LE6 (APPENDICITIES & COLON/RECTUM/ANUS) Flashcards
(56 cards)
- A 24-year-old man is suspected of having acute appendicitis. On physical examination, his abdomen is soft and non-distended. He does not have pain with coughing or reproduction of tenderness in the right lower quadrant when palpated in the left lower quadrant. He experiences abdominal pain during the extension of the right thigh while lying on his left side. He does not have pain with passive rotation of his right hip in a flexed position. Where do you suspect the location of the tip of his appendix to be?
A. In the left lower quadrant
B. Retrocecal over the psoas muscle
C. Extraperitoneal and lying anterior to the cecum
D. Displaced to the right upper quadrant
E. In the pelvis
B. Retrocecal over the psoas muscle
The psoas sign (pain with passive extension of the right thigh while lying on the left side) suggests that the inflamed appendix is in the retrocecal position, as the psoas muscle is irritated.
- Which of the following statements regarding the appendix is false?
A. The blood supply to the appendix is from the appendicular artery, a branch of the ileocolic artery.
B. Innervation of the appendix is derived from the somatic nervous system.
C. The lymphatic drainage of the appendix goes through the ileocolic nodes.
D. The average length of an adult appendix is 9 cm.
E. The appendix contains large amounts of lymphoid aggregates, but it has no significant exocrine function.
B. Innervation of the appendix is derived from the somatic nervous system. (False statement)
The appendix is innervated by the autonomic nervous system, particularly the visceral afferent fibers from T10, not the somatic nervous system, which controls voluntary movements.
- Which of the following statements regarding the pathogenesis of appendicitis is false?
A. Obstruction of the lumen may occur as a result of inspissated stool or a foreign body.
B. The antimesenteric border has the poorest blood supply and is usually the site of perforation.
C. Viral or bacterial infections can precede an episode of appendicitis.
D. Fecaliths are commonly responsible for appendicitis in children.
E. Obstruction of venous outflow and then arterial inflow results in gangrene.
D. Fecaliths are commonly responsible for appendicitis in children. (False statement)
In children, appendicitis is usually caused by lymphoid hyperplasia due to infections, not fecaliths, which are more common in adults.
- A 38-year-old man presents with migratory right lower quadrant (RLQ) pain, leukocytosis, and a CT scan consistent with acute, uncomplicated appendicitis. He is physiologically normal, and it is 2 AM. You are planning an appendectomy. What difference might be expected in his outcome if his operation is delayed until the next morning?
A. Increased risk of surgical-site infection.
B. Decreased operative time.
C. Increased risk of perforation.
D. No difference in perforation rates, surgical-site infection, abscess, conversion rate, or operative time.
E. Increased risk of an intra-abdominal abscess.
D. No difference in perforation rates, surgical-site infection, abscess, conversion rate, or operative time.
Studies have shown that a delay of less than 12 hours in stable patients does not increase the risk of perforation or complications
- You are performing a laparoscopic appendectomy on a 35-year-old male who presented with classic acute appendicitis. During the operation, you note that the appendix is necrotic and perforated at the base. What is the best way to proceed with the appendectomy?
A. Perform a limited cecal resection using a stapling device.
B. Place an endoloop around the base of the appendix.
C. Irrigate and place a drain with plans to perform an interval appendectomy in 6 weeks.
D. Staple across the necrotic base of the appendix, making sure the perforation is closed.
E. Perform an ileocecectomy.
A. Perform a limited cecal resection using a stapling device.
Perforation at the base may compromise the cecum, requiring a limited cecal resection to ensure all infected and necrotic tissue is removed.
- Which of the following is true regarding the location of the appendix?
A. The appendix is often retrocecal and extraperitoneal.
B. After the fifth gestational month of pregnancy, the appendix is shifted posteriorly and laterally by the gravid uterus.
C. The base of the appendix can always be found at the confluence of the cecal taenia.
D. The tip of the appendix is found in the pelvis in the majority of cases.
E. The position of the tip of the appendix does not determine the symptoms of the patient with appendicitis.
C. The base of the appendix can always be found at the confluence of the cecal taenia.
The three taeniae coli (longitudinal smooth muscle bands of the colon) converge at the base of the appendix, making it a constant anatomical landmark.
- When a mucocele of the appendix is found at the time of surgery, which of the following is an appropriate initial therapy?
A. Routine right hemicolectomy with lymph node dissection.
B. Appendectomy.
C. Incisional biopsy with subsequent appendectomy if malignancy is confirmed by frozen section.
D. Needle aspiration of cystic fluid for cytologic examination.
E. Closure and observation.
B. Appendectomy.
A mucocele of the appendix can be benign or malignant. The standard treatment is appendectomy, avoiding rupture that could lead to pseudomyxoma peritonei.
- A 35-year-old man is admitted to the emergency department complaining of pain in the umbilical region that moves to the right iliac fossa. Which is a corroborative sign of acute appendicitis?
A. Referred pain in the right side with pressure on the left.
B. Hyperesthesia in the right lower abdomen.
C. Relief of pain in the lower abdomen with internal rotation of the right thigh.
D. Relief of pain in the lower abdomen with extension of the thigh.
E. Increase in pain with testicular elevation.
A. Referred pain in the right side with pressure on the left (Rovsing sign).
Rovsing’s sign is positive when palpation of the left lower quadrant elicits pain in the right lower quadrant, suggesting peritoneal irritation from appendicitis.
- With regard to appendicitis in immunocompromised patients, which of the following statements is false?
A. CT is particularly useful in immunocompromised patients.
B. Immunocompromised patients with appendicitis often have a fever, a normal WBC count, and nonspecific abdominal pain.
C. Cytomegalovirus (CMV) infections and Kaposi sarcoma can occlude the appendiceal orifice and cause acute appendicitis.
D. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis.
E. Typhlitis often mimics acute appendicitis.
D. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis. (False statement)
In immunocompromised patients, infections like mycobacteria, protozoa, and fungi can mimic appendicitis and must be considered in the differential diagnosis.
- While reviewing pathology of a recent laparoscopic appendectomy, you note that in addition to acute appendicitis, the patient had a 1.5-cm carcinoid tumor located at the base of the appendix. The patient is otherwise healthy and recovering well from surgery. What would you recommend?
A. Right hemicolectomy.
B. Adjuvant chemotherapy.
C. Radical appendectomy.
D. No additional therapy necessary.
A. Right hemicolectomy.
A carcinoid tumor ≥2 cm, located at the base of the appendix, or showing invasive features requires a right hemicolectomy due to the risk of spread.
- A 27-year-old man has a 1-day history of right lower quadrant pain and leukocytosis. Probable nonperforated acute appendicitis is diagnosed. What is the best antibiotic and surgical management for this patient?
A. Operate and then await the results of peritoneal fluid cultures to tailor the selection of antibiotics.
B. Begin ceftriaxone and metronidazole (Flagyl), monitor the patient with serial abdominal examinations, and operate if he fails to improve.
C. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery.
D. Begin clindamycin perioperatively, because Bacteroides fragilis is the most common organism involved in acute appendicitis, and proceed with surgery.
E. Administer cefazolin perioperatively to reduce the risk of wound infection and then operate.
C. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery.
The standard antibiotic regimen for acute, nonperforated appendicitis is ceftriaxone (or cefazolin) + metronidazole, which covers gram-negative and anaerobic bacteria. Surgery should proceed without delay, as conservative management is reserved for special cases.
- Which of the following is true regarding appendiceal carcinoid tumors?
A. Carcinoid tumors arise from the smooth muscle within the appendiceal wall.
B. Carcinoid tumor is the second most common tumor of the appendix.
C. For tumors greater than 2 cm, a formal right hemicolectomy is indicated.
D. All tumors less than 2 cm that do not involve the appendiceal base can be treated with an appendectomy alone.
E. Nearly 75% of appendiceal carcinoid tumors are located in the proximal one-third of the appendix.
C. For tumors greater than 2 cm, a formal right hemicolectomy is indicated.
Appendiceal carcinoid tumors >2 cm have an increased risk of nodal and distant metastasis, warranting right hemicolectomy. Tumors <2 cm without mesoappendiceal invasion can be treated with appendectomy alone.
- With regard to appendicitis in the elderly, which statement is false?
A. Perforation has an associated mortality rate of 50%.
B. Elderly patients have a higher rate of perforation because of omental atrophy.
C. Appendicitis may mimic bowel obstruction.
D. Symptoms of appendicitis along with anemia should raise suspicion for a concomitant cecal neoplasm.
E. Elderly patients tend to present later in the course of acute appendicitis.
A. Perforation has an associated mortality rate of 50%. (False statement)
While elderly patients have higher morbidity and mortality due to late presentation, the mortality rate from perforation is ~15%, not 50%. The delay in diagnosis is due to atypical presentations and reduced inflammatory response.
- A 68-year-old male with a complaint of watery diarrhea underwent a colonoscopy and was found to have a mass within the appendiceal orifice. This was biopsied, and the pathology was consistent with a carcinoid tumor. A CT of the chest, abdomen, and pelvis showed a 3-cm appendiceal base mass and two liver lesions. Which of the following is true?
A. Synchronous treatment with a right hemicolectomy and radiofrequency ablation of the liver metastases is appropriate.
B. Carcinoid syndrome occurs when the primary tumor becomes larger than 2 cm and secretes hormones.
C. Octreotide decreases metastatic tumor progression and improves survival rates.
D. Appendiceal carcinoid tumors with metastases to the liver are fast growing and have a 5-year survival rate of only 10%.
E. Hepatic resection of liver metastases is not recommended as a method for tumor debulking and symptom control.
A. Synchronous treatment with right hemicolectomy and radiofrequency ablation of liver metastases is appropriate.
Explanation:
1. Right hemicolectomy is the preferred surgical approach for appendiceal carcinoid tumors located at the base and >2 cm in size, as it ensures complete resection with appropriate lymphadenectomy.
2. Liver metastases from neuroendocrine tumors (NETs) can be managed with hepatic resection or radiofrequency ablation (RFA), especially when limited to the liver, to prolong survival and control symptoms.
3. Octreotide (a somatostatin analog) helps in symptom control and reduces hormone secretion but is not the primary treatment for metastatic disease.
4. Carcinoid syndrome is typically associated with hepatic metastases rather than tumor size alone.
5. Appendiceal carcinoid tumors with liver metastases have a relatively favorable prognosis, with a 5-year survival rate of 20–40% after resection, contrary to the 10% survival stated in option E.
- A 28-year-old woman who is 28 weeks pregnant presents with right-sided abdominal pain, leukocytosis, and an abdominal ultrasound that does not visualize the appendix. What intervention would you recommend?
A. Serial clinical observations.
B. Abdominal CT scan.
C. Exploratory laparoscopy.
D. Abdominal magnetic resonance imaging (MRI) scan.
D. Abdominal magnetic resonance imaging (MRI) scan.
In pregnancy, MRI is the preferred imaging modality when ultrasound is inconclusive, as it avoids radiation exposure from CT scans.
- A 79-year-old man has had abdominal pain for four days. An operation is performed, and a gangrenous appendix is removed. The stump is inverted. Why does acute appendicitis in elderly patients and in children have a worse prognosis?
A. The appendix is longer in these age groups.
B. The appendix is in the preileal position.
C. The appendix is retrocecal.
D. The omentum and peritoneal cavity appear to be less efficient in localizing the disease in these age groups.
E. The appendix is in the pelvic position.
D. The omentum and peritoneal cavity appear to be less efficient in localizing the disease in these age groups.
In elderly and pediatric patients, weaker omental response leads to delayed containment of inflammation, increasing the risk of perforation and sepsis.
- A 20-year-old, 28-week pregnant female presents to the emergency department with a 24-hour history of right upper quadrant abdominal pain. The white blood cell (WBC) count is 18,000. An ultrasound was done showing a normal gallbladder and viable fetus. The appendix was not visualized. What is the next best step?
A. Proceed with laparoscopy after delivery.
B. Admit the patient for serial abdominal examinations and repeat lab tests in the morning.
C. Obtain a magnetic resonance imaging (MRI) and proceed with an appendectomy if positive.
D. Treat with antibiotics in an attempt to avoid an operation.
E. Obtain a CT abdomen/pelvis.
C. Obtain a magnetic resonance imaging (MRI) and proceed with an appendectomy if positive.
MRI is the next best step in pregnant patients with suspected appendicitis when ultrasound is inconclusive. If positive, surgery is indicated to prevent complications.
- A 45-year-old male underwent a laparoscopic appendectomy. On final pathology, he was found to have a 1.4-cm carcinoid tumor in the mid-appendix with direct extension to the mesoappendix, negative margins, and no lymphovascular invasion. What is the best treatment plan?
A. Medical treatment with octreotide.
B. Chemotherapy.
C. Right hemicolectomy.
D. No further treatment needed.
E. Ileocecectomy.
C. Right hemicolectomy.
A carcinoid tumor >1 cm, with mesoappendiceal invasion, requires right hemicolectomy due to a higher risk of lymph node metastasis.
- A 10-year-old boy presents to the emergency department complaining of generalized abdominal pain for the past 24 hours. Laboratory tests reveal a leukocytosis of 13,000, and he is tender in the RLQ on physical examination. He is taken to the operating room for laparoscopic appendectomy. Removal of the appendix has been associated with a protective effect against which of the following?
A. Crohn colitis.
B. Carcinoid.
C. Ulcerative colitis.
D. Clostridium difficile.
C. Ulcerative colitis.
Appendectomy has a protective effect against ulcerative colitis (UC), possibly due to immune modulation and reduced gut-associated lymphoid tissue (GALT) activity.
- A 76-year-old female presents with a 5-day history of right lower quadrant abdominal pain and nausea. A computed tomography (CT) of the abdomen and pelvis shows perforated appendicitis with a 5-cm abscess. She was started on broad-spectrum antibiotics and underwent percutaneous drainage of the abscess. In 72 hours, she was afebrile, and her leukocytosis and symptoms had resolved. What should the next treatment step be?
A. Ileocecectomy in 6 weeks.
B. Appendectomy prior to discharge.
C. Continue broad-spectrum antibiotics until drain removal.
D. Interval appendectomy in 4 weeks.
E. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks.
E. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks.
In older patients, perforated appendicitis may be associated with underlying malignancy, warranting colonoscopy before considering an interval appendectomy.
- A 43-year-old man has CT scan evidence of complicated appendicitis with a contained abscess in the RLQ. He is mildly tachycardic, afebrile, and normotensive with focal RLQ tenderness but no peritonitis. What is the optimal approach to this patient?
A. Immediate laparotomy
B. IV fluids, bowel rest, and broad-spectrum antibiotics
C. Percutaneous drainage, IV fluids, bowel rest, and broad-spectrum antibiotics
D. Laparoscopic exploration and abscess drainage
C. Percutaneous drainage, IV fluids, bowel rest, and broad-spectrum antibiotics
For complicated appendicitis with a contained abscess, nonoperative management with percutaneous drainage and IV antibiotics is preferred. Immediate surgery (A, D) risks spillage and increased morbidity.
- A patient suspected of having acute appendicitis underwent exploration. An inflamed terminal ileum consistent with Crohn’s disease was found. Which of the following is true?
A. An inflamed appendix, cecum, and terminal ileum should be resected.
B. Perforated bowel and advanced Crohn’s disease with obstruction should be resected.
C. All grossly involved bowels, including the appendix, should be resected.
D. The normal appendix should always be removed.
E. Only the tip of the appendix should be resected if the base is found to be involved with Crohn’s disease.
B. Perforated bowel and advanced Crohn’s disease with obstruction should be resected.
In Crohn’s disease, resection is reserved for perforation, obstruction, or severe disease. Otherwise, conservative management is preferred because excessive bowel resection increases the risk of short bowel syndrome.
- What imaging finding would exclude appendicitis?
A. A barium enema where a short (2 cm) appendix was clearly identified.
B. A computed tomographic (CT) scan with a nonvisualized appendix.
C. An ultrasound study with a compressible appendix that is <5 mm in diameter.
D. A CT scan showing an edematous but retrocecal appendix.
C. An ultrasound study with a compressible appendix that is <5 mm in diameter.
A compressible appendix <5 mm is highly suggestive of a normal, non-inflamed appendix, ruling out appendicitis. A nonvisualized appendix on CT (B) does not exclude appendicitis, as it may be hidden by bowel gas or inflammation.
- A 20-year-old woman is operated on through a right lower quadrant incision for presumed appendicitis, but the appendix is normal. At this point, which of the following would be an appropriate treatment?
A. Exploration and appendectomy if no other pathology is found.
B. Exploration and diverticulectomy if a Meckel’s diverticulum is present and is normal by inspection and palpation.
C. Exploration, treatment of any associated pathologic condition, as indicated, and avoiding removal of a healthy-appearing appendix.
D. Midline laparotomy for complete exploration if no pathology can be seen through the right lower quadrant incision.
E. Exploration and ileal resection if the terminal ileum appears acutely inflamed.
A. Exploration and appendectomy if no other pathology is found
Explanation:
If a normal appendix is found during surgery, other possible causes of right lower quadrant (RLQ) pain must be explored, including Meckel’s diverticulum, Crohn’s disease, mesenteric adenitis, gynecologic pathology, diverticulitis, or epiploic appendagitis.
Appendectomy is typically performed unless there is Crohn’s disease involving the cecum and ileum, where removing a normal appendix might cause unnecessary complications.
Laparoscopic exploration is helpful for evaluating adjacent pelvic and gastrointestinal structures before proceeding with unnecessary additional surgical interventions.
