The Large Intestine - Appendicitis

Question 1

What is Appendicitis?

Answer 1

Inflammation of the vermiform appendix - a small, thin tube of bowel sprouting from the Caecum.

Question 2

What are the commonest positions of the Appendix? (3)

Answer 2

1. Retrocaecal.
2. Pelvic.
3. Subsecal.

Question 3

Presentation of Appendicitis in Children.

Answer 3

Uncommon but often with perforation.

Question 4

Differential Diagnoses of Appendicitis (4).

Answer 4

1. ECTOPIC PREGNANCY (female of childbearing age + exclude using serum/urine hCG).
2. OVARIAN CYSTS (present with rupture/torsion).
3. MECKEL’S DIVERTICULUM
   (malformation of distal ileum in 2% of people that is asymptomatic and no treatment - if it bleeds, it becomes inflamed).
4. MESENTERIC ADENITIS (inflamed abdominal lymph nodes, with abdominal pain, in younger kids with tonsillits/URTI).

Question 5

When can an appendix mass occur?

Answer 5

When the omentum surrounds and sticks to the inflamed appendix to form a RIF mass.

Question 6

How can an appendix mass be managed?

Answer 6

Conservatively with supportive treatment and antibiotics and appendicectomy once acute condition resolves.

Question 7

Epidemiology of Appendicitis (2).

Answer 7

1. Peak Incidence = 10-20.
2. Less common in young kids + adults over 50.

Question 8

Clinical Presentation of Appendicitis (4).

Answer 8

1. Periumbilical Pain that moves to the RIF within the first 24 hours.
2. Anorexia - loss of appetite.
3. N&V.
4. Low-Grade Fever (High - Mesenteric Adenitis).

Question 9

Examination Findings of Appendicitis (6).

Answer 9

1. Tenderness at McBurney’s Point (1/3 distance from ASIS-Umbilicus).
2. Rovsing’s Sign (Palpation of LIF causes pain in RIF).
3. Guarding on Abdominal Palpation.
4. Rebound Tenderness in RIF (increased pain when suddenly releasing the pressure of deep palpation).
5. Percussion Tenderness.
6. Psoas Sign (extending the hip if the appendix is retrocaecal).

Question 10

What do Percussion and Rebound Tenderness suggest?

Answer 10

Peritonitis - indicating a ruptured appendix.

Question 11

Why does the pain begin peri-umbilical position?

Answer 11

Visceral stretching of the appendix lumen + appendix is a midgut structure.

Question 12

Structure of the Appendix.

Answer 12

Small thin tube arising from the caecum, where the three teniae coli meet - it has a single opening that connects it to the bowel and leads to a dead end.

Question 13

What are teniae coli?

Answer 13

Longitudinal muscles that run the length of the large intestine.

Question 14

Pathophysiology of Appendicitis (5).

Answer 14

1. Faecolith/Lymphoid Hyperplasia cause obstruction of the appendix lumen.
2. Pathogens can get trapped at the point where the appendix meets the bowel.
3. Trapping = infection and inflammation.
4. Gangrene + Rupture.
5. Rupture = release of faecal contents and infective material into peritoneal cavity = peritonitis.

Question 15

Investigations of Appendicitis (2).

Answer 15

1. Diagnosis - Clinical Presentation and Raised Inflammatory Markers (+ Potentially Neutrophil-Predominant Leucocytosis).
2. US - only to exclude ovarian and gynaecological pathology.

Question 16

Management of Appendicitis (5).

Answer 16

1. Emergency Admission to Hospital.
2. Definitive = Laparoscopic Appendicectomy (Removal of the Inflamed Appendix).
3. Prophylactic IV Antibiotics (longer course if perforated)
4. Copious Abdominal Lavage if Perforated.
5. NBM.

Question 17

Complications of Appendicitis (3).

Answer 17

1. Local Abscess.
2. Perforation.
3. Gangrene (appendicular artery - end artery of ileocolic artery).