 And so we get to the clinical picture of acute appendicitis. It is very important to take a thorough history and do a proper clinical examination. Appendicitis can mimic many other diseases and other diseases can mimic appendicitis. There are many special investigations available. But clinical history, clinical examination still plays the most important part in making the diagnosis of acute appendicitis. So what are the symptoms? Well, the hallmark of acute appendicitis is of course abdominal pain. Why do these patients have pain? Well, it's inflammatory and infective. Now, we used to think that the inflammation starts off with by obstruction of the lumen of the appendix. That's a fecalith, that's a hard dish. A piece of stool obstructs the lumen. You have some swelling, edema, hyperemia, eventually the blood flow gets obstructed and you get gangrene around the small vessels which can go throughout the lumen and eventually cause perforation. We do know though that less than half of specimens investigated do not have a fecalith. Do not seem to have obstruction. So clearly something else also plays a part. Some other thoughts might be that all of this is initiated by viral infection, that there's some loss of integrity of the mucosal surface with the invasion of bacteria and that sets off the acute appendicitis. So we're not 100% clear as to how this happens. In the end though, we do have a bacterial infection. So with this inflammation, with infection we have pain. Most people will start with a non-specific periombolycol pain. Once again, we're not 100% sure how this works. It is common to read that it is a visceral pain. Remember the appendix is in the mid-gut, embryological mid-gut. There's visceral nerve supply, in other words a type of nerve supply that cannot differentiate area very well so that you get this periombolycol type of pain. There's some research though that suggests that it might just be pyloric spasm and that pyloric spasm is very common in any kind of bowel disease that you might get it early on in colon cancer, that you might get it in diverticular disease, for instance diverticulitis, and that it is the pyloric spasm that causes the initial non-specific periombolycol pain. So there are different ways to look at this as well. Eventually though, as this inflammation and infection spreads, it is going to start affecting the peritoneum, the parietal peritoneum, and this has somatic nerve supply. In other words, you will be able to localize that pain. Now for most of us, our appendix is in our right lower quadrant so we're going to localize this pain down in the right quadrant. But not everyone is the same. Some people might have malrotation, maybe not full malrotation. People have their appendices in different locations. For instance, it's very common to have a retrocecal appendix, but it might be buried so deep in the retroperitoneal space that infection has to really be avert before you start getting the lateral pain as it touches the peritoneum in the right flank. And some patients have an appendix down, way down into the pelvis and that can cause its own problems. And we'll discuss this very shortly. In any event, the parietal peritoneum with its somatic nerve supply will cause the pain to be localized in a certain spot and we can use this localization of the pain to help us in the making of the diagnosis of acute appendicitis. Many patients will have constipation in as much as there's a local inflammatory process. It causes a slight paralysis of the bowel in that area and with that leads to a bit of constipation. Patients with a pelvic appendix, in other words, the tip of the appendix lying down into the pelvis might touch the rectum, might irritate the rectum and they might present with a bit of diarrhea and that might be confusing. It might also touch the bladder with a bit of urinary symptoms, dysuria, frequenturia. Loss of appetite, though, is very common. Most patients will have a loss of appetite. Nausea and vomiting, not so much, maybe half or slightly less than half of patients might actually be nauseous and vomit. So the classic symptoms is this pain periombolycol, vague pain, space to the right iliac faso, and loss of appetite. Not all patients present like this, though. If you look at the literature critically, maybe only half of patients present in this classical form. So keep your ears peeled, listen to the patient, ask more and more questions specifically about other organ systems as well, trying to list symptoms that might suggest other organ systems have been the cause of the pain. Let's move on to the signs. Remember a thorough and systematic clinical examination head to toe. If you start off with the vital signs, most patients will have a tachycardia. It might not be by definition over 100, but certainly an elevated heart rate. Very common to have a low-grade pyrroxia. Patients with a higher temperature might be suggestive of something else, maybe a viral infection, or that the appendicitis has become severely complicated. Those patients also present with a much higher fever. Hypertension, bad sign. Usually, a sign that septicemia and septic shock has actually set in. You don't want to wait until that becomes an avert sign. Because of the loss of appetite, people also don't take in enough fluids. You will find signs of dry mucosal surfaces, signs of dehydration. You have to look out for lymphadenopathy as well in the differential diagnosis. We have something called mesenteric adenitis. We'll discuss it briefly. It may be preceded by a bit of upper-airway infection. Patients might have a bit of cervical lymphadenopathy, specifically in children, might help you to make the diagnosis of mesenteric adenitis versus acute appendicitis. The whole point here is to do a thorough examination, start with your vital signs, do your general examination, systematic examination of all the systems, and then go to the abdomen. So what do we do with the abdomen? We facilitate, percuss, and examine by touch. With the inspection, you shouldn't find much. Not really avert signs of appendicitis that you can see by just inspecting the abdomen. Listening for bowel sounds really is not that specific, and way too much was written in the literature previously about the different sounds and absence of sounds as far as bowel function is concerned by listening for bowel sounds. Not something that really truly helps you. Percussion. Percussion is a very good way to elicit signs of peritoneal irritation. It's actually more tolerable for the patient just to be percussed as opposed to having deep palpation, causing a lot of discomfort and pain. So just percussing the abdomen, start far away from the point of maximal pain, work your way towards it, and if the patient has percussion tenderness over McBurnie's point, well, that really leans towards a diagnosis of acute appendicitis. With examination, we're going to start our palpation again far away from the point of maximal pain and work our way towards that. Do not cause the patient avert discomfort by repeatedly looking for signs of peritonism. Now remember though, it's not only peritonism we're also looking for other problems. Are there enlarged organs? Something you have to watch out for is there a mass in the area of the appendix. Remember an appendix mass and even an appendix abscess should be treated differently from normal appendicitis. So we're looking for masses and we're looking for enlarged organs. Remember at this time we're not 100% sure that we are examining a patient with acute appendicitis. So be thorough in your examination there. Now I use the term peritonism. I use it in a definition that might suggest that there is inflammation and infection of the parietal peritonium. And I can elicit signs to suggest that that is so. So what can I do? When I do examine over the point of maximal pain the patient will involuntary guard. In other words, they will tense up the abdominal wall muscles and they don't have much control over that. It is a protective mechanism and it is a sign that there is peritonial inflammation or infection or peritonism. There is also rebound tenderness where you actually do a bit of deep palpation and suddenly let go. Really not necessary to do. Very uncomfortable, very painful and certainly don't do it twice and don't call all your colleagues to come and have a look at it. It's really not your main thing to do to a human being. For that matter, a very quick note on analgesia. Remember, analgesia is not going to hide the presence of acute appendicitis from you. Again, if it's going to take a long time before the patient can be evaluated do not withhold analgesia. It will not make appendicitis hide away from you. Okay, you've got to make as far as the peritonism or signs of peritonitis is concerned try and elicit it all over the abdomen. You need to know whether this is a local process, meaning when you do open procedure, open surgical procedure that you can make your incision there or if it's diffuse, this appendix is perforated, it is passed throughout the abdomen, you would need to do a full laparotomy. I will leave laparoscopy out until a bit later. So you need to know whether this process is local or diffuse. And then we get to the touchy subject of rectal or vaginal examination. And away in the past, it might have been on the forefront and it was felt that your examination was not complete unless you performed these examinations really were leaning away from that. There's not a lot that you can really add in your decision-making ability when you do a rectal and vaginal examination. Now that being said, on the other hand, if there were things in your systematic examination of the patient or in the history indeed that might make you believe that there's another diagnosis here that makes rectal or vaginal examination mandatory, of course you've got to go ahead and do it. But there are many laboratory and special investigations that really are a lot more helpful than subjecting a patient to a rectal or vaginal examination. So in the next video, we're going to move on to our laboratory and other special investigations.