eSurgery

History:
Most important symptom is abdominal pain – pain in the right lower abdomen. History of central(around belly button), intermittent pain moving to the right side of the abdomen(and the pain becoming constant). Patients may give history of being sore to move, of feeling all the bumps in the drive to hospital.
Other symptoms:
1. Loss of appetite – but beware, a young patient who has not eaten for some time can still say they feel hungry even with appendicitis
2. Nausea and vomiting – usually the vomiting is mild
3. Loose bowel action, abdominal pain on urinating(if inflammed appendix tip is sitting on the bladder)
4. Fever

Examination findings:
Patient lying still in bed, sore to move around
Vital signs – may have fever and tachycardia
Abdominal examination : Tender in right iliac fossa, rebound tenderness , crossed tenderness
(note: the tenderness can only be mild if the inflammed appendix is sitting behind the caecum – ie retrocaecal appendicitits)

Ix:
Imaging – an increasingly used modality, helps reduce incidence of negative appendicectomy; Ultrasound can show a swollen appendix(but may not pick up an early appendicitis, also dependent on sonographer and body habitus) CT abdomen – can be helpful but the disadvantage is the radiation exposure
Blood test – elevated white cell count in particular neutrophilia with left shift, elevated C-reactive protein(an inflammatory marker)..but there are cases of appendicitis where the blood test is normal early on

Treatment:
Nil by mouth
Intravenous antibiotics as soon as diagnosis is suspected(why wait?)
Surgery – Appendicectomy : through short incision if diagnosis is confirmed on CT/US, Laparoscopy if uncertain eg in females ?ovarian pathology ?endometriosis or other pathology

Differentials – other diseases that can mimic appendicitis:
1. Diverticulitis – ie if long redundant sigmoid colon, esp in elderly
2. Cancer of caecum
3. Inflammatory bowel disease involving the caecum or terminal ileum
4. Meckel’s diverticulitis
5. Gynaecological – ovarian cyst rupture, Mittelschmerz, torsion of ovary, ectopic pregnancy
6. Worms – eg pin worm
7. Torsion of fat around right colon
8. Low lying inflammed gallbladder