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Acute appendicitis
- 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
- 5. Relevant Anatomy 1. The Appendix is… 2. McBurney‟s Poin Transverse colon Asc. colon Terminal Ileum Desc. colon ASIS Caecum Here! Sigmoid colon
- 6. 3. Places the appendix can hide… Relevant Anatomy … and during pregnancy
- 7. Paired organs Relevant 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. 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. “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 obstruction Pain: Location: Periumbilical (T10) Character: Dull Over time: Colicky Associated symptoms: Vomiting mucus distention Anorexia
- 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. 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. 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
- 16. Complications Ruptureand 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 2. What things could rule in or rule out other diagnoses?
- 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. 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
- 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. 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
- 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 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