Colorectal

Question 1

what causes acute appendicitis

Answer 1

change in diet — decreased dietary fibre, increased refined carbs

bacterial infection — sec to obstruction of appendiceal lumen
faecoliths (most common in adults)
lymphoid hyperplasia (most common in children)
following viral illness, or due to inflammatory diseases

other less common causes
parasitic worms
TB
tumour of caecum or appendix

Question 2

typical presentation of acute appendicitis

Answer 2

symptoms (Hx)
anorexia
abdominal pain — intense + localised — starting in umbilicus then to RIF
N&V
fever

signs (exam)
McBurney’s Point — 1/3 way from ASIS to umbilics
signs of local peritonism — rebound tenderness, gaurding
rovsing sign — RIF pain w deep palpation of LIF
psoas sign — RIF pain w passive right hip flexion
(if retrocaecal appendix)
obturator sign — RIF pain w internal rotation of flexed right hip
cough sign — RIF pain on coughing (due to peritonism)

Question 3

what Ix to order for suspected appendicitis

Answer 3

bloods
FB — raised total white
U&Es

CTAP — enlarged appendix, target sign (thickened appendix wall w enancement), periappendiceal fat stranding

r/o alternatives
urine dipstick
pregnancy test
blood cultures
ECG
LFTs

Question 4

what scoring system do we use in acute appendix to guide management?

Answer 4

Alvarado score
to help determine if further imaging is required or to go straight to surgical consult

criteria — MANTTRLS
symptoms
M: migratory RIF pain – 1
A: anorexia — 1
N: Nausea and/or vomiting — 1

signs
T: tenderness (RIF) — 2
T: temperature (>37.3) — 1
R: rebound tenderness — 1

labs
L: leukocytosis >10,000 — 2
S: left shift of neutrophils — 1

interpretation
max: 10 pts
3 or less = unlikely to be appendicitis
4-6 = CT scan
7 or more = surgical consult
male = appendectomy
female = diagnostic laparoscopy

Question 5

what Tx for acute appendicitis

Answer 5

NBM + IV hydration
correct any electrolyte abnormalities

symptomatic relief: antiemetics + analgesia

open or laparoscopic appendectomy

but if presents late or compliated appendicitis = Ochsner Sherren regime
eg. appendiceal abscess or phlegmon
Abx only as long as haemodynamically stable + non-peritonitic

Question 6

complications of acute appendicitis

Answer 6

perforation —- localised vs generalised
RIF mass —- if densely adherent to caecum & omentum?? ie phlegmon?
RIF abscess —- perforated retrocaecal appendix
pelvic abscess — perforated pelvic appendix