A 1o year old girl presented with severe abdominal pain, vomiting and fever for 3 days duration. The child was being taken care of by an aunt at the time and could barely walk without clutching her abdomen. The pain had become progressively worse over the 3 days.<\/p>\n
What to ask in the history?<\/em><\/strong><\/p>\n When it comes to pain (or any symptom really) a useful mnemonic that I was taught in medical school was \u201cSOCRATES\u201d which stands for:<\/p>\n This will take up most of the presenting complaint of the patient. You can then rule out your differential diagnosis (main ones listed below).<\/p>\n Why does the pain migrate?<\/em><\/strong><\/p>\n There are two types of nociceptive pain: visceral and somatic. Somatic pain arises more superficially (i.e. from the abdominal wall) whilst visceral pain arises from deep within (i.e. your organs). Visceral pain is very non-specific and poorly localised which means that as the inflammation starts in the appendix, the visceral nociceptors sense it \u2013 so the pain is more generalised, i.e. over the umbilicus. Once the inflammation increases and irritates the abdominal wall it is detected by somatic nociceptors and so the pain becomes more localised. The appendix is located in the right lower quadrant and so the pain becomes localised to the right lower quadrant.<\/p>\n Whats to be found on examination?<\/em><\/strong><\/p>\n There are tons of specific signs that need to be elicited in addition to doing your standard abdominal examination. Remember the patient will exhibit signs such as febrile, tachypnoea, tachycardia, a coated tongue (super rare!) and tenderness localized over McBurney\u2019s point (2\/3rd between the umbilicus and ASIS).<\/p>\n Signs to be elicited \u2013\u00a0<\/em><\/p>\n Investigations and management<\/em><\/p>\n The ALVARADO Score is a\u00a0scoring system used to\u00a0predict the likeliness of the abdominal pain being appendicitis. \u00a0The mnemonic used is \u201cMANTRELS\u201d. The scoring system has got a lot of criticism as it\u2019s not a reliable test (poor sensitivity), but examiners love to ask you about it. All of the components are scored +1, except the 2 highlighted with an asterix. A score of more than 7 is strongly suspicious for appendicitis.<\/p>\n Once you suspect that the patient has appendicitis it is safer to keep the patient nil by mouth as part of the prep for GA. You should take bloods \u2013 FBC, CRP, UFR and a hCG test<\/strong> as a minimum. USS can be used to aid the diagnosis, but remember appendicitis is a CLINICAL DIAGNOSIS<\/strong>(even the ALVARADO score doesn\u2019t cut it).<\/p>\n The definite treatment of appendicitis is an appendicectomy. Many GPs unfortunately give patients antibiotics and this may resolve the pain initially, but more often than not these patients get readmitted with a recurrence rate. Giving antibiotics prior to admission also makes the diagnosis trickier.<\/p>\n If by chance the patient is in septic shock clinically (BP, pulse, temp) \u2013 manage appropriately with oxygen via face mask, take bloods quickly, give normal saline boluses and start IV antibiotics immediately.<\/p>\n Remember to give the patient adequate analgesia pre- and post-op. Some cochrane reviews have found that giving IV morphine will not change the pain required for diagnosis, but my hospital ain\u2019t that fancy and so we don\u2019t give any morphine. NSAIDs also have a risk of bleeding during surgery, so check with your department about the protocol for pain management. Also remember your IV fluids post-op. Some consultants practice ERAS (enhanced recovery after surgery) and so early oral intake after surgery may be possible.<\/p>\n The incision used is either a grid iron incision (an oblique incision by splitting the muscle layer over McBurney\u2019s point) or via a Lanz incision (more transverse \u2013 cosmetically better results). Laparoscopic appendicectomies are now happening so this could also be an option \u2013 much better cosmetic appearance, but there is a chance it might be converted into an open appendicectomy.<\/p>\n An Ochsner-Sherren regimen is used to treat an appendicular abscess which is a complication of appendicitis. It is a conservative way of treating appendicular abscess (which can be felt on abdominal palpation) by giving the patient IV fluids, IV antibiotics, insert an NG tube and you mark the abscess size on the abdomen. Monitor vitals, the IP\/OP chart and the size of the abscess. An interval appendectomy is then done 6-8 weeks later. The conservative method will reduce the inflammation in the mean time. Differentials of an appendicular abscess is appendicular carcinoma or even Crohn\u2019s disease.<\/p>\n How would you prepare a patient for surgery?<\/em><\/p>\n Histopathology specimen of an appendix<\/p>\n<\/div>\n Causes of appendicitis<\/em><\/p>\n Intestinal worms, faecoliths, lymphadenitis and foreign bodies.<\/p>\n What instrument do you use in surgery to hold the appendix?<\/em><\/p>\n A random question that could be asked by examiners. A Babcock artery forceps is used to hold the appendix during an appendicectomy.<\/p>\n Can you get appendicitis after you have had an appendicectomy?<\/em><\/p>\n Yes you can and it\u2019s called \u2018stump appendicitis\u2019. It occurs when you don\u2019t get the base of the appendix during the appendicectomy and so you have a piece of the appendix remaining which can get infected again.<\/p>\n What are the common complications of appendicitis?<\/em><\/p>\n\n
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