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 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
 Relevant Anatomy
1. The Appendix is… 2. McBurney‟s Poin
Transverse colon

Asc. colon
Terminal Ileum
Desc. colon

ASIS
Caecum

Sigmoid colon
Here!
3. Places the appendix can hide…

Relevant Anato my

… and during pregnancy

 Paired organs unpaired
Relevant Anatomy
4. Innervation of appendix & other organs T6

Foregut
(inc. duodenum)

Midgut
T10
umbilicus
(inc. appendix)

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
Anorexia
 distention
 Later Appendicitis Distention causing
ischaemia
Pain:

Location:
 R Iliac Fossa
Character: Localised
 Localised peritoneal
Over time: Constant
 inflammation

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
obstruction/early distension Perforation, localised
(localised) /generalised
appendicitis –
visceral peritoneal •Constant RIF peritonitis, mass
irritation 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 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
Complications
Rupture and
 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
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, crohn‟s ectopic etc
etc
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

 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)
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
“Keyhole”
 surgery
Lower complication rate, quicker recovery

Sometimes difficulty in mobilisation requiring

open procedure
 Appendicectomy - Open
Incision
 over 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
