SU28.15 | Appendicitis and Appendicular Complications — Summary & Reflection

KEY TAKEAWAYS

Acute appendicitis is the commonest abdominal surgical emergency and a primarily clinical diagnosis. The classic story is central pain migrating to the right iliac fossa with anorexia and nausea; examination shows tenderness, guarding and rebound at McBurney's point, with supporting Rovsing's, psoas and obturator signs. The pathology is luminal obstruction (faecolith / lymphoid hyperplasia) → distension → end-artery ischaemia → bacterial invasion → gangrene → perforation, after which the appendix is either walled off (appendicular mass or abscess) or causes generalised peritonitis. Investigation supports the diagnosis: the Alvarado (MANTRELS) score, neutrophil leucocytosis and CRP, and selective ultrasound (children, women, pregnancy) or CT (uncertainty, elderly); always a pregnancy test in women. Treatment is appendicectomy (laparoscopic or open) with antibiotics; perforation with peritonitis needs urgent surgery and lavage. The key complication distinction: an appendicular mass is managed conservatively by the Ochsner–Sherren regimen with interval appendicectomy, whereas an appendicular abscess needs drainage. Keep the threshold low in pregnancy, the elderly and children, where presentation is atypical and perforation common.

REFLECT

Think back to a patient you have seen with right iliac fossa pain, or imagine clerking one on the take. Did you specifically ask about the migration of the pain and about anorexia, examine for tenderness and rebound at McBurney's point and elicit Rovsing's or the psoas sign, and remember the pregnancy test in a woman of childbearing age? Now consider the harder cases: would the muted picture of an elderly patient or the displaced pain of a pregnant woman have lowered, rather than raised, your suspicion? And faced with a patient days into the illness with a tender mass, could you confidently decide between conservative Ochsner–Sherren management and drainage? Reflect on how a disciplined, anatomy-grounded approach to right iliac fossa pain would make your next such assessment both safer and more decisive.