Intestinal Diseases 1 Flashcards
(269 cards)
1
Q
where is the ligament of treitz
A
junction of duodenum to the jejunum
2
Q
where is the iliocecal valve?
A
junction of the ileum to the cecum
3
Q
what are villi and what are their purpose?
A
1mm projections containing a single branch of arteriole, venous, and lymphatic circulation present in the small intestine which increase SA for absorption
4
Q
what kind of cells line the surface of villi
A
enterocytes
5
Q
how many microvilli do each villi have?
A
3000-5000
6
Q
what do the microvilli contain at the tips?
A
an enzyme that aid digestion and absorption
7
Q
what is the dense packing of microvilli called?
A
the brush border
8
Q
where are plica circulates found?
A
the jejunum
9
Q
how can you see the small intestines (of an adult) on xray?
A
normal adult: hardly seen
pathologic supine position: small dilated bowel loops
pathologic erect position: air fluid levels seen
10
Q
what does a dilated jejunum look like?
A
a stack of coins
11
Q
what does a dilated ileum look like?
A
a cylindrical tube
12
Q
how are CHO normally broken down?
A
started by salivary and pancreatic amylase –> finished by the brush border
13
Q
how much of dietary starch passes into the colon in an unabsorbed state?
A
10%
14
Q
what happens when CHO are not properly broken down?
A
they transfer to the colon where bacteria degrade CHO
produces CO2, hydrogen and methane (smelly farts)
15
Q
symptoms of CHO malabsorption
A
watery diarrhea
flatulence
acidic stool pH
milk intolerance
16
Q
what test do we use for CHO malabsorption syndrome
A
D-xylose test
17
Q
D-xylose test determines what?
A
if the problem with CHO malabsorption is with intestinal epithelium unable to absorb CHO
tests permeability of proximal small intestine
18
Q
how to conduct D-xylose test
A
have pt fast overnight
give them 25g of D-xylose
urine collected for 5 hours measuring excretion of D-xylose
19
Q
normal results of D-xylose test
A
D-xylose is absorbed in intestines, filtered by the liver, excreted in the urine unchanged
20
Q
pathologic results of D-xylose test
A
not absorbed by intestines, substance not filtered out of kidneys, low levels of D-xylose in urine (<4.5g)
21
Q
what does an abnormal D-xylose test suggest?
A
Celiac disease, abnormalities in intestinal epithelium
22
Q
How will the D-xylose test read if the malabsorption syndrome is from a pancreatic abnormality?
A
normal
23
Q
most to least common ethnicities with lactose intolerance
A
native americans
african americans
hispanics
whites
24
Q
symptoms of lactose intolerance
A
diarrhea
abdominal pain
flatulence all after ingestion of lactose
25
cause of lactose intolerance
low intestinal lactase levels from mucosal injury or genetic abnormality
26
when do we do a test to determine if it's lactose intolerance?
if it is not cut and dry from food diary results
27
two types of lactose intolerance testing
serum testing
| lactose hydrogen breath testing
28
describe serum testing
drink 50g dose of lactose
collect serum blood glucose at 0,60,120 minutes
diagnostic: blood glucose raises by less than 20 and have symptoms of diarrhea, abdominal and, and flatulence
29
describe lactose hydrogen breath testing
```
oral lactose (weight based) is given in a fasting state
oral hydrogen is measured every 30 minutes for 3 hours
elevated hydrogen indicates lactose intolerance
```
30
what gives a false positive for lactose hydrogen breath test?
smoking
recent use of abx
baseline drug disorder
31
when wouldn't you use the lactose hydrogen breath test
in patients less than 5 years old
32
first line treatment for lactose intolerance
reduce lactose intake to less than 8oz milk per day
33
worst lactose offenders
milk, evaporated milk, condensed milk, goat milk, yogurt, ice cream
34
dairy foods with less lactose
mozzarella, butter, sour cream
35
enzyme replacement products
lactaid: reduces hydrogen breath test but not symptoms
lactrase: reduces symptoms but not breath test
dairyease
36
how to eliminate collateral damage for lactose intolerance patients?
make sure they're taking calcium supplements for 1200-1500mg daily
37
what is needed to break down fat?
release of gastric H+ into the duodenum to release secretin
| secretin enhances pancreatic bicarb secretion to raise the pH to be more basic so that fat can be absorbed
38
how does chronic pancreatitis affect fat malabsorption
they have chronic pancreatic enzyme insufficiency therefor they cannot secrete bicarbs, the intraluminal pH is to low and fat cannot be absorbed
39
how does ZES affect fat malabsorption
decreases the pH of the duodenum abnormally
40
what deficiencies do we have to be careful of in fat malabsorption syndromes?
vitamins A,D,E,K, and B12
41
step 1 of fat break down
it stays in triglyceride form until attacked by lipase secreted lingually and pancreatically.
42
what helps lipase latch onto the TG
colipase
43
what hang out in the intestinal lumen and follow the fat to the ileum?
bile salts
44
where are bile salts reabsorbed and where do they go from there?
absorbed at the ileum
go to the portal circulation
re-secreted into the bile
45
what is the main component of bile?
cholesterol
46
clinical relevance of gastric bypass surgery (roux-en-y)
takes out all of the duodenum, and part of the jejunum and stomach therefore the fat cannot be absorbed causing a fat malabsorption syndrome
47
how much of dietary fat is normally absorbed
>94%
48
what defines a fat malabsorption syndrome
>7g of fat in stool per day based on a 100g fat per day diet
49
symptoms of a fat malabsorption syndrome?
greasy, foul smelling diarrhea
difficult to flush
weight loss
concominant nutritional deficiencies (failure to thrive and vitamin deficiencies)
50
ileum cause of fat malabsorption
when 100cm of the terminal ileum is diseased or resected
| results in severe impairment of absorption of bile salts
51
what happens with <100cm of the terminal ileum being diseased or resected?
not fat malabsorption syndrome, but chronic diarrhea because bile salts are not absorbed and their osmotic activity draws water into the colon
52
how does the pancreas contribute to fat malabsorption syndromes?
loss of pancreatic enzymes from chronic pancreatitis, pancreatic duct obstruction, and cystic fibrosis
53
how does the liver contribute to fat malabsorption syndromes?
loss of bile release die to cirrhosis or biliary tree obstruction
54
how does celiac disease contribute to fat malabsorption
the mucosal malformation does not allow the absorption of fat
55
describe fecal fat testing scale
>7g fecal fat/day > steatorrhea
15-25g fecal fat/day > small intestine origin
>32g fecal fat/day > pancreatic origin
56
how do you conduct fecal fat testing
make sure the pt is on a 70-120g fat/dat diet
| collect 3-5/day samples
57
explain sudan III stain test
tests for fat malabsorption syndrome
test one stool obtained during clinical visit
detects 90% of patients with significant steatorrhea
allows for microscopic visualization of lipid globules
58
what contents in the stomach are important for protein digestion?
pepsinogen and pepsin
59
how does pepsin work?
breaks down the protein, stimulates release of CCK, stimulates release of pancreatic enzymes
60
how does the duodenum contribute to protein digestion?
trypsinogen is converted into trypsin which breaks down the protein
61
where does protein absorption occur?
proximal jejunum
62
is protein malabsorption common?
no
63
symptoms of protein deficiency?
```
vague
edema
muscle atrophy (failure to thrive in children)
hypoalbuminemia
hypoproteinemia
```
64
what diagnostic test do we use for protein malabsorption?
there is no good one
65
when does protein malaborption usually develop?
childhood
66
where are most vitamins and minerals absorbed
the proximal half of the small intestines
67
where is vitamin B12 absorbed
in the ileum after it complexes with intrinsic factor (released by parietal cells)
68
other names for celiac disease
celiac sprue
gluten sensitive enteropathy
non-tropical sprue
69
celiac disease defined
a small bowel disorder characterized by
mucosal inflammation
villous atrophy and crypt hyperplasia
occurs upon exposure to dietary gluten
70
epidemiology of celiac disease
most common in white european ancestry but at ANY age
71
3 major features present in classic celiac disease
villous atrophy
malabsorption symptoms (nausea, bloating, gas, foul smelling stools)
resolution of mucosal lesions and symptoms with d/c of gluten foods in weeks to months
72
celiac patients usually possess Ab to which 2 substances?
gliadin and tissue transglutaminase
73
does severity of histologic changes correlate with severity of clinical manifestation?
no
74
symptoms of Atypical celiac disease
```
minor GI complaints
anemia
unexplained elevated LFTs
neuro symptoms
arthritis
dental enamel defects
YET (severe mucosal damage and positive antibody pattern)
```
75
asymptomatic (silent) celiac disease why
no clinical symptoms
76
what portion of people with celiacs are asymptomatic?
40%
77
how does asymptomatic celiac disease happen?
the small intestine can compensate if the degree of involvement is limited
78
what do celiac pt's have intolerance to?
gliadin (an alcohol soluble fraction of gluten commonly found in wheat, rye, and barley)
79
what kind of disorder is celiacs?
autoimmune
80
what kind of comonents contributes to development of celiacs?
```
genetic mutation which is heritable
surgery
pregnancy
viral infection
severe illness
emotional stress
```
81
what happens to villi in celiacs?
they get atrophied and can no longer absorb as intended
82
clinical GI manifestations of celiacs
```
diarrhea that is bulky, foul smelling, and floating
failure to thrive in children
weight loss
severe anemia
vitamin B,D, and calcium deficiency
```
83
neuropsychiatric disease associations in celiacs
peripheral neuropathy in 1/2 associated with B12, B6 (paroxidine, or E deficiency)
depression
anxiety
epilepsy
84
effects on bones from celiacs
increased risk of osteopenia and osteoporosis due to secondary hyperparathyroidism due to Vit D deficiency
85
effects on skin from celiacs
dermatitis herpetiformis
multiple intensely itchy papules and vesicles that occur in clusters around elbows, forearms, knees, scalp, back and butt
86
what complexes in dermatitis herpetiformis?
IgA deposits
87
how to resolve dermatitis herpetiformis?
gluten withdraw
88
risk of malignancy in celiacs?
```
yes, 3-6x more likely to develop non-hodgkin's lymphoma
GI cancers (oral,esophageal, small intestine adenocarcinoma)
```
89
do we treat sub-clinical celiac disease?
yes! because of risk of malignancy
90
relate risk of malignancy in symptomatic vs asymptomatic patients?
risk is lower in asymptomatic, but not zero
| once the disease is in remission regardless, risk approaches that of a normal person
91
how does celiacs affect pregnant women?
association of low-birth weight infants
92
co-occurrence of autoimmune diseases with celiacs
DM1 (same genetic location)
sjogren's
scleroderma
autoimmune thyroiditis
93
who should we test for celiacs?
```
chronic or recurrent diarrhea
malabsorption concern
unexplained weight loss
abdominal distension
DM1 patients
1st degree relatives of Celiacs
Down syndrome
```
94
also screen for celiacs with patients without explanation of
```
iron deficiency anemia
folate or B12 deficiency
persistent LFT elevation
short stature
delayed puberty
recurrent fetal loss
low birth weight infants
idiopathic peripheral neuropathy
recurrent migraine headaches
```
95
what is important to maintain while testing for celiacs?
a gluten rich diet
96
step 1 celiac testing?
serologic tests looking for IgA anti-tissue transglutaminase antibody (IgA TTG test)
best for patients over 2y.o
97
what must you do next if serologic testing for celiacs comes back positive?
small bowel biopsy
98
what must you do next if serologic testing for celiacs came back negative but you suspect celiacs?
small bowel biopsy and genetic testing
99
what does scalloping of mucosal folds upon scoping indicate?
celiacs
100
first line treatment for celiacs
avoid wheat, rye, barley, rolled oats
| creamed vegetables, dried fruits, condiments, french fries, fruit pie fillings, processed meats, salad dressings
101
how long does it typically take for antibody levels to return to normal in celiac patients?
3-12 months
102
what is diverticular disease?
presence of diverticula
103
what are diverticula?
outpouching of intestine
104
how many people over 60 in western countries have diverticular disease and diverticulosis?
50% and 20% respectively
105
average age of presentation of diverticular disease?
59
106
why is the diagnosis age of diverticular disease becoming younger>
low fiber diets?
107
gender preference of diverticular disease?
equal
108
where does diverticular disease occur most commonly?
where the vasa recta penetrate the circular muscle layer in the sigmoid colon
109
most common cause of lower GI bleeding in adults
diverticulosis
110
presentation of diverticulosis
abrupt painless BRBPR (left colon), maroon (right colon)
crampy pains followed by a bloody bowel movement
possible hemodynamic instability
111
does bleeding usually stop on its own with diverticulosis?
yes
112
test of choice for diverticulosis suspicion?
colonoscopy
113
how to schedule a colonoscopy for diverticulosis
do within 12-48 hours of presentation
| must prescribe something to clean the colon such as GoLytely etc
114
what else is colonoscopy useful for in diverticulosis?
treat active bleeding
| assess for stigmata
115
what raises chances of being a stigmata in diverticulosis?
protuberant vessels and pigmented spots
116
those at risk for poor outcomes of diverticulosis
comorbid disease
liver disease
poor nutrition
117
describe recommendation for colonoscopies
no more than normal
118
number one recommendation for diverticulosis treatment
eat 30g fiber daily
119
what to do if you incedentally find diverticula upon endoscopy
advise pt to eat 30g fiber daily and quit smoking if they do
120
what causes diverticulitis
food particle becomes caught in a diverticula and forms a fecalith causing erosion of the vasa recti and then causing bleeding and perforation
121
what amount of diverticulitis is uncomplicated
75%
122
how many diverticulitis cases stay unsymptomatic if treated?
1/3
123
recurrence rate of diverticulitis?
20-40%
124
clinical presentation of diverticulitis
constant abdominal pain in the LLQ present several day s prior to presentation
Nausea and Vomiting
low grade temp
tender palpable mass (20%)
change in bowel habits (diarrhea or constipation)
hematochezia
urency, dysuria, frequency due to bladder irritation mimicking an UTI
125
is diverticulitis pain abrupt or insidious?
insidious
126
when does right sided pain occur with diverticulitis?
with cecal diverticulitis in asian americans
127
when does N/V occur with divverticulitis
obstructions due to inflammation or functional ileus from local peritonitis
128
lab results of CBC with diverticulitis
mild leukocytosis in 1/2
129
best diagnosing test for diverticulitis
CT with oral and IV contrast
130
what are you looking for on a CT ordered for diverticulitis?
sigmoid diverticula
thickened colonic wall
inflammation within pericolic fat with or without collection of contrast material or fluid
fat stranding
131
what must you do before giving IV contrast for CT scan?
recent kidney function test
132
role of abdominal ultrasound for diverticulitis
rule out other pathology or alternative to CT scan
133
what can an ultrasound detect in diverticulitis
bowel wall thickening, diverticula, some complications
134
what shouldn't we do during the acute phase of illness in diverticulitis? why?
colonoscopy or barium enema
| risk of colonic perforation
135
when should a colonoscopy be done for diverticulitis?
6 weeks after resolution of symptoms
136
treatment for symptomatic uncomplicated diverticulitis
bowel rest, NPO, and antibiotics
137
when to consider inpatient diverticulitis care
if they have toxic systemic symptoms
comorbid disease
are they reliable to pursue future appointments?
138
when should diverticulitis patients be hospitalized?
elderly
immunosuppressed
high fever
significant leukocytosis
139
duration of antibiotic course for diverticulitis
10-14 days depending on resoution of symptoms
140
bacteria targeted in diverticulitis
gram - rods and anaerobes
| most commonly e. coli and b. fragilis
141
antibiotics of choice for diverticulitis
ciprofloxacin (gram -) plus metronidazole (anaerobes)
142
alternative to cipro and flagyl for diverticulitis
augmentin (amoxicillin-clavulanate) 875mg/125mg BID
143
what class is cipro part of?
fluoroquinolones
144
moa for cipro?
moderate activity against gram +
excellent activity against gram -
bacteriocidal by inhibiting DNA synthesis (transcription and replication_
145
what is cipro absorption impaired by?
antacids (take 2-4 hours after cipro)
146
cannot use cipro when?
in patients under 18 (interferes with cartilage growth leading to arthropathy
myasthenia gravis patients (leads to worsening muscle weakness)
147
side effects of cipro
peripheral neuropathy (pain, burning, tingling, numbness, weakness, change in sensation to light touch, pain, temp, proprioception)
IV or PO
lasts months to years, maybe irreversible
148
black box warning for cipro
associated with risk of tendon rupture in all ages but mostly 60+ or those on corticosteroids
do not use in myasthenia gravis patients
149
combo medication containing amox and beta-lactamase inhibitor
augmentin
150
what decreases GI upset with augmentin?
take WF
151
MOA of augmentin?
bacteriocidal against
+: staph aureus only
-: all
amox susciptible to degredation by beta lactamases so clavulanic acid protects it by degrading some of these enzymes found in microorganisms
152
important side effects of augmentin
GI upset (most common)
hepatic dysfunction (elevated liver enzymes, liver failure, usually reversible)
not as common
more common in elderly or those with prolonged treatment
can occur while on treatment of weeks thereafter
153
diet recommendations for diverticulitis
clear liquid for several days (bowel rest)
| see improvement of symptoms in 2-3 days then slowly advance diet
154
monitoring of the clinical course, when do see them back
increasing pain, fever, inability to tolerate PO after a few days
failure to improve after a few days
155
what to do after resolution of diverticulitis
colonoscopy 6 weeks after to exclude other diagnosis of cancer and evaluate extent
156
chances of recurrence of diverticulitis
20-40%
157
elective surgery in diverticulitis
not necessary in patients who respond to medical therapy
158
complicated diverticulitis
abscess on sigmoid (feel on palpation or from CT scan)
obstruction
fistula
perforation
159
who is more likely to develop a complicated diverticulitis?
smokers
160
how many patients with complicated diverticulitis will get associated abscesses?
1/5
161
when to worry about abscesses in diverticulitis?
patients with uncomplicated diverticulitis with no improvement in abdominal pain or persistent fever despite three days of ABX treatment
162
why do obstructions in complicated diverticulitis occur
occur from luminal narrowing 2ndary to inflammation or narrowed from compression of abscess
163
where do obstructions usually occur in complicated diverticulitis?
at the flexures because it's already narrow there
164
how many patients with complicated diverticulitis get fistulas?
20%
165
where do fistulas in complicated diverticulitis usually occur?
from colon to bladder causing pneumaturia, fecaluria, dysuria
or to skin: enteric cutaneous
166
is perforation common with complicated diverticulitis?
```
no, only 1-2% of the time
present with peritoneal signs, rigid abdomin, rebond tenderness
high mortality rate
cutaneous hyperesthesias
these patients look VERY sick
```
167
antibiotics for complicated diverticulitis cover
gram - and anaerobic pathogens
168
antibiotics for complicated diverticulitis in form of
IV until inflammation stabilized and pain/tenderness resolves (3-5 days or more)
169
average LOS for patients with diverticulitis
8 days
170
choice 1 of antibiotics for complicated diverticulitis
ceftriaxone (Rocephin) PLUS metronidazole (Flagyl)
once stable on IV go to same regimen PO
171
drug class of ceftriaxone
Cephalosporin
172
is ceftriaxone available in PO?
no, must transfer to cipro
173
MOA of Rocephin?
inhibition of cell wall synthesis
| high degree of stability in the presence of b-lactimase enzymes used by microorganisms
174
coverage of cephtriaxone?
gram - and +
175
exceptions of coverage of rocephin?
c. diff and MRSA
176
side effects of ceftriaxone?
```
biliary sludge (thick bile)- found on ultrasound
biliary colic (RUQ colicky abd pain)
discontinue rocephin with s.e.
```
177
choice 2 antibiotic for complicated diverticulitis
unasyn (ampicillin/sulbactam)
zosyn (pipercillin/tazobactam)
timentin (ticarcillin/clavulanate)
178
how expensive are choice 2 antibiotics for complicated diverticulitis?
(unasyn, zosyn, timentin?)
$1000s per dose
179
what is the purpose of the second drug listed after the slash in unasyn, timentin, and zosyn?
it protects the first drug
180
when will you prescribe unasyn, zosyn, and timentin?
just for a day or two to control complicated diverticulitis that switch to rosphin or flagyl
181
why should you prescribe zosyn, unasyn, and timentin cautiously?
cross-reactivity between cephalosporins and penicillin
182
how many patients with complicated diverticulitis require surgical intervention?>
20%
183
what kind of patients get surgical intervention for diverticulitis
complicated diverticulitis
| several episodes of recurrent uncomplicated diverticulitis
184
surgical goals of diverticulitis surgery
remove septic focus by resecting the colon
treat obstruction or fistula (kill the blood supply to this portion of the colon > dead bowel)
restore bowel continuity
185
challenges with surgery for diverticulitis
bowel can be very friable so difficult to resect and sew back together > may form a primary anastomosis
186
how to minimizes challenges of bowel resection with diverticulitis
wait until symptoms resolved if possible
| make a colostomy until the tissues is healthy then go back later and connect
187
how are bowel resections done for diverticulitis
laproscopically > may need to be converted into an open procedure
188
in emergent or semi-emergent settings for surgical fix of diverticulitis do a ___
two stage procedure
1. hartman's procedure (resection of diseased colon and creation of a rectal stump and colostomy
2. reversal of colostomy about 3 months later
189
most common congenital anomaly of the GI tract
meckel's diverticulum
190
what patholgy is associated with the rule of two's?
meckel's diverticulum
191
is there familial predisposition in meckel's?
no
192
what is the cause of meckel's diverticulum?
incomplete obliteration of the vitelline duct
193
what is the vitelline duct?
a long narrow tube connecting the yolk sac to the midgut lumen in utero
should close at birth
194
yolk sac
membranous sac attached to an embryo providing early nourishment to developing embryo before internal circulation takes over
195
rule of two's
```
for meckel's diverticulum
2% of population
2:1 male to female
within 2 feet of ileocecal valve
can be 2 inches in length
2-4% of patients develop complication over the course of their lives
```
196
is meckel's usually symptomatic or asymptomatic?
asymptomatic, usually found incidentally
197
who is more likely to be symptomatic for meckel's?
2cm length
| presence of histologically abnormal tissues increasing chance with more features
198
most patients with symptoms are within what age range?
<10 years old!
199
suspect meckel's in patients with
painless lower GI bleeding <10
intussusception
features of acute appendicitis without their appendix
adults with obscure GI bleeds
200
why does GI bleeding occur in Meckel's diverticulum?
associated with an ulceration of the small bowel due to acid secreted by ectopic gastric mucosa residing within the diverticulum
201
does the diverticulum itself bleed in meckel's?
no!
202
describe intensity of bleeding in meckel's
chronic and insidious or acute and massive
203
1st line diagnosis for meckel's
meckel's scan: 99m technetium
204
how does 99m technetium work?
has a high affinity for gastric mucosa and should identify the diverticulum
205
downside of meckel's scan?
meckel's diverticulum could have ectopic mucosa belonging to the pancreas, duodenum, or etc
206
what population does meckel's scan work best in?
pediatrics?
207
mesenteric arteriography or abdominal exploration
used for adults which we suspect meckel's in
208
treatment of meckel's
surgery is 1st line therapy
209
what can result if surgery is not done in meckel's?
compartment syndrome which can result in complete lack of use or amputation
210
when should surgery/resection definitely be done with meckel's?
if it's symptomatic
211
when is surgery controversial in meckel's?
asymptomatic
212
do we resect meckels: seen on imaging
no
213
do we resect meckels: child up to 20
yes
214
do we resect meckels: young and otherwise healthy <50
only if longer than 2cm or has a broad base >2cm
215
do we resect meckels: if older than 50
no
216
appendicitis
inflammation of the vestigal vermiform appendix
217
where is the appendix located?
at the base of the cecum near the ileocecal valve where the taeniua coli converge
218
what is considered a true diverticulum of the cecum?
the appendix
219
is the appendix considered part of the cecum?
yes
220
where does the appendix's blood supply come from?
the appendiceal artery (a terminal branch of the ileocolic artery)
221
what can change where the pain is in appendicitis?
the direction that the appendix is pointing off the cecum
222
step 1 of appendicitis
initial inflammation of the appendiceal wall occurs as a result of
fecaliths
calculi
lymphoid hyperplasia (in teens and children)
infection
tumor (benign or malignant) > both which would be removed
223
step 2 of appendicitis
inflammation or actual structure results in obstruction leading to local ischemia (disrupts blood supply) which leads to perforation
224
after perforation of the appendix what happens?
a contained abscess may form in small perforations (microabscesses) and body reacts quickly
generalized peritonitis (pus spilling into general abdominal area and body can't keep up with the flow) < quick burst
225
what kind of bacterial overgrowth happens in appedicitis
early course: aerobic
| late course: mixed infections (kitchen sink)
226
when obstruction causes the appendix to burst
increased intraluminal pressure resulting in thrombosis and occlusion of blood supply to appendix
engorged appendiz causes visceral nerves entering spinal cord at T8-10 become stimulated > periumbilical pain
227
as appendicitis progresses where does the pain migrate to
RLQ
228
what happens when translocation of bacteria occurs in appendicitis
sepsis
229
what increases the risk of perforation
the length a patient has symptoms (>48 hours greatly increases)
230
when does appendicitis most commonly happen
ages 10-19 (2nd and 3rd decades of life)
231
gender predominance in appendicitis
1.4: 1 (slightly more men)
232
McBurney's Point
1/3 of distance for ASIS to umbilicus (where migratory pain starts in 50-60% of patients with appendicitis)
233
where is appendicitis pain if appendix is retrocecal
dull abd ache
back pain
flank pain
234
other symptoms of appendicitis
anorexia
| NV FOLLOWING onset of pain
235
atypical presentations of appendicitis
```
indigestion
flatulence
bowel irregularity
diarrhea (pelvic appedicitis)
general malaise
dysuria/frequency (mocks UTI)
```
236
physical exam presentation of appendicitis
early signs subtle
low grade temp of 101F in nonperforated patients
103+ in perforated patients
McBurney's point tenderness
237
rovsing's sign
appendicitis
| RLQ pain upon palpation of LLQ
238
psoas sign
pain in RLQ with passive hip extension
| (retrocecal appendix)
239
obturator sign
(pelvic appendix)
| lays along right obturator internis muscle and when flex the leg and internally rotate >RLE pain
240
lab findings of appendicitis
WBC
acute average: 14.5
gangrenous: 17.1
perforated: 17.9
241
imaging of choice for appendicitis suspicion in adults
CT scan of abdomen and pelvis with IV and PO contrast
242
what is found on CT indicating appendicitis?
```
enlarged diameter of appendix >6mm with occluded lumen
appendiceal wall thickening >2mm
periappendiceal fat stranding
appendiceal wall enhancement (contrast)
appendicolith
no air in lumen of appendix
none in early course of progression
```
243
is it okay to do surgery even if no CT indication of appendicitis
yes, have convo with pt prior to immaging
244
drawback of CT for appendicitis
2 hours to administer oral ocntrast
difficulty keeping contrast down
radiation exposure
potential for contrast induced renal failure
245
role of US for appendicitis
```
children
can't tolerate CT or contrast
look for appendiceal diameter of >6mm
fast results
no radiation
no contrast
```
246
disadvantages of using US for appendicitis
constipation or obesity can obscure view
less accurate
less likely to reveal alternative diagnosis
accuracy based on operator
247
xrays for appendicitis
cannot diagnose appendicitis but can give alternative diagnosis
248
disease severity grades
1: inflamed
2: gangrenous
3: perforated with localized free fluid
4: perforated with regional abscess
5: perforated with diffuse peritonitis
249
goal of therap for appendicitis
early diagnosis and early operative intervention
250
what is the gold standard of care for appendicitis
appendectomy
251
how are appendectomies primarily done
```
laproscopically because
lower rate of wound infection
less pain POD #1
shorter LOS
helpful if dx unsure
```
252
what do we do prophylactically for appendectomy pre op?
antibiotics
prevent wound infection, intra-abdominal abscess
irrigation
253
whats the target of prophylactic appendectomy abx?
anaerobes and gram- aerobes
254
when do we give prophylactic abx for appendectomies
60 minutes prior to initial incision
255
abx used for acute non-perforated appendicitis
cefoxitin (Mefoxin) IV
| cefazolin (Ancef) IV plus metronidazole (flagyl)
256
drug class of cefozitin
second generation cephalosporin
257
how is mefoxin available?
IV or IM
258
MOA of cefozitin?
bactericidal, inhibiting cell wall synthesis
| active agains +, -, and anaerobes (broad spectrum)
259
S.E. of mefoxin
normal, GI upset, rash, c. diff risks
260
drug class of cefazolin
1st generation cephalosporin
261
how is ancef available?
IV or IM
262
MOA of cefazolin?
bactericidal, inhibiting cell wall snythesis
active against: gram - (e. coli and proteus mirabilis)
no anaerobic coverage so we add flagyl
263
S.E. of ancef?
same as cefozitin
264
most common complication post op appendectomy
infection
simple would infection or intrabdominal abscess
occur in patients with perforated appendicitis, not simple
265
what is done during surgery to minimize infection?
irrigation
266
is there a role for delayed closure in appendectomies>
no
267
does illeus occur?
yes, could happen after any abd surgery
268
what happens if surgery is initiated and appendix is fine?
happens in 10-15% of patients
more common in infants, elderly, and young women
look for another cause
still remove the appendix to look at histology
269
elderly complications with appendicitis
may not mount an immune response
delay seeking care
diverticulitis and neoplasm can mimic appendicitis
