[Music] [Applause] [Music] hi this is tom from zero2finals.com in this video i'm going to be going through appendicitis and you can find written notes on this topic at zerodefinals.com general surgery or in the general surgery section of the zero to finals surgery book so let's jump straight in appendicitis is inflammation of the appendix the peak incidence of appendicitis is in patients aged 10 to 20 years old and it can occur at any age but it's less common in young children and adults over the age of 50. let's talk a bit about the pathophysiology the appendix is a small tube that arises from the cecum which is part of the large bowel it is located at the point where the three tinier coli meet the teeny e coli are longitudinal muscles that run the length of the large intestine there is a single opening to the appendix that connects it to the bowel and this leads to a dead end in the appendix pathogens can get trapped due to obstruction at the point where the appendix meets the bowel trapping of pathogens leads to infection and inflammation inflammation may proceed to gangrene and rupture of the appendix when the appendix ruptures fecal contents and infective material are released into the peritoneal cavity and this leads to peritonitis which is inflammation of the peritoneal lining let's talk about the signs and symptoms the key presenting feature of appendicitis is abdominal pain this typically starts as central abdominal pain that moves down to the right iliac fossa or rif within the first 24 hours eventually becoming localized in the reitaliac fossa on palpation of the abdomen there is tenderness at mcburney's point and mcburney's point refers to a specific area one third of the distance from the anterior superior iliac spine or asus to the umbilicus or the belly button other classical features of appendicitis are loss of appetite which we call anorexia nausea and vomiting a low-grade fever rov sings sign which is palpation of the left iliac fossa causing pain in the right aliac fossa guarding on abdominal palpation [Music] rebound tenderness in the right iliac fossa and this is where the pain increases when you suddenly release the pressure of deep palpation and the pain of releasing the pressure is worse than the pain of the actual pressure itself and percussion tenderness and this is pain and tenderness when percussing the abdomen rebound tenderness and percussion tenderness suggest peritonitis which is inflammation of the peritoneal lining potentially indicating a ruptured appendix let's talk about the diagnosis diagnosis is based on the clinical presentation and raised inflammatory markers performing a ct scan can be useful to confirm the diagnosis particularly where another diagnosis is more likely an ultrasound scan is often used in female patients to exclude ovarian and gynecological pathology ultrasound can also be useful in children where a ct scan is less appropriate due to the dose of radiation appendicitis is mostly a clinical diagnosis meaning it's based on the signs and symptoms rather than a diagnostic test where the diagnosis is unclear a period of observation can be used with repeated examinations over time to see whether the symptoms resolve or get worse when a patient has a clinical presentation suggestive of appendicitis but investigations are negative the next step is to perform a diagnostic laparoscopy to visualize the appendix directly the surgeon can proceed to appendisectomy during the same procedure if indicated let's talk about the key differential diagnoses of appendicitis firstly ectopic pregnancy consider ectopic pregnancy in females of child bearing age this is a gynecological emergency with a relatively high mortality if it's mismanaged performing a serum or a urine human chorionic gonadotrophin or hcg can be used to exclude pregnancy this is essential in any female of childbearing age presenting with unilateral pelvic pain ovarian cysts are another differential and ovarian cyst can cause pelvic and iliac fossa pain particularly when they rupture or there's torsion an ovarian cyst can be investigated with an ultrasound of the pelvis another differential is meccal's diverticulum diverticulum is a malformation of the distal ileum that occurs in approximately two percent of the population it's usually asymptomatic and does not require any treatment however it can bleed become inflamed rupture or cause a volvulus or interception and the final differential we'll talk about is mesenteric adenitis mesenteric describes inflamed abdominal lymph nodes it presents with abdominal pain usually in younger children and is often associated with tonsillitis or an upper respiratory tract infection no specific treatment is required for the mesenterocardinitis a tom tip for you when seeing female patients of childbearing age assume they are pregnant until proven otherwise with a pregnancy test this is especially important in patients with abdominal pain where an ectopic pregnancy is a key differential diagnosis or where you're requesting ct scans or x-rays a serum human chorionic gonadotropin or hcg is typically part of the normal abdominal pain blood panel when you're clarking patients in a e let's talk about appendix mass an appendix mass occurs when the omentum surrounds and sticks to the inflamed appendix forming a mass in the right aliac fossa this is typically managed conservatively with supportive treatment and antibiotics followed by appendisectomy once the acute condition is resolved let's talk about management of appendicitis patients with suspected appendicitis need emergency admission to hospital under the surgical team removal of the inflamed appendix and appendicectomy is the definitive management for acute appendicitis laparoscopic surgery is associated with fewer risks and a faster recovery compared to open surgery which is called a laparotomy there's a few complications to be aware of of an appendicectomy and these include bleeding infection pain and scars damage to the bowel bladder or other organs removal of a normal appendix the risks associated with the anaesthetic and venous thromboembolism such as a deep vein thrombosis or a pulmonary embolism a final tom tip for you older children for example those aged above 10 years will often be managed by adult general surgical teams at local hospitals provided there is a pediatric department in the hospital this means you may end up visiting the pediatrics awards whilst on your adult surgery rotations it's worth making friends with the pediatric doctors and nurses who can be very helpful if you're unsure about pain relief or iv fluid prescriptions in children as this is quite different to adults if you like this video consider joining the zero to finals patreon account where you get early access to these videos before they appear on youtube you also get access to my comprehensive course on how to learn medicine and do well in medical exams digital flashcards for rapidly testing the key facts you need for medical exams early access to the zero to finals podcast episodes and question podcasts which you can use to test your knowledge on the go thanks for watching and i'll see you in the next video