Appendicitis Flashcards
Appendicitis is the most common what?
Surgical emergency.
Define appendicitis.
Acute inflammation of the vermiform appendix.
How does appendicitis typically present?
As acute abdominal pain starting in the mid-abdomen and later localising to the RIF.
Who is affected?
· Slightly more common in males.
· Incidence is lower in populations with a high-fibre diet.
· More commonly seen in patients aged between early teens and late 40s.
What is the pathophysiology for appendicitis?
· The lumen distal to the obstruction starts to fill with mucous and acts as a closed-loop obstruction.
· This leads to distension and an increase in intraluminal and intramural pressure.
· The resident bacteria in the appendix rapidly multiply.
· Distension of the lumen causes anorexia, N&V and visceral pain.
· As the pressure of the lumen exceeds the venous pressure, the venules and capillaries become thrombosed but arterioles remain open, which leads to engorgement and congestion of the appendix.
· The inflammatory process soon involves the serosa of the appendix, hence the parietal peritoneum in the region, causing RIF pain.
· Once the small arterioles are thrombosed, the area at the anti-mesenteric border becomes ischaemic, and infarction and perforation occur.
Prognosis?
Good if treated in a timely manner.
What is the aetiology of appendicitis?
· Appendix lumen obstruction is the main cause.
· Faecolith (hard mass of faecal matter), normal stool or lymphoid hyperplasia are the main causes of obstruction.
· Faecolith alone causes simple appendicitis in 40%, gangrenous non-perforated appendicitis in 65% and perforated appendicitis in 90% of cases.
Suggest risk factors which may cause appendicitis?
· <6 months of breastfeeding.
· Low dietary fibre - constipation.
· Improved personal hygiene - GI microbial flora.
· Smoking - increased passive and actual smoking increases risk.
What are the main 2 symptoms patients with appendicitis present with?
- Abdominal pain.
2. Anorexia.
What 4 signs may be present on examination?
- McBurney’s sign - RIF pain - maximal site of tenderness, pain.
- Rovsing’s sign - RIF pain when compression LIF - palpation of the left lower quadrant increases the pain in the right lower quadrant.
- Psoas sign - Pain occurs at RIF by extension of the right thigh on left lateral position.
- Obturator sign - Pain occurs at RIF by internal rotation of the flexed right thigh.
What investigations would you request if you suspected a patient had appendicitis?
No single investigation to rule out appendicitis, however there are some tests to rule out differentials:
· FBC - Mild leukocytosis with increased neutrophils.
· Urinalysis and pregnancy test.
· USS or CT scan.
What scoring system is used for appendicitis?
Alvardo Scoring System – scoring system for acute appendicitis, not very good:
- Migration of Pain, Nausea/Vomiting, Anorexia, Rebound Pain, Temp >37.3, Neutrophil Count >75%»_space;> 1 Point each.
- RIF Tenderness, WCC >Q0X109/L»_space;> 2 Points each.
- 5-6 = Possible, 7-8 = Probable, >9 = Very Probable
Suggest some GI differential diagnoses.
· Acute mesenteric adenitis - usually in children with recent URTI, diffuse pain not localised, generalised lymphadenopathy.
· Viral gastroenteritis - profuse diarrhoea, nausea and vomiting, no localising signs.
· Meckel’s diverticulum - usually asymptomatic.
· Intussusception - occurs in young children, sudden onset of colicky pain, sausage-shaped mass in the RIF.
· Crohn’s disease.
· Peptic ulcer disease.
Suggest some urological differential diagnoses.
· Right sided ureteric stone - colicky pain and severe.
· Cholecystitis - RUQ.
· UTI.
· Primary peritonitis.
Suggest some gynaecological differential diagnoses.
· ID - bilateral pain, vaginal discharge.
· Ectopic pregnancy - vaginal bleeding or spotting, high HCG.
· Ovarian torsion.
