Gen Surg: Appendicitis Flashcards
What is acute appendicitis?
https://www.youtube.com/watch?v=r9amif1DQMc
A common surgical emergency that is caused by inflammation of the appendix
What is the pathogenesis of acute appendicitis?
Gut organisms invade the appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or filarial worms. There is inflammation of the vermiform appendix.
This leads to oedema, ischaemic necrosis and perforation.
What is the most common cause of appendicitis?
Faecolith - hard mass of faecal matter
What are main causes of obstruction of the appendix?
- Faecolith
- Normal stool
- Lymphoid hyperplasia
What are the three types of appendicitis?
- Mucosal - mildest form
- Phlegmonous - Slow onset and relatively slow progression
- Necrotic - often due to acute bacterial infeciton with ischaemic necrosis - leads to perforation
What are symptoms of appendicitis?
- Periumbilical pain that moves and localises to to RIF (inflammation of overlying peritoneum). Worse on movement.
- Anorexia (loss of eppetitie for food)
- Constipation (more often)/diarrhoea
What are signs of appendicitis?
- Tachycardia
- Fever (mild)
- Peritonism - guarding, rebound tenderness, percussion tenderness in RIF
- Rovsig’s sign
- Murphy’s Sign
- Psoas sign
- Obturator sign
What is the obturator sign?
Pain on internal rotation of the thigh.
What is the mechanism behind the obturator sign?
The inflamed appendix lies in contact with the obturator internus muscle. When the leg is rotated, the obturator moves and the appendix is stretched and irritated.
What is Mcburney’s point tenderness?
A point of maximum tenderness on palpation located one-third of the distance from the right anterior superior iliac spine to the umbilicus
What condition(s) is Mcburney’s Point associated with?
Appendicitis
What is the mechanism behind the presentation of Mcburney’s point tenderness?
McBurney’s point is said to be the most common surface location of the appendix.
When the appendix becomes inflamed such that it is no longer in the lumen of the bowel the peritoneum becomes locally irritated and tender.
What is Rovsing’s sign?
When the left lower quadrant is palpated, the patient feels pain in the right lower quadrant
What is rovsing’s sign caused by?
Traditionally appendicitis; although theoretically inflammation of any organ in the right lower quadrant may elicit Rovsing’s sign.
What is the psoas sign?
The patient experiences pain on passive extension of the thigh
What is murphy’s sign
Indication of gallbladder inflammation
What is the mechanism behind the psoas sign?
If the appendix is in a retro-caecal position, it may be in contact with the psoas muscle. Therefore, movement of this muscle will irritate the inflamed appendix, causing pain. A similar process occurs with a psoas abscess.
What is the psoas sign indicative of?
- Appendicitis
- Psoas abscess
What variations in clinical presentation can present in a child?
Can have classical presentation, but can also just have vague abdominal pain causing them to not eat their favourite food
What differential diagnosis would you consider for someone with features of appendicitis?
-
GI
- Acute terminal ileitis - Crohn’s disease / Yersinia infection
- Inflamed Meckel’s diverticulum/Diverticulitis
- Perforated ulcer
- Crohn’s Disease
-
Urological
- Cystitis
- UTI
- Ureteric stones
- Pyelonephritis
- Testicular torision
- Epididymo-orthcitis
-
Gyn
- Ruptured ectopic
- Ovarian cyst,
- Acute salpingitis,
- PID
-
Other
- Nonspecific mesenteric lymphadenitis
- Food poisoning
What investigations would you consider doing in someoen with suspected appendicitis?
-
Bloods
- FBC (raised WCC),
- CRP,
- ESR,
- U+Es,
- Amylase
- bHCG - must rule out pregnancy
-
Abdo ultrasound
- Presence of free fluid would riase suspicion
- CT abdo/pelvis
- Laparoscopy 0 can be diagnostic and therapeutic
What procedure has the highest diagnostic accuracy when it comes to investigating for acute appendicitis?
CT abdo/pelvis - reduces -ve appendicectomy rate
What are complications of appendicitis?
- Perforation - leading to generalised peritonitis, localised appendix abscess, pelvic abscess
- Appendix mass - omentum may cover inflamed appendix
- Appendix abscess
- Pelvic abscess
- Surgical site infection
What is an appendix mass?
Inflamed appendix with an adherent covering of omentum and small bowel.
What cause of appendicitis is most likely to cause perforation?
Faecolith
How would you manage an appendix abscess/mass?
- Antibiotics
- Appendicetomy
- Consider Surgical drainage / US/CT-guided drainage
How would you manage someone with acute appendicitis?
Confirm diagnosis - primarily clinical diagnosis
- ABCDE - manage sepsis
- Antibiotics - avoid giving without clear diagnosis
-
Appendicectomy
- Open
- Laparoscopic
- Abdominal lavage in pateitns with perforation
What antibiotic therapy would you consider using in someone with acute appendicitis?
3-7 days
- IV Gentamicin + Metranidazole +/- amoxicillin (if pen allergic -> Co-trimoxazole)
- Switch to oral Metranidazole and either Doxycyline/Co-trimoxazole
Complications of appendectomy
http://teachmesurgery.com/consent/general/appendicectomy/
Explain the procedure of an appendectomy
http://www.dialogmedical.com/wp-content/uploads/2010/04/Appendectomy-Note%20with%20Pre%20and%20Post%20Instru.pdf
