appendicitis

Question 1

def of appendicitis

Answer 1

acute inflammation and infection of the appendicitis

Question 2

pathophysiology of appendicitis

Answer 2

luminal obstruction (by lymphoid hyperplasia, faecolith or filarial worm) results in proliferation of bowel flora and inflammation that extends transmurally

swelling = obstruction and thrombosis of end arteries = appendix becomes gangrenous and necrotic

inflammation may become localised by omentum or bowel loops to form an appendix mass or abscess, or perforation and spreading peritonitis may occur if not treated, or oedema

Question 3

aetiology of appendicitis

Answer 3

thought to be initiated by luminal obstruction by faecolith (inspissated faeces), lymphoid hyperplasia or oedema

may be associated with low fibre diet

Question 4

epidemiology of appendicitis

Answer 4

any age, most common <40, highest incidence 10-20yrs. Rare before 2yrs because appendix is cone shaped and has larger lumen

appendicectomy is one of the most common emergency surgical operations, with about 1/6 lifetime risk

Question 5

classic presentation of appendicitis

Answer 5

abdo pain usually <72hrs

• initially diffuse, periumbilical and colicky (visceral pain lasting a few hours)
• pain becomes sharp and localised to the RIF (somatic pain as parietal peritoneum is involved)

anorexia - most constant symptom

nausea

vomiting may develop hours after pain onset

constipation usual, diarrhoea can occur

Question 6

alternative presentations of appendicitis

Answer 6

pain in R flank - retrocaecal appendix

pain in RUQ - long appendix

lower abdomen - pelvic appendix

may be associated urinary frequency or loose stools due to bladder or bowel irritation by the inflammed appendix

child with vague abdo pain that wont eat they’re fave food

shocked and confused octogenarian who is not in pain

Appendicitis occurs in ~1/1000 pregnancies. Mortality is higher, especially from 20wks’ gestation. Perforation is more common, and increases fetal mortality. Pain is often less well localized (may be RUQ) and signs of peritonism less obvious.

Question 7

signs of appendicitis

Answer 7

mild pyrexia, facial flush and tachycardia

Abdominal pain often maximal at McBurney’s point (2/3 along a line from the umbilicus to the anterior superior iliac spine) with rebound tenderness (demonstrable on percussion) and guarding.

signs of peritoneal inflammation - pain on coughing or while sucking in or blowing out the abdominal wall

Rovsing’s sign is pain in the RIF elicited by pressure over the LIF, but is unreliable.

psoas sign - pain on extending hip if retroceacal appendix

cope sign - pain on flexion and internal rotation of R hip if appendix in close relation to obturator internus

Question 8

ix for appendicitis

Answer 8

it is a clinical diagnosis - no definitive test to confirm or exclude it

bloods - raised WCC and CRP (especially in later stages), amylase - to exclude pancreatitis, U&Es

urine - for microscopy, culture and sensitivity to exclude infection, pregnancy test for women of childbearing age

imaging - AXR or US - not usually diagnostic

CT most useful diagnostically

Question 9

general mx of appendicitis

Answer 9

rehydration with IV fluids

broad spectrum AB pre and peri-op (cefuroxime, metronidazole)

if symptoms or signs are equivocal, observation with frequent re-examination.

Question 10

surgical mx of appendicitis

Answer 10

appendicectomy

in young women diagnostic laparoscopy may be necessary if diagnosis isnt certain

Post-op, antibiotics may be given for up to 48 h in early cases but for 7–10 days incases of gangrenous or perforated appendix - piperacillin/tazobactam 4.5g/8h, 1 to 3 doses IV starting 1h pre-op, reduces wound infections. .

if an appendix abscess is present drainage must be performed either percutaneously with ultrasound control or intra-operatively (with appendicectomy if safe).

Management of an appendiceal mass may be non-operative with antibiotics, parenteral fluids and frequent reassessment, with operation if clinical deterioration occurs. Interval appendicectomy performed 6–8 weeks later (Ochsner–Sherren approach). If this is not performed in adults, imaging such as barium enema or colonocopy should be done to exclude a local perforation, e.g. of carcinoma of the right colon.

laproscopy has diagnostic and therapeutic advantages if surgeon experienced, especially in women and obese. Not recommended in cases of suspected gangrenous perforation as the rate of abscess formation may be higher

Question 11

complications of appendicitis

Answer 11

formation of an inflammatory mass, appendix abscess, perforation and peritonitis, rarely portal pyemia

postop - wound infection, wound abscess, abdominal abscess, adynamic ileus, rarely a faecal fistula from the appendix stump

perforation is more common if faecolith is present and in young children because the diagnosis is more often delayed

appendix mass - inflammed appendix becomes covered with omentum, US/CT help with diagnosis. Either early surgery or initial conservative measurement (NBM and AB). If mass resolves some perform interval (ie delayed) appendicectomy). Exclude a colonic tumour (laparotomy or colonoscopy) which can present from 40yrs

appendix abscess - if appendix mass fails to resolve but enlarges and the pt gets more unwell. Treatment - drainage (surgical/percutaneous under US/CT guidance) AB may bring resolution

Question 12

px of appendicitis

Answer 12

appendicectomy is curative

if untreated it can be life threatening

diagnosis is very difficult in the very young, elderly and in pregnancy - mobidity nad mortality in these groups are higher