Appendicitis Approach

– History –

  • CC: most likely will present as LLQ pain:
    • Onset: first time? When\duration? Sudden\gradual? Continues\intermittent? Getting worse? Prev URTI\sore throat?
    • Location: where? Started peri-umbilical? Does it radiate anywhere else (groin)?
    • Character: colicky, dull, stabbing?
    • Aggravating\relieving factors: food? Position? Coughing? Pain killers?
    • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
  • Associated sx:
    • Constitutional: fever, chills, wt loss, loss of appetite
    • GI: jaundice, abdominal swelling\distension, N\V, diarrhea\constipation, blood in stool?
    • Urine: burning urination, change in color, bloody?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • GI: IBD, diverticulosis, IBS
      • GU: UTI, stones
      • Infections
      • Malignancy
    • Medications
    • Surgery, hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
    • Menstrual Hx
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx
    • Diet, exercise

 


 – Abdominal Physical Exam –

  • WIPE, blah blah 🙂
  • “Take vital signs”
  • Position: flat, arms on the side, pillow below the head
  • Proper exposure: from xiphoid to mid-thigh
  • General inspection of the pt and surroundings

1. Inspection: (stand at the end of the bed)

  • Symmetry and contour
  • Abdominal distention + flank fullness
  • Scars, skin changes\discoloration, rashes, straie
  • Obvious masses or swelling
  • Dilated veins\caput medusa
  • Visible pulsations
  • Umbilicus (inverted\everted?)
  • Hernias (ask pt to cough)

2. Palpation + percussion: (ask pt if they have any pain?)

  • Superficial and deep palpation: “abdomen soft and lax, no tenderness, no masses, no peritoneal signs”
    • Tenderness
    • Guarding\rigidity
    • Masses
  • Special signs of appendicitis:
    • Rebound tenderness
    • Dunphy sign: ask pt to cough -> increased pain
    • Rovsing sign: palpate left side (which moves gas over) -> pain in RLQ
    • Obturator sign: flex knee + internally rotate hip -> RLQ pain [pelvic appendix]
    • Iliopsoas sign: extend hip -> RLQ pain [retrocecal appendix]

3. Auscultation:

  • Bowel sounds
  • Bruits: Aortic, renal, femoral

4. To complete:

  • Digital rectal exam (PR)
  • Genital exam
  • Fecal occult blood test

 


– Investigations –

  • Remember; appendicitis is a clinical diagnosis!
  • Labs:
    • CBC: to check for leukocytosis, neutrophilia
    • CRP
    • Renal and liver function tests
    • Amylase + lipase
    • U\A
  • Imaging:
    • AXR: fecalith, bowel obstruction
    • US: esp in children and ladies in child-bearing age. Findings:
      • Dilated (> 6 mm diameter), non-compressible appendix
      • Hyper vascular wall
      • Surrounded by inflamed fat
      • Fecalith
    • CT: more accurate. Findings:
      • Dilated (> 6 mm diameter)
      • Thickened + enhanced wall
      • Peri appendicular fat stranding
      • Fecalith
      • Localized ileus or ceccal wall thickening

– Management –

  • Analgesia
  • IVF
  • Abx
  • Appendectomy: either open or lap, unless in certain pts, where lap appendectomy is more preferred:
    • Obese pts
    • Ladies in child-bearing age
    • Elderly pts

Laparoscopy

Advantages Disadvantages
–   Evaluation of abdominal\pelvic organs

–   ↓ Post-op stay + pain

–   Earlier recovery -> earlier return to activity

–   Better cosmetic results

–   Expensive

–   Requires skilled surgeon

  • If you find a normal appendix? take it out and look for Meckel’s diverticulum

 


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