You can have it more than once - getting it does not always mean an operation or admission to hospital is required
A normal appendix is removed in 1:5 cases
There are no diagnostic tests, scoring systems or algorithms that give a conclusive diagnosis – Appendicitis is a clinical diagnosis based on experience.
As for diagnosing the type of inguinal hernia - you will be wrong 50% of the time
In general, 50% of the RIF pain you see in A&E goes home, 25% have mesenteric adenitis and the rest genuine appendicitis.
Please remember to do an Amylase!
Please remember to do a pregnancy test in ALL women who are in their childbearing years.
Don’t waste money on CRP, or ESR, but do dipstick the urine!
Don’t start antibiotics before surgery, unless the patient is septic and you have done blood cultures first.
Clinical Features
Classically - central colicky abdominal pain moving becoming sharp right iliac fossa pain
Nausea, vomiting, anorexia, foetor oris
Pyrexia - degree depends on level of sepsis
Rovsing's sign = pain in right iliac fossa on palpation of the left iliac fossa - NOT diagnostic or always present
Investigations
Are for narrowing the differential (below), not for making the diagnosis
Pregnacy test - see above
Amylase - see above
Plain AXR - waste of time
USS - useful in experienced hands, but only if the appendix can be visualised
CT - only really indicated if a mass is palpable (but do USS first in younger patients)
Differential Diagnosis
Mesenteric Adenitis
UTI
Non-specific abdominal pain (NSAP)
Pelvic inflammatory disease (PID)
Renal colic
Ectopic pregnancy
Constipation (this is not a diagnosis, but a symptom)
Crohn's disease
Caecal carcinoma
Mucocele of the gallbladder
Psoas abscess
Pelvic kidney
Ovarian cyst
diverticulitis
Treatment
Adequate analgesia
Antibiotics only with evidence of sepsis
Period of active observation if there is clinical doubt (esp in children) - this means free fluids can be taken
Never be afraid to ask for a second opinion (esp in children)
Diagnostic laparoscopy is very useful esp in women. If a 'firm' clinical diagnosis is made in men, there is little benefit in laparoscopy except in overweight patients.
5mm laparoscope in children is useful
Try to avoid muscle cutting incisions - they are painful
