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Surgery M4 part 2 > Appendix > Flashcards

Appendix Flashcards

1
Q

What is the appendix?

A

blind muscular tube at the base of the cecum

base is fixed at confluence of the 3 tenia coli of the cecum

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2
Q

What is the most common position of the appendix?

A
  • retrocecal (74%)

- pelvic (20%)

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3
Q

What is the function of the appendix?

A
  • immunity
  • gut flora regulation
  • appendectomy protective against ulcerative colitis
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4
Q

What is the normal size of the appendix?

A

7.5-10cm

<6mm in diameter

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5
Q

What is the most common cause of acute abdomen in young adults?

A

appendicitis

  • common in childhood & early adulthood
  • peaks in teens & early 20s
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6
Q

What are the causes of appendicitis?

A
  • decreased dietary fibers
  • increased consumption of refined carbohydrates
  • bacterial proliferation (E. coli)
  • obstruction of lumen (ficolith, stricture, cecal carcinoma, intestinal parasite)
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7
Q

What is the pathogenesis of appendicitis?

A

aggregating factor -> mucosal inflammation & lymphoid hyperplasia -> obstruction of lumen -> edema & mucosal ulceration -> bacterial translocation to submucosa -> venous obstruction & ischemia -> bacterial invasion of muscularis propria -> ischemic necrosis -> gangrene & perforation -> peritonitis

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8
Q

how does an appendiceal mass form?

A

adherence of greater omentum

- leads to phlegmon, appendicial mass, paracecal abscess

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9
Q

What are the risk factors for appendiceal perforation & peritonitis?

A
  • extremes of age
  • immunosuppression
  • diabetes mellitus
  • fecolith obstruction
  • pelvic appendix
  • previous abdominal surgery

DO NOT DELAY SURGERY

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10
Q

what are the symptoms of appendicitis?

A
  • periumbilical colicky pain
  • pain shifting to right iliac fossa, sharper
  • anorexia
  • nausea +- vomiting
  • suprapubic discomfort & tenesmus
  • low grade fever (if high grade -> peritonitis)
  • diarrhea
  • RUQ pain in pregnancy
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11
Q

What are the signs of appendicitis?

A
  • low grade fever
  • RIF tenderness (McBurney’s point)
  • rebound tenderness
  • guarding
  • Rovsing’s sign (push on one side pain felt on the other)
  • Psoas sign (hip extension causes pain)
  • obturator sign
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12
Q

Where is McBurney’s point?

A

between ASIS & umbilicus

lateral 1/3 & medial 2/3

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13
Q

What is the DD of appendicitis?

A

in children:

  • gastroenteritis
  • mesenteric adenitis
  • Meckel’s diverticulitis

in adults:

  • regional enteritis
  • ureteric colitis
  • perforated peptic ulcer (valentino sign)
  • torsion of testis
  • ectopic pregnancy
  • pancreatitis
  • pyelonephritis

in elderly:

  • diverticulitis
  • intestinal obstruction
  • colonic carcinoma
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14
Q

What is the Alvarado score?

A 
score of 7 or more is highly predictive of acute appendicitis 
Migratory pain 1
Anorexia 1
Nausea & vomiting 1
Tenderness RIF 2
Rebound tenderness 1
Elevated temperature 1
Leucocytosis 2
Shift to left 1
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15
Q

What are the investigations that should be done for suspected appendicitis?

A
  • CBC
  • urinalysis
  • pregnancy test
  • urea & electrolytes (hypokalemia hypochloremia)
  • ULTRASOUND
  • CT with contrast
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16
Q

When should an ultrasound be preformed & what will be its findings?

A
  • in young females
  • in children
  • in low Alvarado score

findings:

  • non compressible distended (>6mm) appendix
  • fluid around appendix
  • target sign
17
Q

When should CT be preformed & what are its findings?

A
  • obese
  • elderly
  • urgent cases iff <18 year olds

findings:

  • distended edematous appendix
  • periappendiceal fat stranding
  • perforation
  • abscess
18
Q

How should appendicitis be treated?

A
  • if an appendicial mass is felt -> conservative & antibiotics till mass gets smaller
    (cephalosporin & metronidazole) for 1-2 weeks then surgery after 3 months
  • appendectomy
19
Q

What are the post-op complications?

A
  • wound infection
  • intra-abdominal abscess
  • ileus (esp after peritonitis)
  • portal pyemia/pylephlebitis
  • fecal fistula (V. common in Crohn’s so do right hemicolectomy instead)
  • DVT, adhesions…..
20
Q

where do carcinoid tumors most commonly arise in GI tract?

A
  • in terminal ileum & appendix
  • rarely metastasize
  • asymptomatic due to hepatic metabolism of serotonin
21
Q

What are the signs of metastatic carcinoid tumors?

A

Carcinoid syndrome

  • diarrhea & abdominal cramps
  • cutaneous flushing
  • tachycardia & fluctuating blood pressure if severe
  • dyspnea, wheezing (asthma like due to histamine)
  • palpitations
22
Q

What investigations should be done to confirm presence of carcinoid tumor?

A
  • CHROMOGRANIN-A (hallmark)
  • 24h-urinary 5 HIAA
  • octreotide scan
  • CT/MRI abdomen
23
Q

How is an appendiceal carcinoid tumor treated?

A 
appendectomy UNLESS:
- cecum is involved 
- >2cm 
- lymph node is involved 
do right hemicolectomy
24
Q

What is the classification of epithelial neoplasia of the appendix?

A

ADENOMA

  • tubular -> benign
  • tubulovillous -> borderline
  • villous -> precancerous

NON-MUCINOUS ADENOCARCINOMA -> right hemicolectomy

MUCINOUS NEOPLASM

  • low grade (LAMN) -> benign
  • if it perforates -> pseudomyxoma peritonei (PMP)
  • high-grade (HAMN)
  • mucinous adenocarcinoma

ADENOCARCINOMA with <50% Signet rings

SIGNET RING CARCINOMA >50% (worst)

25
Q

What is the pathophysiology of PMP?

A

slow leak or sudden release of mucus -> free mucinous epithelial tumor cells in peritoneal cavity -> cells continue to proliferate -> mucinous ascites

  • progressive peritoneal tumor deposits
  • mucinous ascites
  • omental cake
  • ovarian involvement in females
26
Q

How does PMP present?

A
  • progressive massive abdominal distension JELLY BELLY
  • anorexia
  • symptoms of bowel dysfunction or intestinal obstruction
  • ovarian mass causing lower abdominal/pelvic pain
27
Q

What investigations should be done for epithelial appendiceal tumors?

A
  • colonoscopy
  • CA 125, CA 19-9, CEA
  • CT abdomen & pelvis
28
Q

How should epithelial appendicial tumors be managed?

A

NO PMP

  • low grade, non-mucinous, localized to appendix -> appendectomy + surveillance for 5 years
  • high grade, invasive adenocarcinoma, goblet cell tumor, mucinous -> right hemicolectomy + prophylactic regional peritonectomy, omentectomy +/- HIPEC +/- prophylactic bilateral oophorectomy

PMP:
- cytoreductive surgery (CRS) + HIPEC

Surgery M4 part 2 (36 decks)

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