Appendix Flashcards
What is the appendix?
- It is a blind ending hollow tube that originates from the caecum 2,5 cm away
- It is 8 cm on average
- arterial supply is the ileocolic artery
- nerve supply is the autonomic nervous system
What age does it peak?
Between 10 and 30 years
What is the most accepted postulation about appendicitis?
Lymphoid hyperplasia(swelling of lymphoid tissue), faecoliths that get stuck and causes increased secretions, dehydration and parasites
How does the luminal obstruction come about?
-It arises as a result of the increased mucus which becomes stagnant which leads to bacterial overgrowth which produces pus and increases the luminal pressure . Ischaemia and infarction occurs which leads to perforation and abscess formation locally or becomes generalised peritonitis
What is the clinical presentation of a patient with appendicitis?
- Vague central abdominal pain and nausea and vomiting in 75% of patients
- Anorexia in 90%
- low grade fever 37,8
- The pain then travels to the right iliac fossa(tenderness over Mcburneys point) and becomes constant and worse
- Nausea and vomiting that occurs after the pain
Where is Mcburneys point located?
The intersection of the middle and lateral thirds of an oblique line from the umbilicus to the anterior superior iliac spine
What are the late signs of appendiciis?
Peritonitis with percussion tenderness, muscle guarding, rebound tenderness
Local: abscess or appendix mass
Free perforation: generalised peritonitis and septic shock
In which patients does it occur atypically and why?
- Pregnant- occurs in the RUQ because pregnancy pushes the appendix upwards
- Infants/children- can occur hemiscrotally because the pus can travel down the patent processus vaginalis and can be confused for acute testicular torsion
- Retrocaecal- Presents in the right upper quadrant
- When it is in the pelvis: affecting the bladder and rectum-dysuria and feeling of defecation
Who are the patients that are usually immuno-surpressed and prone to appendicitis?
- old and young
- Diabetes, HIV/AIDS
- Immunosuppressant drugs
What are the signs that we can ellicit on physical exam?
- Rovsings sign: pain in the right inferior flank when we press on the left inferior flank
- Obturators sign: pain with passive internal rotation of the flexed hip (pelvic appendix)
- Dunphy’s sign: increase in the abdominal pain when coughing
- Iliopsoas sign: pain with extension of the right hip(retrocaceal appendix)
What do you find when you do bloods on this patient:
- Leucocytosis(raised white cell count) average of 15 000 and only 10% are normal
- Differential to the left: 75% of neutrophils in 75% of cases
- Raised CRP
What imaging would you do in this particular patient?
- AXR- may only show the faecolith and the right psoas margin may be ill-defined
- Abdominal ultrasound: we can diagnose if we see >2mm in the thickness and >6mm in appendiceal diameter and free fluid
- CT scan: >2mm, >7mm increased diamter of the appendix, presence of a phlegmon/absess/free fluid
What is the differential diagnosis of pain in RIF?
- Gynaecological: ectopic pregnancy, endometriosis, salpingitis, ovarian pathology
- mesenteric adenitis
- Crohns disease, TB , lymphoma,
- Meckels diverticulitis
- Urinary tract infections/stones
- caecal carcinoma
What are the complications with appendicitis?
- perforation: localised(absess)
free perforation(generalised peritonitis)
increased incidence of infertility - Liver abscess
- Septic shock: multi-organ failure
- Pylephlebitis: suppurative thromobophlebitis of the portal venous system
What is the Mx of a patient with appendicitis?
- open or laparoscopic appendicectomy
- Give IV antibiotics that you start preoperatively
- Give IV fluid and analgesia
- If patient is in septic shock then ICU is NB
