79. Acute Appendicitis Flashcards
What is the appendix?
blind ended tube coming from the cecum, 3cm from ileocecal valve
Average diameter of the appendix
6-11mm
average thickenss of 1.5mm
Where does appendix nerves enter SC?
T10
How does appendicitis occur?
- obstruction of appendicieal lumen –>mucous production and bacterial stasis
- eventually pain turns to loss of blood flow –> tissue ishcemi and inflamm
- can allow bacteriia to invade the wall, typically why RLQ pain
- if cont: can become necrotic and perforate
MC cause of obstruction in nonperforated appendicits
fecaliths
then appendicoliths (cal)
lymphoid hyperplasia
Tip vs stump appendicits
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)
Best LR+ adult for appendicitis
RLQ pain
rebound tenderness
rigidity
migration/periumbilical pain
Best LR- adult for appendicitis
RLQ
guarding
rebound tenderness
Best LR+ child for appendicitis
obtuator sign
psoas sign
rebound tenderness
Best LR- child for appendicitis
guarding
anorexia
vomiting
Psoas sign
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
DDX appendicits peds pt sp: 3
mesenteric lymphadenitis
HSP
meckel diverticulum
Studies of lab tests in appendicitis: normal values of WBC and CRP combined resulted in a NPV of ?%
88
Alvarado score for diagnosing appendicitis: adds up to 10 - componenets?
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%
Pediatric appendicitis score, adds up to 12 - components?
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
Appendicitis inflammatory response score - up to 12, hgih risk >90 gives adults 89% risk - components?
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
Ultrasound dx of appendicits
appendiceal diameter >/=6-7mm and noncompressible
with fat stranding and peritoneal fluid
CT dx of appendicits
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
?
considered the test of choice for definitive assessment for possible appendicitis in nonpregnant patients.
A CT of the abdomen exposes the patient to an average dose of _ mSv of ionizing radiation
8
Nonpregnant pt vs pregnant imaging choices cascade per Rosen’s
Non: 1. u/s then if neg/nondiasnostic: ct with contast
pregn: u/s then if unclear MRI
Management of appendicitis
- NPO
- IVF
- anti nausea
- abx start
- consult surgery
Antibiotic options for acute, uncomplicated appendicits: 3
- 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.
Antibiotic options for patients with systemic illness, immunosuppressed or advanced age:
imipenem-cilastatin, meropenem, doripe- nem, piperacillin-tazobactam, or metronidazole PLUS cefepime.
Complicated appendicitis defn
with gangrene, phlegmon, abscess or perf
Name 5 complications of appendicitis
(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
Best known RF for conservative treatment failure is presence of ?
fecalith/appendicolith
Nonoperative management - RF pt need to be aware of ? and what should they have over 40
1-2% assoc malignancy
over 40y
Preferred tx approach in pregnancy with appendicitis?
operative
Management of complicated appendicits?
surgical
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?
- 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
- What percentage of women with acute appendicitis have accompa- nying cervical motion tenderness (CMT)?
a. <5%
b. 15%
c. 25%
d. 50%
e. 75%
c
- 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.
b
. 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
e
- 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
e
Appendicitis: age mc
<30
appendix ___ role
immunologic
Anatomy originates from
cecum
appendix size
8-10cm
mc retrocecal, vs pelvic vs other
why does appendicitis occur?
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
progression of pain why?
initial periumbilical pain at lumen
then ruq from bacterial translation
Appendicitis special tests - sn vs sp
sp
not sn
Top 3 LR + for appendicitis
rlq pain
rigid
migration/periumb pain
kids: obtur and psoas
DDX appendicitis
gastroenteritis
sbo
ibd
ovarian torsion
testicular torsion
pid
epididymitis
mesenteric lymphadenitis
HSP
intestinal perforation
Best imaging for appendicitis sn vs sp
ct 90-100 (sn and sp)
u/s sn75-90,sp 85-95
+ CT findings for appy
diameter >6mm
wall thcikness >2mm
appendicolith
fat stranding
peri-appendiceal fluid or abscess
+ u/s for appy
diameter >6mm
noncompressive
fat stranding
peri appendiceal fluid
Alvarado score low vs mod vs high risk
<4
4-6
>6
components of pARC - peds appendicits risk calculator
settine: comm vs ped ed
sex
duration of pain
wbc
neutrophil
pain with walking
maximal rlq
abdo guard
hx migration pain to RLQ
When can you manage appendicitis conservatively:
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
Non op abx choices for appys
ceftr 2g + flagyl 500 q8h OR levo 750 with metro as above
or oral
cefdinir + metro
cipro or levo
amox clav
Disadv of conservative management appy
10-20% fail 30d
30-40% recur 1y
40-50% recur at 5y
small risk of missed neoplasm in olrder pt
SAGES recommendation for surgery vs. conservative
surgery
When to abx in appy
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)
