Acute appendicitis

1. 10% population will develop it
2. Commonest between 10 and 20.
   1. Uncommon before 2 years
3. A normal appendix is removed at 10-20% of appendicectomies.

1. An obstructed system gets infected.

   Annotations:

   • Cholangitis and pyelonephritis are similar in this respect.
   1. Faecolith or enlarged piece of lymphoid tissue ? response to viral illness.
      1. Much rarer causes are caecal cancer and carcinoid tumours

1. Initially colicky midgut pain
   1. Peritonitic pain as the inflammation spreads to involve the parietal peritoneum.
      1. Associated with fever, anorexia, N+V
         1. Pain before the vomiting usually. Constipation rather than D
2. Abdo tenderness, guarding, rebound and percussion tenderness.
   1. Rovsing's sign positive

      Annotations:

      • Palpation of the left iliac fossa makes the pain worse as the peritoneum is being stretched.
   2. Tenderness on digital rectal exam.
      1. Inflammatory fluids, maybe pus tracked into the pouch of Douglas.
   3. Psoas sign

      Annotations:

      • Pain on extending the hip
      1. Retrocaecal appendix
   4. Cope sign

      Annotations:

      • Pain on flexion and int flexion of R hip
      1. Appendix in close relation to obturator internus
3. Appendix mass
   1. Walled off by the omentum and small bowel, and then presents.

      Annotations:

      • Usually occurs 72 after the inflammation begins/onset of symptoms.
      1. Palpable mass
         1. Gets better with Abx, or abscess that requires drainage.
            1. Elective appendicectomy 3 months later (Ochsner-Sherren regimen).

               Annotations:

               • 20% may develop recurrent appendicitis otherwise.

Annotations:

• Need to know the basic operation.

1. RIF mass
   1. Appendix mass
      1. Gynae mass - ovarian cyst
         1. Caecal cancer
            1. Soft tissue tumour e.g. sarcoma
               1. LN mass
                  1. TB
                     1. Actinomycoses
                        1. Transplant kidney
                           1. Iliac aneurysm
2. RIF pain
   1. Ectopic pregnancy
      1. Acute appendicitis
         1. PID
            1. Ovarian cyst
               1. Perforated PU
                  1. Meckel's
                     1. UTI
                        1. Ureteric colic
                           1. Mesenteric adenitis
                              1. Crohn's disease
                                 1. Caecal cancer
3. Periumbilical (colicky pain)
   1. SBO
      1. Early appendicitis
         1. Ischaemic bowel
            1. Mesenteric adenitis
               1. Pancreatitis

1. CT scan
   1. Decreases false negative operation rate, but increases delay