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Acute Appendicitis
By- Dr. Armaan Singh
Take home points Appendicitis is common- 7-9% lifetime risk Delay in diagnosis/management causes significant morbidity-
can be a surgical emergency Usually clinical diagnosis- not reliant on imaging Has classic presentation but often presents atypically- it is a
common pitfall!
What is appendicitis? Who gets it? Appendicitis = Inflammation of the appendix. Obstruction of opening distention perforation Mostly young people (age 10-20) but can present at any age M>F (1.4:1) Common – 7-9% lifetime risk
Relevant Anatomy1. Where is the appendix? What is it attached
to?2. Where is McBurney’s point and what is it?3. What places can the appendix hide?4. What nerve root (roughly) supplies the
appendix and where does it refer visceral pain to?
5. What are some other things near the appendix?
6. What organs cause R sided abdo pain?7. What organs cause lower abdo pain?
costal margin
umbilicus
ASIS
Pubicsymphisis
Relevant Anatomy1. The Appendix is…
Here!
Transverse colon
Asc. colon
Desc. colon
Sigmoid colon
Terminal Ileum
Caecum
2. McBurney’s Point
ASIS
Relevant Anatomy
3. Places the appendix can hide…
… and during pregnancy
Relevant Anatomy
costal margin
umbilicus
ASIS
Pubicsymphisis
T6
T10
T12
unpaired
Paired organs
4. Innervation of appendix & other organs
Foregut(inc. duodenum)
Midgut(inc. appendix)
HindgutLower urinary tract
Sexual organs
Relevant Anatomy5. Structures near the appendix
• Caecum• Ileum• Ureter• Ovary• Bladder• Asc Colon• Psoas• Inguinal canal• Iliac vessels
6. R abdominal pain
7. Pelvic/lower abdo pain
“Typical” Presentation Dull, crampy central abdo pain Malaise/vomiting/anorexia/low grade fevers Pain worsens & localises to RIF with cough/movement
tenderness Systemic symptoms
Early Appendicitis
Pain: Location: Periumbilical (T10) Character: Dull Over time: Colicky Associated symptoms:
Vomiting Anorexia
obstruction
distention
Later Appendicitis Pain:
Location: R Iliac Fossa Character: Localised Over time: Constant Aggravating: going over bumps, coughing, walking Relieving: hip flexion, staying still
Exam findings: “peritonism”
Guarding rebound tenderness percussion tenderness
Rovsing, psoas, other signs
Distention causingischaemia
Localised peritonealinflammation
Late Appendicitis Pain:
Location: lower abdominal/generalised Character: diffuse, severe Over time: constant Aggravating: movement, coughing, palpation, rebound Associated: Fever
Exam findings: Systemic features- fever, tachycardia, hypotension Abdominal – severe, generalised “peritonism” RIF mass (sometimes)
Gangrene
Time Course
Special Clinical signs Abdominal examination Psoas Sign – pain on hip extension Rovsing Sign – RIF pain on palpating LIF “The walk” – walk with R hip
flexed, bent over Pain on coughing/unable to cough
Atypical presentationsLocation of appendix
Signs/symptoms
McBurney’s point “typical” presentation, Rovsig sign
Retro/paracaecal Psoas sign/flank pain/absence of peritonism
Retro/paraileal Diarrhoea, crampy pain
Pelvic Suprapubic pain, urinary frequency, pyuria
Complications Rupture and sepsis Periappendiceal Abscess Death
Clinching the diagnosis Appendicitis is usually a clinical diagnosis- ie history +
examination. However sometimes you’re just not sure! All those ovaries,
fallopian tubes, ureters, atypical presentations… …perhaps you could order some tests?
What to order?1. What things could support your diagnosis?
ie inflamed/infected/obstructed appendix
1. What things could rule in or rule out other diagnoses?
Diagnostic scoring
What to order?1. What things could support your diagnosis
ie inflamed/infected/obstructed appendix
1. What things could rule out other diagnoses Ie gastro, sbo, ovarian problems, PID, UTI, renal colic,
diverticulitis, crohn’s ectopic etc etc
Differential Diagnosis
Pathology/Lab investigations White cell count (WCC) – usually mildly elevated, around 11-14,000 C reactive protein (CRP) – also elevated
Urinalysis sometimes positive for blood, leuks; not very helpful in discriminating vs UTI
Electrolytes, renal function, haemoglobin, platelets, liver function, coagulation should all be normal unless profoundly unwell- if abnormal think of other things.
Imaging CT
Good for getting an overview of all the structures esp bowel Accurate- sensitive and specific >90% Less good at pelvic anatomy than abdo anatomy Radiation exposure
Ultrasound Good at visualising tubular structures & cysts Not as accurate as CT (sens 70%, spec 90%), sometimes difficult to see
appendix Good if you need to rule out things like ectopic or ovarian pathology
Diagnostic Laparoscopy
Safe Useful for when diagnosis is unclear Esp in females w/ suspected gynae pathology (eg
PCOS/endometriosis/menstruating/ovulating)
Management1. Supportive and symptomatic management
Antibiotics/fluids/etc
1. Treatment of underlying cause
Appendicectomy
What to do in ED/awaiting surgery Resuscitation!
A: ensure airway patent B: ensure adequate oxygenation C: correct hypotension/tachycardia/instability
Septic shock Systemic inflammatory response- usual appropriate local responses
make no sense when systemic Generalised vasodilation (flushing), capillary leak- fluid leaves central
circulation Hypotension, tachycardia- organs not perfused properly Either fever or hypothermia Other complications like coagulopathy/DIC/multiorgan failure ARDS in severe sepsis- hypoxia
Treatment of infection, sepsis Antibiotics- in appendicitis cover gram negs
(gentamicin/ceftriaxone), enterococcus (ampicillin/vancomycin), anaerobes (metronidazole)
Drain pus, remove infected material Replace fluid that is lost peripherally – IV cannula, fluid resuscitation Blood tests, imaging, other tests- find source Correct other organ dysfunction If necessary ICU and advanced life support
Procedures Appendicectomy
Laparoscopic Open
Diagnostic laparoscopy Laparotomy
Appendicectomy - Laparoscopic “Keyhole” surgery Lower complication rate, quicker recovery Sometimes difficulty in mobilisation requiring open procedure
Appendicectomy - Open Incision over McBurney’s point or point of maximal tenderness Straightforward, good exposure, technically easier Longer recovery, risk of hernia & adhesions, can’t see pelvic
structures as well
Summary Careful history & examination is very important! Principles of treatment- operation, antibiotics, supportive
care Early diagnosis & management (ie surgical r/v) is crucial Many pitfalls in dx