Appendicitis/cholecystitis Flashcards
Peritoneum
general
regions and folds
Broad serous membranous sac surrounded by connective tissue that holds the digestive organs within the abdominal cavity in place
Composed of two regions:
Parietal peritoneum: lines the abdominal wall
Visceral peritoneum: envelops the abdominal organs
Five major peritoneal folds:
Greater omentum, lesser omentum, falciform ligament, mesentery, mesocolon
Watery fluid acts as a lubricant to minimize friction between surfaces
Appendix
general
Also referred to as the vermiform appendix or cecal appendix
Finger-like, blind-ended tube extending from the cecum in the right lower quadrant
Appendix
functions
Contains lymphoid tissue and is a primary site for IgA production, which is vital for maintaining homeostasis of the intestinal flora
Rich in biofilms and continuously sheds healthy bacteria into the intestinal lumen
Can be used as a replacement bladder
appendix
Position of the free-end of the appendix is highly variable and can be categorized into seven main locations:
Pre-ileal– anterior to the terminal ileum –1 or 2 o’clock
Post-ileal– posterior to the terminal ileum – 1 or 2 o’clock
Sub-ileal– parallel with the terminal ileum – 3 o’clock
Pelvic– descending over the pelvic brim – 5 o’clock
Subcecal– below the cecum – 6 o’clock
Paracecal– alongside the lateral border of the cecum – 10 o’clock
Retrocecal– behind the cecum – 11 o’clock
Variable location of the appendix causes variations in the clinical presentation, making diagnosis challenging
retrocecal most common
Acute Appendicitis
general
Acute inflammation of the vermiform appendix
One of the most common causes of acute abdominal pain in adults and children
Affects ~6% of the population
Commonly occurs between 10-30 years of age
Most common:
Acute surgical problem in the pediatric population
Non-obstetric surgical emergency during pregnancy
appendicitis
Etiology
Luminal obstruction
Fecalith
Lymphoid hyperplasia
Tumors (benign or malignant)
appendicitis
patho
Obstruction of appendiceal orifice
Mucus accumulation and luminal distention:
Bacterial overgrowth (aerobes andanaerobes):
Escherichia coli
Peptostreptococcus
Pseudomonas
Bacteroides fragilis
Increase in transmural pressure →thrombosisand occlusion of small vessels
Ischemiaandnecrosis(gangrene)
Eventualperforation
Perforation contained by the greater omentum → appendiceal abscess
Perforation into the abdominal cavity → peritonitis
appendicitis
Classic signs
Appear in < 50% of patients
McBurney point tenderness
Psoas sign
Obturator sign
Rovsing sign
appendicitis
classic symptoms
Abdominal pain
Periumbilical pain that later migrates to the RLQ (24 hours)
Localized rigidity
↑ pain with cough or movement
Low-grade fever
Nausea/vomiting
Anorexia → dehydration
appendicitis
McBurney Point
Point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitis
2/3 of the way between umbilicus and ASIS (2/3 down) on right side
appendicitis
psoas sign
An increase in pain caused by passive extension of the right hip joint while applying counter resistance to the right hip (asterisk)
Indicates a retrocecal orientation of the appendix
can also be done by having them attempt to raise right leg against resistance
appendicitis
obturator sign
Pain caused by passive internal rotation of the flexed right thigh
better for more anterior position of appendix
Appendicitis
Rovsing sign
Palpation of the left lower quadrant of the abdomen followed by quick release causes increased pain felt in the right lower quadrant
rebound/ referred tenderness
appendicitis
Clinical Dx
can be made if classic symptoms and signs are present
appendicitis
Labs
Atypical or equivocal findings:
Labs:
Pregnancy test
Perform on all females of reproductive age
CBC
Leukocytosis (12,000-15,000/mcL) with left shift
appendicitis
imaging
Ultrasound - children and pregnant women
Contrast-enhanced CT scan of the abdomen and pelvis unless contraindicated
Laparoscopy
Can be used for diagnosis and definitive treatment of appendicitis
Enlarged appendix with an appendicolith (yellow arrow)
Appendicolith (white arrow) with a large abscess (dashed blue line) containing a foci of air (red arrow)
appendicitis
The Alvarado score is the best studied clinical decision rule in adults and children
Imaging is not required for diagnosis if theAlvarado scoreis very low (< 4) or high (> 7)
Interpretation:
0–4: Appendicitis is less likely
5–6: Appendicitis is possible; imaging evaluation needed
7–8: Appendicitis is probable → surgical consultation
9–10: Appendicitis is highly likely → surgical consultation
cholecystitis
RF (6 F’s)
pregnancy or hormone therapy
older age
natice american/hispanic
obesity:rapid gain or loss
Diabetes
cholecystitis
Murphy’s sign
Develops within 2-3 hours
Deep inspiration exacerbates pain during palpation of the RUQ subcostal region and halts inspiration
cholecystitis
US findings
Findings:
Gallbladder wall thickening > 4 mm
Gallbladder wall edema
Pericholecystic fluid
Presence of gallstones
Air in the GB wall (indicative ofgangrene)
cholecystitis
Hepatobiliary iminodiacetic acid (HIDA) scan or cholescintigraphy
Performed if the ultrasound is equivocal
4 hour fast prior to the procedure
Uses a radioactive tracer to access the filling of the gallbladder
If the cystic duct is not obstructed, the tracer will be excreted in the bile
Acute cholecystitis on ultrasound. The closed arrow points to gallbladder wall thickening. Open arrow points to stones in the gallbladder.
Acute cholecystitis with the fat stranding around the enlarged gallbladder.
cholecystitis
surgical Tx
Cholecystectomy
Definitive treatment
Early cholecystectomy (within 24-48 hours) is preferred
Approach:
Laparoscopic is thestandard of care(lower risk of infection, shorter hospital stay).
Open surgery: reserved for complicated cases
