Appendicitis

Key points

Younger patients e.g. <5 years, patients with Autism/ADHD will present atypically with appendicitis

Have very low threshold for imaging in these patients

May present with obstruction

Examination

Psoas sign: Pain on passive extension of the right hip - indicates retrocaecal appendicitis

Obturator sign: Pain on internal rotation of the right hip -indicates pelvic appendicitis

Rosving sign: Pain in RIF when LIF is pressed - sign of appendicitis

Management

Always ensure pateints are adequately fluid resuscitated and treated with antibiotics before operation, as general anaesthetic can cause hypotension and arrest

Consider managing patients with histories > 1 week conservatively

Can place percutaneous or transrectal drain if large collection

Interval appendicectomy 3 months later

Atypical findings during appendicectomy

Crohn's disease - signs may be ileal inflammation, mesenteric fat creeping

Should try and avoid appendicectomy in these cases if possible as can cause fistula

Carcinoid tumour and lymphoma - see oncology section

In neutropenic patient or those may require ACE or Mitrofanoff in future, aim for conservative management +/- drain

Special scenario - Appendix mass

Ensure resuscitated

History -

Duration of symptoms

Differential is Crohn's mass - ask about IBD symptoms and family history

Examination -

Signs of IBD

Mass

Generalised peritonitis

Distension - obstruction

Investigations -

Discuss CT with radiologist

Management

Initially conservative - IV antibiotics, oral step down, clinic to discuss interval appendicectomy

Interval appendicectomy can be done at patient/parent choice - Hall et al open label trial - approx 10% risk of recurrent appendicitis or complication from surgery at 1 year

Indications for operation:

1. Generalised peritonitis

2. Obstruction

3. Failure of antibiotics to control sepsis