Appendicitis

Question 1

What age group is most commonly affected by appendicitis?

Answer 1

10-30 year olds

Question 2

What causes acute appendicitis?

Answer 2

Typically luminal obstruction due to faecolith or lymphoid hyperplasia

Can be due to malignancy e.g. caecal adenocarcinoma

When obstructed, commensal bacteria multiply - acute inflammation

Reduced venous drainage + inflammation cause increased pressure leading to ischaemia, going on to cause necrosis then perforation

Question 3

What is McBurney’s point?

Answer 3

One third of the distance from the ASIS to the umbilicus

Question 4

What are the classic features of appendicitis?

Answer 4

-Rebound and percussion tenderness at McBurney’s point

-Anorexia

-Nausea and vomiting

-Low-grade fever

-Rosving’s sign (palpation of the LIF causes pain in the RIF)

-Guarding on abdominal palpation

-Rebound tenderness

-Percussion tenderness

Rosving's Sign

Question 5

What two specific signs can be found on examination of appendicitis?

Answer 5

Rovsing’s sign

Psoas sign - RIF pain with extension of right hip
Retrocaecal appendix

Question 6

How is appendicitis diagnosed?

Answer 6

Clinical presentation and raised inflammatory markers

CT can be useful if another diagnosis is more likely

Ultrasound to exclude gynaecological pathology

Question 7

What is the next step if a patient has a clinical presentation suggestive of appendicitis but negative investigations

Answer 7

Diagnostic laparoscopy

Question 8

What are the key differential diagnoses of appendicitis?

Answer 8

Ectopic pregnancy
Ovarian cysts
Meckel’s diverticulum
Mesenteric adenitis (inflamed abdominal lymph nodes)

Children -
- Gastroenteritis
- Intussusception
- UTI

Question 9

What is mesenteric adenitis associated with?

Answer 9

Younger children
Tonsilitis
URTI

Question 10

What investigations are done in suspected appendicitis?

Answer 10

Urinalysis - assess for renal cause
Pregnancy test
Routine bloods - clotting + G&S
Serum bhCG

Question 11

What causes an appendix mass?

Answer 11

Omentum surrounds and sticks to inflamed appendix

Mass forms in the RIF

Treat conservatively initially with prolonged antibiotics, higher risk of visceral injury and post-op complications

Once inflammation reduces - appendectomy

Question 12

How is appendicitis managed?

Answer 12

Laparoscopic appendicectomy - gold standard

Open approach - Lanz incision. can be used

Give all patients pre-op antibiotics

Question 13

What are the complications of appendicectomy?

Answer 13

• Perforation - if untreated can perforate
• Surgical site infection
• Appendiceal mass
• Abscess formation
• Bleeding, infection, pain and scars
• Damage to bowel, bladder or other organs
• Removal of a normal appendix
• VTE
• Anaesthetic risks

Question 14

What imaging is done for appendicitis?

Answer 14

Imaging can be used to confirm diagnosis

• USS - first line if differential has gynae pathology
• CT
• MRI- alternative to radiation

Question 15

When is conservative management used?

Answer 15

High-risk surgical candidates with uncomplicated appendicitis

Antibiotics