Appendicitis

Question 1

Define appendicitis

Answer 1

Acute inflammation of the vermiform appendix

Question 2

What is the aetiology of appendicitis

Answer 2

Obstruction of the lumen of the appendix is the main cause of acute appendicitis
Faecolith (hard mass of faecal matter), normal stool, or lymphoid hyperplasia are the main causes

Question 3

What are the risk factors for appendicitis

Answer 3

Teenage
Low dietary fibre
Improved personal hygiene
Smoking

Question 4

What is the epidemiology of appendicitis

Answer 4

Most common cause of abdominal pain in childhood requiring emergency abdominal surgery
Peak incidence in teens
Rare <3yo

Question 5

What are the symptoms of appendicits

Answer 5

May present as a child complaining of general tummy pain, withdrawn and will not move posture

Anorexia
Nausea and vomiting
Abdominal pain
- Umbilical region to RIF (1-12hrs later)
- Acute onset
- Constant with intermittent cramps (colicky pain)
- Worse on movement and coughing
Fever
Loose stool (low volume, not usually offensive) OR Constipation
Collapse and generalised peritonitis (Due to rapid physiological deterioration in this age group from a narrow appendiceal lumen)

Question 6

What do the sites of pain in appendicitis indicate

Answer 6

Flank or back: retrocaecal appendix
Testicular pain: retroileal/pre-ileal appendix
Suprapubic pain: pelvic appendix

Question 7

What are the differentials for appendicitis

Answer 7

Ovarian torsion
Ectopic pregnancy
Mesenteric adenitis
Colic
Intussusception
Meckel’s diverticulitis
Mittelschmerz
PID

Question 8

What are the signs of appendicitis on examination

Answer 8

General and obs
- Hypotension and tachycardia
- Low-grade pyrexia
- Flushed face and a fetor
- Patient staying still -> peritonitis (due to rupture)

Abdominal
- Tense, rigid abdomen
- Right lower quadrant tenderness, rebound tenderness
- Palpable mass
- Reduced bowel sounds
- Rovsing’s sign: Pain in the RIF when the LIF is palpated
- Cope’s sign: Pain on passive flexion and internal rotation of the hip
- Psoas sign: Pain on extending the hip (patient lies on side)*

Question 9

What investigations should be done for appendicits

Answer 9

Bedside: urinalysis and dipstick, pregnancy test (childbearing age)

Blood: FBC(↑WCC), CRP (↑), G&S, U&Es

Other:
- US abdomen (Aperistaltic or non-compressible structure with outer diameter >6 mm)
- AXR (faecolith)
- CT abdomen (Abnormal appendix, diameter >6mm, or calcified appendix. Appendicolith seen in association with peri-appendiceal inflammation)

Question 10

What is the management for uncomplicated appendicitis

Answer 10

1. A-E assessment
2. Call the surgical on-call team
3. supportive treatment (AGAME)
   - Analgesia e.g. paracetamol, diclofenac, morphine
   - G&S
   - Antibiotics (see below)
   - MRSA screen
   - Eating and drinking - make NBM + NG feeds

No signs of sepsis → IV Abx co-amoxiclav

Signs of sepsis → laparoscopic appendicectomy ± post-op Abx (amoxicillin + metronidazole)

Question 11

What are the complications of appendicitis

Answer 11

Perforation (more common with faecolith i.e. in children)
Generalised peritonitis
Appendicular mass
Appendicular abscess

Question 12

What is the prognosis for appendicitis

Answer 12

If treated, prognosis is good
Wound infection and intra-abdominal abscess are potential complications associated with appendicectomy
Laparopscopic appendicectomy has been shown to decrease the incidence of overall complications

Question 13

Which factors predict perforated appendix

Answer 13

Under 9yo
Abdominal pain >48 hours
Temp. >37.9
Signs of peritoneal irritation