Acute appendicitis

Acute appendicitis

1. Acute Appendicitis
By- Dr. Armaan Singh

2. 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!

3. 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

4. Relevant Anatomy
1.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
m
argin
umbilicus
ASIS
Pubic
symphisis

5. Relevant Anatomy
1. The Appendix is…
Here!
Transverse colon
Asc. colon
Desc. colon
Sigmoid colon
Terminal Ileum
Caecum
2. McBurney’s Point
ASIS

6. Relevant Anatomy
3. Places the appendix can hide…
… and during pregnancy

7. Relevant Anatomy
costal
m
argin
umbilicus
ASIS
Pubic
symphisis
T6
T10
T12
unpaired
Paired organs
4. Innervation of appendix & other organs
Foregut
(inc. duodenum)
Midgut
(inc. appendix)
Hindgut
Lower urinary tract
Sexual organs

8. Relevant Anatomy
5. 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

9. “Typical” Presentation
Dull, crampy central abdo pain
Malaise/vomiting/anorexia/low grade fevers
Pain worsens & localises to RIF with cough/movement
tenderness
Systemic symptoms

10. Early Appendicitis
Pain:
Location: Periumbilical (T10)
Character: Dull
Over time: Colicky
Associated symptoms:
Vomiting
Anorexia
obstruction
distention

11. 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 causing
ischaemia
Localised peritoneal
inflammation

12. 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

13. Time Course

14. 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

15. Atypical presentations
Location 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

16. Complications
Rupture and sepsis
Periappendiceal Abscess
Death

17. 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?

18. 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?

19. Diagnostic scoring

20. 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

21. Differential Diagnosis

22. 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.

23. 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

24. Diagnostic Laparoscopy
Safe
Useful for when diagnosis is unclear
Esp in females w/ suspected gynae pathology (eg
PCOS/endometriosis/menstruating/ovulating)

25. Management
1.Supportive and symptomatic management
Antibiotics/fluids/etc
1.Treatment of underlying cause
Appendicectomy

26. What to do in ED/awaiting surgery
Resuscitation!
A: ensure airway patent
B: ensure adequate oxygenation
C: correct hypotension/tachycardia/instability

27. 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

28. 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

29. Procedures
Appendicectomy
Laparoscopic
Open
Diagnostic laparoscopy
Laparotomy

30. Appendicectomy - Laparoscopic
“Keyhole” surgery
Lower complication rate, quicker recovery
Sometimes difficulty in mobilisation requiring open procedure

31. 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

32. 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