Acute appendicitis


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Acute appendicitis

  1. 1. AcuteAppendicitis
  2. 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. 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. 4. 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
  5. 5. Relevant Anatomy 1. The Appendix is… 2. McBurney‟s Poin Transverse colonAsc. colon Terminal Ileum Desc. colon ASISCaecum Here! Sigmoid colon
  6. 6. 3. Places the appendix can hide… Relevant Anatomy … and during pregnancy
  7. 7. Paired organsRelevant Anatomy unpaired 4. Innervation of appendix & other organs T6 Foregut (inc. duodenum) Midgut (inc. appendix) T10 umbilicus ASIS T12 Hindgut Lower urinary tract Pubic Sexual organs symphisis
  8. 8. Relevant Anatomy 5. Structures near the appendix 6. R abdominal pain• Caecum• Ileum• Ureter• Ovary• Bladder• Asc Colon• Psoas• Inguinal canal• Iliac vessels 7. Pelvic/lower abdo pain
  9. 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. 10. Early Appendicitis obstruction  Pain:  Location: Periumbilical (T10)  Character: Dull  Over time: Colicky  Associated symptoms:  Vomiting mucus distention  Anorexia
  11. 11. Later Appendicitis Distention causing ischaemia Pain:  Location: R Iliac Fossa  Character: Localised Localised peritoneal inflammation  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
  12. 12. Late Appendicitis Gangrene 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)
  13. 13. 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
  14. 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. 15. 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
  16. 16. Complications Ruptureand sepsis Periappendiceal Abscess Death
  17. 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. 18. 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?
  19. 19. Diagnostic scoring Alvarado score  RIF tenderness +2  1-4: Very unlikely  Increased WCC +2  5-6: Possible  Pain that migrates to RIF  7-8: Very probable +1  9-10: Definite  Rebound tenderness +1  Anorexia +1  Nausea/Vomiting +1  Fever +1  WCC- „left shift‟ +1
  20. 20. 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
  21. 21. Differential Diagnosis GI tract - asc  Urinary tract – colon, caecum, ileum ureters, bladder  Infectious gastroenteritis  UTI  Mesenteric adenitis  Renal/ureteric colic (post-viral)  Female reproductive  R sided diverticulitis (inc tract- ovaries, tubes Meckel’s)  Mittelschmerz  Crohn‟s/IBD  PID  Tumour  Cyst rupture  SBO  Torted cyst/tube  herniae  Ectopic pregnancy  Weird/wonderful  Musculoskeletal  Shingles
  22. 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. 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. 24. Diagnostic Laparoscopy Safe Useful for when diagnosis is unclear Esp in females w/ suspected gynae pathology (eg PCOS/endometriosis/menstruating/ovulating)
  25. 25. Management1. Supportive and symptomatic management Antibiotics/fluids/etc2. Treatment of underlying cause Appendicectomy
  26. 26. What to do in ED/awaitingsurgery Resuscitation!  A: ensure airway patent  B: ensure adequate oxygenation  C: correct hypotension/tachycardia/instability
  27. 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. 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. 29. Procedures Appendicectomy  Laparoscopic  Open Diagnostic laparoscopy Laparotomy
  30. 30. Appendicectomy -Laparoscopic “Keyhole”surgery Lower complication rate, quicker recovery Sometimes difficulty in mobilisation requiring open procedure
  31. 31. 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
  32. 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