Medbear Appendicitis

Question 1

Describe on the appendix anatomy

Answer 1

• Blind muscular tube (6-9cm) with mucosal, submucosal, muscularis and serosa layers
• Fx: Participates in secretion of Ig (e.g IgA)
• Appendix location - RETROCECAL POSITION (75%)

Meso-appendix contents
- Appendicular artery (branch of the ileocolic artery branch)
- Lymphatic channels (empty to ileocecal lymph nodes)

Question 2

State (3) etiology of acute appendicitis

Answer 2

• Change in dietary habits - decrease dietary fiber and increased refined carbohydrates
• Infection secondary to obstruction of appendiceal lumen
  1. Fecoliths (most common cause in adults) composed of calcium salts + fecal debris collecting around the nidus
  2. Lymphoid hyperplasia: associated with inflammatory (Crohn’s)
  2. Less common cause: parasitic worm, TB
• Hyperplasia (most common cause in children)

Question 3

Explain about the pathology of acute appendicitis

Answer 3

Obstruction -> Distension by mucus -> Increased luminal and intraluminal pressure -> thrombosis and occlusion of blood supply + stasis of lymphatic flow -> ISCHEMIA (periumbilical abdominal pain) -> NECROSIS -> Bacterial overgrowth and invasion -> fibropurulent reaction on serosa -> irritation of parietal peritoneum (localised pain at MCBURNEY POINT)

Question 4

State 3 complicated conditions of acute appendicitis

Answer 4

• Suppurative (e.g pus filled)
• Gangrenous (e.g hemorrhagic ulceration and necrosis in the wall)
• Perforated

Question 5

State the common clinical presentation of acute appendicitis

Answer 5

• Anorexia (75%)
• Nausea and vomiting (Almost occur after pain)
• Abdominal pain (umbilicus to RIF)
• Diarrhea or constipation

Question 6

What positive findings and clinical signs to elicit upon abdominal examination?

Answer 6

• Check McBurney’s point (1/3 distance from right ASIS to umbilicus)
• Any signs of localized peritonism
  1. Rebound tenderness
  2. Voluntary guarding (early), involuntary, true reflex rigidity (late)

Signs to elicit:
- Rovsing sign (RIF pain with deep palpation of the LIF)
- Psoas sign (RIF pain with passive right hip flexion) -> suggesting inflamed RETROCECAL APPENDIX
- Obturator sign (RIF pain with internal rotation of a flexed right hip) -> suggesting inflamed PELVIC APPENDIX
- Cough sign (RIF pain on coughing)

Question 7

State the components of Alvorado score

Answer 7

Question 8

State (4) possible findings on CTAP for acute appendicitis

Answer 8

• Enlarged appendix >6mm
• Thickened appendix wall >2mm with enhancement - TARGET SIGN
• Periappendiceal fat stranding
• Presence of appendicolith

Don’t forget to rule out other etiologies and look for complications

Question 9

How would you manage a case of acute appendicitis?

Answer 9

• Keep NBM, IV hydration, correct electrolyte abnormalities
• IV antibiotics (CEPHALOSPORINS and METRONIDAZOLE)
• Symptomatic relief: Anti-emetics, analgesia

Definitive treatment: Open or laparoscopic appendectomy

Question 10

State the regime for non-operative management of complicated appendicitis and describe it

Answer 10

OCHSNER SHERREN REGIME
- Omentum wraps around inflamed appendix containing inflammatory process (PHLEGMON)
- Immediate appendectomy is associated with higher complication rates -> treat conservatively if patient is hemodynamically stable
- May benefit from PERCUTANEOUS DRAINAGE of appendiceal abscess

Question 11

State (5) complication of appendectomy

Answer 11

• Hemorrhage
• Infection/sepsis
• Risk of conversion to open surgery
• Risk of limited bowel resection
• Paralytic ileus
• Local (stump): retained fecolith??
  Late: adhesions leading to small bowel obstruction

Question 12

Define pseudomyxoma peritonei

Answer 12

Mucinous ascites arising from rupture appendiceal or ovarian adenocarcinoma