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? umbilicus7. What organs cause lower abdo pain? ASIS Pubic symphisis
Time Course Irritation of parietalAppendiceal Appendiceal peritoneum Perforation, localisedobstruction/early distension (localised) /generalisedappendicitis –visceral peritoneal peritonitis, mass •Constant RIFirritation pain, pain on • Anorexia, vomi coughing, going •Fever/Sepsis • Periumbilical ting, malaise over bumps etc colicky pain
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 Signs/symptomsappendixMcBurney‟s point “typical” presentation, Rovsig signRetro/paracaecal Psoas sign/flank pain/absence of peritonismRetro/paraileal Diarrhoea, crampy painPelvic Suprapubic pain, urinary frequency, pyuria
Complications Ruptureand 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 appendix2. What things could rule in or rule out other diagnoses?
What to order?1. What things could support your diagnosis ie inflamed/infected/obstructed appendix2. What things could rule out other diagnoses Ie gastro, sbo, ovarian problems, PID, UTI, renal colic, diverticulitis, crohn‟s ectopic etc etc
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/etc2. Treatment of underlying cause Appendicectomy
What to do in ED/awaitingsurgery 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
Appendicectomy -Laparoscopic “Keyhole”surgery Lower complication rate, quicker recovery Sometimes difficulty in mobilisation requiring open procedure
Appendicectomy - Open Incisionover 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
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