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
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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 Point
Transverse colon

Asc. colon
Terminal Ileum
Desc. colon

ASIS
Caecum

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

Relevant Anatomy

… and during pregnancy

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

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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
 Anorexia distention
 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/generalis
appendicitis –
visceral peritoneal ed 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
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
 Increased WCC +2
 Pain that migrates to
RIF +1  1-4: Very unlikely
 Rebound tenderness
 5-6: Possible
+1
 Anorexia +1  7-8: Very probable
 Nausea/Vomiting +1  9-10: Definite
 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 colon,
 Urinary tract – ureters,
caecum, ileum bladder
 Infectious  UTI
gastroenteritis  Renal/ureteric colic
 Mesenteric adenitis  Female reproductive
(post-viral) tract- ovaries, tubes
 R sided diverticulitis  Mittelschmerz
(inc Meckel’s)  PID
 Crohn’s/IBD  Cyst rupture
 Tumour  Torted cyst/tube
 SBO  Ectopic pregnancy
 herniae
 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
 Systemicinflammatory 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
 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
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