Appendicitis and Peritonitis

Question 1

Pathophysiology of appendicitis

Answer 1

1. lymphoid hyperplasia or a faecolith cause direct luminal obstruction
2. gut organisms invade the appendix wall → inflammation
3. leads to oedema, ischaemia +/- perforation

Question 2

How does appendicitis present?

Answer 2

1. Abdominal pain
2. Tenderness in McBurney’s point
3. Loss of appetite (anorexia)
4. Nausea and vomiting

Question 3

What is the location of McBurney’s point and what is its significance?

Answer 3

Located ⅓ of the distance from the ASIS to the umbilicus

Pain in appendicitis typically starts at the umbilicus and migrates towards McBurney’s point (central to RIF)

Question 4

Features of appendicitis on examination

Answer 4

1. Rovsing’s sign
2. Guarding on abdominal palpation
3. Rebound tenderness
4. Percussion tenderness

Question 5

What is Rovsing’s sign?

Answer 5

Palpation of the left iliac fossa causes pain in the RIF

Question 6

What is rebound and percussion tenderness

What do these indicate in suspected appendicitis?

Answer 6

1. Rebound: increased pain when quickly releasing pressure on RIF
2. Percussion: pain on percussing abdomen

Both suggest peritonitis, caused by a ruptured appendix

Question 7

Why is appendicitis and medical emergency?

Answer 7

Can quickly proceed to gangrene and rupture

if it ruptures, it releases faecal content and infective material into the abdomen → peritonitis

Question 8

How is appendicitis diagnosed?

Answer 8

Clinical presentation and raised inflammatory markers

CT scan to confirm diagnosis

Question 9

What scoring system exists for appendicitis?

Answer 9

Alvarado

7+ out of 10 indicates appendicitis]

Question 10

List 4 key differentials for appendicitis

Answer 10

1. Ectopic Pregnancy
2. Ovarian Cysts
3. Meckel’s Diverticulum
4. Mesenteric Adenitis
5. Appendix Mass

Question 11

Management of appendicitis?

Answer 11

Appendicectomy

Question 12

List 3 complications of untreated appendicitis

Answer 12

1. Local abscess
2. Perforation
3. Gangrene

Question 13

List 4 complications of an appendectomy?

Answer 13

1. Bleeding, infection, pain and scars
2. Damage to bowel, bladder or other organs
3. Removal of a normal appendix
4. Anaesthetic risks
5. VTE or PE

Question 14

What are the 2 main categories of peritonitis?

Answer 14

1. Spontaneous bacterial peritonitis
2. Secondary peritonitis (ie. perforation of an organ)

Question 15

List 4 causes of peritonitis

Answer 15

1. Boerhaave syndrome
2. Perforated duodenal/gastric ulcer
3. Perforation 2^o to appendicitis, diverticulitis, IBD
4. Spontaneous bacterial peritonitis

Question 16

What is the key manifestation of peritonitis

Answer 16

Acute abdominal pain

Question 17

List 4 signs of peritonitis on examination

Answer 17

1. Abdominal rigidity / involuntary abdominal guarding
2. Rebound tenderness
3. Fever, vomiting, tachycardia and hypotension

Question 18

SBP most commonly occurs in which patients?

Answer 18

Patients with ascites secondary to liver cirrhosis

Question 19

List 3 features of SBP

Answer 19

1. ascites
2. abdominal pain
3. fever.

Question 20

How is a diagnosis of SBP made?

Answer 20

Paracentesis: neutrophil count > 250 cells/ul

Question 21

Most common causative organism on ascitic fluid culture in SBP?

Answer 21

E. coli

Question 22

Management of SBP?

Answer 22

IV cefotaxime

Question 23

In patients with ascites, who is antibiotic prophylaxis offered too?

Answer 23

1. Previous episode of SBP
2. 2. Fluid protein <15 g/l and either a Child-Pugh score of at least 9 or hepatorenal syndrome

Question 24

What organism is the most common cause of peritonitis in Peritoneal dialysis?

Answer 24

Coagulase-negative staphylococci ie. Staph epidermidis

Question 25

Most worrying complication of peritonitis?

Answer 25

Sepsis