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AIP: Abdominal pain > Appendicitis > Flashcards

Appendicitis Flashcards

1
Q

At what age is acute appendicitis most common?

A

age 10-20 years (but can occur at any age)

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2
Q

What is the key feature of the presentation of acute appendicitis, seen in the vast majority of patients?

A

abdominal pain

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3
Q

What is the nature of abdominal pain in acute appendicitis?

A
  • peri-umbilical abdominal pain due to visceral stretching of appendix lumen, and appendix is a midgut structure
  • radiates to right iliac fossa (RIF) due to localised parietal peritoneal inflammation
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4
Q

Which feature of the history is one of the strongest indicators of appendicitis?

A

migration of pain from the centre to the RIF

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5
Q

What are 3 things said to exacerbate the pain of appendicitis?

A
  1. Pain worse on coughing
  2. Pain worse going over speed bumps
  3. Children can’t hop on right leg due to the pain
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6
Q

In addition to abdominal pain, what are 3 further key features of acute appendicitis?

A
  1. Vomiting - usually once or twice (marked and persistent is unusual)
  2. Mild pyrexia - temperature usually 37.5-38
  3. Anorexia - very common
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7
Q

What type of vomiting would you expect to see in appendicitis?

A

vomit once or twice - marked and persistent is unusual

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8
Q

What are 2 things that can cause diarrhoea from appendicitis, despites its being rare?

A
  1. Pelvic appendicitis may cause localised rectal irritation / some loose stools
  2. Pelvic abscess can cause diarrhoea
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9
Q

With typical appendicitis features and temperatures above 38, what would be a more likely differential?

A

conditions like mesenteric adenitis

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10
Q

What proportion of patients present with the typical symptoms of appendicitis (anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain)?

A

50%

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11
Q

What are 4 possible signs on abdominal examination of appendicitis?

A
  1. Generalised peritonitis if perforation has occurred, or localised peritonism
  2. Retrocaecal appendicitis may have few signs
  3. Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or right-sided tenderness with a pelvic appendix
  4. Rovsing’s sign
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12
Q

What is Rovsing’s sign?

A

palpation in the left iliac fossa causes pain in the right iliac fossa

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13
Q

What is now thought about the value of Rovsing’s sign when diagnosing appendicitis?

A

now thought to be of limited value

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14
Q

What is thought to be the cause of appendicitis?

A

probably initiated by luminal obstruction caused by impacted faeces or a faecolith

mucosa becomes inflamed, extends through submucosa to involve muscular and serosal (peritoneal) layers

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15
Q

How can appendicitis lead to perforation?

A

end-arteries supplying appendix thrombose and infarcted appendix becomes necrotic or gangrenous at distal end, begins to disintegrate. perforation soon follows and faecally contaminated contents spread into peritoneum

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16
Q

What are the positions that the appendix may be located in?

A
  • can be retrocaecal: platered to posterior wall of caecum, close to right ureter and psoas
  • can be ‘pelvis’: close to fallopian tube, rectum or ureter
  • can be anywhere on the circumference shown by the arrowed arc in the drawing
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17
Q

Why is the classic picture of appendicitis seen in relatively few cases?

A

localising symptoms and signs vary with the anatomical relations of the inflamed appendix and vigour of the body’s defences

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18
Q

What are 6 atypical presentations of acute appendicitis?

A
  1. Local irritation and diarhoea: if inflamed/perforated and in pelvis near rectum
  2. Abdominal pain + diarrhoea for >5 days in children: in children with pelvic collection second to appendicitis
  3. Urinary frequency, dysuria and (microscopic) pyruia: if near bladder or ureter
  4. No usual localising symptoms but irritation of psoas muscle causing involuntary right hip flexion and pain on extension: if inflamed retrocaecal appendix
  5. Pain and tenderness below right costal margin: if high retrocaecal appendix
  6. Pelvix pain suggestive of acute gynae disorder: if near Fallopain tube
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19
Q

How long does the early phase of appendicitis with poorly localised pain typically last?

A

few hours - until peritoneal inflammation produces localising signs

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20
Q

If untreated, how long may it take for an inflamed appendix to become gangrenous and perforate?

A

12-24 hours

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21
Q

How will peritonitis due to perforation present?

A

whole abdomen becomes rigid and tender, marked systemic toxicity

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22
Q

In which patient group is appendix perforation common?

A

young children

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23
Q

In older patients, what is more likely the outcome of a gangrenous or perforated appendix?

A

more likely to be contained by greater omentum or loops of small bowel, resulting in a palpable appendix mass

may contain free pus and is then known as an appendiceal abscess

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24
Q

What is the usual outcome of an appendix mass in older patients, following a perforated appendix?

A

usually resolve spontaneously over 2-6 weeks

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25
Q

What are 5 investigations which may be used to aid the diagnosis of appendicitis?

A
  1. Inflam​matory markers: these + history should be enough to justify appendicectomy
  2. Urinalysis: renal colic and UTI. In appendicitis, may show mild leucocytosis (but no nitrites)
  3. Pregancy test: in women of childbearing age
  4. Ultrasound: useful in females where pelvic organ pathology suspected; not always possible to visualise appendix on ultrasound but presence of free fluid (always pathological in males) should raise suspicion
  5. CT: widely used in US but not UK (radiation and resource limitations)
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26
Q

What may urinalysis show in appendicitis?

A

mild leucocytosis but no nitrites

27
Q

What type of raised inflammatory markers are seen in 80-90% of cases of appendicitis?

A

neutrophil-predominant leucocytosis

28
Q

What can ultrasound sometimes be useful for in suspected appendicitis? 3 things

A
  1. useful in females where pelvic organ pathology suspected;
  2. not always possible to visualise appendix on ultrasound but presence of free fluid (always pathological in males) should raise suspicion
  3. can also be helpful to detect an abscess or mass
29
Q

What is the management of appendicitis?

A

appendicectomy: can be performed via open or laparoscopic approach

laparoscopic appendicectomy is now the treatment of choice

30
Q

What medication is given alongside appendicectomy and why?

A

prophylactic IV antibiotics to reduce wound infection rates

31
Q

What additional management is required for patients with a perforated appendicitis?

A

copious abdominal lavage

32
Q

What proportion of patients with appendicitis have a perforation?

A

15-20%

33
Q

What is the management of patients with appendicitis and an appendix mass?

A

broad-spectrum-antibiotics, consideration given to performing an interval appendicectomy

34
Q

What are 2 differentials for appendicitis to bear in mind in older patients?

A
  1. underlying caecal malignancy
  2. perforated sigmoid diverticular disease
35
Q

What does evidence suggest is the efficacy of IV antibiotics alone to treat appendicitis?

A

evidence currently suggests that whilst this is successful in majority of patients, it’s associated with longer hospital stay and up to 20% of patients go on to have an appendicectomy within 12 months

36
Q

Overall, what can the diagnosis of appendicitis be said to be based on?

A

clinical diagnosis: relies almost entirely on history and examination (+ blood tests = enough for appendicectomy)

37
Q

What are said to be 7 cardinal features of acute appendicitis?

A
  1. Abdominal pain for <72h
  2. Vomiting one to three times
  3. Facial flush
  4. Tenderness concentrated on the right iliac fossa
  5. Anterior tenderness on rectal examination
  6. Fever between 37.3-38.5oC
  7. No evidence of urinary tract infection on urine microscopy
38
Q

What features favour a diagnosis of mesenteric adenitis in children rather than appendicitis?

A

recent or current sore throat or viral-type illness

39
Q

What is the exception to the rule that a temperature over 38 makes appendicitis unlikely?

A

perforated appendix

40
Q

What is the usual appearance of a patient with appendicitis on general inspection?

A

quiet, apathetic and flushed with limited abdominal wall movement

41
Q

What specific things should you ask a patient to do on examination to help diagnose appendicitis? 2 key things

A
  • ask patient to cough
  • ask to blow out abdominal wall and draw it in
  • these will cause pain if parietal peritoneum is inflamed
42
Q

What is meant by rebound tenderness?

A

traditionally demonstrated by palpating deeply then suddenly releasing the hand - but can cause excessive and unexpected pain so gentle percussion in RIF better

43
Q

What type of appendicitis will produce anterior peritoneal tenderness on rectal examination?

A

pelvic appendicitis

44
Q

What are 2 things to be done if the diagnosis of appendicitis in unequivocal / no clear evidence for it?

A
  1. admit and observe patient, repeated examinations every few hours until cause becomes clear/it settles
  2. diagnostic laparoscopy in some cases
45
Q

What is the best known scoring system that helps improve the accuracy of clinical diagnosis of appendicitis?

A

Alvarado score

46
Q

How useful is the Alvarado score for helping improve diagnostic accuracy for appendicitis?

A

unreliable for diagnosing acute appendicitis, but value lies with patients with initial score of <5 who are very unlikely to have appendicitis and do not need admission unless symptoms worsen

47
Q

What are 10 differentials for appendicitis?

A
  1. Urinary tract infection
  2. Mesenteric adenitis
  3. Constipation
  4. Diverticulitis
  5. Gynaecological disorders (mittelschmerz, salpingitis, torsion/haemorrhage into right ovarian cyst, ectopic pregnancy)
  6. Meckel diverticulum
  7. Terminal ileitis (Crohn’s or Yersinia pseudotuberculosis)
  8. Necrotic small bowel from strangulation
  9. Acute pancreatitis
  10. Gastroenteritis
48
Q

What are 8 blood tests to consider in a patient with suspected appendicitis?

A
  1. FBC (for WCC)
  2. CRP
  3. U&Es if dehydrated
  4. LFTs
  5. amylase (latter 2 to rule out biliary differentials)
  6. Clotting
  7. G&S for theatre
  8. Blood cultures if septic
49
Q

When might you perform an erect chest x-ray in appendicitis?

A

to exclude perforation (pneumoperitoneum)

50
Q

What risk factor exists for appendicitis?

A

western diet/low fibre diet

51
Q

What are 4 examples of problems of diagnosis of appendicitis?

A
  1. Patients <2years
  2. Elderly
  3. Pregnancy
  4. Grumbling appendix
52
Q

Why do patients <2 years pose difficulties for diagnosing appendicitis and what is the management?

A

typical signs obscure/absent, generalised peritonitis occurs rapidly. Laparotomy usually indicated

53
Q

Why do elderly patients pose difficulties for diagnosing appendicitis?

A

develops more slowly, many cases resolve spontaneously due to omentum walling off area. Longer history and features of obstruction present. Palpable mass

54
Q

Why does pregnancy cause problems in the diagnosis of appendicitis?

A

appendix displaced upwards, pain in higher position. Laparoscopy may be indicated but is technically difficult beyond 26 weeks

liaise with obstetrician

55
Q

What is meant by the grumbling appendix and why does it pose difficulties for diagnosis?

A
  • reccurent bouts of right iliac fossa pain.
  • appendicular pathology probably not cause in most or may be low grade acute appendicitis or colic. may hav severable abortive admissions for abdo pain and eventually may be justifiable to remove appendix to allay parental anxiety
56
Q

What factor in appendicitis makes intra-abdominal infective complications and wound infections more likely to occur?

A

in perforated or gangrenous appendicitis

57
Q

What antibiotic covers most uncomplicated infective organisms that may complicate appendicitis? How is this given?

A
  • Metronidazole
  • Rectal suppositories as effective as IV and cheaper, but best given 2 hours before operation
  • some surgeons advocate + cephalosporin for aerobic organisms too
58
Q

In what proportion fo appendectomies are appendiceal neoplasms present and which 2 types are most of these?

A
  • 0.5-0.9%
  • most innocent carinoid-type, others mucinous adenocarcinomas
59
Q

What are 8 intraperitoneal complications of appendicitis?

A
  1. Appendix stump blow-out: spillage of colonic contents into peritoneum
  2. Generalised peritonitis
  3. Abscesses
  4. Retained faecolith causing chronic local infection
  5. Haematoma - slippage of vascular ligature or mesenteric or omental tear
  6. Small bowel injury at laparoscopy
  7. Intestinal obstruction caused by adhesions
  8. Infertility caused by tubal occlusion following pelvic infection
60
Q

What are 4 abdominal wall complications of appendicitis?

A
  1. Superficial wound infection
  2. Deep wound infection
  3. Dehiscence
  4. Incisional hernia
61
Q

What is meant by the term ‘Lily-White appendix’?

A

if the apendix is found not to be inflamed at open operation

62
Q

What is the management if a Lily-White appenix is found at open operation?

A

should always perform appendicectomy because scar would lead future doctors to assume appendix has been removed

abdomen explored to search for cause of symptoms: mesenteric lymph nodes, terminal ileum (Crohn’s), Mecekl diverticulum, both ovaries, cholecystitis, sigmoid diverticulitis, leaking aneurysm

63
Q

What is the management of the appendix mass?

A

conservative regimen

interval appendiectomy 6 weeks later (Ochsner-Sherren regimen) previously recommended by early operation under antibiotic cover now performed more frequently

AIP: Abdominal pain (20 decks)

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