 11

How is Appendicitis treated?

Answer 11

Prompt Appendicectomy

Antibiotics: Co-amox + Metro

Question 12

List some similarly presenting differentials for Appendicitis:

(8 GI, 4 Uro, 3 O+G)

Answer 12

GI:

• Gastroenteritis
• Intestinal obstruction, intussusception or perforation
• Incarcerated inguinal hernia
• Cholecystitis
• Diverticulitis
• Pancreatitis
• IBD
• Constipation

Urological:

• Right ureteric colic
• Right Pyelonephritis
• UTI
• Urinary retention

O+G:

• Ectopic pregnancy
• Ruptured ovarian cyst or ovarian torsion
• Endometriosis

Question 13

Name three possible complications of Appendicitis:

Answer 13

Perforation - leading to peritonitis

Appendiceal mass - when the inflamed appendix becomes covered with omentum

Periappendiceal Abscess: may occur if mass fails to resolve - requires drainage and Abx