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

Question 36

Appendicitis: age mc

Answer 36

<30

Question 37

appendix ___ role

Answer 37

immunologic

Question 38

Anatomy originates from

Answer 38

cecum

Question 39

appendix size

Answer 39

8-10cm mc retrocecal, vs pelvic vs other

Question 40

why does appendicitis occur?

Answer 40

lumen ostructed with trapped bacteria and mucous luminal distension from trapped space, ongoing production of mucous,bbacteria incr pressure --> perfusion impaired --> ischemic ischemia - bacteria transmural migration and resultant infllammation progression can result in necrosis and perforation

Question 41

progression of pain why?

Answer 41

initial periumbilical pain at lumen then ruq from bacterial translation

Question 42

Appendicitis special tests - sn vs sp

Answer 42

sp not sn

Question 43

Top 3 LR + for appendicitis

Answer 43

rlq pain rigid migration/periumb pain kids: obtur and psoas

Question 44

DDX appendicitis

Answer 44

gastroenteritis sbo ibd ovarian torsion testicular torsion pid epididymitis mesenteric lymphadenitis HSP intestinal perforation

Question 45

Best imaging for appendicitis sn vs sp

Answer 45

ct 90-100 (sn and sp) u/s sn75-90,sp 85-95

Question 46

+ CT findings for appy

Answer 46

diameter >6mm wall thcikness >2mm appendicolith fat stranding peri-appendiceal fluid or abscess

Question 47

+ u/s for appy

Answer 47

diameter >6mm noncompressive fat stranding peri appendiceal fluid

Question 48

Alvarado score low vs mod vs high risk

Answer 48

<4 4-6 >6

Question 49

components of pARC - peds appendicits risk calculator

Answer 49

settine: comm vs ped ed sex duration of pain wbc neutrophil pain with walking maximal rlq abdo guard hx migration pain to RLQ

Question 50

When can you manage appendicitis conservatively:

Answer 50

no peritonitis no HD instable no severe sepsis no pregnancy no immunosuppression no hx IBD adv and disadv discussed no appendicolith observe abx 1-3d hsop or ED if improve home 7-10d

Question 51

Non op abx choices for appys

Answer 51

ceftr 2g + flagyl 500 q8h OR levo 750 with metro as above or oral cefdinir + metro cipro or levo amox clav

Question 52

Disadv of conservative management appy

Answer 52

10-20% fail 30d 30-40% recur 1y 40-50% recur at 5y small risk of missed neoplasm in olrder pt

Question 53

SAGES recommendation for surgery vs. conservative

Answer 53

surgery

Question 54

When to abx in appy

Answer 54

nonperf appy, stable pt performed in 24h unlikely to add complications abx 60min pre initial incision (ancef and flagyl, cefotetan) if at night and am OR planned, start IV abx (piptazo, cefotaxime or ceftriaxone or cipro or levo with metronidazole)