Appendicitis

Introduction

  • Accounts for 2-10% surgical admissions
  • Almost twice as common in men
  • Any age affected, commonest in 20s & 30s
  • 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

 

 

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