Inflammation of the appendix, mostly occuring when lumen of the appendix becomes obstructed with a faecolith (however in some cases there is only generalised acute inflammation). If the appendix is not removed at this stage, gangrene occurs with perforation, leading to a localised abscess or to generalised peritonitis. Affects all age groups. Most common surgical emergency.
- Abdominal pain - intiallly vaguely central then moving to right iliac fossa
The anatomical location of the appendix can influence the presentation of appendicitis:
- Retrocaecal (70%) - poorly localised abdominal pain or even RUQ in a long appendix. A positive psoas sign can indicate a retroceacal appendix.
- Pelvic (21%) - diarrhoea due to proximity to the rectum
- Close to bladder - frequency and dysuria
- The anatomical location of the appendix is commonly referred to as McBurney's point and is located 1/3 of the distance from the umbilicus to the anterior superior iliac spine (ASIS).
Perform a full abdominal examination in patients with appendicitis
- Patients will often lie down and flex their hips and knees to try and relieve the pain
- Tenderness in right iliac fossa
- Guarding (localised peritonitis)
- Tender mass in right iliac fossa
- Rebound tenderness (pain worsening on release of pressure)
- Ectopic Pregnancy – Abnormal implantation of embryo mainly in fallopian tubes causing abdo pain
- Mesenteric adenitis – Inflamed lymph nodes secondary to infection. Can cause RLQ pain and fever.
- Urinary tract infection. Frequency, dysuria, abdo pain and fever.
- Cholecystitis – Inflammed gallbladder. Poorly localised abdo pain
- Diverticulitis – Inflammed outpouchings of colon. Abdo pain, fever, nausea
- Salpingitis – Infection and inflammation of fallopian tubes. Abdo pain, fever, nausea and vomiting (PID)
- Dysmenorrhoea – Pain during menstruation. Lower abdo pain, fever, nausea and vomiting
- Pelvic Inflammatory Disease (PID)
- Ovarian cyst or torsion of ovarian cyst (when the cyst twists around and cuts off its own blood supply leading to infarction and severe pain)
- Crohn's Disease – IBD. Abdo pain, fever
- Perforated ulcer – Perforated peptic ulcer. Abdo pain, fever, nausea and vomiting.
- Gastroenteritis – An inflamed appendix next to rectum can cause diarrhoea symptoms.
- Meckel’s Divertivulum – Congenital diverticulum in distal ileum can become inflammed. Abdo pain, fever, nausea and vomiting
- Intussusception - mostly seen in paediatrics (an area of bowel telescopes in on itself and compromises its blood supply leading to pain and blood in stool)
- Urinalysis – Dipstick to exclude UTI
- Pregnancy test – beta HCG to exclude ectopic pregnancy
- Chest X Ray– pneumoperitoneum showing perforated bowel
- Ultrasound - detection of inflamed appendix, and reveals abscesses
If further conformation is required in unusual cases:
- MRI scan
- PR and PV exam to exclude IBD, gynaecological causes
- Exploratory laproscopy
Primarily clinical from the history and examination of the patient. The Alvarado score can be used to crudely assess the probablity of appendicitis in a patient although research has shown it is sensitive it is not specific enough to be validated.
|Symptoms||Migration of pain||1|
|Temperature > 37.3 °C||1|
|Neutrophils > 75% WCC||1|
<= 4 Appendicitis unlikely
5-6 Observe patient
>= 7 Operation required
- IV access
- Give IV fluids and antibiotics
- Give analgesia and antiemetics as required
- Appendectomy - either laparotomy/laparoscopy