Appendicitis pt.1

Question 1

What is the most common cause of urgent abdominal surgery?

Answer 1

Appendicitis

Question 2

How many people will get appendicitis in their life?

Answer 2

Approximately 9% of men and 7% of women will experience an episode during their lifetime

Question 3

Appendicitis age

Answer 3

• Can affect any age
• Appendicitis occurs most
  commonly in 10- to 19-year-olds; however, the average age at diagnosis
  appears to be gradually increasing
• Overall, 70% of patients are
  <30 years old, and most are men
• Uncommon under the age of 4 and over the age of 80

Question 4

What is a complication with appendicitis that leads to increased morbidity and mortality?

Answer 4

• One of the more common complications and most important causes of excess morbidity and mortality is perforation, whether it is contained and localized or unconstrained within the peritoneal cavity
• This can lead to abscess formation, generalized peritonitis, sepsis, and intra-abdominal adhesions

Question 5

How many patients with appendicitis will present with evidence of perforation?

Answer 5

Approximately 20% of all patients will present with evidence of perforation, but the percentage risk is much higher in patients <5 or >65 years of age.

Question 6

Etiology of appendicitis

Answer 6

• Although not proven, obstruction of the appendiceal lumen is believed to be an important step in the development of appendicitis— at least in about 50% of cases
• Faecolith (a hard mass of faecal matter) or appendicoliths, normal stool, or lymphoid hyperplasia (during an infection) are the main causes for obstruction

Question 7

Pathophysiology of appendicitis

Answer 7

• The lumen distal to the obstruction starts to fill with mucus and acts as a closed-loop obstruction.
• This leads to distension and an increase in intraluminal and intramural pressure. - As the condition progresses, the resident bacteria in the appendix rapidly multiply.
• Distension of the lumen of the appendix causes reflex anorexia, nausea and vomiting, and visceral pain.
• As the pressure of the lumen exceeds the venous pressure, the small venules and capillaries become thrombosed but arterioles remain open, which leads to engorgement and congestion of the appendix. The inflammatory process soon involves the serosa of the appendix, hence the parietal peritoneum in the region, which causes classic right lower quadrant pain, at McBurney’s point.
• Once the small arterioles are thrombosed, the anti-mesenteric border becomes ischaemic, and infarction and perforation ensue.
• Bacteria leak out through the dying wall and pus forms (suppuration) within and around the appendix.
• Perforations are usually seen just beyond the obstruction rather than at the tip of the appendix

Question 8

Genetics and appendicitis

Answer 8

A positive family history is associated with a nearly three-fold increased risk of appendicitis

Question 9

What can appendicitis be divided into?

Answer 9

Appendicitis may be uncomplicated (non-perforating) or complicated (perforating or gangrenous)

Question 10

When should appendicitis be added in the differential in a patient?

Answer 10

Appendicitis should be included in the differential diagnosis of abdominal pain for every patient in any age group unless it is certain that the organ has been previously removed

Question 11

What is the appendix?

Answer 11

The appendix is a narrow, blind-ending tube, usually 6–10cm long in the adult

Question 12

Appendix anatomy

Answer 12

• It joins the posteromedial wall of the caecum below the ileocaecal junction
• It usually lies in the right iliac fossa but its distal end may occupy one of several positions
• In clinical practice, the tip is most commonly (65%) retrocaecal (behind the caecum, anterior to iliacus and psoas major), or pelvic (30%) (close to the right uterine tube and ovary in females).
• Other positions include subcaecal (2%), and pre- or post-ileal (1%)(anterior or posterior to the terminal ileum, respectively)

Question 13

Surface anatomy appendix

Answer 13

The surface marking for the base of the appendix has traditionally been described by McBurney’s point (two-thirds of the way along a line between the umbilicus and right anterior superior iliac spine) but its position is variable and is affected by posture, caecal distension and other factors

Question 14

What can influence how a patient presents with appendicitis?

Answer 14

• The appendix’s anatomic location, which varies, may directly influence
  how the patient presents.
• Where the appendix can be “found”
  ranges from local differences in how the appendiceal body and tip
  lie relative to its attachment to the cecum to where the appendix is actually situated in the peritoneal cavity—for
  example, from its typical location in the right lower quadrant, to the
  pelvis, right flank, right upper quadrant (as may be observed during
  pregnancy), or even the left side of the abdomen for patients with malrotation
  or who have severely redundant colons

Question 15

Classic history of a patient with appendicitis

Answer 15

• Nonspecific complaints occur first.
• Patients may notice changes in bowel habits or malaise and vague,
  perhaps intermittent, crampy abdominal pain in the epigastric or periumbilical
  region.
• The pain subsequently migrates to the right lower quadrant over 12–24 h, where it is sharper and can be definitively localized as transmural inflammation when the appendix irritates the parietal peritoneum.
• Parietal peritoneal irritation may be associated with local muscle rigidity and stiffness.
• Patients with appendicitis will most
  often observe that their nausea, if present, followed the development of
  abdominal pain, which can help distinguish them from patients with
  gastroenteritis, for example, in whom nausea occurs first.
• Emesis, if present, also occurs after the onset of pain and is typically mild and
  scant.
• Anorexia is so common that the diagnosis of appendicitis
  should be questioned in its absence.

Question 16

Symptoms of appendicitis

Answer 16

Question 17

Signs of appendicitis

Question 18

Abdominal pain in appendicitis

Answer 18

• Abdominal pain is the main presenting symptom.
• Typically starts as central abdominal pain, and 1 to 12 hours later it moves to the right lower quadrant as the inflammation progresses.
• Usually constant with intermittent cramps
• Patients with appendicitis will be found to lie quite still to avoid peritoneal irritation caused by movement, and some will report discomfort caused by a bumpy car ride on the way to the hospital or clinic, coughing, sneezing, or other actions that replicate a Valsalva maneuver

Question 19

Location of pain in the abdomen in appendicitis

Answer 19

Varies, and consequently so does the location of the pain.[25]
- Classically,
maximal tenderness is identified where the appendix is most often located—in the right lower quadrant at or near McBurney’s point
- A retrocaecal appendix can cause flank or back pain
- A retroileal appendix can cause testicular pain due to irritation of the spermatic artery or ureter
- A pelvic appendix can cause suprapubic pain
- A paracolic long appendix with tip inflammation in the right upper quadrant may cause pain in this region.

Question 20

What are signs that can be elicited in a patient that are associated with appendicitis

Answer 20

Rovsing’s sign, Obturator sign, Psoas sign

Question 21

What is Rovsing’s sign?

Answer 21

Gentle pressure in the left lower quadrant may elicit pain in the right lower quadrant if the appendix is located there

Question 22

Heart rate and fever in appendicitis

Answer 22

• Patients with simple appendicitis normally only appear mildly ill
  with a pulse and temperature that are usually only slightly above normal.
• The provider should be concerned about other disease processes
  beside appendicitis or the presence of complications such as perforation,
  phlegmon, or abscess formation if the temperature is >38.3°C
  (~101°F) and if there are rigors.

Question 23

What is Obturator sign

Answer 23

• RLQ Pain on passive internal rotation of the hip when the right knee is flexed.
• It is present when the inflamed appendix is in contact with the obturator internus muscle

Question 24

Psoas sign

Answer 24

• Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed backward.
• RLQ Pain may indicate an inflamed appendix overlying the psoas muscle.
• OR, passive extension of the right thigh with the person in the left lateral position elicits pain in the right lower quadrant

Question 25

Origin of pain in the appendicitis

Answer 25

• Visceral afferent fibres within adjacent nerves are responsible for the initial symptoms of acute appendicitis (colicky pain with or without emesis) that are caused by distension and inflammation of the appendix.
• Abdominal pain from appendicitis is poorly localized initially and referred to the umbilical region of the abdomen, consistent with the midgut derivation of the appendix.
• It is not until parietal peritoneum adjacent to the appendix becomes involved in the inflammatory process that somatic nociceptors are stimulated, resulting in localization of pain to the right iliac fossa.