Appendix

Question 1

Appendicitis - aetiology

Answer 1

> Obstruction of lumen with faecolith

> Bacterial
Viral
Parasites

Question 2

Appendicitis - pathology

Answer 2

> Lumen may or may not be occluded
> Mucosal inflammation
> Lymphoid hyperplasia
> Obstruction
> Build-up of mucous and exudate
> Venous obstruction
> Ischaemia
> Perforation 

–> Suppuration of pus

Peritonitis can be fatal

Question 3

Symptoms

Answer 3

> Central pain that migrates to RIF
> Anorexia
> Nausea
> One or two vomits
> May not have moved bowels
> Pelvic - vaguer pain localisation
> Rectal tenderness

Question 4

Signs

Answer 4

> Mild pyrexia
> Mild tachycardia
> Localised pain in RIF
> Guarding
> Rebound

Question 5

Special cases of appendix location

Answer 5

> Retrocoecal appendix
> Pelvic appendix 
--- diarrhoea
> Postileal
---rare, diarrhoea, vomiting

Question 6

Which operation is most feasible in a pregnancy with appendicitis?

Answer 6

Laporotomy

Question 7

Differential - children

Answer 7

> Gastroenteritis
> Mesenteric adenitis
> Meckels diverticulum
> Intususseption
> Henoch-schonlein purpurn
> Lobar pneumonia

Question 8

Differential - adults and elderly

Answer 8

Adults//

• terminal ileitis
• ureteric colic
• acute pyelonephritis
• perforated ulcer
• pancreatitis
• rectus sheath haematoma

Elderly//

• sigmoid diverticulitis
• instestinal obstruction
• carcinoma of the caecum

Women//

Ectopic pregnancy
ovarian cyst
mittelschmerz (ovulation pain)

Question 9

Appendicitis - investigation

Answer 9

> Ultrasound scan
AXR to exclude other causes
Bloods (CRP, WCC)
Urinalysis

Question 10

Scoring system used?

Answer 10

Alvarado score
“MANTRELS”

Migration of pain
Anorexia
Nausea and vomiting
Tenderness in RLQ
Rebound pain 
Elevated temp
Leukocytosis
Shift of white blood cell count to left

Question 11

Appendicitis - management

Answer 11

> Analgesia
> Antipyretics
> Theatre
> Abx
> Appendicectomy
--- laparoscopic (best
--- convert to open

Question 12

Appendix mass

Answer 12

> Exclude carcinoma 
> Abx first line
> Can operate or not
> Theatre if fails or complications
--- tachy
--- worsening pain
--- increase in size
--- vomiting or copious NG aspirates

Question 13

Appendix abscess

Answer 13

Liquidised

Radiological drains

Question 14

Appendicitis - complications

Answer 14

Pelvic abscess
Wound infection
Intra-abdominal abscess
Ileus
Respiratory
DVT/PE
Portal pyaemia
Faecal fistula
Adhesions
Right sided inguinal hernia

Question 15

Carcinoid tumour of the appendix

Answer 15

Occurs in Crypts of Lieberkuhn

Stains for chromagrannin

Metastatic risk relative to size

< 1 cm = appendicectomy

> 2cm = complete right hemicolectomy