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Flashcards in Appendix Deck (26)
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1

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

2

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

3

Incidence of appendicitis

Usually people in 2nd/3rd decade, previously healthy

Men:Women = 3:2

4

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%

5

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

6

What are some rarer mimics of appendicitis?

SBO

Crohn

Meckel

Tumors

Henoch-Schonlein purpura

Rectus sheath hematoma

Yrsenia enterolytica causing mesenteric adenitis***

7

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

8

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)

9

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)

10

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

11

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

12

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

13

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)

14

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%)

15

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

16

Blood supply of appendix

Appendicular artery
- branch of ileocolic which is branch of SMA

17

Lifetime incidence of acute appendicitis in USA

7%

18

Is a compressible appendix on U/S a good sign?

Usually

Good be false negative though. Appendix become compressible after perforation

19

Appendicitis in pregnant patients

Appendicitis is #1 surgical emergency in pregnant patients

Fetal mortality increases 3-8% with appendicitis and 30% with perforation

Surgery is standard tx, though 10-15% of women will experience premature labor

Pregnant patients may present with RUQ pain

20

Appendicitis in elderly

Presents atypically, leading to delays in dx

Present later in course and with less pain. May present as an SBO

Delayed leukocytosis

Higher risk of perf and higher mortality than in younger patients

21

Appendicitis in immunocomprosied

AIDS, high dose chemo

Although they may not have absolute leukocytosis, compared to baseline WBC they will demonstrate relative leukocytosis

Ddx should expand to include opportunistic infections like CMV-related bowel perf and neutropenic colitis

22

Carcinoid def

Relatively low grade neuroendocrine tumor (secretes enzymes aberrantly; enzymes typically cause nausea, diarrhea, flushing)

Appendix is #1 site of carcinoid tumors of GI tract

Carcinoid is #2 most common type of appendiceal tumor (#1 = mucinous adenocarcinoma)

23

Carcinoid dx and tx

Increased 5-HIAA in urine and increased serum serotonin

Tx: Size is the determinant of malignant potential and treatment

2cm = right hemicolectomy

Serotonin antagonists (cyproheptadine) or somatostatin analogues (octreotide) can be used for symptoms of carcinoid syndrome

***Carcinoid will not typically present unless tumor has metastasized to liver

24

Mucinous tumors

Can rupture, causing pseudomyxoma peritonei with mucin implants on peritoneal surfaces and omentum

Women:Men 3:2

Complications include bowel obstruction and perf

Have been associated with migratory thrombophlebitis

25

Adenocarcinoma

Colon cancer that arises from appendix

Very rare and almost never diagnosed preop

Rapid spread to regional LNs, ovaries, peritoneal surfaces

If confined to appendix and local LNs, R hemicolectomy is treatment of choice

26

Appendiceal abscess

Signs: similar to acute appendicitis

Increasing RLQ pain

Tender, fluctuant RLQ mass that is palpable on rectal exam

Anorexia

Think of this when you see appendicitis + RLQ mass

Fever

Localizing peritonitis

Leukocytosis

Dx = CT

Tx = percutaneous or operative drainage