disease of the small bowel and appendix

Question 1

appendicitis - blood supply

Answer 1

-appendicular artery

Question 2

appendicitis - who gets it ?

Answer 2

rare in infancy, usually childhood / young adulthood, another peak however in the elderly, men are more likely than women to get it (3:2) before the age of 25 - after 25 its equal 1:1

Question 3

what is the relevance of McBurney’s point and appendicitis ?

Answer 3

this is the right iliac fossa 1/3 between the ASIS and the umbilicus and it is where the appendix lies and so people often present with pain at this point

Question 4

appendicitis - aetiology

Answer 4

• obstruction of the lumen with faecolith (just faeces?)
• bacterial infection
• viral infection
• parasites ie worms
• obstruction due to tumour

Question 5

appendicitis - pathology

Answer 5

*there is a huge variation - lumen may or may not be occluded

• starts with mucosal inflammation which then leads to lymphoid hyperplasia - which then causes more inflammation
• then there is obstruction of the lumen
• there will be a build up of mucus and exudate
• if it continues then venous obstruction will occur leading to ischaemia > allowing for bacterial invasion through the wall
• perforation of the appendix occurs

Question 6

appendicitis - pathology concerned with surrounding features

Answer 6

• when there is inflammation in the abdomen it brings the greater omentum to this site
• the small bowel also adheres to the inflamed site resulting in a ‘phlegmonous mass’
• this mass can burst and all the puss contained can ooze elsewhere and cause fatal peritonitis

-fatal peritonitis due to appendicitis is normally found in the elderly, those immunocompromised, diabetic and with their omentum removed

Question 7

appendicitis - symptoms

Answer 7

• starts with colic central abdominal pain which then shifts to the RIF
• is sore when patients cough, laugh or jump around
• loss of appetite
• vomitting not usual but can happen
• will not have opened their bowels due to ileus (lack of normal contraction in the intestines)
• patients can be quite flushed

Question 8

appendicitis - signs

Answer 8

• mild pyrexia
• mild tachycardia
• localised RIF pain
• guarding (tensing the abdominal wall to guard inflamed organ)
• rebound (when pressure is applied at the site and pain is felt when pressure is removed suddenly)

Question 9

appendicitis - special signs

Answer 9

• Rosving’s : pressing on the left causes pain on the right
• Psoas : patients keeps the right hip flexed as this lifts appendix off the psoas
• Obturator :
  if the appendix is touching obturator internus then flexing the hip and internally rotating will cause pain
• Pointing :
  where did it start , where is it now ? ie central colicky pain that has shift to RIF

Question 10

special cases of appendicitis

Answer 10

> Retrocaecal appendicitis - there may be very few signs because appendix is tucked away behind the caecum
- check for fetor oris (bad breath due to rotting substance in abdomen)

> Pelvic appendix - diarrhoea , frequency of micturition (as appendix presses on bladder)

> Postileal -
appendix can sit behind the terminal ileum causing diarrhoea and vomiting

> other : people with weird BMIs ie the obese, the elderly don’t present until very late, children and pregnant women ie is it stretching of the appendix or appendicitis

Question 11

appendicitis - investigations

Answer 11

• very much a clinical diagnosis
• USS is useful in women and children
• AXR to exclude other causes
• bloods (WCC , CRP)
• urinalysis

Question 12

what score can be used for appendicitis ?

Answer 12

Alvarado / MANTRELS

m - migration of pain to RIF
a - anorexia (put off food) 
n - nausea / vomit
t - tenderness in RIF
r - rebound pain 
e - elevated temp. 
l - leukocytosis 
s - shifts of WCC rot left 

each scores a single point , <5 unlikely to have appendicitis , > 7 appendicitis is likely

Question 13

appendicits - management

Answer 13

• analgesia (paracetamol)
• antipyretics
• theatre ?
• antibiotics
• appendicectomy = laparoscopic is the best

Question 14

appendicitis - management for appendix mass

Answer 14

-this is when patients have left it really last minute to come in ie blood and puss everywhere , quite difficult to operate on

• antibiotics are first line
• decide whether or not to operate
• theatre if antibiotics fails or it becomes complicated (tachycardic, worsening pain, increase in size, vomiting or copious NG aspirates (ileus)