Lower GIT

Question 1

Appendicitis

Answer 1

Inflammation of the vermiform appendix

Question 2

Appendicitis - Pathophys

Answer 2

• Obstruction of the lumen of the appendix (by stool, faecalith, gallstone) -> infection -> appendicitis
• Organisms invade the wall of the appendix and are lodged in the submucosa -> full thickness of the wall becomes involved -> acute inflammation - becomes swollen and reddened
• The appendix becomes distended -> venous stasis, arterial occlusion -> gangrene at the tip of the appendix or at the site of obstruction
• Necrosis -> perforation -> peritonitis
• Peritonitis can localised by the greater omentum and loops of small bowel or may become generalised with diffuse contamination of the peritoneal cavity

Question 3

Appendicitis - clinical features

Answer 3

1) Anorexia
2) Followed by peri-umbilical pain
3) Nausea, vomiting
4) Pain in RIF
- 24hrs later -> persistent pain, growing in intensity, significant nausea, vomiting, fever
- Pain may be aggravated by walking or coughing

Question 4

Appendicitis - O/E

Answer 4

GI: appear unwell, positioning of patient - lying still, pain
Vitals: tachcardic, febrile

Abdomen

• Inspection - scars, masses, distension
• Ask patient to point to where pain is worst (McBurney’s point)
• Palpation - guarding, McBurney’s sign, Rovsing’s sign
• Percussion - tenderness
• Auscultation
• Ask patient to cough -> grimace suggests local inflammation
• Psoas sign
• Obturator sign

Female - may need to do vaginal exam

Question 5

Appendicitis - Differentials

Answer 5

1. Abdominal
   - Mesenteric adenitis
   Clinical features are similar, however appendix is normal, enlarged lymph nodes in the mesentery of the terminal ileum
   Most common in children
   - Meckel diverticulitis
2. Urological
   - UTI
3. Gynaecological
   - Ectopic
   - Ovarian cyst,
   - Mittelschmerz
   - PID - salpingitis

Question 6

Appendicitis - investigations

Answer 6

Urinalysis - rule out UTI
Bloods:
- FBC - WBCs (elevated in 80% of cases)
- CRP - raised (if it is normal, can be used to rule out appendicitis)
- UEC - assess hydration prior to surgery
- bHCG

Imaging

• Ultrasound - abdominal, pelvic - female
• CT
• Distended appendix - ?diameter > 6mm in adults, >8mm in children
• Periappendiceal inflammation
• Appendicolith
• Fat stranding
• Appendiceal wall thickening

Question 7

Appendicitis - management

Answer 7

If diagnosis is obvious -> laparoscopic appendicectomy

If diagnosis is suspected by not definite -> observe for 12-24hrs

• Analgesia
• IV fluids (if dehydrated or low BP)

Abx - only recommended intra-operatively