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Flashcards in Acute Abdomen Deck (144)
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What type of pain would someone with appendicitis complain of?

central abdominal pain that moves into the right iliac fossa


Typically, how does someone with appendicitis present?

  • tends to be a young person (5 - 40 years old)


  • acute onset within 12 - 24 hours 


  • present with umbilical pain that moves to the right iliac fossa


  • nausea and/or vomiting 


  • diarrhoea or constipation


  • fever


What might be present on general inspection and palpation of someone with appendicitis?

  • in the early stages there is general pain and peri-umbilical pain on palpation


  • in the later stages, the person will often stay very still due to peritonitis
    • this occurs after the appendix has ruptured, and the peritoneum has become inflamed


on palpation, there will be right iliac fossa pain


What signs might be present in appendicitis?

  • Rovsing's sign


  • Cope's sign


  • Psoas sign


  • rebound tenderness 


What is Rovsing's sign?

  • pain is greater in the RIF than the LIF when the LIF is pressed


  • this is specific to appendicitis 


What is Cope's sign?

  • there is pain on passive flexion and internal rotation of the hip


  • it indicates irritation to the obturator internus muscle


  • the appendix becomes inflamed and enlarged and may come into contact with the obturator internus muscle when this move is performed


What is Psoas sign?

  • there is pain on extending the hip 


  • pain indicates an inflamed appendix overlying the iliopsoas muscles


  • this only occurs with retrocaecal appendix
    • (as the iliopsoas muscle is retroperioneal)
    • this indicates that the inflamed appendix sits behind the caecum


When might rebound tenderness be evident in appendicitis?


What is this?

  • this indicates that the infection is involving the peritoneum


  • there is pain upon removal of pressure from the abdomen rather than application of pressure to the abdomen


  • this is indicative of peritonitis 


  • there may also be abdominal guarding - the abdominal muscles tense up to avoid pain


What are the investigations involved in appendicitis?

  • first line investigation is CT abdomen
    • USS can be done if CT is not available


  • this will show increased appendix diameter and increased wall enhancement


  • bloods - which will show leucocytosis and elevated CRP


What is the most common cause of appendicitis in adults?

  • appendicitis results from obstruction of the appendix lumen


  • this may be due to a fecalith (hardened lump of faecal matter) that wedges itself within the lumen
    • it can also be due to undigested seeds or pinworm infections 


What is a common cause of appendicitis in adolescents?

lymphoid hyperplasia


  • this involves growth of the lymphoid follicles, which are dense collections of lymphocytes


  • these reach their maximum size in adolescence and can obstruct the lumen of the appendix


  • when exposed to viral infections or immunisations, the follicles can increase in size 


How does obstruction of the lumen of the appendix lead to pain?

  • the intestinal mucosa secretes mucus and fluids to keep pathogens from entering the bloodstream and to keep the tissue moist


  • even when obstructed, the appendix keeps secreting


  • there is a build up of fluid and mucus in the appendix, which increases the pressure


  • the appendix gets bigger and physically pushes on afferent visceral nerve fibres nearby, causing pain


Why is there is an increase in serum WBC count in acute appendicitis?


What processes have to occur prior to this for it to occur?

  • as there is an obstruction, flora and bacteria in the gut are trapped
    • E. coli and bacteroides fragilis 


  • these bacteria are now free to multiply


  • this causes the immune system to produce WBCs, which leads to the build up of pus in the appendix 


What happens if the obstruction in the appendix persists past the build-up of pus in the appendix?

  • the pressure in the appendix increases even further


  • it expands and begins to compress small blood vessels that supply it with blood and oxygen


  • without oxygen, the cells in the wall of the appendix become ischaemic and die


  • these cells were responsible for secreting mucus and keeping bacteria out, so now the growing colony of bacteria can invade the wall of the appendix 


What leads to rupture of the appendix?


What happens if the appendix ruptures?

  • as more cells in the wall of the appendix die, it becomes weaker and weaker


  • in a small proportion of patients, the appendix wall becomes so weak that it ruptures


  • this leads to bacteria entering into the peritoneum and causing peritonitis
    • this leads to abdominal guarding and rebound tenderness at McBurney's point


What is the most common complication of a ruptured appendix?

  • formation of a periappendiceal abscess
    • this is a collection of fluid and pus around the ruptured appendix


  • sometimes smaller subphrenic abscesses can form
    • these are below the diaphragm, but above the liver/spleen


What is the treatment for appendicitis?



  • this is surgical removal of the appendix, followed by antibiotics


  • if there is an abscess, this must be drained first


What scoring system is used to determine the severity of appendicitis?

Alvarado score


  • score of 1 to 4 is discharged


  • score of 5 to 6 is observed


  • score of 7 to 10 needs surgery


Which antibiotics are given following appendicetomy?

  • cefotaxime


  • metronidazole
    • this is an anti-anaerobe antibiotic for the gut


What are the 3 possible complications of appendicitis?

  • perforation


  • appendix abscess


  • appendix mass
    • the inflamed appendix becomes covered in omentum and forms a mass
    • this tends to occur in older men who avoid coming to the doctors when they get pain


B-hCG test


  • the first line investigation in any woman with an abdominal pathology should ALWAYS be a pregnancy test


What is meant by diverticulosis?

  • the presence of diverticulae


  • these are outpouchings of the colonic mucosa and submucosa throughout the large bowel


  • high pressure in the bowel causes these outpouchings to form
    • e.g. chronic constipation



What is meant by diverticulitis?


Which part of the bowel is more commonly affected?

  • acute inflammation and infection of the diverticulae


  • most commonly affects the sigmoid colon


What is the structure of the large intestine wall like?


What is the difference between a true diverticula and a pseudo-diverticula (false)?

  • the wall of the large intestine is made up of 4 layers
    • mucosa
    • submucosa
    • muscle layer
    • serosa


  • a true diverticula involves all 4 layers of the intestine


  • a false (pseudo) diverticula includes only the mucosa and submucosa
    • these 2 layers are covered by serosa only, and the muscle layer is not involved 
    • these are more common



Why do diverticula form?

  • they are formed by high pressure within the lumen of the large intestine


  • smooth muscle in the intestinal wall contracts to push food along the bowel
    • when it contracts, higher pressures are generated inside the lumen as it "squeezes" air inside


  • contractions in someone with diverticula are abnormal


  • instead of pressure being distributed evenly throughout the lumen, there are areas of very high pressure during abnormal smooth muscle contraction, which leads to diverticula formation


What is the most common location for diverticula to form and why?

sigmoid colon


  • this has the smallest lumen diameter, and so it subject to the highest intraluminal pressures 


Does rectal bleeding (haematochezia) occur in diverticulosis and/or diverticulitis?



  • PR bleeding can occur in diverticulosis 
    • a diverticulum can form where blood vessels traverse the muscle layer, as this point of the wall is weaker
    • the blood vessel becomes separated from the intestinal lumen only by mucosa
    • it is predisposed to rupture, meaning blood enters the large intestine


  • PR bleeding does NOT occur in diverticulitis
    • this is because the blood vessels become scarred from inflammation


What genetic conditions and lifestyle factors are associated with an increased risk of diverticular disease?

  • anything that increases the stress on the intestinal walls or decreases their strength predisposes to diverticula


  • Marfan syndrome & Ehlers-Danlos are genetic conditions that affect connective tissue
    • diverticula can form in the absence of strong connective tissue supporting the intestinal wall


  • diets low in fibre and high in fatty foods and red meat increases risk of symptomatic diverticular disease