Acute Appendicitis

Nasal septal hematoma is a rare but potentially serious complication of nasal trauma.

The trauma allows blood to pass into both mucoperichondrial planes.

Because the septal cartilage has no blood supply of itself and receives all of its nutrients and oxygen from the perichondrium, untreated septal hematoma may lead to destruction of the septum resulting in a saddle nose deformity.

Immediate drainage is necessary.

Yersinia enterocolitica is the pathogen producing this clinical syndrome.

Yersinia is transmitted to patients via the oral route, via contaminated blood products, or by cutaneous inoculation.

Patients developing iron overload because of multiple transfusions (i.e., thalassemia patients) are at increased risk of Yersinia infections because some strains are unable to synthesize bacterial iron chelators called siderophores.

They can, however, use host-chelated iron stores or the drug deferoxamine (a siderophore produced by Streptomyces pilosus).

Yersinia is associated with reactive arthritis following an infection by an enteropathogenic organism.

Most patients who develop arthritis express HLA-B27.

Ans. is ‘b’ i.e., The specificity of temperature greater than 37.5°C as a marker for appendicitis is 42/70

o Suppose, there are 100 persons, then

Persons with the disease (appendicitis) —> 30 Persons without the disease  —> 70

o Assume that the screening criteria for the presence of appendicitis is temperature above 37.5°C

o First,

No. of persons with the disease

We know that the no. of persons with appendicitis are                   —> 30

No of patients with appendicitis and with temp > 37.5°c                  —>70%= 70×30/100 = 21

These patients are true positive

No. of patients with appendicitis but without temperature elevation –> 30-21 =9 These patient are false negative.

o Now

Total no of persons without the disease –> 70

No. of persons without the disease but with temperature elevated —> 40×70/ 100 = 28 These patient are false positive cases.

Persons without appendicitis who also do not have temperature elevation —> 70-28 = 42 These are true negative

Screening test                                        Patient with                                           Patient without

(fever) results                                         appendicitis                                          appendicitis

Fever present                                         21(True postive)                                  28 (False positive)

Fever not present                                  9 (false negative)                                 42 (true negative)

o Specificity = True negative/True negative + False positive = 42/42+28 = 42/70

o Sensitivity = True positive/True positive + False negative = 21/21+9 = 21/30

o Positive predictive value = True positive/(true+false) postive = 21/21+28 = 21/49

o Negative predictive value = True negative/(true+false) negative = 42/42+9 = 42/51

Ans. is ‘d’ i.e., Yersinia enterocolitica 

Ans. is a, b, c, and d ie Clinical examination, USG, CT scan and Blood counts 

As described in the above question, the diagnosis of appendicitis is primarily clinical, assisted by blood counts. Ultrasound and CT can be utilized to make the diagnosis in equivocal cases.

Lets also see the management of appendicitis:

Management of appendicitis:  [Ref Sabiston 18/e p1339; Schwartz 9/e p1084]

The treatment of appendicitis is appendectomy. (It can be done open or laparoscopically)

Prophylactic antibiotics are indicated preoperatively. Postoperative antibiotic coverage is of no use in simple (uncomplicated) acute appendicitis. If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count.

Perforated Appendicitis (Maingot’s 11/e p603)

Rupture is suspected in the presence of fever with a temperature of >39°C (102°F) and a white blood cell count of >18,000 cells/mm3.

The management of perforation depends on the nature of the perforation.

If the perforation is free causing intraperitoneal dissemination of pus and fecal material, urgent laparotomy is done for appendectomy and irrigation and drainage of the peritoneal cavity.

If the perforation is contained it would result in an appediceal mass or abscess. This is managed as described under.

Appendiceal Abscess/ Mass

Patients who present late in the course of appendicitis with a palpable or radiographically documented mass (abscess or phlegmon) are treated with‑

conservative therapy and interval appendectomy 6 to 10 weeks later.

(conservative management includes intravenous antibiotics and fluids as well as bowel rest.)

– Patients with large abscesses, greater than 4 to 6 cm in size, and especially those patients with abscess and high fever, benefit from abscess drainage.

Patients who continue to have fever, persistent pain and leukocytosis or develop complications like bowel obstruction after several days of nonoperative treatment are likely to require immediate appendectomy during the same hospitalization, whereas those who improve promptly may be considered for interval appendectomy. Bailey lists Criteria for stopping conservative treatment and going for appendectomy

A rising pulse rate

–  increasing or spreading abdominal pain

–   increasing size of the mass

Ans is ‘a’ i.e. Early rupture of appendix

Perforation of appendix in acute appendicitis commonly leads to an abscess cavity walled off by the small bowel loops and the omentum, forming a phlegmon. Rarely the appendix may perforate freely into the peritoneal cavity and cause generalized peritonitis. This usually occurs in cases of early rupture of the appendix as inflammatory process did not get time to be localized by the omentum and bowel loops.

Usually the rupture of appendix is a late sequelae of appendicitis, usually occurring 48 to 72 hours from the onset of symptoms.

Ans. is ‘a’ i.e., Pain 

Schwartz writes – In more than 95% of patients with acute appendicitis, anorexia is the first symptom, followed by abdominal pain, which is followed in turn, by vomiting (if vomiting occurs). If vomiting precedes the onset of pain, the diagnosis of appendicitis should be questioned”.

Ans. Two options are correct ‘a’ i.e. Faecoliths & ‘b’ i.e. Worms of ileo-caecal region 

Ans. is ‘b’ i.e., Sterility 

Ans. is ‘d’ i.e., Purgation 

Ans. is ‘a’ i.e., Rovsing’s 

Ans. C: Fever >42 degree celsius

Appendicitis is more common in men The risk of perforation is:

• Less than 10 years old = 50%
• 10-50 years old = 10%
• Over 50 years old = 30%

Clinical features of appendicitis:

• Central abdominal pain moving to right iliac fossa
• Nausea, vomiting, anorexia
• Low-grade pyrexia (37.2-37.7 degree celsius)
• Localised tenderness in right iliac fossa
• Right iliac fossa peritonism
• Percussion tenderness is a kinder sign of peritonism than rebound
• Rovsing’s sign = pain in right iliac fossa on palpation of the left iliac fossa

Ans. b. Ultrasound