Acute Abdomen/ Appendicitis

Question 0

Visceral pain

Answer 0

From the internal organs and the visceral peritoneum. Transmitted by C sympathetic nerve fibers.
Best respond to stretching.

Question 1

Somatic pain

Answer 1

From the abdominal wall or the parietal peritoneum. Transmitted by both A and C nerve fibers.

Question 2

RUQ pain

Answer 2

Liver and Gall bladder disease (Cholecystitis**, etc)
Perforated duodenal ulcer
Retrocecal appendicitis
RLL pneumonia
Regional enteritis
MI**

Question 3

LUQ pain

Answer 3

Gastritis**
Acute pancreatitis
Splenic enlargement, rupture, infection
LLL pneumonia
Regional enteritis
MI**

Question 4

RLQ pain

Answer 4

Appendicitis**
Regional enteritis
Meckel's diverticulum
Cecal diverticulosis
Leaking aortic aneurysm
Ruptured ectopic pregnancy
Twisted ovarian cyst
PID
Endometriosis
Ureteral calculus
Inguinal hernia

Question 5

LLQ pain

Answer 5

Sigmoid diverticulosis**
Ruptured ectopic pregnancy
Twisted ovarian cyst
PID
Endometriosis
Ureteral calculus
Incarcerated inguinal hernia
Regional enteritis
Anterior rupture of aortic aneurysm

Question 6

Generalized abdo pain

Answer 6

Perforation- Trauma, PUD, Appendicitis, Foreign body puncture of bowel
Obstruction
Ruptured cyst or abscess
Dissecting aortic aneurysm

Question 7

Various positions of appendix

Answer 7

Retrocecal 74%
Pelvic 21%
Paracaecal 2%
Subcaecal 1.5%
Preileal 1%
Postileal 0.5%

Question 8

Appendicitis path

Answer 8

1: Impacted fecal material (Fecolith)
2: Hyperplasia of the submucosal lymphoid follicles

Question 9

Suppurative appendicitis

Answer 9

Transmural spread of bacteria.
The inflamed serosa comes in contact with the parietal peritoneum, causing classic shift of pain to the right lower quadrant.

Question 10

Gangrenous appendicitis

Answer 10

Increased intramural pressure leads to arterial compromise resulting in venous arterial thrombosis.
Mostly occurs at the anti-mesenteric border.

Question 11

Perforated appendicitis

Answer 11

Persisting tissue ischemia results in appendiceal infarction and perforation.
Risk factors- Extremes of age, Immuno-suppression (DM), Pelvic appendix, Previous abdominal surgery.

Question 12

History of appendicitis

Answer 12

Tenesmus (Urge to pass stool), Obstipation or Diarrhea, UTI like presentation.
The migration of pain is the most discriminating historical feature
Anorexia-> Pain-> Vomiting

Question 13

Appendicitis- lab

Answer 13

Leukocytosis (>10,000/mm3)
Neutrophilia (95%)
Urine test may be performed to exclude urinary tract infection as the cause
Barium enema (*Complete filling of appendix excludes appendicitis)
Plain radiograph (Visualization of appendicolith is highly suggestive)
CT- more accurate than U/S- better for abscess and phlegm identification.

Question 14

Appendicitis-Tx

Answer 14

Appendicectomy!!

• open (McBurney or Rocky Davis incision [skin crease transverse incision])
• laproscopic

Question 15

Management of pts with appendicular mass

Answer 15

DO NOT OPERATE- UK, Europe, Some centers in US
-follow Oschener-Sherren regimen- (charting, diet, IV, antibiotics, rest)
Mass and sx usually resolve within 1-2 weeks
Conduct interval appendicectomy after 6 weeks

Question 16

Criteria for stopping conservative tx and go for surgery

Answer 16

• a rising pulse rate
• increasing or spreading abdominal pain
• increasing size of mass
• vomiting or copious gastric aspirate

Question 17

Infants

Answer 17

Perforation is common

Peritonitis is severe due to underdeveloped greater omentum

Question 18

Children

Answer 18

Gastroenteritis, UTI- most common

Question 19

Women of childbearing age

Answer 19

Most common misdiagnosis is PID