Lecture 10

Question 1

what is the most likely cause of RLQ pain?

Answer 1

appendicitis

Question 2

what are the 3 most likely causes of RLQ pain?

Answer 2

appendicitis
mesenteric lymphadenitis
meckel’s diverticulits

Question 3

what is the most common general surgical emergency?

Answer 3

appendicitis

Question 4

what time of year is appendicitis most common?

Answer 4

spring and summer

Question 5

how long is the appendix?

Answer 5

10cm

Question 6

what does the base of the appendix join to?

Answer 6

cecum

Question 7

where is the tip of the appendix usually located?

Answer 7

behind the cecum

Question 8

where is the appendix located in relation to the ileocecal valve?

Answer 8

posterior and caudad

Question 9

what artery supplies the appendix?

Answer 9

appendiceal artery –> branch of ileocolic artery

Question 10

what is located in the submucosa of the appendix?

Answer 10

lymphoid follicles

Question 11

what mucosal layer of the appendix are lymphoid follicles located?

Answer 11

submucosa

Question 12

what is the cascade of events leading to appendicitis?

Answer 12

obstruction of lumen due to inspissated stool –> lymphoid hyperplasia –> bacterial overgrowth –> distension w/ vascular compromise - causing visceral pain –> necrosis and irritation of peritoneum

Question 13

what are symptoms of appendicitis?

Answer 13

loss of appetite
nausea
vomiting
fever
tachycardia
elevated WBC

Question 14

how can you differentiate gastroenteritis from appendicitis?

Answer 14

gastroenteritis: vomiting and diarrhea first –> pain later
appendicitis: pain first –> vomiting later

Question 15

what is Dunphy’s sign?

Answer 15

coughing exacerbates RLQ pain

Question 16

what is Rovsing’s sing?

Answer 16

pain in RLQ during palpation in LLQ

Question 17

what is Obturator’s sign?

Answer 17

pain w/ internal rotation of hip

Question 18

what is McBurney’s point?

Answer 18

point 1/3 distance along a line from the anterior iliac spine to the umbilicus

Question 19

what will labs show in appendicitis?

Answer 19

elevated WBC

Question 20

what should you suspect with WBC >20K in appendicitis?

Answer 20

perforation and abscess

Question 21

what is the gold standard diagnostic test for appendicitis?

Answer 21

CT

Question 22

what is the test of choice for appendicitis diagnosis in a pregnant woman?

Answer 22

US

Question 23

what is seen on a CT scan w/ appendicitis?

Answer 23

distended appendix >7mm
fecolith
circumferential wall thickening and enhancement
fat stranding in surrounding tissue
free fluid or abscess

Question 24

what is the treatment for appendicitis?

Answer 24

surgery

antibiotics if using a non-operative approach

Question 25

how is an open appendectomy performed?

Answer 25

transverse RLQ incision --> muscle splitting incision --> divide, clamp, and tie the mesenteric/appendicular artery as it enters the cecum

Question 26

how is a laparoscopic appendectomy performed?

Answer 26

3 ports (1 for camera and 2 for working) --> mesentery divided w/ mascular stapler and appendix divided w/ bowel stapler --> remove appendix through one of the ports

Question 27

when should a patient w/ appendicitis be treated non operatively?

Answer 27

patient w/ acute uncomplicated appendicitis w/ prohibitive operative or anesthesia risk

Question 28

how do you treat acute uncomplicated appendicitis non operatively?

Answer 28

admit for 23-48hrs observation IV antibiotics 10 days of at home antibiotics follow up in clinic

Question 29

are longer patient delays or hospital delays associated with a worsening grade of appendicitis?

Answer 29

patient delays

Question 30

the risk of appendix rupture is very low during what time frame?

Answer 30

<35hrs from symptom onset

Question 31

what is the treatment for ruptured appendicitis?

Answer 31

``` admit fluids foley antibiotics drain abscess ```

Question 32

what is the preferred method of drainage for a ruptured appendix?

Answer 32

percutaneous

Question 33

where do the lymph nodes involved in mesenteric lymphadenitis drain to?

Answer 33

ileo-cecal region

Question 34

how do affected nodes appear in mesenteric lymphadenitis?

Answer 34

enlarges discrete soft pink

Question 35

what histological changes are seen in mesenteric lymphadenitis?

Answer 35

reactive hyperplasia

Question 36

mesenteric lymphadenitis is often preceded by what?

Answer 36

recent illness

Question 37

what is the first symptom of mesenteric lymphadenitis?

Answer 37

pain

Question 38

where is pain due to mesenteric lymphadenitis located?

Answer 38

RLQ

Question 39

what is the most common true diverticulum of the GI tract?

Answer 39

Meckel's diverticulum

Question 40

how does Meckel's diverticulum present?

Answer 40

blood in stool due to ulceration | bowel obstruction symptoms