Summerise the Epidemiology of Appendicitis:
Most common surgical emergency
Most common 10-20 yrs
Define Appendicitis:
Sudden inflammation of the Vermiform Appendix usually initiated by obstruction of the lumen
What are the common causes of Appendicitis?
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
Describe the Pathophysiology of Appendicitis:
- Lumen Obstructed
- Appendix wall continues to secrete mucous
- Gut Flora thrive
- Immune response to this - pus
- Appendix expands - pain
- If continues, vascular supply compromised
- Bacteria invade the appendix wall
- Appendix may rupture and leak pus into peritoneum - peritonitis
How might Appendicitis present?
(5 symptoms)
Left-lower quadrant pain
Anorexia
Vomiting (may occur after pain)
Constipation
Diarrhoea
What general signs might you see on examination of someone with acute Appendicitis?
Acute Abdomen
Tachycardia
Fever
Furred tongue
Lying still
Coughing hurts
Shallow breathing
Describe the pattern of pain in Appendicitis:
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
What signs may you see on abdominal examination of someone with Appendicitis?
(Include general signs and special signs)
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)
Describe three abnormal presentations of Appendicitis:
- Inflammation of retrocaecal/retroperitoneal appendix may cause flank pain or RUQ pain
- A child may have vague abdo pain and not eat their favourite food
- A shocked confused 80+ yo who is not in any pain
What three investigations may you perform when you suspect Appendicitis?
Bloods: (high WCC - mainly neutrophils)
Ultrasound
CT - high diagnostic accuracy
How is Appendicitis treated?
Prompt Appendicectomy
Antibiotics: Co-amox + Metro
List some similarly presenting differentials for Appendicitis:
(8 GI, 4 Uro, 3 O+G)
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
Name three possible complications of Appendicitis:
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
