4 - Appendicitis

Question 1

Quick pathophys of appendicitis

Answer 1

Lumen obstructed -> distention -> infection -> ischemia -> perforation

Question 2

Distention of the appendix following obstruction leads to what sxs?

Answer 2

Periumbilical pain
N/V
Mildly tender abdomen
Systemic inflammatory response syndrome

Question 3

When the appendix is ischemic, what sxs occur?

Answer 3

Pain radiating to the RLQ

Low grade fever

Mild bump in WBC’s

SIRS -> Sepsis

Question 4

When the appendix perforates, what sxs occur?

Answer 4

Succus spills out -> peritonitis

Increased pain / TTP

High fever / WBC’s

Sepsis -> septic shock

Question 5

Overview if appendicitis symptoms:

Answer 5

Periumbilical pain FIRST, then radiates to RLQ

Almost always anorexia then vomiting

Tenderness develops later

Question 6

If the appendix is in the iliac fossa, where is the pain?

Answer 6

McBurney’s point

Question 7

If the appendix is in the pelvis, where is the pain?

Answer 7

Rectal tenderness

Obturator sign

Question 8

If the appendix is retrocecal or retroperitoneum, where is the pain?

Answer 8

Along the psoas

Question 9

When might the pain of appendicitis be in the RUQ?

Answer 9

Pregnancy

Question 10

Appendicitis workup:

Answer 10

PE findings usually give it away

CBC (leukocytosis expected)
CMP (liver, kidney, blood glucose)
UA (hydration status)
HCG (to r/o ectopic pregnancy)

Question 11

Imaging for appendicitis

Answer 11

Acute abdominal series (flat, upright, CXR)(not very diagnostic for appendicitis, but may show ileus or fecolith)

US - may show inflamed appendix

CT

MRI - usually done in kids to avoid ionizing radiation of CT

Question 12

What will you see on CT with appendicitis?

Answer 12

Fat stranding

Question 13

MANTRELS mnemonic

Answer 13

Migration to R iliac fossa
Anorexia
N/V
Tenderness in R iliac fossa
Rebound pain
Elevated temp
Leukocytosis
Shift of leukocytes to the left

Question 14

Appendicitis management

Answer 14

NPO

IVF (use UOP as guide)

IV ABX against gram (-), strep, anaerobes (2nd or 3rd gen cephalosporin with metronidazole)

NG suction for gastric decompression

Anti-emetics, pain control (don’t worry about “masking” sxs - treat their pain)

Question 15

Which populations have a higher rate of perforation and/or delay in dx?

Answer 15

Children
Elderly
Developmentally delayed

Question 16

Special note regarding pregnancy and appendicitis

Answer 16

Gall bladder dz and appendicitis very common during pregnancy

US to help differentiate (CT CI’d in pregnancy)

Question 17

Two major surgical techniques:

Answer 17

Open (McBurney incision, takes appx one hour)

Laparoscopic (better visualization of ABD/pelvis)(can convert to open if needed)

Question 18

DDx for appendicitis:

(In parentheses, why it WOULDN’T be appendicitis)

Long card, sorry

Answer 18

Gastroenteritis (appendicitis doesn’t usually present with diarrhea as CC)(hyperactive BS)

UTI (UA will show many WBC’s, foul smell, leuk-es and/or nitrites)

Calculi (sudden and intense onset, UA with RBC’s)

Ovarian cyst (NOT an infection)

Ectopic pregnancy (check the HCG and US)

PID (bilateral adnexal tenderness, discharge from cervical os)

Meckel’s Diverticulum (gastric or pancreatic tissue, 2 feet of ilio-cecal junction, 2% of population)(surgically removed along with appendix, even if not appendicitis)

Crohn’s (regional enteritis, treated medically, still remove appendix if cecum not inflamed)

Diverticulitis (usually in older patients, often guaiac (+), normally L-sided pain)

Colon CA (usually older patients, often guaiac (+))

Question 19

Suppurative appendix

Answer 19

Early, some pus but no tissue necrosis or perforation

Question 20

Gangrenous appendix

Answer 20

Tissue necrosis but not yet perforated

Question 21

Perforated appendix

Answer 21

Generalized peritonitis - operate ASAP

Localized abscess - ABX and percutaneous drainage then appendectomy usually after 6 weeks

Question 22

Rare pathologies associated with appendicitis

Answer 22

Carcinoid (MC)
Lymphoma
Adenocarcinoma

Question 23

Complications of appendectomy

Answer 23

Surgical site infection (remove sutures, irrigate, oral ABX, follow-up closely)

Deeper infection (muscle to fascia)(fever, anorexia, ill-appearing - may need exploratory surg and IV ABX)

Question 24

Overall goal of txt of appendicitis

Answer 24

Prevent septic shock

Prevent perforation

Standard of care for appendicitis is surgery

Question 25

MC CA found in the appendix?

Answer 25

Carcinoid

Question 26

I tried to look up impotence on the Internet

Answer 26

but nothing came up