Appendicitis

What is it?

Fig 1

Appendicitis is an acute inflammation of the appendix, which is a small, narrow tube (about 5–10 cm) that is connected to the caecum (the proximal part of the large intestine).

It is thought to be caused by infection secondary to obstruction of the lumen of the appendix.

Risk Factors

• Age (most common between the ages of 10–20 years)

• Male sex

• Frequent antibiotic use

• Smoking.

Prevalence

• Appendicitis accounts for more than 40,000 hospital admissions in England every year.

• It is one of the most common causes of abdominal pain in young adults and children in the UK.

Complications

• Appendix perforation

• Generalized peritonitis

• Appendix mass or abscess

• Sepsis

• Death. However, the prognosis is good if the person is managed promptly.

Diagnosis

Fig. 2 – Most common causes of abdominal pain per region 

The diagnosis of appendicitis relies on a thorough history and examination. The classic symptoms are:

• Abdominal pain — this is the primary presenting complaint, and it is typically described as a peri-umbilical or epigastric pain that worsens during the first 24 hours (becoming constant and sharp) and migrates to the right iliac fossa (RIF). The pain is typically worsened by movement.

 • Loss of appetite — almost always present.

• Nausea.

• Constipation.

• Vomiting (profuse vomiting may indicate development of peritonitis).

Examination

On examination, there may be:

• Tenderness on percussion

• Guarding, and rebound tenderness in the RLQ — these are the most reliable clinical findings.

Fig. 3 – Signs and Symptoms of Appendicitis 

 • Facial flushing

• Dry tongue

• Halitosis (bad breath)

• Low-grade fever (not more than 38°C), and/or tachycardia.

The classic presentations of appendicitis may only occur in 50% of people. They:

• Often do not appear in young children, pregnant women, and elderly people — there should be a low threshold for referral in these groups of people.

• Can be influenced by the anatomical position of the appendix, which can vary. (See figure 4 )

Differential diagnosis

Differential diagnoses of appendicitis include:

• Gastrointestinal conditions, such as intestinal obstruction, perforated peptic ulcer, and diverticulitis 

• Urological conditions, such as right ureteric colic and urinary tract infection.

• Gynaecological conditions, such as ectopic pregnancy and pelvic inflammatory disease.

Treatment

Fig. 4 –  Anatomical locations of the appendix

• There are no specific investigations needed to diagnose appendicitis; however, blood and urine tests may be useful to exclude alternative diagnoses.

• Follow Sepsis protocol if triggered on NEWS score or bloods / blood gas

• Seek early surgical opinion

• Appendectomy (surgical removal of the appendix) is the treatment of choice.

Key Points to Remember

• Not all patients present the same way, and pain may not be in traditional places 

• Paediatrics can compensate for a long time and may appears well before a sudden deterioration

• Diagnosis is not by one test. Build a clinical picture by taking a full history and then using observations, blood results and looking at the patient to make a plan. 

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