FN: Acute appendicitis

Question 1

Definition

Answer 1

Inflammation of the vermiform apendix ranging from oedema to ischaemia necrosis and perforation

Question 2

Epi

Answer 2

Incidence: 6% lifetime incidence, commonest surgical emergency
Age: rare

Question 3

Pathogeneis:

Answer 3

1. Obstruction of the appendic

2. Gut organisms

Question 4

Obstruction

Answer 4

1. feacolith most commonly
2. Lymphoid hyperplasia post-infection
3. Tumour (e.g. caecal Ca, carcinoid)
4. Worms (e.g. ascaris lumbicoides, schisto)

Question 5

Gut infection and compications

Answer 5

Infection behind obstruction
Oedema + ischaemia + necrosis and perforation
1. Peritonitis
2. Abcess
3. Appendix mass

Question 6

Signs

Answer 6

Low-grade pyrexiaL 37.5-38.5
raised HR, shallow breathing
Foetor oris
Guarding and tenderness @ Mc burneys point +cough/percussion tenderness
Apppendix mass may be palpable
Pain PR suggest pelvic appendix

Question 7

Special signs

Answer 7

Rovsings sign
Psoas sign
Bope sign

Question 8

Rovsings

Answer 8

Pressure in LIF = more pain in RIF

Question 9

Psoas sign

Answer 9

Pain on extending the hip: retrocaecal appendix

Question 10

Cope sign

Answer 10

Flexion + internal rotation of R hip - pain: appendix lying close to obturator internus

Question 11

Differential: surgical

Answer 11

Cholecysitis
Diverticulitis
Meckels diverticulitis

Question 12

Differential: gynae

Answer 12

Cyst accident: torsion, rupture, haemorrhage
Salpingitis/PID
Ruptured ectopic

Question 13

Differential: Medical

Answer 13

Mesenteric adenitis
UTI
Crohns

Question 14

Investigations

Answer 14

Bloods: FBC, CRP, amylase, G+S, clotting

Question 15

Urine shows

Answer 15

Sterile pyuria, may indicate bladder irritation
Ketones: anorexia
Exclude UTI
Beta-HCG

Question 16

Imaging

Answer 16

US: exlcude gynae pah, visulaise inflamed appendix
CT: can be used

Question 17

Diagnostic

Answer 17

Lap

Question 18

Management

Answer 18

Fluids
Abx: cef 1.5g + met 500g IV TDS
analgesia
Certain Dx: appendicectomy (open or lap)
Uncertain Dx: Active observation

Question 19

complications

Answer 19

1. inflamed appendix with adherent covering of omentum and smll bowel
   Dx: US or CT
   Management
2. Initially: ABx + NBM
3. Resolution of mass - interval appendicectomy
4. Exlcude a colonic tumour: colonoscopy

Question 20

appendix abscess

Answer 20

results if appendic mass doesnt resolve

Mass enlarges, pt. deteriorates

Question 21

Appendix abscess management

Answer 21

Abx + NBM
Ct- guided percutaneous drainage
If no resolution, surgery may involve right hemicolectomy

Question 22

Perforation

Answer 22

commoner if faecolith present and in young children (as Dx is often delayed)
Deteriorating with peritonitis