79. Acute Appendicitis

Question 1

What is the appendix?

Answer 1

blind ended tube coming from the cecum, 3cm from ileocecal valve

Question 2

Average diameter of the appendix

Answer 2

6-11mm
average thickenss of 1.5mm

Question 3

Where does appendix nerves enter SC?

Answer 3

T10

Question 4

How does appendicitis occur?

Answer 4

1. obstruction of appendicieal lumen –>mucous production and bacterial stasis
2. eventually pain turns to loss of blood flow –> tissue ishcemi and inflamm
3. can allow bacteriia to invade the wall, typically why RLQ pain
4. if cont: can become necrotic and perforate

Question 5

MC cause of obstruction in nonperforated appendicits

Answer 5

fecaliths

then appendicoliths (cal)
lymphoid hyperplasia

Question 6

Tip vs stump appendicits

Answer 6

tip appendici- tis is inflammation localized to the distal end of the appendix - higher risk being missed on imaging

stump - inflamm of appendiceal remnant that may persist after appy (rare)

Question 7

Best LR+ adult for appendicitis

Answer 7

RLQ pain
rebound tenderness
rigidity
migration/periumbilical pain

Question 8

Best LR- adult for appendicitis

Answer 8

RLQ
guarding
rebound tenderness

Question 9

Best LR+ child for appendicitis

Answer 9

obtuator sign
psoas sign
rebound tenderness

Question 10

Best LR- child for appendicitis

Answer 10

guarding
anorexia
vomiting

Question 11

Psoas sign

Answer 11

Increased abdominal pain with patient lying on left side while provider passively extends the patient’s
right leg at the hip with both knees extended

Question 12

DDX appendicits peds pt sp: 3

Answer 12

mesenteric lymphadenitis
HSP
meckel diverticulum

Question 13

Studies of lab tests in appendicitis: normal values of WBC and CRP combined resulted in a NPV of ?%

Answer 13

88

Question 14

Alvarado score for diagnosing appendicitis: adds up to 10 - componenets?

Answer 14

migration of pain -1
anorexia -1
n/v -1
rlq pain -1
rlq tenderness 2
rebound pain 1
temp >37.7 -1
leuks >/10 -2
PMN >/=72% -1

high risk score >/=7 adults.= 87% percent prob, child 67%

Question 15

Pediatric appendicitis score, adds up to 12 - components?

Answer 15

migration of pain -1
anorexia -1
n/v-1
rlq tenderness -1
rlq pain with cough/hop,percuss -2
temp >/=28 -1
leukks >/=10 -1
PMN >/=75% -1

high risk child >/=8 - 80% risk

Question 16

Appendicitis inflammatory response score - up to 12, hgih risk >90 gives adults 89% risk - components?

Answer 16

all 1 pt unless noted:
vomit
Right iliac fossa pain
rebound pain light ,med 2, strong 3
temp >/=38.5
leuks >/=10-14.9
leuks >/=15 -2
PMN 70-84%, ?=85% -2
CRP 10-49 vs >/=50 2

Question 17

Ultrasound dx of appendicits

Answer 17

appendiceal diameter >/=6-7mm and noncompressible
with fat stranding and peritoneal fluid

Question 18

CT dx of appendicits

Answer 18

Not all criteria listed below need to be fulfilled, but the combination and severity of these findings contribute to a diagnosis:
appendiceal diameter >6mm with surroudning inflamm or 8mm without changes; appendical circumferential wall thickening >3mm with mural enhancement

calcified appendicolth
signs of inflamm: fat strand

Question 19

?

Answer 19

considered the test of choice for definitive assessment for possible appendicitis in nonpregnant patients.

Question 20

A CT of the abdomen exposes the patient to an average dose of _ mSv of ionizing radiation

Answer 20

8

Question 21

Nonpregnant pt vs pregnant imaging choices cascade per Rosen’s

Answer 21

Non: 1. u/s then if neg/nondiasnostic: ct with contast

pregn: u/s then if unclear MRI

Question 22

Management of appendicitis

Answer 22

1. NPO
2. IVF
3. anti nausea
4. abx start
5. consult surgery

Question 23

Antibiotic options for acute, uncomplicated appendicits: 3

Answer 23

• Ertapenem 1g (adult) IV daily or 15 mg/kg (child, to max of 1g/day) IV twice daily,
• Piperacillin-tazobactam 3.375 g (adult) or 60–75 mg/kg of pipera- cillin (child, to max 3 g dose) IV every 6 hours, OR
  Ceftriaxone 1 g (adult) or 50–75 mg/kg (child, to max of 1 g) IV daily PLUS metronidazole 500 mg (adult) IV or 10 mg/kg (child, to max of 500 mg/dose) IV every 8 hours.

Question 24

Antibiotic options for patients with systemic illness, immunosuppressed or advanced age:

Answer 24

imipenem-cilastatin, meropenem, doripe- nem, piperacillin-tazobactam, or metronidazole PLUS cefepime.

Question 25

Complicated appendicitis defn

Answer 25

with gangrene, phlegmon, abscess or perf

Question 26

Name 5 complications of appendicitis

Answer 26

(organ space infection, deep incisional infection, wound disruption, urinary tract infection, pneumonia, unplanned intubation, venous thromboembolism, acute renal insufficiency, septic shock, myocardial infarction, or cardiac arrest

Question 27

Best known RF for conservative treatment failure is presence of ?

Answer 27

fecalith/appendicolith

Question 28

Nonoperative management - RF pt need to be aware of ? and what should they have over 40

Answer 28

1-2% assoc malignancy
over 40y

Question 29

Preferred tx approach in pregnancy with appendicitis?

Answer 29

operative

Question 30

Management of complicated appendicits?

Answer 30

surgical

Question 31

Previously, NOM required multiday hospitalization, however, recent research has demonstrated the potential for outpatient manage- ment. A small study determined that discharge from the ED was possi- ble for patients meeting the following criteria:

what are they?

Answer 31

• Age 14 years or older
• Systolic blood pressure > 90 mm Hg
• Heart rate < 100 beats per minute
• Temperature < 38.5°C
• Pain controlled by oral analgesics
• Tolerating oral fluids and medication
• Able to return for further evaluation
• Treating physician comfortable with discharge * Patient comfortable with discharge

Not really used so idk

Question 32

1. What percentage of women with acute appendicitis have accompa- nying cervical motion tenderness (CMT)?
   a. <5%
   b. 15%
   c. 25%
   d. 50%
   e. 75%

Answer 32

c

Question 33

2. Which of the following statements regarding ultrasonographic visualization of the appendix is true?
   a. A compressible appendix is a positive finding.
   b. An appendiceal diameter greater than 6 or 7 mm is a positive
   finding.
   c. The sensitivity of ultrasound for appendicitis is 94% to 98%.
   d. Ultrasonography has good reliability for detecting a retrocecal
   appendix.
   e. Ultrasonography compares favorably with computed tomogra-
   phy (CT) scanning for the detection of appendicitis.

Answer 33

b

Question 34

. A 27-year-old G3P2 woman at 22 weeks of gestation presents with 2 days of right lower quadrant (RLQ) abdominal pain. It began mid- line and later became more pronounced in the RLQ. The physical examination is remarkable for RLQ tenderness without rebound. The gynecologic examination is negative except for a nontender gravid uterus, with good fetal movement by transabdominal ultrasound. Urinalysis shows 8 to 10 white blood cells (WBCs) high-power field (HPF) and occasional bacteria. Complete blood count (CBC) shows a WBC count of 12,700/mm3 with 77% neutro- phils. Hemoglobin level is 11 g/dL. RLQ ultrasound examination is limited, without visualization of the appendix or secondary signs of appendicitis. Transvaginal ultrasound does not show a gynecologic or obstetric problem. Repeat examination shows continued RLQ tenderness. What is the most appropriate intervention at this point? a. Administer cephalexin for urinary tract infection and schedule a
48-hour clinic recheck
b. Admit for observation and serial examination
c. Obtain surgical consultation for laparotomy
d. Order a CT scan of the abdomen.
e. Order a magnetic resonance imaging (MRI) scan

Answer 34

e

Question 35

4. In young patients with classic symptoms and signs of appendicitis, what is the most appropriate initial intervention?
   a. Antibiotics and serial abdominal examinations
   b. CT scan of the abdomen
   c. MRI scan of the abdomen
   d. Surgery
   e. Ultrasonography

Answer 35

e