ACUTE APPENDICITIS- AI Simulated Case Scenario discussions- Acute Abdomen

Acute Appendicitis Study Guide

Introduction and Etiology

• Acute appendicitis is a leading cause of right lower quadrant abdominal pain .

• Obstructive etiology includes the presence of fecoliths, worms such as Enterobius vermicularis, and lymphoid hyperplasia which is particularly common in children .

• Non-obstructive causes may include catarrhal infections .

  
  

Pathological Progression Timeline

• Phase 1 is the destructive trigger which may be initiated by a fecolith or mucosal inflammation .

• Phase 2 involves visceral distension where mucosal inflammation leads to sympathetic nerve stimulation .

• This phase results in poorly localized periumbilical pain and may be accompanied by nausea and vomiting .

• Phase 3 is somatic localization where the inflammation extends to the serosa and the parietal peritoneum .

• During this stage, pain migrates and localizes specifically to the right lower quadrant .

• Phase 4 represents the termination points where an extensive walling off reaction can form an appendix mass or the appendix may become gangrenous and perforate, leading to general peritonitis.

  
  

Clinical Presentation and Murphy’s Triad

• Murphy’s Triad is a classic diagnostic sequence consisting of pain in the right iliac fossa, followed by anorexia, nausea, or vomiting, and finally fever .

• The migration of pain from the periumbilical region to the right iliac fossa is considered highly specific for the diagnosis .

• Patients may also report constipation and a slightly elevated body temperature around 37.8 degrees Celsius .

  
  

Physical Examination Signs

• Tenderness is typically maximal at McBurney’s point .

• Rebound tenderness, also known as Blumberg’s sign, is a key indicator of localized peritoneal irritation .

• Rovsing’s Sign is positive when palpation of the left lower quadrant elicits pain in the right lower quadrant.

• Cope’s Psoas Test involves pain during the hyperextension of the right hip, which often suggests a retrocecal appendix.

• Cope’s Obturator Test involves pain on the internal rotation of the flexed right hip, indicating irritation of the obturator internus muscle.

• Cutaneous hyperesthesia may be detected within Sherren’s Triangle.

  
  

Alvarado Scoring System

• This system, often remembered by the mnemonic MANTRELS, uses a 10 point scale to guide clinical decisions .

• One point is assigned for each of the following symptoms: migration of pain, anorexia, and nausea or vomiting .

• Signs include right lower quadrant tenderness for 2 points, rebound tenderness for 1 point, and an elevated temperature above 37.5 degrees Celsius for 1 point.

• Laboratory criteria include leukocytosis for 2 points and a shift to the left of neutrophils greater than 75 percent for 1 point.

• A score less than 4 indicates a low probability and the patient can usually be discharged with instructions.

• A score between 5 and 7 warrants admission for active observation and serial examinations.

• A score between 8 and 10 indicates a high probability that requires immediate surgical intervention.

  
  

Diagnostic Investigations

• Essential laboratory tests include a total white blood cell count, C-Reactive Protein levels, and urinalysis to exclude urinary tract pathology.

• A Beta-HCG pregnancy test is mandatory for all women of childbearing age to rule out a life-threatening ectopic pregnancy.

• Ultrasound using a graded compression technique is the first-line imaging choice to avoid radiation exposure .

• Ultrasound findings of appendicitis include a non-compressible tubular structure with a diameter greater than 6mm and periappendicular fluid collection .

• Computed Tomography of the abdomen and pelvis provides the highest sensitivity, showing a dilated hypodense appendix, periappendicular fat stranding, and localized collections.

• An abdominal X-ray may occasionally reveal a fecolith or signs of a focal ileus .

  
  

Management and Treatment

• Laparoscopic appendectomy is the standard of care for uncomplicated appendicitis, offering faster recovery and lower infection rates.

• Perforated appendicitis requires an exploratory laparotomy or laparoscopy with thorough peritoneal toileting and intravenous antibiotics.

• An appendicular abscess smaller than 5cm is typically managed with ultrasound guided needle aspiration or a percutaneous tube drain .

• Abscesses larger than 5cm may necessitate an open surgical drain .

• An appendicular lump or phlegmon is generally managed conservatively through the Oschner-Sherren Regimen.

• The Oschner-Sherren Regimen involves keeping the patient nil per os, administering intravenous fluids and broad spectrum antibiotics, providing analgesics, and monitoring vital signs every 2 hours .

• Interval appendicectomy is often performed 6 to 8 weeks after successful conservative management of an appendicular lump .

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