Appendicitis

Front 1

What is the definition of acute appendicitis?

Back 1

An acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix.

Front 2

What sorts of things can obstruct the lumen of the appendix?

Back 2

Foecalith, normal stool, infective agents, lymphoid hyperplasia.

Front 3

Who gets appendicitis?

Back 3

It is mainly a disease of the young, with peak incidence between 20 - 40 year old, though it is common in children and teens. It rarely occurs in children under 3 years of age.

Front 4

What happens to the lumen distal to the obstruction?

Back 4

It fills with mucous and acts as a closed loop obstruction. The leads to distension and an increase in intraluminal and intramural pressure.

Front 5

What are the most common bacteria in the appendix and what happens to them during appendicitis?

Back 5

The resident bacteria, mainly E. Coli and Bacteriodes fragalis, rapidly multiply.

Front 6

What does distension of the lumen of the appendix cause by reflex?

Back 6

Anorexia, nausea and vomiting and visceral pain.

Front 7

What happens when the pressure inside the lumen exceeds venous pressure?

Back 7

The small venules and capillaries become thrombosed, but the arterioles remain open, so the appendix becomes engorged and congested.

Front 8

What happens to the character of the pain when the inflammation extends to the serosa?

Back 8

The serosa of the appendix is equivalent to the parietal peritoneum, which causes classic right lower quadrant pain.

Front 9

What happens when the small arterioles become thrombosed?

Back 9

The area at the antimesenteric border becomes ischaemic, and infarction and then perforation may insue. Bacteria can leak out through the dying appendix an suppuration forms around the walls.

Front 10

Where are perforations usually seen?

Back 10

The are usually seen just beyond the obstruction, rather than at the tip of the appendix.

Front 11

What are the key diagnostic factors of acute appendicits?

Back 11

Abdominal pain (middle, then shifts to RLQ)
Anorexia
Nausea/vomiting

Front 12

What is McBurney's sign?

Back 12

Right lower quadrant abdominal pain in appendicitis.

Front 13

What is Rosving's sign?

Back 13

Compressing pain in the LLQ causes pain in the RLQ in appendicitis.

Front 14

What is the psoas sign?

Back 14

Pain elicited by placing the patient on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle, in appendicitis.

Front 15

What is the obturator sign?

Back 15

Pain elicited by placing the patient on their left side and internal rotating the flexed right thigh.

Front 16

What happens to bowel sounds in appendicitis?

Back 16

They are normally reduced, particularly on the R side compared to the L.

Front 17

Is fever a feature of appendicitis?

Back 17

A low grade fever, usually by an increase of 1 degreem =, is common.

Front 18

What are the first diagnostic tests to order when appendicitis is suspected?

Back 18

FBC, abdominal or pelvic CT scan, pregnancy test.

Front 19

What might an FBC show during acute appendicitis?

Back 19

Increased polymorphonuclear leukocytes (>75%).

Front 20

What might an abdominal and pelvic CT scan show during acute appendicitis?

Back 20

Abnormal appendix (diameter >6 mm) identified or calcified appendicolith seen in association with peri-appendiceal inflammation .

Front 21

What should one do if a urinary pregnancy test is positive during a confirmed appendicitis?

Back 21

The possibility of an ectopic pregnancy should be confirmed.

Front 22

What are some differentials for acute appendicitis?

Back 22

Merkel's diverticulitis.
Acute mesenteric adenitis.
Viral gastroenteritis.
Intusseception.

Front 23

When does acute mesenteric adenitis present?

Back 23

It usually presents in children with a recent history of an URTI.

Front 24

What distinguishes acute mesenteric adenitis from acute appendicitis?

Back 24

Pain in the abdomen is usually diffuse and not localised to the RLQ. Generalised lymphadenopathy is also noted.
Acute mesenteric adenitis is essentially a diagnosis of exclusion as there are no specific tests.

Front 25

How does viral gastroenteritis mimic appendicitis?

Back 25

Crampy abdominal pain.

Front 26

How is viral gastroenteritis differentiated from appendicits?

Back 26

Crampy abdominal pain usually precedes profuse, watery diarrhoea, nausea and vomiting.

Front 27

What are the characteristics of viral gastroenteritis caused by the typhoid virus?

Back 27

When caused my typhoid fever, intestinal perforation may cause localised abdominal pain and/or generalised or rebound tenderness.

Front 28

How can typhoid gastroenteritis be distinguished from acute appendicitis?

Back 28

Typhoid fever will cause a maculopapular rash, inappropriate bradycardia and leukopenia.

Front 29

What are the features of intusseception distinguishing it from acute appendicitis?

Back 29

It usually occurs in children <2 years of age.
There are intense colicky periods of pain, between which the child is calm.
A sausage-shaped mass may be palpable in the RLQ.

Front 30

Where would the pain from a retrocaecal appendix localise to?

Back 30

Flank or back pain.

Front 31

Where would the pain from a retroileal appendix localise to?

Back 31

Testicular pain due to irritation of the spermatic artery or ureter.

Front 32

Where would a pelvic appendix cause pain?

Back 32

The suprapubic region.

Front 33

What is the sequence of pain in 95% of patients with acute appendicitis?

Back 33

Anorexia, abdominal pain, vomiting.

Front 34

When does complicated appendicitis become more likely?

Back 34

The longer the duration of symptoms, and in elderly patients.

Front 35

What is a MANTRELS score used for?

Back 35

M - Migration of pain to lower quandrant.
A - Anorexia
N - Nausea
T - Tenderness in RLQ.
R - Rebound tenderness
E - Elevated temperature.
L - Leukocytosis.
S - Shift of WBC to left.
The higher the closer to 10, the more risk of having appendicitis.

Front 36

How is an uncomplicated appendicitis treated?

Back 36

Appendicectomy +/- IV antibiotics.

Front 37

How is a patient prepared for an appendicectomy?

Back 37

Nil by mouth, supportive IV fluids, surgery without delay to decrease risk of perforation.

Front 38

What antibiotics are appropriate post-surgery for uncomplicated appendicectomy?

Back 38

cefoxitin : 1-2 g intravenously as a single dose before surgery, followed by 1-2 g every 8 hours for 2 doses post-surgery

Front 39

How should an appendicectomy be managed when a perforation or abscess is suspected?

Back 39

Nil by mouth
IV fluids (treat shock if necessary)
IV antibiotics with cefoxitin (or carbapenem) until afrebrile and no leukocytosis

Front 40

Anatomy.
What is the appendix?

Back 40

A narrow, hollow, blind-ended tube connected to the caecum. It has large aggregations of lymphoid tissues in its walls.

Front 41

Anatomy.
What and where is McBurney's point?

Back 41

McBurney's point is the surface projection of the base of the appendix at the junction of the lateral and middle on third of a line from the ASIS to the umbilicus.

Front 42

Anatomy.
What is the arterial supply to the appendix?

Back 42

The appendicular artery from the ileocolic artery (from the superior mesenteric artery).

Front 43

What are some of the possible complications of appendicitis?

Back 43

Perforation, abscess, peritonitis, surgical wound infection.

Front 44

How does a perforated appendix present?

Back 44

Usually due to a delay in treatment. Temperature rise is higher, severe abdominal pain, localised bowel sounds and increased tenderness.

Front 45

How does an appendicular abscess present?

Back 45

Usually as a progression of the disease process. Presents with tender right quandrant mass, swinging fever and leucocytosis. Ultrasonography or CT scan will show the abscess.

Front 46

How should an appendicular abscess be treated?

Back 46

Give IV antibiotics and CT-scan guided drainage of the abscess. If symptoms resolve, interval removal of the appendix is unnecessary. If symptoms continue, remove appendix.

Front 47

How can the risk of surgical wound infection be decreased?

Back 47

Laparoscopic approach and IV antibiotics.

Front 48

How soon can a patient return home after an appendicitis?

Back 48

Patients are usually discharged home from the hospital one day after an uncomplicated appendicitis. The patient should be followed up 1 week after discharge.

Front 49

What instructions should be given to the patient following an appendicectomy?

Back 49

Clear liquid diet on the same day as operation (if no complications). Then start regular diet the next day. Patients are given one week off work or school.

Front 50

Should IV antibiotics be given prophylactically?

Back 50

Controversial. Currently it is recommended to give cefotixin (a cephalosporin) in uncomplicated appendicitis to decrease the risk of wound infection.