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1536708775065Complications00Complications14605008775700Acute: perforation (pain >36 hours; diffuse; less likely to localised to RIF; pain free interval in 5%; vomiting, fever, change in bowel habit more common; suspect if WBC >15, T >38°C), abscess, peritonitisPost-op: wound infection, pelvic collection (fever, abdominal pain, mucous diarrhoea; within days), peritonitis (rare, due to poor surgical technique)Long term: infertility, adhesions (uncommon)00Acute: perforation (pain >36 hours; diffuse; less likely to localised to RIF; pain free interval in 5%; vomiting, fever, change in bowel habit more common; suspect if WBC >15, T >38°C), abscess, peritonitisPost-op: wound infection, pelvic collection (fever, abdominal pain, mucous diarrhoea; within days), peritonitis (rare, due to poor surgical technique)Long term: infertility, adhesions (uncommon)2463804584700Assessment00Assessment14605004583430Symptoms: 60-90% anorexia > 75% nausea > 70% pain (colickly and generalised migrates to RIF in 50% = 81% sensitivity, 53% specificity; > 55% vomiting (usually after pain) > 10% diarrhea or constipation; less likely if symptoms >72 hours, unless palpable mass; 50-75% present with classical signs and symptomsExamination: low grade fever; RIF tenderness; 10% have tenderness elsewhere, 25% have generalised tenderness; McBurney’s point = 1/3 (3-4cm) along line from ASIS to umbilicus (appendix medial and \ inferior to this); 75% abnormal bowel sounds > 50% rebound tenderness > 40% rectal tenderness > 10- 15% mass > 10% rigidity Others: Sherren’s sign (cutaneous hyperaesthsia) Psoas sign (RLQ pain on hyperextension R hip; 16% sensitivity, 95% specificity) Obturator sign (RLQ pain on interior rotation R hip) Rovsking’s sigh (RLQ pain on palpation LLQ) – helpful in obeseLikelihood ratio +: +ive CT = 16 +ive USS = 15 CRP >10, WCC >15, rigidity = 4 Guarding, WCC >10, pain before vomiting, RT = 3 Fever = 2 Vomiting = 1Likelihood ratio -: -ive CT = 0.03 CRP <10 = 0.1 -ive USS, no RT = 0.2 No guarding = 0.3 WCC <10, no pain migration = 0.5 No fever = 0.6Predictive of PID: no pain migration, bilateral abdominal tenderness, no nausea or vomiting; highly unlikely appendicitis if all 3Mantrels / Alvarado scoring system: migration of pain, anorexia, nausea/vomiting, RIF tenderness, rebound tenderness, T >37.2°C, WCC >10, L shift or >75% neutrophils; max score 10; >6 needs immediate OT; observe if <7In paediatrics: may not localise to RIF; diarrhoea in 30-50% <3yrsIn elderly: most will have symptoms for >24 hours; 1/3 have constipationIn pregnancy: RUQ and flank pain in 3rd trimester; less frequent signs of peritoneal irritation; WCC up to 18 normal00Symptoms: 60-90% anorexia > 75% nausea > 70% pain (colickly and generalised migrates to RIF in 50% = 81% sensitivity, 53% specificity; > 55% vomiting (usually after pain) > 10% diarrhea or constipation; less likely if symptoms >72 hours, unless palpable mass; 50-75% present with classical signs and symptomsExamination: low grade fever; RIF tenderness; 10% have tenderness elsewhere, 25% have generalised tenderness; McBurney’s point = 1/3 (3-4cm) along line from ASIS to umbilicus (appendix medial and \ inferior to this); 75% abnormal bowel sounds > 50% rebound tenderness > 40% rectal tenderness > 10- 15% mass > 10% rigidity Others: Sherren’s sign (cutaneous hyperaesthsia) Psoas sign (RLQ pain on hyperextension R hip; 16% sensitivity, 95% specificity) Obturator sign (RLQ pain on interior rotation R hip) Rovsking’s sigh (RLQ pain on palpation LLQ) – helpful in obeseLikelihood ratio +: +ive CT = 16 +ive USS = 15 CRP >10, WCC >15, rigidity = 4 Guarding, WCC >10, pain before vomiting, RT = 3 Fever = 2 Vomiting = 1Likelihood ratio -: -ive CT = 0.03 CRP <10 = 0.1 -ive USS, no RT = 0.2 No guarding = 0.3 WCC <10, no pain migration = 0.5 No fever = 0.6Predictive of PID: no pain migration, bilateral abdominal tenderness, no nausea or vomiting; highly unlikely appendicitis if all 3Mantrels / Alvarado scoring system: migration of pain, anorexia, nausea/vomiting, RIF tenderness, rebound tenderness, T >37.2°C, WCC >10, L shift or >75% neutrophils; max score 10; >6 needs immediate OT; observe if <7In paediatrics: may not localise to RIF; diarrhoea in 30-50% <3yrsIn elderly: most will have symptoms for >24 hours; 1/3 have constipationIn pregnancy: RUQ and flank pain in 3rd trimester; less frequent signs of peritoneal irritation; WCC up to 18 normal2463802252345Patho-physiology00Patho-physiology14605002252346Long thin diverticulum arising from inferior tip of caecum; 9-10cm long; lined with colonic epithelial and submucosal lymphoid follicles which proliferate at 15-20yr then ? at 30yrs30% retrocaecal = 30% pelvic; 4% RUQ ; 2% subcaecal = 2% inside hernial sac; 1% ant / preileal; 0.06% LUQ 0.04% LIFIn elderly: weak appendix wall due to less lymphoid tissue and more fibrosis, impaired blood flow due to atherosclerosis, depressed immune systemIn pregnancy: appendix higher in 1st trimester >90% above iliac crest at 32/40; 80% move up toward R subcostal area; at term may overlie R kidney; pain more lateral and higherLumen obstruction (due to viral illness, lymphoid follicular hyperplasia, faecolith, foreign body, cancer, parasites, seeds, barium, bones, chewing gum; may occur without obstruction with direct bacterial invasion) distension ? pressure ? lymphatic and venous drainage bacterial invasion (polymicrobial; most common = Bacteroides fragilis, E coli, peptostreptococcus, Pseudomonas) oedema and ? arterial blood flow00Long thin diverticulum arising from inferior tip of caecum; 9-10cm long; lined with colonic epithelial and submucosal lymphoid follicles which proliferate at 15-20yr then ? at 30yrs30% retrocaecal = 30% pelvic; 4% RUQ ; 2% subcaecal = 2% inside hernial sac; 1% ant / preileal; 0.06% LUQ 0.04% LIFIn elderly: weak appendix wall due to less lymphoid tissue and more fibrosis, impaired blood flow due to atherosclerosis, depressed immune systemIn pregnancy: appendix higher in 1st trimester >90% above iliac crest at 32/40; 80% move up toward R subcostal area; at term may overlie R kidney; pain more lateral and higherLumen obstruction (due to viral illness, lymphoid follicular hyperplasia, faecolith, foreign body, cancer, parasites, seeds, barium, bones, chewing gum; may occur without obstruction with direct bacterial invasion) distension ? pressure ? lymphatic and venous drainage bacterial invasion (polymicrobial; most common = Bacteroides fragilis, E coli, peptostreptococcus, Pseudomonas) oedema and ? arterial blood flow246380330200Appendicitis00Appendicitis246380965200Epidemiology00Epidemiology14605009652007% lifetime risk; 1:1000/year; ? risk with family history; peak 11-20yrs; 2/3 during winter; 1/3 presentations are atypicalIn paediatrics: low incidence <2yrs; most initially misdiagnosed (12.5% <15/12, 57% <6/12); perforation in 9 90% <1yr, 80% 1-4yrs, 10-20% adolescents; peak incidence in late teensIn elderly: 5-10% all cases; >50% all deaths; most perforated; 50% post-op complication rateIn pregnancy: most common abdominal surgical emergency; incidence 1:1500; fetal loss 20% overall, 1-5% in uncomplicated appendicitis, up to 30% in perforation007% lifetime risk; 1:1000/year; ? risk with family history; peak 11-20yrs; 2/3 during winter; 1/3 presentations are atypicalIn paediatrics: low incidence <2yrs; most initially misdiagnosed (12.5% <15/12, 57% <6/12); perforation in 9 90% <1yr, 80% 1-4yrs, 10-20% adolescents; peak incidence in late teensIn elderly: 5-10% all cases; >50% all deaths; most perforated; 50% post-op complication rateIn pregnancy: most common abdominal surgical emergency; incidence 1:1500; fetal loss 20% overall, 1-5% in uncomplicated appendicitis, up to 30% in perforation3302002062480Management00Management15716252062480Analgesia, NBM, IV fluidsGive antibiotics if: perforation, systemic sepsis ampicillin + gentamicin + metronidazole 24 hours IV ceftriaxone and metronidazole followed by 10/7 PO antibiotics effective in 50% suspected appendicitis; consider if remote or patient refuses OTOT: acceptable –ive laparotomy rate 10-20% (15-35% in pregnancy); can be safely delayed 8-12 hoursLaparoscopy: pros: -ive laparotomy rate has 0.07% mortality; 17% complications in laparotomy (wound infection, pneumonia, bowel obstruction); lower mortality (0.01%) and morbidity (2%) than laparotomy cons: time consuming; requires training; early appendicitis may appear normal00Analgesia, NBM, IV fluidsGive antibiotics if: perforation, systemic sepsis ampicillin + gentamicin + metronidazole 24 hours IV ceftriaxone and metronidazole followed by 10/7 PO antibiotics effective in 50% suspected appendicitis; consider if remote or patient refuses OTOT: acceptable –ive laparotomy rate 10-20% (15-35% in pregnancy); can be safely delayed 8-12 hoursLaparoscopy: pros: -ive laparotomy rate has 0.07% mortality; 17% complications in laparotomy (wound infection, pneumonia, bowel obstruction); lower mortality (0.01%) and morbidity (2%) than laparotomy cons: time consuming; requires training; early appendicitis may appear normal329565317500Investigations00Investigations1571625330200Bloods: WCC 70-90% sensitivity, low specificity; neutrophilia in >75% (abnormal early); CRP >8 in 70- 100% (normal early); ? CRP and WCC and neutrophils = 100% sensitivity, 50% specificityUrine: >5 WBC / RBC in 30%; bacteruria in 15% (especially if retrocaecal or symptoms for >48 hours)USS: 80-90% sensitivity (sensitivity 30% if gangrenous / perforation), 90-100% spec; finds alternate cause in 40-50%; unable to visualise appendix in 10% Diagnostic findings: appendix diameter >6cm; target sign with 5 concentric layers; distension / obstruction of lumen; high echogenicitiy around appendix; appendicolith; pericaecal / vesical free fluid; wall thickness >2mm; no appendix peristalsis; prominent pericaecal fat; non-compressibleCT abdomen: 90-95% sensitivity, 95% specificity; reduces –ive laparotomy rate by <10%MRI: 90-95% sensitivity, 95% specificity; consider in pregnancy00Bloods: WCC 70-90% sensitivity, low specificity; neutrophilia in >75% (abnormal early); CRP >8 in 70- 100% (normal early); ? CRP and WCC and neutrophils = 100% sensitivity, 50% specificityUrine: >5 WBC / RBC in 30%; bacteruria in 15% (especially if retrocaecal or symptoms for >48 hours)USS: 80-90% sensitivity (sensitivity 30% if gangrenous / perforation), 90-100% spec; finds alternate cause in 40-50%; unable to visualise appendix in 10% Diagnostic findings: appendix diameter >6cm; target sign with 5 concentric layers; distension / obstruction of lumen; high echogenicitiy around appendix; appendicolith; pericaecal / vesical free fluid; wall thickness >2mm; no appendix peristalsis; prominent pericaecal fat; non-compressibleCT abdomen: 90-95% sensitivity, 95% specificity; reduces –ive laparotomy rate by <10%MRI: 90-95% sensitivity, 95% specificity; consider in pregnancy ................
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