2 - Acute Appenditicits

Question 1

MC patient type for appendicitis

Answer 1

Atraumatic acute abd pain without prior appendenctomy

Age 10 to 19 yrs

Question 2

Appendicitis caused by:

Answer 2

Luminal obstruction of the vermiform appendix (typically a fecoltih)

Question 3

McBurnery’s point

Answer 3

One third of the distance from the ASIS spine to the umbilicus

Right lower quadrant is MC spot for point tenderness / rebound tenderness

Question 4

Early sxs appendicitis

Answer 4

General malaise
Indigestion
Bowel irregularity

Anorexia common

Periumbilical or central ABD pain generally develop after non-specific sxs

Possibly N/V

Question 5

As it progresses, pain moves:

Answer 5

To the lower right quadrant

Flank pain, dysuria, hematuria can occur

Question 6

What can help establish the dx?

Answer 6

Aggravating and alleviating features

Question 7

If pain suddenly goes away, that’s good, right?

Answer 7

Nope! Could mean appendiceal rupture

Question 8

Rebound tenderness and involuntary guarding suggests:

Answer 8

Peritonitis

(+) heel test

Question 9

Rovsing’s Sign

Answer 9

Reproduces pain over McBurney’s point as the clinician palpates the descending colon in the LLQ

Question 10

Psoas sign

Answer 10

Elicited if ABD pain is produced with extension of the right leg at the hip while pt lies on the left side

Question 11

Obturator test

Answer 11

Pain with internal and external rotation of the flexed right thigh at the hip

Question 12

If patient comes in with pain that looks like appendicitis and they’ve had pain there before,

Answer 12

Decreases likelihood that it’s appendicitis

Question 13

Dx of appendicitis?

Answer 13

No H and P finding is sufficient to rule in or rule out appendicitis

May be happening but not clinically apparent

Question 14

Consider appendicitis in any patient with:

Answer 14

Atraumatic right-sided abdominal, periumbilical, or flank pain who has their appendix

Question 15

Slide 13

Answer 15

DDx for LRQ pain

Question 16

Labs to order if you think appy?

Answer 16

WBC

Question 17

Lab testing overall?

Answer 17

Slide 15

Basically useless - nonspecific - good for finding other causes besides appendicitis

Question 18

Suspect appendicitis - call surgeon first or order imaging first?

Answer 18

Call the surgeon

Question 19

Goals of imaging

Answer 19

Establish the dx
Avoid a negative appendectomy
Identify perforation
Exclude other causes

Question 20

Plain films for appendicitis?

Answer 20

Useless

Question 21

Initial imaging modality of of choice in preggos and kids?

Answer 21

Graded compression US

Question 22

Typical US findings in appendicitis

Answer 22

Thickened, non-compressible appendix > 6mm

Question 23

Cut-off on US for appendix?

Answer 23

Less than 6mm = okay

Greater than 6mm = not okay

Question 24

Test for appendicitis?

Answer 24

Non-contrast CT - excellent performance in the dx of acute appendicitis

Question 25

When to consider MRI

Answer 25

Preggos and kids

Or

If CT neg but strong suspicion

Question 26

For the test

Answer 26

“Gold standard” = CT with contrast

The right test to order for his test - noncontrast

Question 27

As soon as you suspect appendicitis

Answer 27

NPO and consult

Next, mIVF, antiemetics, analgesia

Question 28

Standard of care for acute appendicitis?

Answer 28

Cut that fucker out

Question 29

Acceptable regimen for ABX

Answer 29

KNOW ALL OF THIS

Ampicillin/sulbactam 3gm IV (peds 75mg/kg IV)

Pip-Tazo 4.5gm IV (peds 100mg/kg IV)

Cefoxitin 2gm IV (peds dose 40mg/kg IV)

Metronidazole 500mg PLUS ciprofloxacin 400mg IV

Question 30

Stable pt?

Answer 30

Good pain control, can drink fluids, good to go home and come back within 12 hrs for re-eval

Question 31

Laughter is the best medicine

Answer 31

Unless you had an appendectomy. Please dont do it, you may rip a stitch