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? umbilicus
7. What organs cause lower abdo pain?
ASIS
Pubic
symphisis
13. Time Course
Irritation of parietal
Appendiceal Appendiceal
peritoneum Perforation, localised
obstruction/early distension
(localised) /generalised
appendicitis –
visceral peritoneal peritonitis, mass
•Constant RIF
irritation pain, pain on
• Anorexia, vomi coughing, going •Fever/Sepsis
• Periumbilical ting, malaise over bumps etc
colicky pain
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 Signs/symptoms
appendix
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
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
2. What things could rule in or rule out other
diagnoses?
20. What to order?
1. What things could support your diagnosis
ie inflamed/infected/obstructed
appendix
2. What things could rule out other
diagnoses
Ie gastro, sbo, ovarian
problems, PID, UTI, renal
colic, diverticulitis, crohn‟s ectopic etc
etc
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
2. 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
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. 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
