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Year 3 > Appendicitis (GI) > Flashcards

Appendicitis (GI) Flashcards

1
Q

Define acute appendicitis.

A

Acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix (by faecolith, normal stool, infective agents, or lymphoid hyperplasia)

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2
Q

Describe the aetiology of acute appendicitis.

A
  • obstruction of the lumen of the appendix caused normally by faecolith (hard mass of faecal matter), normal stool, infective agents or lymphoid hyperplasia
  • lumen distal to obstruction starts to fill with mucus –> distension and increase in intraluminal and intramural Pa
  • resident bacteria in appendix (Bacteroides fragilis and Escherichia coli) rapidly multiply
  • Pa of lumen>venous Pa = small venules and capillaries become thrombosed but arterioles remain open –> engorgement and congestion of appendix
  • inflammation progresses to involve outer serosa layer = parietal peritoneum
  • anti-mesenteric border becomes ischaemic –> infarction and perforation
  • bacteria leak out of infarcted wall = pus collects within and around appendix
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3
Q

Describe the epidemiology of acute appendicitis. (2)

A
  • M>F
  • 10-19 years old
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4
Q

How does appendicitis typically present?

A

Acute abdominal pain starting in mid-abdomen and later localising to RLQ, associated with fever, anorexia, N&V and neutrophilia

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5
Q

What are the signs and symptoms of acute appendicitis? (8)

A
  • abdominal pain (starts peri-umbilical then moves to RLQ + worse on moving or coughing)
  • anorexia
  • nausea and vomiting
  • mild pyrexia (37.5-38.5C)
  • RLQ tenderness (McBurney point)
  • diarrhoea / constipation
  • tense, rigid abdomen (peritonitis - could indicate perforated appendix)
  • hypotension and tachycardia
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6
Q

What might you see on examination in acute appendicitis? (8)

A
  • palpable mass (peri-appendiceal abscess caused by perforated appendix)
  • low-grade pyrexia
  • flushed face and a fetor (strong, foul smell)
  • reduced bowel sounds (sign of perforated appendix)
  • Rovsing’s sign
  • psoas sign
  • obturator sign
  • Blumberg sign
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7
Q

Where is McBurney’s point?

A

1/3 of the distance laterally from umbilicus towards right ASIS

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8
Q

What is Rovsing’s sign?

A

Palpation in LIF causing pain in RIF

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9
Q

What is the psoas sign?

A
  • RIF pain on extending hip if retrocaecal appendix (so hip appears flexed)
  • could also be a sign of psoas abscess = CT abdomen should be done
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10
Q

What is the obturator sign?

A

Pain on internal rotation of a flexed thigh

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11
Q

What is the Blumberg sign?

A

Rebound tenderness in RLQ

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12
Q

What could a high fever indicate instead of acute appendicitis?

A

Mesenteric adenitis

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13
Q

What type of pain can a retrocaecal appendix cause?

A

Flank or back pain

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14
Q

What type of pain can a retroileal appendix cause?

A

Testicular pain due to irritation of the spermatic artery or ureter

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15
Q

What type of pain can a pelvic appendix cause?

A

Suprapubic pain (possibly flexed right hip and loose mucus stool)

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16
Q

What are some risk factors for acute appendicitis?

A
  • M > F
  • age 10-30 years
  • Fx
  • white
17
Q

What are the first-line investigations for acute appendicitis? (4)

A
  • FBC
  • CRP
  • abdominal ultrasound
  • contrast-enhanced abdominal CT
18
Q

What test is done to all women of childbearing age presenting with acute appendicitis?

A

Bedside pregnancy test to exclude pregnancy/ectopic pregnancy before any other investigations in women with LIF/RIF pain

19
Q

What is the key FBC finding in acute appendicitis? (In adults vs children)

A
  • leukocytosis (10-18 x 10^9/L) with neutrophilia is present in 80-90% of adults with appendicitis
  • leukocytosis (>16 x 10^9/L) and elevated CRP level (<10mg/L) are strong predictive factors for appendicitis in children
20
Q

What is CRP like in acute appendicitis?

A

Elevated

21
Q

When is urine analysis useful for acute appendicitis?

A
  • useful to exclude pregnancy in women, renal colic and UTI
  • may show mild leukocytosis but no nitrites in appendicitis patient
22
Q

What forms of imaging do we do for acute appendicitis?

A
  • abdominal US - useful in females with suspected appendicitis to rule out ovarian pathology
    • presence of free fluid should raise suspicion - first line in pregnant women
    • in pregnant women if US inconclusive –> MRI
  • if US inconclusive or malignancy suspected –> contrast-enhanced abdominal CT
  • imaging not needed for thin, male patients with high likelihood of appendicitis - may be diagnosed clinically
23
Q

What might you see on imaging for acute appendicitis?

A
  • aperistaltic or non-compressible structure with outer diameter >6mm
  • abnormal appendix (diameter >6mm) identified or calcified appendicolith seen in association with peri-appendiceal inflammation
24
Q

When do we do erect CXR for acute appendicitis?

A

If perforation suspected

25
Q

What diagnostic criteria is used for acute appendicitis?

A
  • Appendicitis Inflammatory Response (AIR) or Adult Appendicitis Score (AAS) to determine risk
  • Alvarado score - used to rule out appendicitis but do not use to positively confirm a diagnosis (not specific enough)
26
Q

What is the Alvarado score diagnostic criteria for acute appendicitis?

A

MANTRELS

  • migration of pain to RLQ (1)
  • anorexia (1)
  • nausea and/or vomiting (1)
  • tenderness in RLQ (2)
  • rebound pain (1)
  • elevated temperature >37.3C (1)
  • leukocytosis (2)
  • shift left of neutrophils (1)

Likelihood:

  • </=4 low
  • 5-6 moderate
  • > /=7 high
27
Q

What are some differential diagnoses for acute appendicitis?

A
  • acute mesenteric adenitis (children, Hx URTI, lymphadenopathy)
  • viral gastroenteritis
  • Meckel’s diverticulitis
  • intussusception (sudden colicky pain)
  • Crohn’s disease
  • peptic ulcer disease
  • right-sided ureteric stone (colicky severe pain from loin to groin)
  • cholecystitis (RUQ)
  • UTI (suprapubic pain)
  • primary peritonitis (abrupt pain, distension, rebound tenderness)
  • pelvic inflammatory disease (bilateral LQ tenderness, purulent discharge from cervical os)
  • ruptured Graafian follicle
  • ectopic pregnancy
  • ovarian torsion (female RLQ pain)
28
Q

What is the standard first choice treatment for uncomplicated appendicitis?

A

Laparoscopic appendicectomy within 24 hours of diagnosis

29
Q

What is 1st line treatment for uncomplicated appendicitis (fit for surgery or with appendicolith)?

A
  • supportive treatment:
    • NBM (IV maintenance fluids) if surgery considered
    • analgesia e.g. paracetamol, morphine
    • prophylactic Abx before surgery - cefuroxime and metronidazole
  • PLUS appendicectomy (laparoscopic > open surgery)
30
Q

What is 1st line treatment for uncomplicated appendicitis (unfit for surgery and without appendicolith)?

A
  • supportive treatment (paracetamol/morphine)
  • antibiotics (ceftriaxone/cefotaxime + metronidazole OR amoxicillin+clavulanate)
  • (in children, if conservative management fails do appendicectomy)
31
Q

What is 1st line treatment for complicated appendicitis (with free perforation)?

A
  • supportive treatment
    • suspected perforation + signs of shock/sepsis: fluid challenge to correct hypotension and tachycardia
    • NBM + IV fluids
    • analgesia
    • prophylactic Abx
  • emergency appendicectomy
  • postoperative Abx (amoxicillin + metronidazole)
32
Q

What is 1st and 2nd line treatment for complicated appendicitis (stable with abscess or phlegmon)?

A

1st line:

  • supportive treatment (NBM, IV fluids, analgesia, prophylactic Abx)
  • laparoscopic appendicectomy
  • postoperative Abx (amoxicillin + metronidazole)

2nd line:

  • supportive treatment (analgesia)
  • Abx and percutaneous image-guided drainage (amoxicillin + metronidazole)
  • consider interval appendicectomy (delayed)
33
Q

What are some complications of appendicitis? (8)

A
  • perforation - signs of shock/sepsis
  • generalised peritonitis - tense, distended abdomen with guarding/rigidity and absent bowel sounds
  • appendicular mass
  • appendicular abscess - tender LQ mass, swinging fever leukocytosis
  • surgical wound infection
  • appendiceal malignancy
  • stump appendicitis
  • pelvic abscess post-appendicectomy
34
Q

What can an appendicitis perforation lead to?

A

Peritonitis

35
Q

What are the symptoms of a pelvic abscess post-appendicectomy, and how do we manage this? (4 + 1)

A
  • pain
  • fever
  • sweats
  • mucus diarrhoea
  • management: drainage
36
Q

Describe the prognosis of acute appendicitis.

A

Good if patients are treated in a timely fashion - laparoscopic appendicectomy decreases incidence of overall complications

Year 3 (22 decks)

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