Appendicitis/cholecystitis

Question 1

Peritoneum

general

regions and folds

Answer 1

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

Question 2

Appendix

general

Answer 2

Also referred to as the vermiform appendix or cecal appendix

Finger-like, blind-ended tube extending from the cecum in the right lower quadrant

Question 3

Appendix

functions

Answer 3

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

Question 4

appendix

Position of the free-end of the appendix is highly variable and can be categorized into seven main locations:

Answer 4

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

Question 5

Answer 5

retrocecal most common

Question 6

Acute Appendicitis

general

Answer 6

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

Question 7

appendicitis

Etiology

Answer 7

Luminal obstruction
Fecalith
Lymphoid hyperplasia
Tumors (benign or malignant)

Question 8

appendicitis

patho

Answer 8

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

Question 9

appendicitis

Classic signs

Answer 9

Appear in < 50% of patients
McBurney point tenderness
Psoas sign
Obturator sign
Rovsing sign

Question 10

appendicitis

classic symptoms

Answer 10

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

Question 11

appendicitis

McBurney Point

Answer 11

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

Question 12

appendicitis

psoas sign

Answer 12

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

Question 13

appendicitis

obturator sign

Answer 13

Pain caused by passive internal rotation of the flexed right thigh

better for more anterior position of appendix

Question 14

Appendicitis

Rovsing sign

Answer 14

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

Question 15

appendicitis

Clinical Dx

Answer 15

can be made if classic symptoms and signs are present

Question 16

appendicitis

Labs

Answer 16

Atypical or equivocal findings:
Labs:

Pregnancy test
Perform on all females of reproductive age
CBC
Leukocytosis (12,000-15,000/mcL) with left shift

Question 17

appendicitis

imaging

Answer 17

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

Question 18

Answer 18

Enlarged appendix with an appendicolith (yellow arrow)

Question 19

Answer 19

Appendicolith (white arrow) with a large abscess (dashed blue line) containing a foci of air (red arrow)

Question 20

appendicitis

Answer 20

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

Question 21

Appendicitis

Supportive Tx

Answer 21

NPO
IV fluids
Analgesics: NSAIDs or opioids
Nausea/vomiting control

Question 22

appendicitis

Abx

Answer 22

30-60 minutes prior to incision
First-generationcephalosporin or fluoroquinolone + anaerobic coverage
cefazolin- metronidazole
ciprofloxacin–metronidazole

Question 23

appendicitis

Surgical Tx

Answer 23

Open or laparoscopic appendectomy
Open – lower rate of intraabdominal infections
Laparoscopic – lower rate of wound infections

Pericolic abscess formation
Drain the abscess by ultrasound-guided percutaneous catheter or by open operation (with appendectomy to follow)

Question 24

Question 25

# Acute Cholecystitis general and types

Answer 25

Inflammation of the gallbladder ♀ > ♂ Peak incidence is 40-50 years Types: **Calculous** - 95% Gallbladder inflammation as a complication of cholelithiasis (gallbladder) **Acalculous** – 5% Gallbladder inflammation due to gallbladder stasis and ischemia More common in critically ill and/or immunocompromised patients | calc is due to stone. Acalc no stone

Question 26

# cholecystitis RF (6 F's)

Answer 26

pregnancy or hormone therapy older age natice american/hispanic obesity:rapid gain or loss Diabetes

Question 27

# cholecystitis patho

Answer 27

Cystic duct **obstruction** leads to bile stasis Stasis triggers the **release of inflammatory enzymes that damage the gallbladder mucosa** Mucosal damage causes **more fluid to be secreted into the gallbladder** lumen than is absorbed leading to an increase in intraluminal pressure Increased pressure results in distention which further the release of inflammatory mediators (**prostaglandins and lysolecithin**) As inflammation increases, mucosal damage worsens leading to **ischemia**

Question 28

# cholecystitis complications Bacterial classification

Answer 28

Bacterial infection can ensue (gram-negative bacteria: E. coli, Enterococcus, Klebsiella) Complications: gangrene (20%) and perforation (20%)

Question 29

# cholecystitis S/Sx Boas sign

Answer 29

Abdominal pain Severe, sudden right upper quadrant pain Often **triggered by a fatty meal** Duration > 6 hours Radiation of pain to the right lower scapula (**Boas’ sign**) Nausea/Vomiting (75%) Fever – low grade **Murphy’s sign**

Question 30

# cholecystitis Murphy’s sign

Answer 30

Develops within 2-3 hours Deep inspiration exacerbates pain during palpation of the RUQ subcostal region and halts inspiration

Question 31

# cholecystitis Dx and labs

Answer 31

Acute cholecystitis should be suspected based on signs and symptoms Labs Performed, but **not diagnostic** CBC: leukocytosis with left shift (12,000-15,000/cmL) Lipase: > 3x normal suggests common bile duct obstruction Liver tests: Elevation of bilirubin and alkaline phosphatase should raise suspicion for complications (cholangitis, choledocholithiasis) Mild elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) 

Question 32

# cholecystitis imaging

Answer 32

Diagnostics Ultrasound Ultrasonographic Murphy’s sign (elicited with US probe pressing on the abdomen)  HIDA

Question 33

# cholecystitis US findings

Answer 33

Findings: Gallbladder wall thickening > 4 mm Gallbladder wall edema Pericholecystic fluid Presence of gallstones Air in the GB wall (indicative of gangrene)

Question 34

# cholecystitis Hepatobiliary iminodiacetic acid (HIDA) scan or cholescintigraphy

Answer 34

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

Question 35

# cholecystitis CT scan of abdomen and pelvis

Answer 35

Used to identify extrabiliary abnormalities or complications of acute cholecystitis best for when suspecting complications not your "go to study"

Question 36

Answer 36

Acute cholecystitis on ultrasound. The closed arrow points to gallbladder wall thickening. Open arrow points to stones in the gallbladder.

Question 37

Answer 37

Acute cholecystitis with the fat stranding around the enlarged gallbladder.

Question 38

# Cholecystitis Tx | supportive and Abx

Answer 38

**Hospital admission** Supportive care NPO IV Hydration Antiemetics NG tube placed for vomiting or if an ileus is present **Analgesics** NSAIDs (ketorolac) or opioids **Antibiotics** Initiated to treat possible infection Empiric coverage directed against gram-negative bacteria Ceftriaxone 1-2 grams IV every 12-24 hours plus metronidazole 500 mg IV every 8 hours- **best for pregnant or child** Piperacillin/tazobactam (Zosyn) 3.375-4.5 grams IV every 6 hours

Question 39

# cholecystitis surgical Tx

Answer 39

Cholecystectomy Definitive treatment Early cholecystectomy (within 24-48 hours) is preferred Approach: Laparoscopic is the standard of care (lower risk of infection, shorter hospital stay). Open surgery: reserved for complicated cases

Question 40

# Chronic cholecystitis General

Answer 40

Long-standing gallbladder inflammation resulting from gallstones and prior episodes of acute cholecystitis Gallbladder becomes fibrotic and contracted Not able to concentrate bile or empty normally

Question 41

# Chronic cholecystitis S/Sx

Answer 41

Recurrent biliary colic, usually without fever RUQ pain is often less intense

Question 42

# Chronic cholecystitis Dx and Tx

Answer 42

Diagnosis Ultrasound Treatment: Laparoscopic cholecystectomy

Question 43

# cholecystitis Key points

Answer 43

* Acute cholecystitis is most often caused by gallstones (95%) * In older patients, symptoms of cholecystitis may be nonspecific (malaise, anorexia, vomiting) and fever may be absent * **Diagnosed via ultrasound and, if results are equivocal, by HIDA scan** * Surgery (cholecystectomy) within **24-48** hours of admission (early) is preferable

Question 44

# cholecystitis First line treatments include (5)

Answer 44

fasting, intravenous fluids, analgesics, antiemetics, and antibiotics