Appendicitis pt.2

Question 1

Appendicitis signs

Answer 1

Question 2

Examination of appendicitis in women

Answer 2

A pelvic examination in women is mandatory to rule out conditions affecting urogynecologic organs that can cause abdominal pain and mimic appendicitis such as pelvic inflammatory
disease, ectopic pregnancy, and ovarian torsion

Question 3

What is the psoas sign

Answer 3

Extending the right hip causes pain along posterolateral back and hip, suggesting retrocecal appendicitis

Question 4

Signs and symptoms of appendicitis in the elderly

Answer 4

• There may be minimal pain or fever; may present with acute confusion or shock
• Nausea, anorexia, and emesis may be
  the predominant complaints.

Question 5

Gender and appendicitis

Answer 5

More common in males

Question 6

Complications of appendicitis

Answer 6

• Usually due to a delay or misdiagnosis of appendicitis
• Perforation – causes peritoneal contamination (can be localized, but more often generalized)
• Pelvic abscess (usually 2° to perforated pelvic appendicitis)
• RIF abscess (usually 2° to perforated retrocaecal appendicitis)
• Sepsis
• Appendix mass – caused by omentum or small bowel adhering to the appendix
• Intra-abdominal adhesions
• Bowel obstruction

Question 7

Differential diagnosis of appendicitis

Answer 7

• Urological: testicular torsion, epididymitis
• Gastrointestinal: diverticulitis, inflammatory bowel disease, obstruction, Meckel’s diverticulum, gastroenteritis, Perforated peptic ulcer
• Renal: ureteric stones, urinary tract infection, pyelonephritis
• Retroperitoneal pathology: Pancreatitis, renal colic
• Gynaecological: ovarian cyst rupture, pelvic inflammatory disease, ectopic pregnancy
• Paediatric: mesenteric adenitis, intussusception
• DKA

Question 8

How is appendicitis diagnosed?

Answer 8

• Clinical diagnosis in most cases
• Imaging and laboratory tests and scoring systems can aid in diagnosis if uncertain and surgery planning

Question 9

Laboratory testing if suspecting appendicitis

Answer 9

• Urinalysis – helps rule out ureteric stones or UTI but leucocytes can be mildly positive in appendicitis (especially if inflamed appendix lies on the bladder)
• Pregnancy test – to exclude ectopic or normal pregnancy
• Capillary blood glucose – vomiting and anorexia can lead to hypoglycaemia, also helps rule out diabetic ketoacidosis which may present similarly
• Bloods: FBC, U/Es ( can be deranged if nausea, vomiting, or diarrhoea are severe), CRP, group and save, clotting, amylase, and LFTs

Question 10

Rule to be remembered in the diagnosis of appendicitis

Answer 10

Remember the rule of 3s:
* Only 3% of patients will have appendicitis with RIF pain, if both WCC
and CRP are normal.
* Also in 3% of patients, CT scan will miss appendicitis

Question 11

WBC in appendicitis

Answer 11

• The white blood cell count is only mildly to moderately elevated in ~70%
  of patients with simple appendicitis (with a leukocytosis of 10,000–
  18,000 cells/μL)
• Neutrophil-predominant leukocytosis is present in 80–90% of people with appendicitis.
• A “left shift” toward immature polymorphonuclear leukocytes is present in >95% of cases.

Question 12

CRP in appendicitis

Answer 12

Raised levels may be present, but normal levels do not exclude a diagnosis of appendicitis.

Question 13

WBC in urine in appendicitis

Answer 13

Be aware that as the appendix often lies in close proximity to the urinary tract, 40% of people with acute appendicitis may have leucocytes in their urine

Question 14

How fast do symptoms develop in appendicitis

Answer 14

There may be a variable length of history of symptoms, which usually develop over 24–48 hours

Question 15

Best symptoms and signs for ruling in appedicitis

Answer 15

Right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best symptoms and signs for ruling in acute appendicitis in adults

Question 16

Appendicitis symptoms in pregnancy

Answer 16

There may be displacement of the appendix by the gravid uterus. In the later stages of pregnancy, may present with right upper quadrant or right flank pain. Nausea and vomiting may be mistaken for pregnancy-related symptoms

Question 17

Imaging in appendicitis

Answer 17

• Not essential to diagnose appendicitis, as it can be a clinical diagnosis. If other diagnoses as likely as appendicitis, imaging can be used as diagnostic adjunct
• Frequently asked to be performed if patient will have surgery
• Plain films of the abdomen are rarely helpful and so are not routinely
  obtained unless the clinician is worried about other conditions such as
  intestinal obstruction, perforated viscus, or ureterolithiasis
• US
• CT imaging (with contrast, unless contraindicated), given its high negative predictive value, may be helpful if the diagnosis is in doubt
• MRI scans are mainly reserved for pregnant women when ultrasound is non-diagnostic

Question 18

Sensitivity and specifity of CT in appendicitis

Answer 18

About 95% for both

Question 19

US in appendicitis

Answer 19

• The effectiveness of ultrasonography as a tool to diagnosis appendicitis
  is highly operator dependent
• Overall sensitivity and specifity of about 80%
• Current practice in many institutions is to first perform ultrasonography and progress to other imaging studies only if
  the findings are equivocal
• USS (pelvis) is indicated in young women of childbearing age to exclude
  gynaecological pathology(1st line imaging), not to diagnose appendicitis. It is therefore
  useless in men
• Useful 1st line imaging in females to rule out gynaecological pathology and in children as it does not involve ionizing radiation
• Not available out of hours, not reliable in patients with significant amount of abdominal fat

Question 20

When to escalate patient with appendicitis

Answer 20

Escalate immediately if:
- Patient is haemodynamically unstable
- 10/10 pain
- Patient looks very unwell
- Involuntary guarding and rigidity

Question 21

CT scanning in appendicitis

Answer 21

• CT is appropriate in adults over the age of 65 or if the diagnosis is
  unclear (such as patients with inflammatory bowel disease) since the
  differential diagnosis is much wider and appendicitis relatively less likely
  above the age of 65.
• CT is the best investigation in suspected appendix mass or abscess.

Question 22

Treatment for appendicitis

Answer 22

• Can be divided into conservative management or operational management
• In the absence of contraindications, most patients who have strongly suggestive medical histories and physical examinations with supportive laboratory findings are candidates for appendectomy.
• Removal of the appendix is the gold standard treatment for uncomplicated appendicitis
• Surgery can be delayed allowing longer active monitoring period in:
  Stable patients admitted overnight, appendix masses, intraperitoneal abscesses
• Establish IV access and rehydrate rapidly if septic.
  -Catheterize and place on a fluid balance chart only if hypotensive or
  septic.

Question 23

Laparoscopic vs open surgery (general)

Answer 23

Laparoscopic and minimally invasive techniques offer less pain, lower incidence of surgical site infection, decreased length of hospital stay, earlier return to work, overall costs, and better quality of life
- In the context of appendicitis, there is a high risk of intraabdominal abscess formation

Question 24

Possible postoperative complications for appendicitis

Answer 24

• The most common postoperative complications are fever and leukocytosis. Continuation of these findings beyond 5 days should raise concern for the presence of an intraabdominal abscess.
• Possible postoperative complications include small bowel obstruction, superficial wound infection, intra-abdominal abscess, stump leakage, and stump appendicitis

Question 25

Non surgical management of appendicitis

Answer 25

• IVF, analgesia, antiemetics
• Primary antibiotic treatment of uncomplicated appendicitis

Question 26

Management of patient with a mass and appendicitis

Answer 26

• Management of those who present with a mass representing a phlegmon or abscess can be more difficult.
• Such patients are best served by treatment with broad-spectrum antibiotics, drainage if there is an abscess >3 cm in diameter, and parenteral fluids and bowel rest if they appear to respond to conservative management.
• The appendix can then be more safely removed 6–12 weeks later when inflammation has
  diminished.

Question 27

Type of operation most often performed for appendicitis

Answer 27

Laparoscopic appendectomy now accounts for the majority of all
appendectomies

Question 28

Failure rate of conservative management in appendicitis

Answer 28

1 of 4 participants given conservative management will require appendectomy within 1 year.

Question 29

Scoring system used in appendicitis

Answer 29

The modified Alvardo scoring system assigns a point value to diagnostic criteria as outlined:
2 points each: tenderness in the right lower quadrant and leukocytosis
1 point each: migratory right lower quadrant pain, rebound tenderness in the right lower quadrant, fever, nausea or vomiting, and anorexia
- The highest score an individual with suspected acute appendicitis can receive is 9 points.
- Higher scores are consistent with a higher probability of acute appendicitis.
- An Alvarado score of 7 points or higher is significantly associated with acute appendicitis

Question 30

Signs and symptoms of perforated or gangrenous appendicitis

Question 31

Additional things to do in a patient with appendicitis aside from testing and diagnosing

Answer 31

• Establish IV access and rehydrate rapidly.
• Catheterize and place on a fluid balance chart only if hypotensive or
  septic.