Marlene

Hall Case 7 Wrap

MARLENE HALL CASE WRAP

Case 7 (Abdominal Pain)

DIAGNOSIS: ACUTE APPENDICITIS

University of Adelaide
MBBS I 2017
 Marlene Hall Case 7 Wrap

TABLE OF CONTENTS
ANATOMY & PHYSIOLOGY .............................................................................................................. 3
1. ANATOMY OF THE PELVIS AND LOWER ABDOMEN .............................................................................. 3
2. NEURAL PATHWAYS & EMBRYOLOGY ............................................................................................... 6

PATHOLOGY AND PATHOPHYSIOLOGY ........................................................................................... 7

1. ACUTE AND CHRONIC INFLAMMATION ............................................................................................. 7
2. APPENDICITIS ............................................................................................................................... 7

CLINICAL REASONING AND CLINICAL SCIENCE ................................................................................. 8

1. DIFFERENTIALS FOR RIGHT ILIAC FOSSA PAIN ..................................................................................... 8
2. ABDOMINAL EXAMINATION & INVESTIGATIONS ................................................................................. 9
3. MECHANISMS ............................................................................................................................ 10

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ANATOMY & PHYSIOLOGY

1. ANATOMY OF THE PELVIS AND LOWER ABDOMEN

Describe the anatomy of the pelvis and lower abdomen.
Abdominal Wall

• Is muscoluaponeurotic
• Extends from thoracic cage to pelvis
th th
• Bounded superiorly by cartilages of 7 – 10 rubs and xiphoid process and inferiorly by inguinal
ligament and superior margins of anterolateral aspects of pelvic girdle

Fascia

• Subcutaneous tissue
o Consistent with that found in most regions above
the umbilicus
o Reinforced by many elastic and collagen fibres
below the umbilicus, has 2 layers
§ Superficial fatty layer (Camper fascia)
§ Deep membranous layer (Scarpa fascia)
• Investing fascia
o Superficial, intermediate and deep layers cover external aspects of 3 muscle layers and their
aponeuroses (flat expanded
tendons)
• Endoabdominal fascia
o Membranous and areolar
sheets of varying thickness
o Transversalis fascia
• Extraperitoneal fat
• Parietal peritoneum

Muscles
• 5 bilaterally paired muscles
• 3 flat muscles
o External oblique
o Internal oblique
o Transversus abdominis
• 2 vertical muscles
o Rectus abdominis
o Pyramidalis

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Muscle Origin Innervation Main Action

th th
External External surfaces of 5 -12 ribs T7-T11 spinal Compresses and supports abdominal
oblique nerves and viscera, flexes and rotates trunk
subcostal nerve

Internal Thoracolumbar fascia, anterior 2/3 of iliac crest, T6-T12 spinal

oblique connective tissue deep to lateral third of inguinal nerves and first
ligament lumbar nerves
th th
Transversus Internal surfaces of 7 -12 costal cartilages, Compresses and supports abdominal viscera
abdominis thoracolumbar fascia, iliac crest, connective
tissue deep to lateral third of inguinal ligament
Rectus Pubic symphysis and pubic crest T6-T12 spinal Flexes trunk and compresses abdominal
abdominis nerves viscera, stabilizes and controls tilt of pelvis
Nerves

• Thoraco-abdominal nerves (T7-T11) à muscles of anterolateral abdominal wall and overlying skin
• Lateral cutaneous brances (T7-T10) à right and left hypochondriac regions
• Subcostal nerve (T12) à superior to iliac crest and inferior to umbilicus
• Iliohypogastric and iluo-inguinal nerves (L1)

Appendix (vermiform appendix)

• Attached to the posteromedial surface of the cecum

• Small mesentery (mesappendix) connects appendix to ileum and cecum
• Position corresponds with McBurney’s point (1/3 the distance from the anterior superior iliac spine
ASIS to the umbilicus)
• Tip of appendix can be variably located, retrocecal is most common

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Female Genitourinary and Reproductive Anatomy

Menstrual cycle (4 phases)

• Menstruation
o Elimination of thickened endometrium
o Average length is between 3 days and one week
• Follicular phase
o Begins first day of menstruation and ends with
ovulation
o Stimulation of pituitary gland from hypothalamus
to release follicle stimulating hormone
o Ovary is stimulated to produce 5-20 follicles which
bead on the surface
o One immature egg matures while the others die
• Ovulation
o Release of mature egg from surface of ovary
o ~ 2 weeks before menstruation starts
• Luteal phase
o Ruptured follicle becomes a corpus luteum which
produces hormones
o Around day 22, if pregnancy does not occur, this
corpus luteum dies, and the drop in hormones
stimulates menstruation

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2. NEURAL PATHWAYS & EMBRYOLOGY

Explain the neural pathways related to the different types of abdominal pain, including an outline of
the embryological origins of the gut.
See Case 6 Wrap for abdominal pain and referred pain

Embryology

• Gut is endoderm-derived
• Ectoderm differentiates to form nervous system and development of gut corresponds with referral pain
to different regions
• Embryo folds ventrally causing piece of yolk sac to punch off to become the primitive gut
• Yolk sac remains connected to gut tube via vitelline duct (can become Meckel’s diverticulum if not
closed properly)

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PATHOLOGY AND PATHOPHYSIOLOGY

1. ACUTE AND CHRONIC INFLAMMATION

Describe in detail the processes involved in acute and chronic inflammation and the systemic effects.
Acute Inflammation

• Biological response of body tissue to harm stimuli

• Protective response involving immune cells, blood vessels and molecular mediators
• Function is to eliminate initial cause of cell injury, clear out necrotic cells and tissues damage and to
initiate tissue repair
• HEAT, PAIN, REDNESS, SWEELING, LOSS OF FUNCTION

Chronic Inflammation

• Occurs when the antigen persists, inflammation response is over stimulated or inflammation response
is under-regulated
• Attempting to heal while damage is still occurring (will result in a scar if stimulus is removed)
• Activation of T-Cells which furthers exacerbates inflammation

2. APPENDICITIS
Explain the aetiology of appendicitis and provide mechanisms for symptoms and signs.
See Mechanisms

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CLINICAL REASONING AND CLINICAL SCIENCE

1. DIFFERENTIALS FOR RIGHT ILIAC FOSSA PAIN

List and explain the differential diagnosis/causes of right iliac fossa pain
Cause of Pain Mechanism of pain Symptoms Risk Factors
Appendicitis Obstruction of appendicitis (due to • Vague diffused pain which then localises to • Occurs in 10% of the
faecalith, undigested seeds, right lower quadrant (McBurney’s point – 1/3 population
lymphoid follicle) à Build-up of of the distance from the anterior superior iliac • Lymphoid follicle occurs
fluids and mucus in appendix à spine to umbilicus) usually during
gut flora multiplies à • Fever adolescence
inflammation of appendix à • Nausea • Ages 10-30
stimulation of visceral fibres à • Vomiting • Recent infection
vague abdominal pain • Rebound tenderness • IBD
• Abdominal guarding • Trauma to appendix
Inflammation à compression of • Low fibre diet
blood vessels à ischaemia à
rupture of appendix à formation
of abscess

Mesenteric Infection à swelling of lymph • Diffused pain which can sometimes be centred • Recent infection
adenitis nodes à irritation of peritoneum on lower, right side • More common in children
à abdominal pain • Abdominal tenderness
• Fever
• Sometimes diarrhoea, nausea and vomiting
Diverticulitis Mechanism is not completely • Tenderness, cramps, pain • Low fibre diet
understood: • Fever • Family Hx of diverticulosis
Inflammation of diverticula • Bloated feeling • Use of NSAIDs
(pouches in wall of colon) à • Diarrhoea
irritation of peritoneum à • Nausea and vomiting
abdominal pain • Loss of appetite
Ectopic Improper implantation of fertilised • Vague, diffused pain which then becomes • Pelvic inflammatory disease
pregnancy egg (usually in fallopian tubes) à sharp pain • Smoking
distension of tissue à irritation of • One-sided abdominal pain • Previous Hx
peritoneum à abdominal pain • Vaginal bleeding • Fertility treatment
• Shoulder tip pain (irritation of phrenic nerve • Increasing age (35-40)
from internal bleeding)
• Pain while passing urine
• Tenderness in suprapubic area
Pelvic Infection in vagina à infection • Lower abdominal pain/tenderness • Chlamydia 50% of cases,
inflammatory spreads to cervix, endometrium • Menstrual disturbances Gonorrhoea 25% of causes
disease and fallopian tubes • Change in smell, colour, amount of vaginal • Sexually active woman <25
discharge years old
• Deep pain during sexual intercourse • Unprotected sex
• Fever • Hx of PID or STI
Bowel Obstruction of bowels à • Colicky pain (more so in small intestines) • Previous surgery in
obstruction distension • Distension/Bloating abdomen
• Constipation • IBD
• Vomiting (more so with small bowel) • Constipation
• Tenderness
• Loss of ppetite

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2. ABDOMINAL EXAMINATION & INVESTIGATIONS

Explain how to perform an organ-specific abdominal examination including renal angle, rectal
examination, abnormal masses.
Interpret the findings of an abdominal examination for abdominal pain.
Interpret investigations related to abdominal pain.
Renal Angle

• Percussion over the area of the back overlying the kidney

(costovertebral angle – angle made by vertebral column and costal
margin)
• Percussion may disturbed inflamed tissue, causing pain
• If pain is caused, indication of infection around kidney

Rectal Examination

Possible positions

• Standing position: standing toes pointing in, leans over table

• Sims position: patient lies on left side with left leg straight and right hip bent
• Knee to chest: Lying face down with knees up to chest bent forward

Inspection of anus

• Look for external haemorrhoids, fissures , skin tags, warts or discharge

Palpation

• Use small amount of lubricant on index finger

• Ask patient to take deep breath and insert finger facing down
• Appreciate the external sphincter tone and then ask patient to bear down and feel for tightening of
sphincter
• Palpate prostate gland
o Note approximate size
o Feel for tenderness
o Feel for nodules or masses
• Palpate rectal wall clockwise

Pregnancy Test

• Rosette inhibition assay for early pregnancy factor (EPF) which is detected in the blood within 48 hours
of fertilization – this is expensive and time-consuming
• Most other tests look for presence of the beta subunit of hCG (human chorionic gonadotropin)

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Urine Microscopy

• Done on a urine sediment – urine centrifuged to concentrate substances

• Substances that could be present:
o RBCs
o WBCs
o Epithelial cells
o Bacteria, yeast, parasites

Complete Blood Examination

• Leukocytes present in inflammatory pathologies

Electrolytes Urea and Creatinite

• Could detect UTI or kidney infection

• Presence of bacteria, blood, protein, urea, creatinine

Laparoscopy

• Right side up, steep Trendelenburg position

• Supraumbilical curvilinear incision above umbilicus
• Inflate abdomen
• 10mm instrument port
• Look for caecum and appendix
• Grasp appendix and divide the mesoappendix toward the base of the appendix
• Encircle the free edge with an endoloop
• Apply clips on proximal and distal end
• Cut and remove appendix via endobag
• Irrigation and suction

3. MECHANISMS
Understand the natural history of appendicitis and account for the symptoms and signs.
Explain the significance and mechanism of vomiting in cases of lower GI pathology.
Explain the mechanisms of disturbances of bowel function.
Explain the mechanism of voluntary/involuntary guarding, rebound tenderness and cross tenderness
during an abdominal examination.
Describe the complications of acute appendicitis and the symptoms and signs associated with those
complications.
Nausea

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Mesenteric Adenitis

Ectopic Pregnancy

Bowel Obstruction

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Diverticulitis

PID/Salpingitis

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Appendicitis/Mega-Mechanism
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