RLQ

Question 1

Abdominal exam for RLQ

Answer 1

Focal pain at Mcburney’s point
Rovsing’s sign
Psoas sign
Obturator sign

Question 2

Rovsing’s

Answer 2

push on LLQ –> mov’t of abdominal contents to RLQ –> peritoneal inflammation

Question 3

Psoas

Answer 3

flex hip –> pain

suggests retrocecal appendix

Question 4

Obturator sign

Answer 4

adduct hip –> pain

Question 5

Labs for RLQ pain

Answer 5

CBC (elevated WBC)
UA (hematuria suggestive of stone)
HCG - r/o pregnancy
Lactate - eval perfusion
General belly pain labs: lipase/amylase, bili, LFTs

Question 6

Imaging:

Answer 6

For classic presentation + healthy male, 90% sensitivity w/ good exam (10-15% acceptable failure rate)
Non-classic presentation - CT higher sensitivity
Peds - U/S
KUB to r/o obstruction

Question 7

DDx:

Answer 7

INFECTIOUS
-appendicitis
-Gastroenteritis
-Ileitis (yersinia, campylobacter, salmonella)
INFLAMMATORY
-IBD
ISCHEMIA
-mesenteric ischemia
OBSTRUCTION
-SBO/volvulus/intussusception
MEDICAL
Typhilitis
OTHER ORGANS:
-Nephrolithiasis/UTI
-GU: testicular/ovarian torsion, Cyst rupture, PID, ectopic pregnancy
-Inguinal/abdominal wall hernia

Question 8

Appendicitis symptoms

Answer 8

periumbilical pain localizing to mcburney’s point

Question 9

why diffuse pain and localizing to specific point?

Answer 9

initial pain due to inflammation of visceral peritoneum (autonomic nerves which refers pain to midline of abdomen)

Question 10

cheeseburger sign

Answer 10

anorexia

Question 11

management of appendicitis (not ruptured)

Answer 11

appendectomy (open vs. laparoscopic; laparoscopic = less pain, faster recovery, quicker return to work, better cosmesis)
24 hrs of a/b
d/c POD1

Question 12

appendicitis perforation management

Answer 12

IV fluid resuscitation
prompt appendectomy
post-op a/b for 3-7D
wound left open after closing fascia (will heal by 2/2 intention / delayed primary closure)

Question 13

phlegmon

Answer 13

diffuse inflammatory process with formation of suppurative/purulent exudate or pus (walled-off, but more viscous than abscess)

Question 14

phlegmon/abscess management

Answer 14

percutaneous drain, fluids, bowel rest, antibiotics

Question 15

what kind antibiotics?

Answer 15

anerobes / gram-negs

cipro/flagyl, augmentin (amoxicillin-clavulanate), zosyn (piperacillin-tazobactam)

Question 16

blood supply to appendix

Answer 16

SMA –> iliocolic –> appendiceal artery (supplies the mesoappendix)

Question 17

management of complicated appendectomy?

Answer 17

high rate of post-op complications if surgery
treat w/ antibiotics
elective appendectomy at later date

Question 18

approach to surgery of appendix

Answer 18

1) identify the appendix
2) isolate blood supply / staple mesoappendix
3) staple / transect appendix at the base of the appendix
4) removal from abdomen
5) irrigate / aspiration until clear

Question 19

what is the fold/ligament of treves?

Answer 19

terminal ileum at the ileocecal junction - this antimesenteric fat fold is the only nonmesenteric fat over the course of the entire small bowel.

Question 20

how can the appendix be located if the cecum has been identified?

Answer 20

teania coli all converge on the appendix

Question 21

what is the mesentery of the appendix

Answer 21

mesoappendix (contains the appnediceal artery)

Question 22

what vessel provides blood supply to appendix?

Answer 22

appendiceal artery - branch of the ileocolic artery

Question 23

valentino’s sign

Answer 23

RLQ pain/peritonitis from succus draining down to the RLQ form a perfrom a perforcated gastric / duodenal ulcer (paracolic gutters) - may be mistaken for appendix-like pain (but diff. origin)

Question 24

where is mcburney’s point?

Answer 24

1/3 distance from ASIS to the umbilicus

Question 25

pathophysiology of the appendix

Answer 25

obstruction of the appendiceal lumen - closed loop --> inflammation that may lead to necrosis / perforation

Question 26

how might you have abnl UA w/ appendicitis?

Answer 26

mild hematuria / pyuria 2/2 to pelvic inflammation --> ureter inflammation

Question 27

what seen on imaging of appendicitis?

Answer 27

large non-compressible appendix / fecalith

Question 28

how to differentiate acute appnedicitis vs. gastroenteritis?

Answer 28

in gastroenteritis, vomiting first then pain | in appendicitis, pain then vomiting

Question 29

CT findings of acute appendicitis

Answer 29

periappendiceal fluid appendiceal diamter > 6 mm periappendiceal fat stranding

Question 30

what are preop meds/prep?

Answer 30

IV fluids - rehydration | pre-op a/b (anaerobic coverage)

Question 31

what is risk of perforation?

Answer 31

25% by 24 hrs 50% by 36 hrs 75% by 48 hrs

Question 32

complications of appendicitis:

Answer 32

abscess, perforation, portal pylethrombophlebitis

Question 33

what is bacteria gastroenteritis (mesenteric adenitis)

Answer 33

yersinia enterolytica

Question 34

compliccations of appendectomy?

Answer 34

SBO, enterocutaneous fistula, wound infection, infertility w/ perforation in women, stump abscess, incr. incidence of right inguinal hernia (3 categories: 1) poor healing - infxn, fistula, abscess; 2) poor healing in long-term - hernia. 3) adhesions - SBO)

Question 35

what are the layers of the abdominal wall?

Answer 35

1) skin 2) subqfat/camper's 3) scarpa's fascia 4) external oblique 5) interal oblique 6) transversus muscle 7) transversalis fascia 8) preperitoneal fat 9) peritoneum

Question 36

what is the significance of the arcuate line of rectus sheath / douglas line?

Answer 36

superior to the arcuate line - internal oblique aponeurosis splits to cover the rectus abdominus inferior to the arcuate line - the internal oblique / transversus abdominis aponeurosis merge and pass anteriorly/superficially to the rectus muscle

Question 37

how do you get to a retrocecal / retroperitoneal appendix

Answer 37

divide the lateral peritoneal attachmentss of the cecum

Question 38

how do you prevent tearing of the mesoappendix?

Answer 38

mesoappendix lies medially | finger sweep lateral to medial along the lateral peritoneum

Question 39

why use electrocautery on exposed mucosa on the appendiceal stump?

Answer 39

kill mucosal cells so they do not form a mucocele

Question 40

if the appendix is normal, what do you inspect intraoperatively?

Answer 40

terminal ileum - meckle's diverticulum, crohn's, intussusception gynecologic - cysts, torsion groin - hernia, rectus sheath hematom, adenopathy/adenitis