Acute

Appendicitis
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 Anatomy
1. Where is the appendix? What is it
attached to?
2. Where is McBurneys 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
 Relevant Anatomy
1. The Appendix is 2. McBurneys Poin
Transverse colon

Asc. colon
Terminal Ileum
Desc. colon

ASIS
Caecum

Here! Sigmoid colon

3. Places the appendix can hide

Relevant Anatomy

and during pregnancy

 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
 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

Typical Presentation
Dull,crampy central abdo pain
Malaise/vomiting/anorexia/low grade
fevers
Pain worsens & localises to RIF with
cough/movement tenderness
Systemic symptoms
Early Appendicitis
obstruction

Pain:
Location: Periumbilical (T10)
Character: Dull
Over time: Colicky
Associated symptoms:
Vomiting

mucus
distention
Anorexia
 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

 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)
 Time Course

Irritation of parietal
Appendiceal Appendiceal
peritoneum Perforation,
obstruction/early distension
(localised) localised/generalise
appendicitis
visceral peritoneal d peritonitis, mass
Constant RIF
irritation pain, pain on
Anorexia, coughing, going Fever/Sepsis
Periumbilical vomiting, over bumps etc
colicky pain malaise
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 presentations
Location of Signs/symptoms
appendix
McBurneys 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
Complications
Ruptureand sepsis
Periappendiceal Abscess
Death
Clinching the diagnosis
Appendicitis is usually a clinical diagnosis-
ie history + examination.
However sometimes youre 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
appendix
2. What things could rule in or rule out other
diagnoses?
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
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, crohns ectopic
etc etc
Differential Diagnosis
GI
tract - asc colon, Urinary
tract ureters,
caecum, ileum bladder
Infectious gastroenteritis UTI
Mesenteric adenitis Renal/ureteric colic
(post-viral) Female reproductive
R sided diverticulitis (inc tract- ovaries, tubes
Meckels) Mittelschmerz
Crohns/IBD PID
Tumour Cyst rupture
SBO Torted cyst/tube
herniae Ectopic pregnancy
Weird/wonderful
Musculoskeletal
Shingles
 Pathology/Lab investigations
Whitecell 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)
Management
1. Supportive and symptomatic
management
Antibiotics/fluids/etc

2. Treatment of underlying cause

Appendicectomy
What to do in ED/awaiting
surgery
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
Procedures
Appendicectomy
Laparoscopic
Open
Diagnostic
laparoscopy
Laparotomy
Appendicectomy -
Laparoscopic
Keyholesurgery
Lower complication rate, quicker recovery
Sometimes difficulty in mobilisation requiring
open procedure
 Appendicectomy - Open
Incisionover McBurneys point or point of maximal
tenderness
Straightforward, good exposure, technically easier
Longer recovery, risk of hernia & adhesions, cant
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