W3 Appendicitis Flashcards
What vessel supplies blood to the appendix?
Appendicular artery
What does the appendicular artery branch from?
Ileocolic artery
What is the ileocolic artery a branch of?
Superior Mesenteric Artery
What age groups is appendicitis typical of?
- Childhood/young adulthood
- elderly
Where is McBurney’s Point?
1/3 of the distance from the right anterior iliac spine to the umbilicus
What does McBurney’s Point correspond to?
Roughly corresponds to most common location of base of appendix where it is attached to caecum
List some causes of appendicitis.
- faecolith sitting at base of appendix
- viral (usually in clusters)
- bacterial trigger
- parasites
Describe pathological changes that occur in appendicitis in appendix.
- mucosal inflammation
- lymphoid hyperplasia
- obstruction of lumen (due to inflammation)
- build up of mucous and exudate
- venous obstruction
- ischaemia (due to pressure build up) and bacterial invasion through wall
- perforation
What can cause lumen obstruction in appendicitis?
- faecolith
- lymphoid hyperplasia
Describe pathological changes that can occur in the abdomen in appendicitis?
- inflammation in appendix causes greater omentum to stick to it
- inflammatory mass can form with greater omentum and small bowel
What is phlegmonous mass in appendicitis?
A mass made of greater omentum and small bowel loops that walls off inflamed appendicitis
What can burst appendix cause?
Peritonitis
What factors make peritonitis more likely in appendicitis?
- age (very young or very old)
- immunosuppressed e.g. on steroids
- previous surgical removal of greater omentum
- diabetes
What sort of diagnosis is appendicitis?
Clinical diagnosis
What are the typical symptoms of appendicitis?
- central abdominal pain that migrates to RIF (sore coming over bumps/cough/laugh)
- lack of appetite (anorexia)
- nausea (maybe vomit once or twice)
- usually haven’t opened bowels
- flushed
What is ileus?
- When peristalsis stops, functional problem not a structural problem causing it
- obstruction of GI tract
Why might patient with appendicitis not have opened their bowels that day?
They can get a degree of ileus due to inflammation
What can be found in rectal exam of patient with appendicitis?
Rectal tenderness
What are the clinical signs of appendicitis?
- mild pyrexia
- tachycardic
- localised pain in RIF
- guarding in RIF
- rebound
What is an alternative to testing for rebound on patient’s abdomen?
Tap on fingers like percussion and if painful
What are the specific signs of appendicitis?
- Rosving’s sign
- Psoas test
- Obturator
- Pointing
What is Rosving’s Sign?
When you press on the left side the patient experiences pain on the right.
What is the Psoas test?
Patient keeps right hip flexed to lift inflamed appendix off the psoas muscle.
What is the Obturator test?
If appendix is touching obturator internus muscle, flexing the hip and internally rotating it will cause pain .
What is the pointing test?
- Where did the pain start and where is it now?
- usually umbilicus out to RIF
How can retrocaecal appendicitis present?
- flushed
- bad breath -> faetor due to rotting tissue inside
- no intra-abdominal peritonitis so pain may not be present or severe
How can pelvic appendicitis present symptomatically?
- pain
- diarrhoea
- frequent micturition
How can post ileal appendicitis present symptomatically and why these symptoms?
- diarrhoea
- vomiting
- due to local irritation at the terminal ileum
How can appendicitis present differently in obese patients and what can be challenging?
- no anorexia
- examining abdomen difficult e.g. testing for guarding/rebound
- operating challenging
What can be different/challenging in diagnosing appendicitis in elderly people?
- usually very advanced
- less reliable history e.g. dementia
What can be different/challenging in diagnosing appendicitis in children?
-getting reliable history
What can be different/challenging in diagnosing appendicitis in pregnant women?
- pain can be due to stretching of organs
- appendix shifts up and out and high so pain potentially in different place
- imaging challenging
List the differential diagnosis of abdominal pain in children. (6) (excluding appendicitis)
- Gastroenteritis
- Mesenteric adenitis
- Meckel’s diverticulum
- Intussusception
- Henoch-Schonlein Purpura
- Lobar pneumonia
What is mesenteric adenitis and why is it typically painful in children?
- Inflamed lymph glands in the abdomen due to viral infection
- pain in children due to stretching of peritoneum which is tighter in children than adults
What is gastroenteritis?
Irritation of lining of stomach and intestines characterised by nausea, vomiting, diarrhoea and cramps.
What is intussusception?
When a segment of intestine slips into (infolds into) an adjacent segment of intestine usually causing bowel obstruction.
What is Henoch-Schonlein Purpura and what clinical presentation is it characterised by and what is the microscopic hallmark of the disease?
- small blood vessels inflammation in skin, joints, bowels, kidney
- purpuric rash on ankles
- deposition of IgA in walls of involved blood vessels
List the differential diagnosis of abdominal pain in adults. (6) (excluding appendicitis)
- Terminal ileitis
- Ureteric colic
- Acute pyelonephritis
- Perforated ulcer
- Pancreatitis
- Rectus sheath haemotoma
What is ureteric colic and what causes the colicky pain?
- When a urinary stone blocks part of the urinary tract
- dilation, stretching and spasm of the ureter
What is pyelonephritis?
Inflammation of the kidney
What usually causes pyelonephritis?
Bacterial infection
What is a rectus sheath haematoma?
An accumulation of blood in the rectus sheath
What causes a rectus sheath haematoma?
- rupture of epigastric artery
- muscular tear
List differential diagnosis of abdominal pain in women. (4) (excluding appendicitis)
- Mittelschmerz
- Ovarian cyst
- Ectopic pregnancy
- Salpingitis
List differential diagnosis of abdominal pain in elderly patients. (3) (excluding appendicitis)
- Sigmoid Diverticulitis
- intestinal obstruction
- carcinoma of the caecum
List 3 rare differential diagnosis of abdominal pain.
- Porphyria
- Diabetic Ketoacidosis
- Typhlitis
What is Mittelschmerz?
Abdominal pain in between periods usually associated with ovulation.
What is salpingitis?
Inflammation of the fallopian tubes.
What can cause salpingitis?
Bacterial infection
Why is sigmoid diverticulitis a differential diagnosis of abdominal pain in elderly people?
Sigmoid can flip onto right side due to being a bit old and floppy.
What is porphyria?
Group of genetic diseases that is characterised by accumulation of porphyrin in body.
What is typhlitis?
Inflammation of caecum
What is typhlitis also known as?
Neutropenic enterocolitis
List appropriate investigations for appendicitis.
- ultrasound (especially useful in women and kids)
- Abdominal Xray (not encouraged)
- bloods (particularly CRP and WCC)
- urinalysis (including HCG)
Describe the Alvarado score. (MANTRELS)
M - Migration of pain to RIF A - Anorexia N - Nausea T - tenderness in RLQ R - Rebound pain E - elevated temp. L - Leukocytosis S - Shift of white blood cell count to left
What does “shift of white blood cell count to left” mean?
That there is an increase in the number of immature leukocytes in the peripheral blood.
What is the appropriate management for appendicitis?
- analgesia
- antipyretic
- theatre
- antibiotics
What are the two ways in which appendicectomy can be carried out?
- laparascopically
- laparotomy
What is the treatment for appendix mass?
- Antibiotics first line and then sometimes appendicectomy later
- can operate but worst time to operate
When does an appendix mass occur?
When people don’t come to hospital
Why not operate on appendix mass until treated?
Very messy, everything is inflamed and there is a lot of pus and blood
When would you operate on patient with appendix mass as first line?
- antibiotics don’t work
- tachycardia
- worsening pain
- increase in size
- vomiting or copious NG aspirates
- ileus
What is an appendix abscess?
- When an appendix mass matures
- presents delayed
- usually liquid ball of pus
How is appendix mass usually managed?
Radiological drain
List some complications of appendicectomy. (10)
- pelvic abscess
- wound infection
- intra-abdominal abscess
- ileus
- respiratory
- DVT/PE
- Portal pyaemia
- Faecal fistula
- adhesions
- right sided inguinal hernia (in open appendicectomy)
What is portal pyaemia?
Condition involving collection of pus in the portal venous system due to inflammation and patients can become septic
What is a faecal fistula?
When abscess ruptures out through the abdominal wall and poo comes out onto their skin
What is carcinoid of the appendix a tumour of?
Tumour of the Crypts of Lieberkuhn
What does the metastatic risk of carcinoid of the appendix relate to?
Size of the tumour
What is a carcinoid?
- Tumour of the neuroendocrine system
- often in digestive tract
- slow-growing tumour
What protein do carcinoids of the appendix stain for?
Chromagrannin
What is treatment for carcinoid of the appendix?
- if <1cm appendicectomy
- if >2cm right hemicolectomy
