Acute Appendicitis Diagnosis Quiz

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Questions and Answers

Which of the following is NOT a potential cause of right iliac fossa pain?

Ectopic pregnancy

Acute appendicitis

Ovarian mass

Granulomatous inflammation (correct)

What is the significance of an elevated white blood cell count with a predominance of polymorphs in appendicitis?

It indicates a viral infection

It indicates a bacterial infection (correct)

It shows an active inflammatory response (correct)

It suggests a chronic condition

Which histological feature is characteristic of acute appendicitis?

Fibrosis in the appendiceal serosa

Granulation tissue

Presence of neutrophils in the appendiceal wall (correct)

Absence of inflammatory cells

What is the primary reason for obtaining a urine culture in a patient suspected of having appendicitis?

To rule out pyelonephritis Signup and view all the answers

Which of the following conditions is included in the differential diagnosis for acute appendicitis?

Meckel’s diverticulum Signup and view all the answers

If a pregnant patient presents with right iliac fossa pain, what is a possible differential diagnosis specifically related to pregnancy?

Ectopic pregnancy Signup and view all the answers

What does the presence of rebound tenderness in the right iliac fossa indicate?

Possible appendicitis Signup and view all the answers

Which of the following describes granulation tissue?

Tissue characterized by fibroblast proliferation and new capillary formation Signup and view all the answers

What is phagocytosis primarily associated with in the inflammatory process?

Killing of pathogens Signup and view all the answers

Which of the following is NOT a typical outcome of acute inflammation?

Metastasis Signup and view all the answers

What is the most common cause of acute appendicitis?

Obstruction due to a faecolith Signup and view all the answers

Which of the following complications can arise from acute appendicitis?

Gangrenous transformation Signup and view all the answers

What defines an abscess in the context of acute inflammation?

A localized collection of pus Signup and view all the answers

What does perforation of the appendix result in?

Leakage of contents into the peritoneum Signup and view all the answers

What are systemic effects of inflammation typically characterized by?

Elevated pyrexia Signup and view all the answers

Which condition may precipitate acute appendicitis apart from faecoliths?

Crohn’s disease Signup and view all the answers

What is the primary treatment for perforated appendicitis?

Surgery and IV antibiotics Signup and view all the answers

Which type of pain is felt in the peri-umbilical area during acute appendicitis?

Visceral pain Signup and view all the answers

What is characteristic of granulation tissue?

Proliferation of fibroblasts and new blood vessels Signup and view all the answers

Which of the following is NOT a cause of granulomatous inflammation?

Allergic reactions Signup and view all the answers

Granulomas are a specific immune response often associated with which type of reaction?

Type IV immune reaction Signup and view all the answers

Which type of cells is primarily involved in chronic inflammation?

Lymphocytes and plasma cells Signup and view all the answers

Which of the following conditions is characterized by the presence of granulomas?

Crohn's disease Signup and view all the answers

Which infectious agent is commonly associated with granulomatous inflammation?

Mycobacterium tuberculosis Signup and view all the answers

In a case of acute appendicitis, what is the significance of rebound tenderness in the right iliac fossa?

Indicates localized inflammation in the abdominal cavity Signup and view all the answers

Which of the following investigations is most useful in confirming the diagnosis of appendicitis?

Ultrasound abdomen Signup and view all the answers

What specific characteristic is associated with the dominant inflammatory cell observed in acute appendicitis?

Neutrophil predominance Signup and view all the answers

What is the clinical significance of an elevated CRP level in a patient suspected of acute appendicitis?

It indicates a non-specific inflammatory response Signup and view all the answers

Which of the following statements about granulomatous inflammation is true?

It typically signifies chronic inflammatory conditions Signup and view all the answers

If a patient has a WCC of 14,500 with 95% polymorphs, what does this indicate?

Acute inflammatory response Signup and view all the answers

In the context of right iliac fossa pain, which organ's involvement would potentially lead to the diagnosis of ectopic pregnancy?

Ovary/adnexa Signup and view all the answers

What is the relevance of the timing of the last menstrual period (LMP) in a female patient with suspected acute appendicitis?

It helps determine pregnancy status Signup and view all the answers

What role do superoxide radicals play in the inflammatory process?

Killing of pathogens Signup and view all the answers

Which of the following is NOT a complication of acute appendicitis?

Fibrosis Signup and view all the answers

What initiates the inflammatory response in acute appendicitis?

Obstruction of the appendix lumen Signup and view all the answers

In the context of acute appendicitis, what does septicemia refer to?

Systemic spread of bacteria Signup and view all the answers

What defines an abscess in the case of acute appendicitis?

Localized collection of pus Signup and view all the answers

What is a notable systemic effect of inflammation?

Production of acute phase proteins Signup and view all the answers

Which type of appendicitis is least likely to resolve completely without intervention?

Gangrenous appendicitis Signup and view all the answers

Which of the following is a common cause, apart from faecoliths, that can precipitate acute appendicitis?

Crohn’s disease Signup and view all the answers

What is the primary component of granulation tissue?

Proliferation of fibroblasts and capillaries Signup and view all the answers

Which mechanism is primarily involved in the formation of granulomas?

Type IV immune reaction Signup and view all the answers

What type of pain typically precedes the localization to the right iliac fossa in appendicitis?

Visceral pain from the peri-umbilical area Signup and view all the answers

Which of the following is NOT a cause of granulomatous inflammation?

Vascular injury Signup and view all the answers

What is a characteristic feature of chronic inflammation?

Occurrence of lymphocytes and plasma cells Signup and view all the answers

Which of the following infections is commonly associated with granulomatous inflammation?

Tuberculosis Signup and view all the answers

What is the potential consequence of severe sepsis in a patient?

Development of disseminated intravascular coagulation (DIC) Signup and view all the answers

What defines the process of granulation tissue formation?

Proliferation of fibroblasts with a loose extracellular matrix Signup and view all the answers

Study Notes

Learning Outcomes

List the differential diagnosis for right iliac fossa (RIF) pain.
Describe the histological features of acute appendicitis.
Summarize the complications of acute appendicitis based on the consequences of inflammation.
Distinguish granulation tissue from granulomatous inflammation.
List the causes of granulomatous inflammation.

History

25-year-old female presenting with RIF pain for 36 hours.
Pain was initially periumbilical before migrating to RIF.
Symptoms include nausea and vomiting.
No significant past medical history or social history.
Last menstrual period was 10 days ago.

Examination

Pyrexia (fever).
Heart rate of 90 beats per minute.
Respiratory rate is normal.
Blood pressure is 120/75 mmHg.
Hydration status, cardiovascular, respiratory, and central nervous systems are normal.

Focused Examination: Abdomen

Rebound tenderness in RIF.
Guarding in RIF.
No rigidity observed.
Bowel sounds present.
Rectal exam normal.

Differential Diagnosis of RIF Pain

Organs located in RIF: appendix, ovary/adnexa, kidney, small bowel.
Potential diagnoses:
- Acute appendicitis.
- Terminal ileitis (Crohn's disease).
- Meckel's diverticulum.
- Urinary tract infection/pyelonephritis.
- Renal/ureteric colic.
- Ectopic pregnancy.
- Salpingitis (inflammation of fallopian tubes).
- Ovarian mass.

Investigations

Full blood count (FBC), particularly white blood cell count (WCC) and differential.
- High WCC indicates infection.
Midstream urine (MSU) for culture and microscopy.
- Necessary to rule out urinary tract infection.
Pregnancy test.
Plain abdominal x-ray.
- To assess for possible free air.
Ultrasound abdomen.
- To visualize the appendix and surrounding organs.

FBC Results

Hemoglobin (Hb): 12.5 g/dL (normal).
Mean corpuscular volume (MCV): 90 fL (normal).
Mean corpuscular hemoglobin concentration (MCHC): 29 pg (normal).
WCC: 14,500/µL (elevated).
Polymorphs: 95% (elevated).
C-reactive protein (CRP): Elevated.

Urine Results

Microscopy: < 5 pus cells.
Culture: Mixed growth of E. coli and Staphylococcus.
Colony count: < 100,000 organisms/mL.

Diagnosis: Acute Appendicitis

Diagnosis based on clinical presentation, investigations, and exclusion of other diagnoses.
The point of maximal tenderness can be found at McBurney's point.

Gross Pathology

Normal appendix vs. inflamed appendix (appendicitis).

Cellular Response

The predominant inflammatory cells in acute appendicitis are neutrophils.

Polymorph Role

Neutrophils (polymorphs) play a critical role in the inflammatory process.
- Phagocytosis: engulfing and destroying pathogens.
- Killing: using superoxide radicals and hydrogen peroxide to eliminate pathogens.

Outcome - Acute Inflammation

Possible outcomes:
- Complete resolution: Rare in acute appendicitis.
- Chronic inflammation.
- Abscess formation.
- Fibrosis.

Management

Patient is prepared for surgery.
Appendicectomy (surgical removal of the appendix) can be performed via open surgery or laparoscopy.
Prophylactic antibiotics are administered (to prevent infection).

Etiology of Appendicitis

Appendicitis is most commonly caused by inflammation of the appendix wall due to native bowel flora.
The infection is often precipitated by obstruction of the appendix lumen.

Obstruction Causes

Faecolith (hardened fecal matter): The most common cause of obstruction.
Stenosis: Narrowing of the appendix lumen due to other factors.

Other Causes

Appendicitis can also be caused by:
- Crohn's disease.
- Yersinia infections.
- Tuberculosis.
- Measles.

Complications of Acute Appendicitis

Can lead to:
- Gangrenous transformation (tissue death).
- Perforation (rupture of the appendix):
  - Peritonitis (inflammation of the peritoneum).
  - Abscess formation.
  - Septicemia (bloodstream infection).

Abscess

A localized collection of pus, containing:
- Dead and degenerate white blood cells.
- Dead and degenerate host tissue cells.
- Edema fluid.
- Dead microorganisms.

Perforation

A hole in the appendix wall, allowing its contents to spill into the peritoneum.
Clinical significance:
- Peritonitis can be localized or generalized.
- Signs of intra-abdominal organ perforation:
  - Air under the diaphragm on an erect chest x-ray.

Systemic Effects of Inflammation

A whole-body response to inflammation.
Includes:
- Acute phase response: release of inflammatory mediators
- Pyrexia (fever).
- Acute phase proteins (e.g., CRP, ESR): elevated in inflammation.
- Leukocytosis (increased white blood cell count).
- Increased blood pressure and pulse.
- Sweating, rigors (shivering), sleep disturbances, anorexia, malaise.
- Severe sepsis: Disseminated intravascular coagulation (DIC), hypotension, shock.

Management of Perforated Appendicitis

Requires:
- Surgery.
- Intravenous antibiotics.

Pain Migration

Classical pain pattern:
- Starts as visceral pain (around the umbilicus). This occurs because the appendix and umbilicus share the same segment of the autonomic nervous system.
- Migrates to somatic pain (localized RIF pain). This happens when the serosal and parietal peritoneum become inflamed.

Chronic Inflammation

Persistent inflammation involving chronic inflammatory cells (e.g., lymphocytes, plasma cells, histiocytes).
Can arise from:
- Progression from acute inflammation.
- Directly (ab initio)
- Autoimmune diseases.

Granulation Tissue vs. Granuloma

Granulation Tissue:
- A non-specific response to injury.
- Characteristic of healing.
- Consists of:
- Proliferating fibroblasts (cells that make connective tissue)
- New, thin-walled capillaries.
- Loose extracellular matrix (space between cells).
- Chronic inflammatory cells.
- Develops connective tissue matrix, ultimately resulting in dense fibrosis (scarring).
Granuloma:
- A specific immune response or a foreign body response.
- Distinctive microscopic structure that forms in specific types of infections or foreign body reactions.

Causes of Granulomatous Inflammation

Can be caused by:
- Infection:
- Bacteria (e.g., tuberculosis (TB), leprosy, cat scratch disease)
- Fungi (e.g., histoplasmosis, blastomycosis)
- Parasites (e.g., schistosomiasis, toxoplasmosis, leishmaniasis)
- Spirochetes (e.g., syphilis)
- Foreign material (e.g., splinter, suture, keratin, silica, hair).
- Metal/dust (e.g., beryllium, silica).
  - Berylliosis: A granulomatous lung disease.
  - Silicosis: A lung disease caused by inhaling silica dust.
- Tumors:
- Response to malignancy.
- Unknown etiology:
- Sarcoidosis: An inflammatory disease affecting multiple organs.
- Crohn's disease: Inflammatory bowel disease.

Aetiology of Granulomas

Caused by:
- Foreign body response, resulting in granulomatous inflammation.
- Type IV immune reaction (delayed-type hypersensitivity) triggered by the presence of foreign antigens.

Acute Appendicitis

Pain in the right iliac fossa (RIF) can be caused by a number of organs, including the appendix, ovary/adnexa, kidney, and small bowel.
Common RIF pain diagnoses include acute appendicitis, terminal ileitis, Meckel’s diverticulum, urinary tract infection/pyelonephritis, renal/ureteric colic, ectopic pregnancy, salpingitis, and ovarian mass.
Investigations typically include a full blood count (FBC), urine microscopy and culture, and a pregnancy test.
An elevated white blood cell count (WCC) with a predominance of neutrophils indicates bacterial infection.
Elevated C-reactive protein (CRP) levels indicate inflammation.
Polymorphs are the predominant inflammatory cell in acute appendicitis, indicating a bacterial infection.
The point of maximal tenderness in appendicitis can be found at McBurney’s point.
Appendicectomy (surgical removal of the appendix) is the standard treatment for acute appendicitis.

Complications of Acute Appendicitis

Complications include gangrenous transformation, perforation leading to peritonitis, abscess formation, and septicemia.
Abscess formation is a localized collection of pus.
Perforation of the appendix allows the contents of the appendix to leak into the peritoneum.
Clinical signs of intra-abdominal organ perforation include air under the diaphragm on an erect x-ray film.
Perforation of the appendix can lead to either localized or generalized peritonitis.

Systemic Effects

Systemic effects of inflammation include the acute phase response, which involves the production of inflammatory mediators causing pyrexia, increased acute phase proteins (e.g., CRP, ESR), leukocytosis, and other symptoms.
Severe sepsis can lead to disseminated intravascular coagulation (DIC), hypotension, and shock.

Pathophysiology of Acute Appendicitis

Appendicitis is typically caused by obstruction of the appendix lumen, often by a faecolith.
Obstruction leads to stasis, bacterial proliferation, inflammation, edema, and reduced blood supply, potentially causing gangrene.
Appendicitis can also be caused by Crohn’s disease, Yersinia infection, tuberculosis, and measles.

Chronic Inflammation & Granulomatous Inflammation

Chronic inflammation is characterized by a persistent presence of chronic inflammatory cells like lymphocytes, plasma cells, and histiocytes.
Granulation tissue is a specific type of tissue involved in healing, characterized by fibroblast proliferation, thin-walled capillaries, and loose extracellular matrix.
Granuloma formation is a specific immune response or foreign body response.
Causes of granulomatous inflammation include infections (e.g., TB, leprosy, fungal infections, parasites), foreign materials (e.g., splinters, sutures, keratin etc.), malignancies, and unknown causes (e.g., sarcoidosis, Crohn's disease).
Granulomas can form in response to foreign bodies, type IV immune reactions, and certain infections.

Pain Migration

The pain of acute appendicitis often migrates from the peri-umbilical area to the RIF.
This is due to visceral pain (innervation of the umbilicus and appendix by the same segment of the autonomic nervous system) transitioning to somatic pain (irritation of the serosal and parietal peritoneum).

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Description

Test your knowledge on the differential diagnosis of right iliac fossa pain and the histological features of acute appendicitis. This quiz covers the complications, causes of granulomatous inflammation, and key clinical manifestations. Perfect for medical students and healthcare professionals.