Appendicitis

Question 1

Define appendicitis.

Answer 1

Acute inflammation of the vermiform appendix.

Question 2

Explain the aetiology/risk factors for appendicitis.

Answer 2

• Obstruction of the appendiceal lumen, causing a cycle of progressive inflammation and bacterial overgrowth.
• Poor dietary fibre intake: Increased, bowel transit time, and the formation of faecaliths.

Question 3

Summarise the epidemiology of appendicitis.

Answer 3

Most common cause of an acute abdomen in children.

Incidence: 4/1000 children. Any age, most common >5 years of age, uncommon <2 years.

Question 4

What are the symptoms of appendicitis?

Answer 4

• Classical presentation is when there colicky umbilcal abdominal pain which then localizes to the right iliac fossa.
• Later the pain becomes constant with peritoneal inflammation and worsens with movement.
• Low grade-fever, loss of appetite, lethargy, vomiting, constipation/diarrhea.

Question 5

What are the signs of appendicits?

Answer 5

General: Tachycardia, pyrexia, reluctance to move.

• *Abdominal examination:** Percussion tenderness signifies inflammation of the peritoneum.
• Guarding may be present in RIF (McBurney’s point).
• Rovsing’s sign (RIF pain reproduced with palpation in the LIF).
• There may also be pain on expansion and recession of the abdomen. Cough may exacerbate pain.
• Peritoneal irritation signs may be absent with a retrocaecal appendicitis.

Rectalexamination: Should be performed by the most senior doctor only when diagnosis is in doubt. There is marked tenderness against anterior rectal wall, especially with a retrocaecal appendix.

Question 6

What are some investigations for appendicitis?

Answer 6

General: Appendicitis is a clinical diagnosis; investigations may aid diagnosis in difficult cases.

Bloods: FBC (normal WCC doesn’t exclude appendicitis), CRP, U&Es (especially if vomiting), clotting. Raised neutrophil count is the most sensitive serological investigation for appendicitis.

Urine: MC&S to exclude UTI, leucocytes may be present with an inflamed appendix against bladder wall (nitrite -ve).

Radiology: Plain AXR not indicated; if performed, may show dilated loops of bowel and a fluid level in the RIF. USS may show the inflamed appendix as a non-compressible tubular structure, presence of free fluid or appendiceal mass.

Question 7

What is the management for appnedicitis?

Answer 7

Refer to paediatric surgery and seniors immediately.

Surgery Planning (“GAME”)

• Group and cross match
  Intravenous antibiotics (cefoxitin or tazocin) – will vary according to trust guidelines.
• MRSA screen
• Nil by mouth (Eating and drinking)- Give intravenous fluids.

Appendectomy (open or laparoscopic): Laparoscopic is preferred in uncomplicated appendicitis. Need an extensive washout – high risk of infection and mortality in children.

If patient is unstable for surgery, they must first be optimized before they undergo surgery.

Question 8

What are complications associated with appendicitis?

Answer 8

• Perforation: <3 years old - 80–100%; >10 years old - 10–20%.
• Complicated appendicitis (perforated/presence of pus)
• Wound infection leading to intra-abdominal abscess formation.
• Decreased fertility in girls after complicated appendicitis (ovarian/fallopian tube involvement)
• Small bowel obstruction
• Adhesions

Question 9

What is the prognosis of appendicitis?

Answer 9

Excellent prognosis with treatment