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PART I: ACUTE APPENDICITIS

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Q1. Clinical Features, Diagnosis & Management of Acute Appendicitis

Anatomy & Incidence

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Clinical Features (Symptoms)

1. Central/periumbilical colicky pain - visceral pain from distension of the appendix (midgut origin)
2. Anorexia - an extremely constant and reliable feature; nearly universal
3. Nausea and 1-2 vomits (vomiting follows pain - Murphy's rule; pain before vomiting is key)
4. Pain shifts to the right iliac fossa (RIF) - as inflammation spreads to parietal peritoneum
5. Low-grade fever (37.3-38.4°C in early appendicitis)
6. Diarrhoea or constipation may be present

• Retrocaecal (most common, ~65%): Loin tenderness, absent anterior rigidity ("silent appendix"), psoas spasm causing hip flexion
• Pelvic: No anterior rigidity, rectal tenderness on PR exam, frequency of micturition, possible early diarrhoea
• Retro-ileal/postileal: Pain may not shift, marked diarrhoea and vomiting

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Signs

• McBurney's point tenderness - 1/3 from ASIS to umbilicus; point of maximum tenderness
• Guarding and rigidity in RIF - distinguishes from NSAP
• Rebound tenderness (Blumberg's sign)
• Rovsing's sign - RIF pain on palpation of left iliac fossa (suggests localised peritonitis)
• Psoas sign - pain on extension of right hip (retrocaecal appendix)
• Obturator sign - pain on internal rotation of flexed right hip (pelvic appendix)
• PR examination - tenderness in rectovesical pouch or pouch of Douglas in pelvic appendicitis

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Investigations

• WBC: Leukocytosis with neutrophilia in ~90% of cases; normal WBC does not exclude appendicitis
• CRP: >10 mg/L; combined elevated WBC + CRP has sensitivity up to 98%
• Urinalysis: Exclude pyelonephritis; trace pyuria/haematuria can occur in appendicitis from proximity to ureter
• Urine/serum beta-hCG: Mandatory in women of reproductive age to exclude ectopic pregnancy
• Imaging:
  • Ultrasound (US): First line in children and pregnant women; non-compressible appendix >6 mm, periappendiceal fluid. Operator-dependent; limited in obese patients
  • CT abdomen/pelvis: Gold standard in adults; shows enlarged appendix, periappendiceal fat stranding, appendicolith, abscess. Best for complicated appendicitis
  • MRI: Used in pregnancy when US inconclusive; avoids radiation

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Management

• Laparoscopic appendicectomy is the standard treatment (lower wound infection rates, earlier recovery)
• Antibiotics alone are an acceptable alternative for uncomplicated cases - multiple RCTs (APPAC, CODA trials) show non-inferiority, but ~25-29% require appendicectomy within 90 days. Patient preference and shared decision-making are key. Risk is higher if appendicolith is present. - Sabiston Textbook of Surgery

• Appendix mass (phlegmon): Conservative - Oschner-Sherren regimen (IV antibiotics, fluids, NBM, close monitoring). Interval appendicectomy at 6-8 weeks (not mandatory in children)
• Appendix abscess: US/CT-guided percutaneous drainage + antibiotics; interval appendicectomy
• Perforated appendicitis with peritonitis: Emergency surgery; peritoneal washout + appendicectomy (laparoscopic or open)

• Children <5 years: Omentum poorly developed, perforation more common; appendix mass may respond to non-operative treatment
• Elderly: Higher threshold for diagnosis; diverticulitis and carcinoma must be excluded

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Q2: Short Notes

A. Alvarado Score (MANTRELS Score)

• Score 1-4: Low risk - unlikely appendicitis (discharge or observe)
• Score 5-6: Possible appendicitis - observe; imaging if needed
• Score 7-8: Probable appendicitis - surgical consultation
• Score 9-10: Very likely appendicitis - operate

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B. Differential Diagnosis of Acute Appendicitis

• Terminal ileitis (Crohn's/Yersinia) can be indistinguishable from appendicitis
• Perforated DU: pain starts in epigastrium then tracks to RIF; more upper rigidity
• In females: always do a pelvic exam; beta-hCG mandatory
• Right basal pneumonia/pleurisy: referred abdominal pain, minimal tenderness, marked pyrexia, chest signs

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C. Complications of Acute Appendicitis

• Perforation - commonest serious complication; leads to peritonitis or abscess
• Appendix mass/phlegmon - omentum and bowel wall off the inflamed appendix; felt as RIF mass
• Appendix abscess - localised collection around a perforated appendix
• Generalised peritonitis - faecal peritonitis; surgical emergency
• Pelvic abscess - in pelvic appendicitis

• Adhesive small bowel obstruction - post-operative
• Portal pyaemia / pylephlebitis - septic thrombophlebitis of portal vein; rare but serious; jaundice + high fever
• Caecal fistula - rare
• Wound infection/dehiscence
• Stump appendicitis - if residual appendix stump is too long

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PART II: INTESTINAL TUBERCULOSIS (Intestinal TB)

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Q3. Etiopathology, Clinical Features, Investigations & Management

Etiopathology

• Mycobacterium tuberculosis (most cases)
• Mycobacterium bovis (contaminated dairy products; rare in developed countries)

1. Primary (direct ingestion): Swallowing of organisms in infected sputum or contaminated food/milk - direct penetration of intestinal mucosa
2. Haematogenous spread: Miliary TB
3. Direct extension from adjacent organs (e.g., fallopian tubes, para-aortic nodes)

• Ileum and caecum most commonly (~75% of cases); ileocaecal region involvement is hallmark
• Both sides of ileocaecal valve are involved - leading to incompetence of the valve; this helps distinguish from Crohn's disease (where valve is usually spared)
• Can affect any region of GI tract: oesophagus, stomach, duodenum, colon, anorectal

• Caseating granulomas - seen in 50-80% of cases; caseation is more common in TB than Crohn's
• Acid-fast bacilli (AFB) in ~20% of mucosal samples
• PCR more sensitive (~65%)

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Clinical Features

• Abdominal pain: Most common (80-90%); chronic, nonspecific, colicky; RIF pain predominant
• Weight loss and anorexia
• Fever - low-grade
• Diarrhoea or constipation (alternating)
• Blood in stool - particularly with ulcerative type
• Palpable RIF mass - in 25-50% of patients (ileocaecal mass; may be mistaken for carcinoma)
• Ascites - peritoneal TB; characteristic "doughy" abdomen
• Perianal disease - fistula in ano
• Features of subacute intestinal obstruction - particularly in stricture (hypertrophic) type

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Investigations

• Raised inflammatory markers (ESR, CRP)
• Mild anaemia (normocytic normochromic)
• Normal or low WBC
• Positive sputum culture/smear (if concurrent pulmonary TB)

• Mantoux test (TST): Positive; not diagnostic alone
• IFN-γ release assays (IGRA, e.g., QuantiFERON-TB): More specific; detects subclinical infection - Bailey and Love

• Chest X-ray: Pulmonary infiltrates; may be normal in primary intestinal TB
• Ultrasound abdomen: Localised ascites, lymphadenopathy, matted bowel loops, ileocaecal mass
• Barium meal and follow-through / Small bowel series:
  • Multiple ileal strictures
  • Subhepatic caecum (caecum pulled up by fibrosis)
  • Incompetent ileocaecal valve
  • Stierlin's sign: Conical deformity of caecum with non-filling and rapid emptying
  • Fleischner sign: Incompetent ileocaecal valve with wide open appearance - Bailey and Love
• CT abdomen: Lymphadenopathy (often with central low density/necrosis), bowel wall thickening, ascites, omental thickening
• Colonoscopy with biopsy: Most useful single investigation; direct visualisation + biopsy for histopathology, AFB stain, PCR and culture with drug sensitivities. (Wear isolation mask if TB suspected)
• Laparoscopy: Useful when colonoscopy inconclusive; peritoneal nodules/biopsies

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Medical Management

• Monitor LFTs (hepatotoxicity from INH, RIF, PZA)
• Nutritional support and correction of anaemia essential
• Follow-up imaging after completion to assess for residual strictures

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Q4. Short Notes on Types, Complications & Role of Surgery in Intestinal TB

Types (Morphological - already covered above)

1. Ulcerative type (60%) - transverse ulcers; risk of perforation, haemorrhage, malabsorption
2. Hypertrophic/Hyperplastic type (10%) - fibrosis and mass; risk of obstruction, mimic of carcinoma
3. Ulcero-hypertrophic type (30%) - mixed; most common clinical type in India; risk of both obstruction and perforation

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Complications

1. Intestinal obstruction - most common complication; results from stricture formation (segmental stenotic disease); may be subacute or acute
2. Intestinal perforation - uncommon but can occur even during treatment; leads to peritonitis
3. Haemorrhage - from ulcers in ulcerative type
4. Fistula formation - entero-enteric, enterocutaneous, entero-vesical, perianal fistulae
5. Malabsorption - due to mucosal involvement and bacterial overgrowth proximal to strictures (SIBO)
6. Ileocaecal mass - may present as acute abdomen; mimics carcinoma
7. Ascites - peritoneal TB
8. Short bowel syndrome - post-extensive surgical resection

• Sleisenger and Fordtran's GI & Liver Disease

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Role of Surgery in Intestinal TB

• On completion of ATT, reimaging of the small bowel is done
• Indications: Residual significant strictures with features of subacute intermittent obstruction

• Limited ileocolic resection with end-to-end anastomosis - for ileocolic hyperplastic disease
• Strictureplasty - for single short ileal stricture; bowel-conserving
• Bowel resection - for multiple closely placed strictures
• Right hemicolectomy - for extensive ileocolic disease not amenable to limited resection

• For perforation, obstruction not responding to ATT, abscess
• Patient is typically malnourished, anaemic, with poor general condition; vigorous resuscitation first
• At laparotomy: minimum life-saving procedure is the aim
  • Resection of diseased segment + proximal ileostomy + distal mucous fistula (avoids anastomosis in sick patient with active infection, high leak risk)
  • One-stage resection and anastomosis only if patient's condition is good
• Post-op: combined physician + surgeon care; full course of ATT (6-12 months); nutritional rehabilitation
• If simple bypass was done initially, reassess after disease quiescence and perform definitive surgery
• Bailey and Love's Short Practice of Surgery, 28th Edition

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