Flashcards in Appendix Deck (66):
What vessel provides blood supply to the appendix?
Appendiceal artery (branch of the ileocolic artery)
What is the mesentery of the appendix called?
How can the appendix be located if the cecum has been identified?
Follow the taenia coli down to the appendix.
The taeniae converge on the appendix.
What is appendicitis?
Inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop with resultant inflammation that can lead to necrosis and perforation
What are the causes of appendicitis?
Lymphoid hyperplasia, fecalith, parasite, foreign body, tumor
What is the lifetime incidence of acute appendicitis in the US?
What is the most common cause of emergent abdominal surgery in the US?
How does appendicitis classically present?
1. Periumbilical pain (intermittent and crampy)
4. Pain migrates to RLQ (constant and intense), usually < 24 hours
Why does periumbilical pain occur in acute appendicitis?
Why does RLQ pain occur in acute appendicitis?
What are the signs and symptoms of acute appendicitis?
Signs of peritoneal irritation may be present; guarding; muscle spasm; rebound tenderness; obturator and psoas signs; low-grade fever; RLQ hyperesthesia
What is the obturator sign?
Pain upon internal rotation of the leg with the hip and knee flexed.
Seen in patients with pelvic appendicitis.
What is the psoas sign?
Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance.
Seen classically with retrocecal appendicitis.
What is Rovsing's sign?
Palpation or rebound pressure of the LLQ results in pain in the RLQ.
Seen in appendicitis.
What is Valentino's sign?
RLQ pain/peritonitis from succus draining down to the RLQ from a perforated gastric or duodenal ulcer
What is McBurney's point?
Point one third from the anterior superior iliac spine to the umbilicus (often the point of maximal tenderness)
What is the differential diagnosis of appendicitis?
Meckel's diverticulum, Crohn's disease, perforated ulcer, pancreatitis, mesenteric LAD, constipation, gastroenteritis, intussusception, volvulus, tumors, UTI, pyelonephritis, torsed epiploicae, cholecystitis, cecal tumor, diverticulitis
For women: ovarian cyst, ovarian torsion, TOA, mittelschmerz, PID, ectopic pregnancy, ruptured pregnancy
What lab tests should be performed for appendicitis?
CBC (increased WBC with left shift); UA (r/o pyelonephritis, renal calculus)
Can you have an abnormal UA with appendicitis?
Yes: mild hematuria and pyuria are common in appendicitis with pelvic inflammation, resulting in inflammation of the ureter
Does a positive UA rule out appendicitis?
No: ureteral inflammation resulting from periappendiceal inflammation can cause abnormal UA
What additional tests (besides CBC, UA) can be performed if the diagnosis of appendicitis is not clear?
Spiral CT; U/S (may see large, non-compressible appendix or fecalith); AXR
In acute appendicitis, what classically precedes vomiting?
Pain (in gastroenteritis, the pain classically follows vomiting)
What radiographic studies are often performed for appendicitis?
CXR: rule out RML or RLL pneumonia, free air
AXR: abdominal films are usually nonspecific, but calcified fecalith can be seen
What are the radiographic signs of appendicitis on AXR?
Fecalith, sentinel loops, scoliosis away from the right because of pain, mass effect (abscess), loss of psoas shadow, loss of preperitoneal fat stripe, and (rarely) a small amount of free air if perforated
With acute appendicitis, in what percentage of cases will a radiopaque fecalith be on AXR?
What are the CT findings with acute appendicitis?
Periappendiceal fat stranding; appendiceal diameter > 6 mm; periappendiceal fluid; fecalith
What are the preoperative medications or preparations for acute appendicitis?
1. Rehydration with IV fluids
2. Preoperative antibiotics with anaerobic coverage (appendix is considered part of the colon)
What is a lap appy?
Used in most cases in women (can see adnexa) or if patient has a need to quickly return to physical activity, or is obese
What is the treatment for non-perforated acute appendicitis?
Prompt appendectomy; 24 hours of antibiotics; discharge from home usually on POD #1
What is the treatment for perforated acute appendicitis?
1. IV fluid resuscitation and prompt appendectomy.
2. All pus is drained with post-operative antibiotics continued for 3-7 days.
3. Would is left open in most cases of perforation after closing the fascia (heals by secondary intention or delayed primary closure).
How is an appendiceal abscess that is diagnosed preoperatively treated?
Usually by percutaneous drainage of the abscess, antibiotic administration, and elective appendectomy about 6 weeks later
If a normal appendix is found upon exploration, should you take out the normal appendix?
How long after removal of an non-ruptured appendix should antibiotics continue post-operatively?
For 24 hours
Which antibiotic is used for non-perforated appendicitis?
Anaerobic coverage (e.g. Cefoxitin, Cefotetan, Unasyn, Cipro, Flagyl)
Which antibiotic is used for a perforated appendix?
Broad-spectrum antibiotics (e.g. Amp/Cipro/Clinda or a penicillin such as Zosyn)
How long do you give antibiotics for perforated appendicitis?
Until the patient has a normal WBC count and is afebrile, ambulating, and eating a regular diet (usually 3-7 days)
What is the risk of perforation in acute appendicitis?
25% by 24 hours
50% by 36 hours
75% by 48 hours
What is the most common general surgical emergency in pregnancy?
What are the possible complications of appendicitis?
Pelvic abscess, liver abscess, free perforation, portal pyelothrombophlebitis (rare)
What percentage of the population has a retrocecal, retroperitoneal appendix?
What percentage of negative appendectomies is acceptable?
Up to 20%
Who is at risk of dying from acute appendicitis?
Very old and very young
What bacteria are associated with mesenteric adenines that can closely mimic acute appendicitis?
What is an incidental appendectomy?
Removal of normal appendix during abdominal operation for different procedure
What are the complications of an appendectomy?
SBO, enterocutaneous fistula, wound infection, infertility with perforation in women, increased incidence of right inguinal hernia, stump abscess
What is the most common post-operative complication?
What is the difference between a McBurney incision and a Rocky-Davis incision?
McBurney: angled down (follows external oblique fibers)
Rocky-Davis: straight across (transverse)
What are the layers of the abdominal wall during a McBurney incision?
(1) Skin, (2) Subcutaneous fat, (3) Scarpa's fascia, (4) External oblique, (5) Internal oblique, (6) Transversus muscle, (7) Transversalis fascia, (8) Preperitoneal fat, (9) Peritoneum
What are the steps in laparoscopic appendectomy?
1. Identify the appendix
2. Staple the mesoappendix (or coagulate)
3. Staple and transect the appendix at the base (or use Endoloop and cut between)
4. Remove the appendix from the abdomen
5. Irrigate and aspirate until clear
Do you routinely get peritoneal cultures for acute appendicitis (non-perforated)?
Which way should your finger sweep trying to find the appendix?
Lateral to medial along the lateral peritoneum (so that you won't tear the mesoappendix that lies medially)
How do you get to a retrocecal and retroperitoneal appendix?
Divide the lateral peritoneal attachments of the cecum
Why use electrocautery on the exposed mucosa on the appendiceal stump?
To kill the mucosal cells so they do not form a mucocele
If you find Crohn's disease in the terminal ileum, will you remove the appendix?
Yes, if the cecal/appendiceal base is not involved
If the appendix is normal what do you inspect intra-operatively?
Terminal ileum: Meckel's diverticulum, Crohn's disease, intussusception
Gynecologic: cysts, torsion, etc.
Groin: hernia, rectus sheath hematoma, adenopathy
Who first described the classic history and treatment for acute appendicitis?
Who performed the first appendectomy?
Harry Hancock in 1848
Who performed the first lap appy?
Dr. Semm in 1983
What is the most common appendiceal tumor?
What is the treatment of appendiceal carcinoid tumor < 1.5 cm?
Appendectomy (if not through the bowel wall)
What is the treatment of appendiceal carcinoid tumor > 1.5 cm?
What percentage of appendiceal carcinoids are malignant?
What is the differential diagnosis of appendiceal tumor?
Carcinoid, adenocarcinoma, malignant mucoid adenocarcinoma
What type of appendiceal tumor can cause the dreaded pseudomyxoma peritonei if the appendix ruptures?
Malignant mucoid adenocarcinoma
What is mittelschmerz?
Pelvic pain caused by ovulation