Appendicitis

Question 1

Definie Appendicitis

Answer 1

Acute appendicitis is an acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix

Question 2

Explain the aetiology/Risk Factors for appendicitis

Answer 2

Obstruction of the lumen of the appendix is the main cause of acute appendicitis.

The main causes for obstruction are:

• Faecolith (a hard mass of faecal matter) - low dietary fibre is a RF
• Normal stool
• Lymphoid hyperplasia

Question 3

Recognise the presenting symptoms of appendicitis

Answer 3

Migrating abdominal pain: most common and specific symptom

• Initial diffuse periumbilical pain; irritation of the visceral peritoneum (pain is referred to T8–T10 dermatomes)
• Localizes to the RLQ within ∼ 12–24 hours; irritation of the parietal peritoneum
• May be peritonitic if appendix has ruptured

Associated nonspecific symptoms

• Nausea & Vomiting
• Anorexia: up to 80% of case
• Low-grade fever

Question 4

Signs on physical examination

Answer 4

• Low grade fever
• Hypotension
• Tachycardia
• Reduced bowel sounds

Clinical Signs:

• McBurney point tenderness
• RLQ guarding and/or rigidity
• Rebound tenderness
• Rovsing sign (palpation of L-side causes R-sided pain)
• Psoas sign (pain on extending hip - retrocaecal appendix)
• Obturator/Cope sign: Pain on (flexion and) internal rotation of the hip

Question 5

Investigations

Answer 5

• 1st LINE: Contrast CT Abdo
  
  • Shows abnormal appendix (diameter >6 mm) or calcified appendicolith in association with peri-appendiceal inflammation
• Abdominal US - 1st line in pregnant women AND children: aperistaltic or non-compressible structure with outer diameter >6 mm
• FBC: Mild leukocytosis
• CRP: Raised
• Pregnancy test in FEMALES

Features strongly in keeping with appendicitis include vomiting, anorexia, migration of pain from the umbilicus, rebound tenderness, low-grade fever, and neutrophilia. Per the Royal College of Surgeons (2014), patients with these features should typically go straight to the theatre if they are septic or if they are young and male (as this presentation is most likely to be appendicitis).

Stable young women who have some features of appendicitis (such as this patient) should first receive imaging to rule out other causes of RIF pain, namely ovarian causes. Ultrasound is the most appropriate initial investigation to rule out ovarian pathology and/or increase the suspicion of appendicitis.

Question 6

Generate a management plan for appendicitis

Answer 6

Supportive treatment

• Fluid resuscitation
• Analgesia (opiates)

SURGERY: Appendicectomy

Prophylactic Antibiotics (before surgery): Metronidazole and Cefotaxime

Question 7

Complications

Answer 7

• Perforation
• Generalised peritonitis
• Appendicular abscess
• Surgical wound infection