Appendicitis Flashcards
What is appendicitis?
Inflammation of the vermiform (aka caecal) appendix, usually secondary to a faecolith obstruction with subsequent bacterial overgrowth (B. fragilis, E. Coli).
Lifetime risk: 1 in 15.
How does appendicitis present?
Symptoms:
Anorexia is usually the first sign, followed by abdominal pain then vomiting.
Abdo pain is initially visceral colicky pain in the umbilical region, which then moves to the right iliac fossa (RIF) and become constant. The RIF pain reflects inflammation affecting the tissue and peritoneum surrounding the appendix.
RIF peritonism: pain on moving or coughing, guarding, rebound tenderness.
Fever, though usually mild. A high fever suggests abscess formation or perforation.
Signs:
Tenderness may be localised at McBurney’s point, one third of the way between the right ASIS and umbilicus.
Rovsing’s sign: RIF pain on pressing the LIF.
Psoas sign: pain on extending hip (if retrocecal appendix).
Cope (aka obturator) sign: pain on flexion and internal rotation of the right hip.
What are the complications of appendicitis?
Complications:
Untreated, it can lead to perforation, generalised peritonitis, and/or abscess formation.
Appendix mass: omentum and small bowel adhere to an inflamed appendix.
How is appendicitis investigated?
Diagnosis is usually clinical.
Bloods: ↑WBC, ↑CRP.
Urine: may contain white cells.
Abdo-pelvis CT is the best imaging tool, but often not required. Ultrasound is less sensitive but an acceptable alternative e.g. in pregnancy, paediatrics.
How is appendicitis managed?
Management
Surgery:
Appendectomy is the definitive treatment.
Relative to open appendectomy, laparoscopic appendectomy leads to fewer complications (post-op pain, abscess formation, ileus) and shorter hospital stay. In pregnancy, however, open is safer.
Open appendectomy is usually through a gridiron incision at Mc Burney’s point, perpendicular to the spinoumbilical line. Alternative is the transverse Lanz incision, which has better cosmesis.
Antibiotics:
Antibiotics IV before surgery and for 24 hours after. Give urgently if perforated.
Most cases of uncomplicated appendicitis would resolve with 10 days antibiotics alone, but surgery is performed due to the risk of recurrence (without surgery, 25% within 1 year and 40% within 5 years) and – in part – because of tradition.
How are appendicitis complications managed?
Managing appendicitis complications:
Abscess can be treated with IV antibiotics and CT-guided drainage.
Appendix mass is treated with antibiotics initially and appendectomy when settled.
Which management options are recommended by BMJ best practice for urgent cases of appendicitis?
In urgent cases-
seek immediate surgical input
consider involving critical care in patients with shock or sepsis
Involve obstetric support for any pregnant patient with appendicitis- requires MDT support
Keep patient nil by mouth if surgery is being considered.
If patient has signs of shock, give fluid challenge to correct hypotension and/or tachycardia.
-give 250ml or 500ml normal saline or Hartmann’s solution IV over 15 minutes.
Refer to your local guidelines for management of sepsis.
What is complicated appendicitis?
Occurs in 4-6% of patients and is defined as appendiitis plus any one of-
- gangrenous appendicitis with or without perforation
- intra-abdominal abscess
- peri-appendicular phlegmon
- purulent-free fluid
What is recommended by the BMJ for initial management of all patients with suspected appendicitis?
- Involve critical care and seek immediate surgical input for any patients with suspected perforated appendix and signs of shock and sepsis.
- In patients with signs of shock give fluid challenge to correct hypotension and tachycardia- give 250ml or 500ml of normal saline or Hartmann’s over 15 minutes
- refer to your local guidelines regarding management of patients with sepsis or shock.
- Give all patients prophylactic antibiotics before surgery to reduce the risk of post-operative complications. Check local microbiology guidelines.
- patients with complicated appendicitis require a post-operative course of antibiotics in addition to this, whereas patients with uncomplicated appendicitis rquire only a single pre-operative dose.
Involve obstetric support for any pregnant patients with appendicitis.
In the community have a low threshold for admitting urgently-
- older patients
- pregnant women
- patients with signs of complications
Arrange for patients with symptoms lasting less than 24 hours and who are systemically well to be seen in hospital in less than 24 hours.
Give adequate analgesia- paracetamol may be used or give an opiod if required. It was previously believed that giving strong analgesics masked symptoms but evidence now shows that giving opiods foes not increase the risk of diagnostic error.
Keep patient nil by mouth if surgery being considered.Run IV maintenance fluids for patients nil by mouth.
How is uncomplicated appendicitis managed?
FIRST LINE
Appendectomy is the standard treatment for uncomplicated appendicitis. Either open or laparoscopic.
Laparoscopic is the first choice for most adults including pregnant women provided an appropriately skilled surgeon is available.
Refer any patient with suspected or confirmed appendicitis within 24 hours, even if they have uncomplicated appendicitis or are stable.
Ensure appendectomy is not delayed to minimise patient discomfort. Evidence shows delaying surgery by up to 24 hours does not increase risk of perforation.
Surgery may be delayed due to awaiting investigation results, trialing conservative management or ensuring adequate staffing levels. Minimise surgical delay for patients >65 years and those with significant comorbidities. These patients may be at increased risk of perforation.
CONSERVATIVE MANAGEMENT W/ ABX
Consider conservative managment with abx for certain patients, including-
-those w/ uncomplicated appendicitis (suspected or confirmed on CT) who do not wish to have surgery/are unfit to have surgery.
ENSURE PATIENT AWARE OF RISK OF RECURRENCE
Conservative approach cannot be used in pregnant women.
Check local guidelines from microbiology as regimens can differ- some include amoxicillin plus metronidazole, piperacillin/tazobactam or amoxicllin/clavulanate.
In which patients are appendicitis complications more liekly to occur?
Those- Have longer duration of symptoms Are >50 years old Are female Have a WCC >16
How is complicated appendicitis managed?
Request immediate surgical review for any patient with confirmed or suspected complicated appendicitis.
Patients w/ perforated appendix require urgent appendectomy. If expertise is available laparoscopic is the method of choice.
There is a debate around best management of appendicitis w/ phlegmon or abscess. Latest evidence suggests laparoscopic is associated with fewer readmissions and complications than conservative management as long as advanced laparoscopic expertise is available.
However in stable patients with appendicael abscess/phlegmon where laparoscopic appenectomy is unavailable- conservative managment with IV antiobiotics and percutaneous image-guided drainage is a reasonable alternative.
Check local guidelines when prescribing abx.
Interval appendectomy should be considered if patient receives conservative management and symptoms persist >6 weeks.
Ensure any patient aged >40 years who has conservative management without interval appendectomy also has investigations to rule out colon malignancy. Including colonoscopy and interval full-dose contrast CT.
Any patient w/ complicated appendicitis should receive post-operative antibiotics. Continue abx typically for 3-5 days. Start with IV and switch to oral. Use lab criteria and improving clinical signs when stopping abx.
Complicated appendicitis is associated with increased surgical site infection- post-operative complication rate is up to 4 times higher than in uncomplicated appendicitis.
