Podcast
Questions and Answers
Which of the following organs is NOT commonly associated with right iliac fossa (RIF) pain?
Which of the following organs is NOT commonly associated with right iliac fossa (RIF) pain?
What investigation is most significant to check for inflammation during the diagnosis of acute appendicitis?
What investigation is most significant to check for inflammation during the diagnosis of acute appendicitis?
Which of the following correctly describes the chief histological feature of acute appendicitis?
Which of the following correctly describes the chief histological feature of acute appendicitis?
Which symptom is typically NOT associated with acute appendicitis?
Which symptom is typically NOT associated with acute appendicitis?
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Which condition would NOT typically present with elevated white blood cells (WCC)?
Which condition would NOT typically present with elevated white blood cells (WCC)?
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What is the main reason for performing an abdominal X-ray in the assessment of suspected appendicitis?
What is the main reason for performing an abdominal X-ray in the assessment of suspected appendicitis?
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Which of the following is the most likely consequence of untreated acute appendicitis?
Which of the following is the most likely consequence of untreated acute appendicitis?
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What percentage of acute appendicitis cases is due to inflammation of the appendix wall by native bowel organisms?
What percentage of acute appendicitis cases is due to inflammation of the appendix wall by native bowel organisms?
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What distinguishes granulomatous inflammation from granulation tissue?
What distinguishes granulomatous inflammation from granulation tissue?
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What is the primary management approach for a patient diagnosed with acute appendicitis?
What is the primary management approach for a patient diagnosed with acute appendicitis?
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What is a significant complication of acute appendicitis?
What is a significant complication of acute appendicitis?
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What role do neutrophils play in the inflammatory process associated with appendicitis?
What role do neutrophils play in the inflammatory process associated with appendicitis?
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Which of the following is NOT a systemic effect of inflammation during acute appendicitis?
Which of the following is NOT a systemic effect of inflammation during acute appendicitis?
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What is an abscess in the context of appendicitis?
What is an abscess in the context of appendicitis?
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What can cause obstruction to the appendix lumen, leading to acute appendicitis?
What can cause obstruction to the appendix lumen, leading to acute appendicitis?
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What is the clinical significance of perforation of the appendix?
What is the clinical significance of perforation of the appendix?
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What type of pain is associated with the migration of appendicitis pain from the peri-umbilical area to the right iliac fossa (RIF)?
What type of pain is associated with the migration of appendicitis pain from the peri-umbilical area to the right iliac fossa (RIF)?
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What cells are primarily involved in chronic inflammation?
What cells are primarily involved in chronic inflammation?
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What characterizes granulation tissue?
What characterizes granulation tissue?
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Which of the following is NOT a common cause of granulomatous inflammation?
Which of the following is NOT a common cause of granulomatous inflammation?
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What type of immune response is granulomatous inflammation classified as?
What type of immune response is granulomatous inflammation classified as?
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Which condition is known to present with granulomatous inflammation?
Which condition is known to present with granulomatous inflammation?
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What type of medication is primarily used in the treatment of perforated appendicitis?
What type of medication is primarily used in the treatment of perforated appendicitis?
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Which of the following infections can lead to granulomatous inflammation?
Which of the following infections can lead to granulomatous inflammation?
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Which of the following conditions is least likely to cause pain in the right iliac fossa (RIF)?
Which of the following conditions is least likely to cause pain in the right iliac fossa (RIF)?
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What is the primary cause of elevated polymorphs in the context of acute appendicitis?
What is the primary cause of elevated polymorphs in the context of acute appendicitis?
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During the examination of a patient suspected of having appendicitis, which finding would be most indicative of inflammation?
During the examination of a patient suspected of having appendicitis, which finding would be most indicative of inflammation?
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Which symptom is most commonly associated with acute appendicitis?
Which symptom is most commonly associated with acute appendicitis?
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What is the role of CRP in the diagnosis of acute appendicitis?
What is the role of CRP in the diagnosis of acute appendicitis?
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Which investigation would be least useful for diagnosing acute appendicitis?
Which investigation would be least useful for diagnosing acute appendicitis?
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In which age group is acute appendicitis most frequently seen?
In which age group is acute appendicitis most frequently seen?
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Which cellular response is predominantly involved in the histological features of acute appendicitis?
Which cellular response is predominantly involved in the histological features of acute appendicitis?
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What is the primary complication associated with perforation of the appendix?
What is the primary complication associated with perforation of the appendix?
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Which of the following is a systemic effect of inflammation during acute appendicitis?
Which of the following is a systemic effect of inflammation during acute appendicitis?
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What is the most common cause of obstruction to the lumen of the appendix leading to acute appendicitis?
What is the most common cause of obstruction to the lumen of the appendix leading to acute appendicitis?
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What typically characterizes an abscess in the context of acute appendicitis?
What typically characterizes an abscess in the context of acute appendicitis?
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What occurs as a result of bacterial proliferation in the case of acute appendicitis?
What occurs as a result of bacterial proliferation in the case of acute appendicitis?
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Which of the following is a known complication of acute appendicitis?
Which of the following is a known complication of acute appendicitis?
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What is the outcome if a patient experiences chronic inflammation following an episode of acute appendicitis?
What is the outcome if a patient experiences chronic inflammation following an episode of acute appendicitis?
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What is the role of eosinophils in the context of inflammation during appendicitis?
What is the role of eosinophils in the context of inflammation during appendicitis?
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What characterizes the transition from acute inflammation to chronic inflammation?
What characterizes the transition from acute inflammation to chronic inflammation?
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Which cell type is most associated with granulation tissue formation?
Which cell type is most associated with granulation tissue formation?
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Which statement best describes a granuloma?
Which statement best describes a granuloma?
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Which type of reaction is classified under tuberculosis in granulomatous inflammation?
Which type of reaction is classified under tuberculosis in granulomatous inflammation?
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What common feature distinguishes granulomatous inflammation from other forms of inflammation?
What common feature distinguishes granulomatous inflammation from other forms of inflammation?
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What is a common cause of granuloma formation in the absence of a foreign body?
What is a common cause of granuloma formation in the absence of a foreign body?
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In the case of retro-caecal appendicitis, how might the clinical presentation differ from typical cases?
In the case of retro-caecal appendicitis, how might the clinical presentation differ from typical cases?
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Which of the following is NOT a typical immunological cause of granulomatous inflammation?
Which of the following is NOT a typical immunological cause of granulomatous inflammation?
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Study Notes
Acute Appendicitis
- A 25 year old female presented with right iliac fossa (RIF) pain for 36 hours.
- Pain began periumbilical and migrated to the RIF.
- Associated symptoms include nausea and vomiting.
- Examination revealed pyrexia, tachycardia, and rebound tenderness in the RIF.
- Guarding was present but no rigidity was noted.
- Bowel sounds were present.
Differential Diagnosis of RIF Pain
- RIF pain can be caused by a variety of conditions affecting the appendix, ovary/adnexa, kidney, and small bowel.
- Possible diagnoses include acute appendicitis, terminal ileitis, Meckel's diverticulum, urinary tract infection (UTI)/pyelonephritis, renal/ureteric colic, ectopic pregnancy, salpingitis, and ovarian mass.
Investigations
- A full blood count (FBC) is essential to assess the white blood cell count (WCC) and differential.
- An elevated WCC with a high proportion of neutrophils suggests an inflammatory process.
- C-reactive protein (CRP) levels are elevated in inflammation.
- A midstream urine (MSU) sample is collected to assess for a urinary tract infection (UTI).
- An abdominal X-ray can be used to rule out other causes of RIF pain, but it is not always diagnostic for appendicitis.
- An abdominal ultrasound is commonly used to visualize the appendix and surrounding structures.
Diagnosis: Acute Appendicitis
- Laboratory findings showed elevated white blood cell count (WCC) with a high proportion of neutrophils, and elevated CRP levels.
- Urine analysis revealed a mixed growth of E-coli and Staphylococcus, but the colony count was less than 100,000 organisms/ml, ruling out a UTI.
Pathology
- Acute appendicitis is characterized by inflammation of the appendix wall, typically due to obstruction of the lumen by a faecolith.
- Obstruction leads to stasis, bacterial proliferation, inflammation, edema, and ultimately reduced blood supply.
- Other causes of acute appendicitis include Crohn's disease, Yersinia infection, tuberculosis, and measles.
- The predominant inflammatory cell in acute appendicitis is the neutrophil.
Management
- Management of acute appendicitis involves surgical removal of the appendix (appendicectomy), which can be performed via open surgery or laparoscopy.
- Prophylactic antibiotics are administered to prevent post-operative infection.
Complications
- Complications of acute appendicitis include gangrenous transformation, perforation, abscess formation, and septicemia.
Systemic Effects of Inflammation
- Inflammation triggers the acute phase response, characterized by the production of various inflammatory mediators.
- Systemic symptoms include fever (pyrexia), increased acute phase proteins (e.g., CRP, ESR), leukocytosis, increased blood pressure and pulse, sweating, rigors, sleep disturbances, anorexia, and malaise.
- Severe sepsis can lead to disseminated intravascular coagulation (DIC), hypotension, and shock.
Chronic Inflammation and Granulomas
- Chronic inflammation is defined by the presence of chronic inflammatory cells, including lymphocytes, plasma cells, and histiocytes.
- Granulation tissue is a characteristic feature of healing and is composed of proliferating fibroblasts, new capillaries, and chronic inflammatory cells. It is a nonspecific response to injury.
- Granulomatous inflammation is a specific immune response or a foreign body response.
- Granulomas are collections of immune cells (macrophages and lymphocytes) that form around a foreign body or pathogen.
Causes of Granulomatous Inflammation
- Granulomas can be caused by infections (e.g., tuberculosis, leprosy, fungal infections), foreign materials (e.g., splinters, sutures, keratin), metals/dust (e.g., berylliosis, silicosis), malignancies, or unknown causes (e.g., sarcoidosis, Crohn's disease).
Aetiology of Granulomas
- Granulomas can develop as a result of a foreign body response or a type IV hypersensitivity reaction (delayed type hypersensitivity).
Learning Outcomes
- List differential diagnoses for pain in the right iliac fossa (RIF)
- Describe the histological features of acute appendicitis
- Summarize complications of acute appendicitis based on the consequences of inflammation
- Distinguish granulation tissue from granulomatous inflammation
- List the causes of granulomatous inflammation
Case Presentation
- A 25-year-old female presents with pain in the RIF for 36 hours
- Pain initially periumbilical, then migrated to RIF accompanied by nausea and one episode of vomiting
Focused Examination
- Pyrexia, elevated heart rate at 90 beats per minute
- Rebound tenderness and guarding in the RIF, normal bowel sounds
- Guarding is involuntary muscle contraction to protect from pain, rigidity is a more severe form of guarding involving total muscle spasm
- Potential organs causing RIF pain include appendix, ovary/adnexa, kidney, and small bowel
Differential Diagnoses of RIF Pain
- Acute appendicitis
- Terminal ileitis
- Meckel's diverticulum
- Urinary tract infection/pyelonephritis
- Renal/ureteric colic
- Ectopic pregnancy
- Salpingitis
- Ovarian mass
Investigations
- Full blood count (FBC) with differential
- Urine microscopy, culture, and sensitivity (MSU)
- Pregnancy test
- Abdominal x-ray
- Abdominal ultrasound
FBC Results
- White blood cell count (WCC) elevated at 14,500, with an elevated percentage of polymorphonuclear neutrophils (95%)
- Elevated polymorphonuclear neutrophils suggest a bacterial infection, while increased lymphocytes typically indicate a viral infection.
Urine Results
- Microscopy: Less than 5 pus cells
- Culture: Mixed growth of E. coli and Staphylococcus
- Colony count: Less than 100,000 organisms per ml
- Urine findings are not consistent with a urinary tract infection
Diagnosis
- Acute appendicitis
Gross Pathology
- Normal appendix vs. Appendicitis
Cellular Components of Acute Appendicitis
- Predominant inflammatory cell is neutrophils
Role of Polymorphonuclear Neutrophils
- Polymorphonuclear neutrophils participate in phagocytosis and killing via superoxide radicals and hydrogen peroxide
- Other cells in the body capable of phagocytosis include macrophages
Outcomes of Acute Inflammation
- Complete resolution (rare in acute appendicitis)
- Chronic inflammation
- Abscess formation
- Fibrosis
Management
- Prepare for surgery
- Appendicectomy via open surgery or laparoscopy
- Administration of prophylactic antibiotics
Causes of Acute Appendicitis
- Primarily due to inflammation of the appendix wall by organisms native to the bowel (98%)
Obstruction of the Appendix Lumen
- Predominantly due to a fecalith, leading to stasis, bacterial proliferation, inflammation, edema, and reduced blood supply, potentially resulting in gangrene
- Stenosis of the appendix lumen can also occur due to other causes (e.g. Crohn's disease, tumors)
Other Causes of Acute Appendicitis
- Crohn's disease
- Yersinia
- Tuberculosis
- Measles
Complications of Acute Appendicitis
- Gangrenous transformation
- Perforation (leading to peritonitis)
- Abscess formation
- Septicemia
Abscess
- A localized collection of pus containing dead and degenerate leukocytes, host tissue cells, edema fluid, and dead microorganisms
Perforation
- A "hole" in the appendix, allowing its contents to enter the peritoneum
- Clinical significance of perforation is peritonitis
Peritonitis
- Inflammatory reaction of the peritoneum, potentially localized or generalized
- Clinical signs include abdominal pain, tenderness, rigidity, fever, and leukocytosis
- Radiological findings on erect abdominal x-ray include air under the diaphragm
Systemic Effects of Inflammation
- Acute phase response triggered by inflammatory mediators produced in response to infection/injury
- Manifestations include pyrexia, elevated acute phase proteins (e.g. CRP, ESR), leukocytosis, increased blood pressure and pulse, sweating, chills, sleep disturbances, anorexia, malaise, and potentially severe sepsis leading to disseminated intravascular coagulation (DIC), hypotension, and shock
Management of Perforated Appendicitis
- Surgery
- Intravenous antibiotics
Pain Migration in Acute Appendicitis
- Pain typically migrates from the periumbilical area to the RIF due to visceral pain (shared innervation of appendix and umbilicus by the autonomic nervous system) followed by somatic pain (serosal and parietal peritoneum irritation)
- Atypical presentation can occur with a retrocaecal or pelvic appendix
Chronic Inflammation
- Inflammation involving chronic inflammatory cells (e.g. lymphocytes, plasma cells, histiocytes)
- Can arise from progressive acute inflammation, develop initially as chronic inflammation, or be associated with autoimmune diseases
Granulation Tissue and Granulomas
- Granulation tissue: A non-specific response to injury characterized by new blood vessels, fibroblasts, and extracellular matrix
- Granuloma: A specific immune response characterized by a cluster of macrophages and lymphocytes
Causes of Granulomatous Inflammation
- Infection (e.g. tuberculosis, leprosy, cat scratch disease, histoplasmosis, blastomycosis, schistosomiasis, toxoplasmosis, leishmaniasis, syphilis)
- Foreign material (e.g. splinters, sutures, keratin, hair, metal, dust)
- Malignancy
- Unknown etiology (e.g. sarcoidosis, Crohn's disease)
Aetiology of Granulomas
- Foreign body response
- Type IV hypersensitivity reaction (delayed-type hypersensitivity)
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Description
Test your knowledge on acute appendicitis by reviewing key symptoms, differential diagnoses, and investigation methods. This quiz will cover patient presentations and clinical findings crucial for diagnosing RIF pain conditions.
