56. Acute appendicitis – classification, clinical presentation, treatment

Question 1

Appendix anatomy

Answer 1

Blind ended tube connected to cecum + located in RLQ

• Blood supply: appendiceal artery – branch of ileocolic a – sup mesenteric a – Ab aorta
• 2-20 cm av. 9cm – contains goblet cells + lymph tissues
• Morphologically undeveloped end of cecum

Question 2

Acute appendicitis - definition

Answer 2

Inflam of appendix.

Most common cause of ‘acute abdomen’

Question 3

Acute appendicitis - Classification

Answer 3

Non obstructive acute appendicitis: inflam starts in mucosa membrane + ends in one of the following:
 resolution
 ulceration
 suppuration
 fibrosis
 gangrene

Obstructive acute appendicitis: obstruction in lumen, wall, outside the wall (adhesions, kinking)
-appendix can be strangulated in inguinal/femoral hernia

Question 4

Classification of acute appendicitis according to ultrasound findings:

Answer 4

Type

Pathological dx

Layer structure of the appendiceal wall

Submucosal layer

            so

Type 1
Catarrhal
Clear
No hypertrophy

Type 2
Phlegmonous
Indistinct
Hypertrophied

Type 3
Gangrenous
Disrupted
Indistinct + partly lost

Question 5

Acute appendicitis - Etiopathogenesis:

Answer 5

Obstruction of lumen in appendix causes

Increased pressure which causes

Continuous secretion of fluids + mucus resulting in

Stagnation (periumbilical pain) resulting in

Invasion of gut bacteria which causes

WBC, pus and increased more pressure. This causes

Impaired venous + lymphatic drainage resulting in

Mucosal ischaemia and eventually

Localised inflammation — RLQ pain

Question 6

Acute appendicitis - Clinical Presentation

Answer 6

Periumbilical pain that moves to RLQ

Anorexia,

N/V

Increased HR

Fever

Pain increases with
coughing

Constipation if SI obstructive

Question 7

Acute appendicitis - Clinical Presentation - Signs

Answer 7

1. Voskresensky sign:
   Left hand on pubis.
   Right hand pressed on epigastric During exhalation of pt the hand quickly + evenly hand slides in direction of right iliac area w/o taking hand away
   a. Acute strengthening of pain
2. Blumberg’s sign: pain when abrupt release of pressure after pressing down on site tenderness (McBurney’s point)
   Mcburney sign - Mcburney point is 1.5-2 inches away from anterior superior iliac spine. Mcburney sign is when Mcburney point is the most tender spot
3. Dunphy’s sign: pain on coughing in RUQ
4. Rousing’s sign: Palpation of Left Lower Quadrant causes pain in Right Lower Quadrant
   a. Pain in right iliac fossa when palpating left iliac fossa
5. Obturator sign: patient is lying supine, and you passively flex their hip and knee, and then internally rotate. If this causes pain in the RLQ – this is a positive obturator sign.
6. Psoas sign: Psoas sign is when the patient lies supine and attempts to flex their hip against resistance. Place your hand on their thigh and ask them to lift their leg. If they have pain in the RLQ – this is a positive Psoas sign.
7. Razdolskyy sign: at percussion painfulness in right iliac area

Question 8

Acute appendicitis - Diagnostic investigations

Answer 8

In case of perforation: intense, diffuse ab pain. Increased HR, fever

Labs: increased WBC, increased CRP

US: 90% specificity for dx of appendicitis = increased size, increased thickness of walls

CT

Diagnostic laparoscopy

Question 9

Acute appendicitis - Treatment

Answer 9

• Open or laparoscopic appendectomy + IV abx (metronidazole + cefuroxime)
• Open maybe transverse muscle splitting incision or oblique (McBurney’s)

Question 10

Acute appendicitis - Complications

Answer 10

1. Perforation/rupture – contents spill into peritoneal cavity – peritonitis
2. Appendix mass: when inflamed appendix covered by omentum
   a. Phlegmon – appendix becomes gangrenous
   b. Tx: surgery or NBM + abx
3. Appendix abscess = A. mass fails to resolve, enlarges = surgical drainage + abx