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Acute Appendicitis
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 Anatomy3. 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
mucu
s
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
Appendiceal obstruction/early appendicitis – visceral peritoneal irritation
• Periumbilical colicky pain
Appendiceal distension
• Anorexia, vomiting, malaise
Irritation of parietal peritoneum (localised)
•Constant RIF pain, pain on coughing, going over bumps etc
Perforation, localised/generalised peritonitis, mass
•Fever/Sepsis
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
2. What things could rule in or rule out other diagnoses?
Diagnostic scoring Alvarado score
RIF tenderness +2 Increased WCC +2 Pain that migrates to
RIF +1 Rebound tenderness +1 Anorexia +1 Nausea/Vomiting +1 Fever +1 WCC- ‘left shift’ +1
1-4: Very unlikely 5-6: Possible 7-8: Very probable 9-10: Definite
What to order?1. What things could support your
diagnosis ie inflamed/infected/obstructed
appendix
2. What things could rule out other diagnoses
Ie gastro, sbo, ovarian problems, PID, UTI, renal colic, diverticulitis, crohn’s ectopic etc etc
Differential Diagnosis GI tract - asc colon,
caecum, ileum Infectious
gastroenteritis Mesenteric adenitis
(post-viral) R sided diverticulitis
(inc Meckel’s) Crohn’s/IBD Tumour SBO herniae
Urinary tract – ureters, bladder UTI Renal/ureteric colic
Female reproductive tract- ovaries, tubes Mittelschmerz PID Cyst rupture Torted cyst/tube Ectopic pregnancy
Weird/wonderful Musculoskeletal Shingles
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
managementAntibiotics/fluids/etc
2. Treatment of underlying causeAppendicectomy
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