Makindo Medical Notes

Related Subjects:Acute Cholecystitis |Acute Appendicitis |Acute Appendicitis in Children |Chronic Peritonitis |Acute Abdominal Pain/Peritonitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

⚠️ If tests are negative but suspicion remains high → consider diagnostic laparoscopy, esp. in young women (gynae mimics common). Even in expert hands, 15–20% of removed appendices may appear normal on histology.

ℹ️ About

• 📊 Prevalence: Affects 6–9% of population. Slight female predominance.
• ⚠️ Significance: Can cause sepsis/peritonitis if untreated.
• 👶 Age: Peak 10–20 yrs, but can occur at any age.
• ⚡ Complications: Higher perforation risk in children, elderly, immunocompromised.
• 🔀 Variable Presentation: Position of appendix alters symptoms (retrocaecal vs pelvic etc.).

🧬 Anatomy

• 📍 Location: Blind tube from caecum, ~8 cm long.
• 🔄 Position: Retrocaecal (60%), pelvic (30%), others rarer.
• 🩸 Blood Supply: Appendicular artery (branch of ileocolic).

🦠 Aetiology

• 🚧 Luminal obstruction: Faecolith = most common.
• 🦠 Infection: Trapped secretions → bacterial overgrowth.
• 💥 Perforation: Rising pressure → gangrene → rupture → peritonitis.

🔎 Causes

• 🧒 Lymphoid hyperplasia: Common in children post-viral illness.
• 💩 Faecolith / faecal stasis
• 🦠 Viral infection
• 🐛 Parasites: e.g. Enterobius (pinworm)
• 🎗️ Neoplasms: Rare, esp. in elderly.

📊 Epidemiology

• 📈 Incidence: ~16% lifetime risk. Declining with modern diet/lifestyle.
• ⏱️ Age: Peak = adolescence/early adulthood.

📍 Common Positions of the Appendix

• ↩️ Retrocaecal (60%): May cause back/flank pain.
• ⬇️ Pelvic (30%): Dysuria/diarrhoea more likely.
• 📍 Paracaecal (2%)
• 📍 Pre-/Post-ileal (1% each): Post-ileal often → diarrhoea.

🩺 Clinical Presentation

• 🌡️ Sepsis: Fever >37.5°C, tachycardia, dehydration.
• ➡️ Pain: Periumbilical → migrates to RIF (classic). Perforation → diffuse peritonitis.
• 👆 Exam: McBurney’s tenderness, guarding, rebound. Rovsing’s sign +ve. Rectal exam if pelvic/retrocaecal suspected.

🧪 Investigations

• 🩸 Bloods: WCC ↑, CRP ↑. β-HCG in females.
• 🖥️ Imaging: • USS → children/pregnancy. • CT → adults (inflamed, >6 mm, appendicolith, fat stranding). • Diagnostic laparoscopy if uncertain.
• 💧 Urinalysis: To rule out UTI.

⚠️ High-Risk Groups

• 👶 Children: Often misdiagnosed as gastroenteritis.
• 👵 Elderly: Atypical signs, higher perforation risk.
• 🤰 Pregnancy: Can mimic obstetric/gynae issues.

📉 Clinical Outcomes

• ✅ Early surgery = excellent recovery.
• 💥 Risk of rupture ↑ after 48 hrs → peritonitis/sepsis.
• 🛡️ Appendix mass/abscess → may wall off → interval appendicectomy later.

🎭 Differentials

• UTI, gastroenteritis, mesenteric adenitis
• IBD (Crohn’s, UC), diverticulitis, TB/Yersinia
• Ectopic pregnancy, ovarian torsion, salpingitis
• Meckel’s diverticulitis

⚠️ Complications

• 💥 Perforation → diffuse peritonitis.
• 🛡️ Appendix mass/abscess.
• 🔪 Surgical risks: bleeding, infection, adhesions, visceral injury.
• 🏥 Post-op: abscess, DVT/PE, ARDS, sepsis.

💊 Management

• 💉 Stabilisation: IV access, fluids, analgesia.
• 🥛 NBM: Prepare for theatre.
• 💊 Antibiotics: IV broad-spectrum (cefuroxime + metronidazole).
• 🔪 Surgery: • Laparoscopic appendicectomy = gold standard (fast recovery, less infection). • Open = if perforated/generalised peritonitis. • Conservative = appendix mass/abscess (interval appendicectomy later).
• 👩‍⚕️ Special notes: • Pregnancy → surgery still safer than untreated appendicitis. • Elderly → maintain high suspicion, as perforation risk high.

Case 1 – Classic acute appendicitis

A 21-year-old student develops vague periumbilical pain that migrates to the right iliac fossa over 12 hours with anorexia, nausea, low-grade fever, and localised guarding. WBC/CRP are elevated; pregnancy test negative. Ultrasound is equivocal, so CT abdomen/pelvis confirms an enlarged, non-compressible appendix with periappendiceal stranding. Manage with IV fluids, analgesia, antibiotics (per local policy), and proceed to laparoscopic appendicectomy; counsel on risks and consider same-day discharge if uncomplicated. 🤒🔪

Case 2 – Atypical in pregnancy

A 28-year-old at 22 weeks gestation presents with constant right upper quadrant/flank pain, vomiting, and low-grade fever; uterine displacement makes localisation atypical. LFTs/urine are normal; MRI (to avoid radiation) shows an inflamed retrocaecal appendix displaced cephalad. Start IV antibiotics, fluids; early laparoscopic appendicectomy by an experienced team is performed with fetal monitoring. Differentiate from biliary disease or pyelonephritis; prompt treatment reduces risks of perforation and preterm labour. 🤰🩺

Case 3 – Appendiceal mass/possible abscess

A 55-year-old presents after 5 days of RIF pain, low-grade fever, and anorexia; exam reveals a tender, fixed RIF mass with raised inflammatory markers. CT shows phlegmon with a small contained collection. Manage conservatively (Ochsner–Sherren): IV antibiotics, fluids, bowel rest, and interventional radiology drainage if sizable abscess. Plan interval appendicectomy and arrange post-episode colonoscopy (age >40) to exclude neoplasm. Watch for deterioration suggesting rupture or generalised peritonitis requiring surgery. 🧪📉