Part 3 - 17, 18, 19, 20, 21, 22, 23, 24 Flashcards Preview

Surgery-Case_Files 2009 > Part 3 - 17, 18, 19, 20, 21, 22, 23, 24 > Flashcards

Flashcards in Part 3 - 17, 18, 19, 20, 21, 22, 23, 24 Deck (43):
1

CASE 17
20 y/o female with 24-hr history of lower abdominal pain that is ATYPICAL for acute appendicitis. She has a low-grade fever and lower abdominal tenderness, with maximal tenderness in the RLQ. Her labs: leukocytosis, microscopic hematuria, and pyuria.
Next step: ??

CT of abdomen and pelvis.

2

What are the advantages to doing a CT for suspected appy?

Identifies appendicitis changes or other pathology (95% accuracy).
Identifies inflammatory changes and thickening of the appendix.

3

What is the MCC of acute abdomen?

Acute appendicitis.

4

Pathophys of acute appy?

Children- Related to obstruction of appendix by lymphoid hyperplasia.
Adults - obstruction by fecalith.

Obstruction --> increase in mucus secretion, venous and lymphatic congestion and bacterial overgrowth --> ischemic necrosis and perforation.

5

Clinical features of acute appendicitis?

Vague periumbilical pain, fever, nausea and vomiting, and urge to defecate; pain eventually localizes to RLQ at McBurney's point.

6

Clinical features of appendiceal rupture?

Peritonitis with guarding and rebound tenderness.

7

What's a common complication of acute appendicitis?

Periappendiceal abscess.

8

What are the disadv of CT for RLQ pain?

Limited sensitivity for early appy and PELVIC path.

9

When is CT recommended for acute RLQ pain?

When inflammatory process not related to pelvic path is suspected.

10

What are the advantages of U/S?

Greater Sn and Sp for Gyne path than CT.

11

What are the disadv of U/S?

Limited by body habitus; appy signs less well defined.

12

Recommended use of U/S for acute RLQ pain?

Suspected Gyne path; Young children (avoid radiation).

13

Advantages of "clinical observation w/ serial lab studies"?

Allows for the natural history of disease evolution.

14

Disadv of "clinical observation w/ serial lab studies"?

limited application if localized pain, fever, and leukocytosis are already present.

15

When is "clinical observation w/ serial lab studies" appropriate?

Possible early appy and w/o localized signs.

16

Advantages to Diagnostic laparoscopy?

Allows accurate assessment of pathology.

17

Disadvantages of diagnostic lap?

Invasive; some morbidity.

18

Diagnostic lap recommended when?

Inflammatory disease or pathology of uncertain source.

19

Define chronic or recurrent appendicitis.

5% of pts w/ appy and may result from Abx administration in patients with early acute appendicitis.

20

Define "Interval appendectomy"

Tx of appy complicated by abscess or phlegmon. Patient tx w/ broad-spectrum Abx and CT-guided drainage of the abscess to resolve the infectious process, followed by appendectomy after several weeks. Since some patients w/ appropriate non-operative treatment do not develop appendicitis recurrences, the role of interval appendectomy remains unclear.

21

What is mesenteric adenitis?

inflammatory condition occurring with a VIRAL illness, resulting in SELF-LIMITING yet painful lymphadenopathy in the small bowel mesentery (mesenteric lymph nodes). This process can be associated with RLQ pain and tenderness and is especially common in children. No need for antibiotics.

22

Approximately how many people with acute appy experience perforation w/in 24 hours of the onset of symptoms?

20%.

23

How many acute appy patient show a "Classic presentation"?

50%.

24

Pathology - luminal obstruction
Clinical correlation -- ???

Poorly localized periumbilical pain, N/V, and urge to defecate.

25

Pathology - inflammation
Clinical correlation -- ???

location of pain depends on position of appendix (eg, McBurney's point); peritonitis is present only if the inflamed appendix or inflammatory changes involve the peritoneum.

26

Pathology - perforation
Clinical correlation -- ???

Transient improvement in pain but an increase in systemic toxicity.

27

T/F there is some relief of abdominal pain when the appendix perforates.

True!

28

Patients with the "classic presentation" require what diagnostic steps?

Thorough H&P, CBC w/ differential count, U/A, and pregnancy test (women only) for diagnosis.

29

T/F Appendicitis classically presents with intermittent pain.

False! Abdominal pain that is intermittent may be d/t gastroenteritis. Appendicitis and pancreatitis are often constant.

30

On Laparoscopy, what would PID look like?

an erythematous tube with purulent drainage from the fimbria.

31

What's the advantage in using a non-contrast CT for pelvico-abdominal pathology?

identify kidney stones.

32

What's the advantage in using a contrast CT for pelvico-abdominal pathology?

Help r/o appendicitis and pyelonephritis.

33

What is the next best step for a "classic" appendicitis presentation?

Emergency appendectomy

34

What is the next best step in an "Atypical" appendectomy?

CT with contrast.

35

What are the complications of a laparoscopic appendectomy?

Same as open appy:
bleeding, wound infection, intra-abdominal abscess, incisional hernia, cecal fistula, or perforation. 3-10% risk of conversion to open technique.

36

T/F Surgery is indicated in acute appendicitis presenting in a pregnant woman.

True!

37

Peak incidence of acute appy?

teens-mid 20's.

38

T/F Prognosis of acute appy is far worse in infants and elderly.

True b/c of higher rate of perforation.

39

T/F Appendicitis is likely when the patient is hungry.

False, Anorexia (not hungry) is almost always present.

40

What is Rovsing's sign?

Deep palpation in LLQ causes referred pain in RLQ.

41

What is the Psoas sign?

RLQ pain when right thigh is extended as patient lies on left side.

42

What is the Obturator sign?

RLQ pain when flexed right thigh is internally rotated when pt is supine.

43

About how many pts thought to have acute appendicitis are found to have a normal appendix during surgery?

Up to 20%, but this is an acceptable surgical risk as it's an emergency.
(End of Case 17)