Appendix Flashcards
Pathophys and order of events in appendicitis
1) appendiceal lumen is occluded, usually by fecolith (possibly lymphoid hyperplasia 2/2 IBD or infections, parasites, foreign objects)
2) bacterial overgrowth
3) Reactive inflammation
4) Increased intraluminal pressure
5) venous outflow obstruction/ischemia
6) loss of epithelial integrity
7) Gengrene/perforation
Anatomy of the appendix
10cm true diverticulum of cecum with its own mesentery (mesoappendix)
Location (in order of decreasing freq):
1) Low cecal
2) Pelvic
3) Retrocecal
Usually at McBurney’s point = 2/3 of the distance from umbilicus to R ASIS
Incidence of appendicitis
Usually people in 2nd/3rd decade, previously healthy
Men:Women = 3:2
Presentation of appendicitis
Initial periumbilical pain that migrades to RLQ (correlates to vague abdominal pain of inflamed appendix coverting to irritation of parietal peritoneum)
But, appendix has variable location (ESP during pregnancy) so location of pain will change as such
N/V, anorexia, fever, increased leukocytes w/ L shift
Typical presentation seen in 50%
Other diagnoses to consider in appendicitis
Cholecystitis and biliary colic
Gastroenteritis
Enterocolitis
Diverticulitis
Pancreatitis
Perforated duodenal ulcer
Renal colic
UTI
In peds:
Lymphadenitis or intussusception
In women of childbearing age who are not pregnant: Ovarian cyst torsion Mittelschmerz Ectopic preg PID
What are some rarer mimics of appendicitis?
SBO
Crohn
Meckel
Tumors
Henoch-Schonlein purpura
Rectus sheath hematoma
Yrsenia enterolytica causing mesenteric adenitis***
What are some helpful physical exam signs that may correlate to appendicitis?
Obturator sign: internal rotation of thigh elicits pain (pelvic appendicitis)
Psoas sign: extension of R thigh elicits pain (retroperitoneal or retrocecal appendicitis)
Dunphy sign: increasing pain with cough
Blumberg sign: rebound tenderness from peritoneal irritation
Guarding
Surgical indications in appendicitis
Persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, esp if leukocytosis is present
If unclear, short period (4-6h) of watchful waiting and a CT scan
surgery is ALWAYS the treatment though for confirmed appendicitis (do NOT need CT to confirm)
Lab studies for appendicitis
CBC
UA (r/o UTI or pyelo)
CRP
Liver and pancreatic enzymes (r/o liver and panc diagnoses)
beta-hCG (r/o pregnancy)
Urinary 5-HIAA (serotonin metabolite that could be early marker of appendicitis)
Imaging for appendicitis
CT with oral contrast or rectal gastrograffin enema.
IV contrast is not usually need. May help differentiate btw appendicitis and other pelvic pathologies
Typical findings are a nonfilling appendix with distention and thickened walls of both the appendix and cecum. Enlarged mesenteric nodes. Periappendiceal inflammation or fluid
CT NOT NEEDED FOR DX
Medical management of appendicitis
no such thing
The only time to delay surgery is if appendix is contained in an abscess. Then give Abx and wait for infection to simmer down before operating
PostOp management for appendicitis
IV Abx
If non-complicated appendicitis, diet may be advanced quickly and the patient is D/C’d once diet is tolerated
In complicated appendicitis, Abx may be required for many days or weeks. Clear liquid started when bowel function returns
Advantages to lap appi
Less postop pain
Better cosmetic result
shorter time to return to usual activities
Lower incidence of wound infection or dehiscence
3 cannulae (umbilical 5mm, suprapublic 12mm, R periumbilical region)
Complications of appendectomy
Avg morbidity = 10%
Wound infection or dehiscence may occur, esp in patients with gangrenous or perf’d appendicitis, persistent ileus, cecal fistuals, and pelvic/abdom abscess
Postop infections usually present with mild fever, ab pain, disorders of bowel transit
Mortality rate is less than 1% if appediceal perf exists. An exception is elderly patients (5%)
Embryo of appendix
Buds off from cecum at week 6
Base is in fixed position…tips are variable.
How do you find it? Find cecum first…then trace the 3 taeniae coli down until they converge at the base
