Appendicitis and Diverticular Disease Flashcards
What is the typical appendicitis patient?
Male, 10-20 year old
How might someone with appendicitis present (classic presentation - 50%)?
- Central abdominal pain that migrates to RIF
- Pain worse on moving, coughing, driving over bumpy roads (peritonism)
- Associated with nausea, vomiting, diarrhoea, anorexia
- Low grade fever
Why is appendicitis very severe in young children?
The omentum is not as fully developed and therefore cannot encapsulate infected tissue effectively so there is a higher risk of mortality
What are 5 examination findings in appendicitis?
1) Guarding
2) Rebound tenderness
3) Percussion tenderness
4) Rovsing sign positive
5) Psoas sign positive
Using what is a diagnosis of appendicitis made?
History, examination, supported by bloods and imaging
What blood test results tend to indicate appendicitis?
Elevated WCC and/or CRP
How many patients with acute appendicitis have perforation?
13-20%
What are causes of appendicitis?
1) Faecoliths
2) Foreign bodies
3) Malignancy
4) Lymphoid hyperplasia during infection
5) Genetic
What happens in appendicitis?
1) Luminal obstruction blocks escape of mucosal secretions
2) Increase in pressure causes engorgement and stasis
3) Necrosis and peforation
When would you do investigations in suspected appendicitis?
To exclude other pathology (and support diagnosis)
What tests would you always do in pre-menopausal women and why?
Pregnancy test and urine dip to exclude kidney-ureter-bladder infection and ectopic pregnancy
With what normal blood test results is appendicitis much less likely?
- CRP
- ECC
- Granulocyte count
- Proportion of polymorphonuclear cells
What imaging technique is best used in appendicitis?
CT with contrast
If CT is contraindicated e.g. pregnancy/young people what are alternative imaging techniques to use in acute appendicitis?
Ultrasound/MRI
What would you see in an uncomplicated acute appendicitis on a CTAP?
- Retrocaecal medial origin inflamed appendix
- Oedematous proximal component with tip extending superiorly and laterally, along right psoas
- No associated collection or pneumoperitoneum
What would you see in a colonoscopy in appendicitis?
The appendices orifice in the caecum will be yellow and covered in pus
What surgery is done to treat appendicitis?
Laparoscopic appendicectomy
What is diverticular disease?
The formation of sac-like protrusions of mucosa through the muscular colonic wall (leads to infection, bleeding, diverticular stricture) - common
What is diverticular disease associated with and why?
Low fibre diet
- Lowers stool bulk
- Increases transit time and intra luminal pressure
What happens to colonic muscle in diverticular disease?
It is hypertrophied
What is diverticulosis?
Presence of diverticula without symptoms
What happens to the patient in diverticular disease?
The diverticula cause intermittent lower abdominal pain, without inflammation or infection
What is diverticulitis?
When the diverticula become infected and/or inflamed, causing marked lower abdominal pain, fever and general malaise
What is complicated diverticulitis?
Diverticulitis accompanied by the formation of an abscess, perforation or fistula
What is the presentation of someone with diverticular disease?
- Intermittent lower abdominal pain
- Change in bowel habit
- 15% of people have abrupt, painless PR bleeding
What are possible complications of diverticulitis?
- Development of an abscess or fistula
- Perforation/peritonitis
- Intestinal obstruction
- Dysuria/frequency
What are the signs and symptoms of a colovesicle fistula?
- Pneumaturia (bubbles on micturition)
- Faecaluria (faecal matters in urine)
- Dysuria
- Haematuria
What is the Hinchey classification used for?
Classification of stages of diverticular disease
How do you treat stage I diverticular disease?
Antibiotics alone (7 day course)
How do you treat stage II diverticular disease?
Percutaneous drainage with antibiotic cover
How do you treat stage III diverticular disease?
Drainage, laparoscopic lavage with antibiotic cover
How do you treat stage IV diverticular disease?
Hartmann’s procedure
What is Hartmann’s procedure used to treat?
- Peritonitis
- IBD
- Diverticular inflammatory mass/abscess/fistula, diverticular perforation/ haemorrhage
- Sigmoid carcinoma - obstruction, perforation
- Sigmoid volvulus
- Colitis
- Massive colonic haemorrhage
Describe Hartmann’s procedure
- Resect pathology in sigmoid colon
- End colostomy and closure of rectal stump
