Acute appendicitis

Question 1

What is appendicitis?

Answer 1

Inflammation of the appendix

Question 2

Which age is most commonly affected by appendicitis?

Answer 2

2nd/3rd decade

Question 3

What is the overall lifetime risk of appendicitis

Answer 3

7-8%

Question 4

What is the typical cause of appendicitis?

Answer 4

Direct luminal obstruction usually secondary to a faecolith or lymphoid hyperplasia, impacted stool or rarely an appendiceal or caecal tumour

Question 5

What happens when the appendix becomes obstructed?

Answer 5

Commensal bacteria multiply, resulting in acute inflammation
Reduced venous drainage and localised inflammation can result in increased pressure within the appendix and in turn can result in ischaemia

Question 6

What happens to the appendix if appendicitis is left untreated?

Answer 6

Necrosis and then perforation

Question 7

List some risk factors for appendicitis

Answer 7

Family history - 30% risk in twin studies

Ethnicity - more common in Caucasians

Environmental - seasonal presentation - during the summer

Question 8

List the symptoms of appendicitis

Answer 8

Abdominal pain - peri-umbicilcal, dull and poorly localised (from visceral peritoneum inflammation) but later migrates to the right iliac fossa where it is localised and sharp

Vomiting

Anorexia

Nausea

Diarrhoea or constipation

Question 9

What is seen on examination of appendicitis?

Answer 9

Rebound tenderness 
Percussion pain over McBurneys point 
Guarding 
Sepsis signs - tachycardic and hypotensive 
RIF mass in case of appendiceal abscess

Question 10

Name two specific signs of appendicitis

Answer 10

Rovsing’s sign

Psoas sign

Question 11

Describe Rovsing’s sign

Answer 11

RIF pain on palpation of the LIF

Question 12

Describe psoas sign

Answer 12

RIF pain with extension of the right hip - suggests inflamed appendix abutting psoas major muscle in retrocaecal position

Question 13

Where is McBurney’s point?

Answer 13

Two thirds of the way between the umbilicus and ASIS

Question 14

How may appendicitis present in children compared to adults

Answer 14

Atypically

Diarrhpea, urinary symptoms or left sided pain

Question 15

List the differentials for appendicitis

Answer 15

Gyanecological - ovarian cyst rupture, ectopic, pelvic inflammatory disease

Renal - ureteric stones, UTI, pyelonephritis

Gastrointestinal - IBD, Meckel’s diverticulum or acute mesenteric adenitis, gastroenteritis, constipation

Urological - testicular torsion, epididymo-orchitis

Question 16

What investigations should be ordered for appendicitis

Answer 16

Urinanalysis
Pregnancy test for those of reproductive age
FBC
CRP
Cross match, Group and save 
U&Es 
LFTs
Imaging - ultrasound or CT imaging

Question 17

Name the risk stratification score used for appendicitis in children

Answer 17

Shera score

Question 18

What is the current definitive treatment for appendicitis?

Answer 18

Laparoscopic appendicectomy and appendix sent for histopathology

Question 19

What is the treatment for an appendiceal mass?

Answer 19

Antibiotic therapy - interval appendectomy performed 6-8 weeks later

Question 20

When is an open approach used?

Answer 20

During pregnancy

Question 21

What is the name of the incision in the open approach?

Answer 21

Lanz incision

Question 22

List the complications of appendicitis

Answer 22

Perforation
Surgical site infection
Appendix mass
Pelvic abscess