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SURGERY ROTATION! > Appendicitis > Flashcards

Appendicitis Flashcards

1
Q

What is appendicitis?

A

Inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop with resultant inflammation that can lead to nerosis and perforation

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2
Q

What are the causes of appendicitis?

A

Lymphoid hyperplasia, fecalith (appendicolith)

Rare: parasite, foreign body, tumor (carcinoid)

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3
Q

Lifetime incidence of acute appendicitis in US?

A

~7%

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4
Q

What is the classic presentation if appendicitis in chronologic order?

A
  1. Periumbilical pain (intermittent and crampy)
  2. nausea/vomiting
  3. anorexia
  4. pain migrates to RLQ (constant/intense pain) usually in <24 hours
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5
Q

Why does the periumbillical pain occur?

A

It is referred pain

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6
Q

Why does the RLQ pain occur?

A

Peritoneal irritation

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7
Q

What are the signs/sx of appendicitis?

A

Signs of peritoneal irritation: guarding, muscle spasm, rebound tenderness, obturator and psoas signs, low-grade fever (high-grade if perforation), RLQ hyperesthesia

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8
Q

What is the obturator sign?

A

Pain upon internal rotation of the leg with the hip and knee flexed

seen in patients with pelvic appendicitis

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9
Q

What is the psoas sign?

A

Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance

Seen classically with retrocecal appendicitis

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10
Q

What is Rovsing’s sign?

A

Palpation or rebound pressure of the LLQ results in pain in the RLQ

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11
Q

What is Valentino’s sign?

A

RLQ pain/peritonitis from succus draining down to the RLQ from a perforated gastric duodenal ulcer

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12
Q

What is McBurney’s point?

A

Point one third from the ASIS to the umbilicus (often point of maximal tenderness)

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13
Q

What are some DDx for everyone with possible appendicitis?

A

Meckel’s diverticulum

Chron’s

perforated ulcer

pancreatitis

mensenteric lymphadenitis

constipation

gastroenteritis

pyelonephritis/UTI

Diverticulitis

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14
Q

What are some Ddx for females with possible appendicitis?

A

Ovarian cyst

Ovarian torsion

Tuboovarian abscess

mittlelschmerz

PID

ectopic/ruptured PG

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15
Q

What labs should be performed with possible appendicitis?

A

CBC: increase WBC (usually >10,000 and with left shift)

UA to evaluate for Pyelo/renal calculus

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16
Q

Can you have an abnormal UA with appendicitis?

A

Yes!

Mild hematuria and pyuria are common if there is pelvic inflammation with the appendicitis leading to ureter inflammtion

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17
Q

What diagnostic tests can be performed if the diagnosis is not clear?

A

Spiral CT

U/S (may see large, noncompressible appedix or fecalith)

AXR

18
Q

What classically precedes vomiting in appendicitis?

A

Pain

(in gastroenteritis- the pain usually FOLLOWS vomiting)

19
Q

What radiographic studies are often performed with appendicitis?

A

CXR: to rule out RML or RLL pneumonia and free air

AXR: usually non-specific, but calcified fecalith in about 5% of cases

20
Q

What are radiographic signs of appendicitis on AXR?

A

Fecalith

Sentinel loops

Scoliosis away from the right because of pain

Mass effect (abscess)

Loss of psoas shadow

Loss of preperitoneal fat stripe

rarely: free air if perforation

21
Q

___% of cases a radiopaque fecalith will be on a ABX with appendicitis?

A

~5%

22
Q

What are the preoperative meds/preps for appendicitis?

A

Rehydration with IV fluids (lactated ringers)

Preoperative antibiotics with anaerobic coverage

23
Q

What is a lap appy?

A

Laparoscopic appendectomy: used in most cases in women (can see adnexa) or if patinet has a need to quickly return to physical activity, or is obese

24
Q

Tx for non-perforated acute appendicitis?

A

Prompt appendectomy (to prevent perforation), 24 hours of antibiotics, discharge home usually on POD #1

25
Q

What is the tx for perforated acute appendicitis?

A

IV fluid resusitation and prompt appendectomy

All pus is drained with postoperative antibiotics contimued for 3-7 days

Wound if left open in most cases after closing the fascia (heals secondary intentionor delayed primary closure)

26
Q

How is an appendiceal abscess that is diagnosed preoperatively tx?

A

Percutaneous drainage of the abscess

Antibiotic admin

elective appendectomy ~ 6 weeks later (interval appendectomy)

27
Q

If a normal appendix is found upon exploration, should you take out the normal appendix?

A

YES!

28
Q

How long after removal of NUNRUPTURED appendix should antibiotics continue postoperatively?

A

24 hours

29
Q

What antibiotics are used for NONPERFORATED appendictis?

A

Anaerobic coverage: Cefoxitin®, Cefotetan®, Unasyn®, Cipro®, and Flagyl®

30
Q

What antibiotics are used for PERFORATED appendicitis?

A

Broad-spectrum antibiotics (e.g., Amp/Cipro®/Clinda or a penicillin such as Zosyn®)

31
Q

How long do you give antibiotics for perforated appendicitis?

A

Until the patient has a normal WBC count and is afebrile, ambulating, and eating a regular diet

Usually 3-7 days

32
Q

What is the risk of perforation?

A

~25% by 24 hours from onset of sx

~50% by 36 hours

~75% by 48 hours

33
Q

Most common general surgical abdominal emergency in PG?

A

Appendicitis

1/1750

*may present in RUQ due to enlarged uterus

34
Q

Possible complications of appendicitis?

A

Pelvic abscess

Liver abscess

Free perforation

Poral pylethrombophlebitis (VERY rare)

35
Q

__% of the population has a retrocecal, retroperitoneal appendix?

A

~15%

36
Q

What % of negative appendecotomies is acceptable?

A

Up to 20% - better than missing a case of acute appendicitis that can rupture

37
Q

Who is at risk for dying from acute appendicitis?

A

Very young and very old patients

38
Q

What bacteria is associated with “mesenteric adenitis” that can closely mimic acute appendicitis?

A

Yersinia enterolytica

39
Q

What is an “incidental appendectomy”?

A

Removal of a normal appendix during abdominal operation for different procedure

40
Q

Complications of appendectomy?

A

SBO

enterocutaneous fistula

wound infection

infertility with perforation in women

increased incidence of inguinal hernia

stump abscess

41
Q

What is the most common postoperative appendectomy complication?

A

Wound infection

SURGERY ROTATION! (4 decks)

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