4 - Appendicitis Flashcards
Quick pathophys of appendicitis
Lumen obstructed -> distention -> infection -> ischemia -> perforation
Distention of the appendix following obstruction leads to what sxs?
Periumbilical pain
N/V
Mildly tender abdomen
Systemic inflammatory response syndrome
When the appendix is ischemic, what sxs occur?
Pain radiating to the RLQ
Low grade fever
Mild bump in WBC’s
SIRS -> Sepsis
When the appendix perforates, what sxs occur?
Succus spills out -> peritonitis
Increased pain / TTP
High fever / WBC’s
Sepsis -> septic shock
Overview if appendicitis symptoms:
Periumbilical pain FIRST, then radiates to RLQ
Almost always anorexia then vomiting
Tenderness develops later
If the appendix is in the iliac fossa, where is the pain?
McBurney’s point
If the appendix is in the pelvis, where is the pain?
Rectal tenderness
Obturator sign
If the appendix is retrocecal or retroperitoneum, where is the pain?
Along the psoas
When might the pain of appendicitis be in the RUQ?
Pregnancy
Appendicitis workup:
PE findings usually give it away
CBC (leukocytosis expected)
CMP (liver, kidney, blood glucose)
UA (hydration status)
HCG (to r/o ectopic pregnancy)
Imaging for appendicitis
Acute abdominal series (flat, upright, CXR)(not very diagnostic for appendicitis, but may show ileus or fecolith)
US - may show inflamed appendix
CT
MRI - usually done in kids to avoid ionizing radiation of CT
What will you see on CT with appendicitis?
Fat stranding
MANTRELS mnemonic
Migration to R iliac fossa Anorexia N/V Tenderness in R iliac fossa Rebound pain Elevated temp Leukocytosis Shift of leukocytes to the left
Appendicitis management
NPO
IVF (use UOP as guide)
IV ABX against gram (-), strep, anaerobes (2nd or 3rd gen cephalosporin with metronidazole)
NG suction for gastric decompression
Anti-emetics, pain control (don’t worry about “masking” sxs - treat their pain)
Which populations have a higher rate of perforation and/or delay in dx?
Children
Elderly
Developmentally delayed
Special note regarding pregnancy and appendicitis
Gall bladder dz and appendicitis very common during pregnancy
US to help differentiate (CT CI’d in pregnancy)
Two major surgical techniques:
Open (McBurney incision, takes appx one hour)
Laparoscopic (better visualization of ABD/pelvis)(can convert to open if needed)
DDx for appendicitis:
(In parentheses, why it WOULDN’T be appendicitis)
Long card, sorry
Gastroenteritis (appendicitis doesn’t usually present with diarrhea as CC)(hyperactive BS)
UTI (UA will show many WBC’s, foul smell, leuk-es and/or nitrites)
Calculi (sudden and intense onset, UA with RBC’s)
Ovarian cyst (NOT an infection)
Ectopic pregnancy (check the HCG and US)
PID (bilateral adnexal tenderness, discharge from cervical os)
Meckel’s Diverticulum (gastric or pancreatic tissue, 2 feet of ilio-cecal junction, 2% of population)(surgically removed along with appendix, even if not appendicitis)
Crohn’s (regional enteritis, treated medically, still remove appendix if cecum not inflamed)
Diverticulitis (usually in older patients, often guaiac (+), normally L-sided pain)
Colon CA (usually older patients, often guaiac (+))
Suppurative appendix
Early, some pus but no tissue necrosis or perforation
Gangrenous appendix
Tissue necrosis but not yet perforated
Perforated appendix
Generalized peritonitis - operate ASAP
Localized abscess - ABX and percutaneous drainage then appendectomy usually after 6 weeks
Rare pathologies associated with appendicitis
Carcinoid (MC)
Lymphoma
Adenocarcinoma
Complications of appendectomy
Surgical site infection (remove sutures, irrigate, oral ABX, follow-up closely)
Deeper infection (muscle to fascia)(fever, anorexia, ill-appearing - may need exploratory surg and IV ABX)
Overall goal of txt of appendicitis
Prevent septic shock
Prevent perforation
Standard of care for appendicitis is surgery
