Appendicitis and Diverticular Disease

Question 1

What is the typical appendicitis patient?

Answer 1

Male, 10-20 year old

Question 2

How might someone with appendicitis present (classic presentation - 50%)?

Answer 2

• 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

Question 3

Why is appendicitis very severe in young children?

Answer 3

The omentum is not as fully developed and therefore cannot encapsulate infected tissue effectively so there is a higher risk of mortality

Question 4

What are 5 examination findings in appendicitis?

Answer 4

1) Guarding
2) Rebound tenderness
3) Percussion tenderness
4) Rovsing sign positive
5) Psoas sign positive

Question 5

Using what is a diagnosis of appendicitis made?

Answer 5

History, examination, supported by bloods and imaging

Question 6

What blood test results tend to indicate appendicitis?

Answer 6

Elevated WCC and/or CRP

Question 7

How many patients with acute appendicitis have perforation?

Answer 7

13-20%

Question 8

What are causes of appendicitis?

Answer 8

1) Faecoliths
2) Foreign bodies
3) Malignancy
4) Lymphoid hyperplasia during infection
5) Genetic

Question 9

What happens in appendicitis?

Answer 9

1) Luminal obstruction blocks escape of mucosal secretions
2) Increase in pressure causes engorgement and stasis
3) Necrosis and peforation

Question 10

When would you do investigations in suspected appendicitis?

Answer 10

To exclude other pathology (and support diagnosis)

Question 11

What tests would you always do in pre-menopausal women and why?

Answer 11

Pregnancy test and urine dip to exclude kidney-ureter-bladder infection and ectopic pregnancy

Question 12

With what normal blood test results is appendicitis much less likely?

Answer 12

• CRP
• ECC
• Granulocyte count
• Proportion of polymorphonuclear cells

Question 13

What imaging technique is best used in appendicitis?

Answer 13

CT with contrast

Question 14

If CT is contraindicated e.g. pregnancy/young people what are alternative imaging techniques to use in acute appendicitis?

Answer 14

Ultrasound/MRI

Question 15

What would you see in an uncomplicated acute appendicitis on a CTAP?

Answer 15

• Retrocaecal medial origin inflamed appendix
• Oedematous proximal component with tip extending superiorly and laterally, along right psoas
• No associated collection or pneumoperitoneum

Question 16

What would you see in a colonoscopy in appendicitis?

Answer 16

The appendices orifice in the caecum will be yellow and covered in pus

Question 17

What surgery is done to treat appendicitis?

Answer 17

Laparoscopic appendicectomy

Question 18

What is diverticular disease?

Answer 18

The formation of sac-like protrusions of mucosa through the muscular colonic wall (leads to infection, bleeding, diverticular stricture) - common

Question 19

What is diverticular disease associated with and why?

Answer 19

Low fibre diet

• Lowers stool bulk
• Increases transit time and intra luminal pressure

Question 20

What happens to colonic muscle in diverticular disease?

Answer 20

It is hypertrophied

Question 21

What is diverticulosis?

Answer 21

Presence of diverticula without symptoms

Question 22

What happens to the patient in diverticular disease?

Answer 22

The diverticula cause intermittent lower abdominal pain, without inflammation or infection

Question 23

What is diverticulitis?

Answer 23

When the diverticula become infected and/or inflamed, causing marked lower abdominal pain, fever and general malaise

Question 24

What is complicated diverticulitis?

Answer 24

Diverticulitis accompanied by the formation of an abscess, perforation or fistula

Question 25

What is the presentation of someone with diverticular disease?

Answer 25

• Intermittent lower abdominal pain
• Change in bowel habit
• 15% of people have abrupt, painless PR bleeding

Question 26

What are possible complications of diverticulitis?

Answer 26

• Development of an abscess or fistula
• Perforation/peritonitis
• Intestinal obstruction
• Dysuria/frequency

Question 27

What are the signs and symptoms of a colovesicle fistula?

Answer 27

• Pneumaturia (bubbles on micturition)
• Faecaluria (faecal matters in urine)
• Dysuria
• Haematuria

Question 28

What is the Hinchey classification used for?

Answer 28

Classification of stages of diverticular disease

Question 29

How do you treat stage I diverticular disease?

Answer 29

Antibiotics alone (7 day course)

Question 30

How do you treat stage II diverticular disease?

Answer 30

Percutaneous drainage with antibiotic cover

Question 31

How do you treat stage III diverticular disease?

Answer 31

Drainage, laparoscopic lavage with antibiotic cover

Question 32

How do you treat stage IV diverticular disease?

Answer 32

Hartmann’s procedure

Question 33

What is Hartmann’s procedure used to treat?

Answer 33

• Peritonitis
• IBD
• Diverticular inflammatory mass/abscess/fistula, diverticular perforation/ haemorrhage
• Sigmoid carcinoma - obstruction, perforation
• Sigmoid volvulus
• Colitis
• Massive colonic haemorrhage

Question 34

Describe Hartmann’s procedure

Answer 34

• Resect pathology in sigmoid colon

- End colostomy and closure of rectal stump