Mastering Acute Appendicitis Management Guidelines for PLAB 2 Success
Introduction
Acute appendicitis is one of the most common surgical emergencies worldwide, and it represents a high-yield topic for the PLAB 2 examination. Understanding the current guidelines for diagnosis, investigation, and management is essential for any candidate appearing for this exam. This comprehensive guide will walk you through everything you need to know about acute appendicitis management in line with the latest UK guidelines and NICE recommendations.
Clinical Presentation and Diagnosis
Typical Symptoms
The classic presentation of acute appendicitis includes:
Abdominal pain: Usually starts periumbilical and migrates to the right iliac fossa (RIF)
Anorexia: Often the earliest symptom
Nausea and vomiting: Typically follows the onset of pain
Fever: Low-grade pyrexia (usually 37.2-38°C)
Clinical Signs
Key physical examination findings include:
McBurney's point tenderness: Located one-third of the distance from the anterior superior iliac spine to the umbilicus
Rovsing's sign: Pain in RIF when pressure is applied to the left iliac fossa
Psoas sign: Pain on extension of the hip (suggests retrocaecal appendicitis)
Obturator sign: Pain on internal rotation of the flexed hip
Investigation Guidelines
Laboratory Tests
According to NICE guidelines, the following investigations are recommended:
Full blood count (FBC): Look for leukocytosis (white cell count > 11 × 10⁹/L)
C-reactive protein (CRP): Elevated in inflammatory conditions
Urinalysis: To rule out urinary tract pathology
Pregnancy test: In female patients of childbearing age
Imaging Guidelines
The NICE guidelines emphasize that imaging should be used judiciously:
Ultrasound scan (USS): First-line imaging modality, especially in young patients and pregnant women
CT scan: Reserved for equivocal cases or when alternative diagnoses are being considered
MRI: Particularly useful in pregnant patients where CT is contraindicated
Management Guidelines
Initial Management
All patients with suspected acute appendicitis should receive:
Nil by mouth (NPO) status
IV fluids for hydration
Analgesia: Paracetamol is first-line; opioids may be required
Antibiotics: According to local antimicrobial guidelines
Surgical vs. Conservative Management
Appendicectomy
The gold standard treatment for acute appendicitis remains appendicectomy, which can be performed via:
Open approach: Traditional method
Laparoscopic approach: Preferred method in most UK centres due to faster recovery
Non-Operative Management
Antibiotics alone may be considered in selected cases:
Patients with mild symptoms
When surgical resources are limited
In patients with high operative risk
However, non-operative management carries a risk of recurrence (approximately 20-30%).
Complications
Understanding complications is crucial for PLAB 2:
Perforation: Occurs in 15-30% of cases, more common in elderly and children
Appendiceal abscess: May require percutaneous drainage
Peritonitis: Diffuse infection of the peritoneal cavity
Wound infection: Post-operative complication
PLAB 2 Examination Tips
History Taking
When taking history for a suspected appendicitis case in PLAB 2:
Enquire about pain migration (highly specific symptom)
Ask about associated symptoms (anorexia, nausea, vomiting)
Clarify bowel habits and urinary symptoms
Document any previous similar episodes
Communication Skills
The exam assesses your ability to:
Explain the diagnosis clearly to the patient
Discuss treatment options and their risks/benefits
Obtain informed consent for surgery
Address patient concerns effectively
Emergency Scenario Management
In acute presentations:
Demonstrate systematic assessment (ABCDE approach)
Recognize signs of complications (perforation, sepsis)
Initiate appropriate investigations promptly
Coordinate with surgical team effectively
Conclusion
Acute appendicitis management is a fundamental topic in PLAB 2. Candidates should be thoroughly familiar with the diagnostic criteria, investigation protocols, and treatment guidelines. The key to success in the exam lies not just in memorizing facts, but in demonstrating sound clinical reasoning and excellent communication skills.
Remember: The NICE guidelines and local hospital protocols are your best friends when preparing for the PLAB 2 examination. Stay updated with the latest recommendations and practice your history-taking and examination skills regularly.
Key Takeaways
Diagnosis: Classic triad includes periumbilical pain migrating to RIF, anorexia, and fever
Investigations: FBC, CRP, urinalysis, and ultrasound are first-line
Management: Appendicectomy remains the gold standard; antibiotics may be considered in selected cases
Complications: Be alert for perforation, abscess, and peritonitis
Exam Focus: Emphasize communication skills, systematic assessment, and evidence-based management
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