APPENDICITIS

Question 1

(a) Most common abdominal surgical emergency.
(b) Most common between the ages of 10 to 30.
(c) Both sexes and all ages can be effected.

Answer 1

APPENDICITIS

Question 2

Pertinent Anatomy of a patient with Appendicitis.

Answer 2

(1) Appendix
(2) Ileum
(3) Cecum
(4) RLQ
(5) McBurney’s Point
(6) Periumbilical abdomen
(7) Epigastric abdomen

Question 3

Whats the function of the appendix

Answer 3

The function of the appendix is unknown. Believed to store normal flora- bacteria.

Question 4

Whats the pathway of appendicitis

Answer 4

It begins by obstruction of the appendix. Obstruction leads to inflammation, rising
intraluminal pressures, and ultimately ischemia.

Question 5

Causes of obstruction (of the appendix) may include:

Answer 5

(a) Fecalith (most common)
(b) Inflammation
(c) Foreign body
(d) Neoplasm

Question 6

Symptoms of a patient with Appendicitis.

Answer 6

(1) Initial onset of vague/colicky periumbilical or epigastric pain.
(2) Pain shifts to RLQ within 12 hours and becomes a steady ache that is made worse withwalking or coughing.
(3) Generalized tenderness which progresses to localized tenderness when pain shifts to RLQ (McBurney’s point). Typically, patients will have localized pain to the RLQ at the time of presentation.
(4) Localized pain when asked to cough
(5) Positive psoas and / or obturator signs
(6) Positive rebound with guarding
(7) Decreased to absent bowel sounds
(8) Possible rectal tenderness along right margin

Question 7

Associated symptoms of a patient with Appendicitis include

Answer 7

(a) Nausea with 1-2 episodes of vomiting (majority of patients).
(b) Anorexia (decreased appetite)
(c) Usually constipated (occasional diarrhea)
(d) Low grade fever

Question 8

Atypical symptoms of a patient with Appendicitis include

Answer 8

(a) Pain and tenderness in the right flank
(b) Urge to defecate and/or urinate associated with lower abdominal pain, often on the left (Pelvic Appendicitis)
(c) No abdominal tenderness

Question 9

Differential Diagnosis

(1) Most common

Answer 9

(a) Viral gastroenteritis
(b) Constipation
(c) Bowel obstruction
(d) GYN disorders

Question 10

Differential Diagnosis

(2) Less Common

Answer 10

(a) Pyelonephritis
(b) Renal colic
(c) Crohn’s disease
(d) Diverticulitis
(e) Cholecystitis

Question 11

Lab

Answer 11

(1) CBC/DIFF: Moderate leukocytosis (10-20K) and neutrophilia is common.
(2) Routine/micro UA: May see hematuria and pyuria on micro

Question 12

Treatment

Answer 12

(1) Broad spectrum IV antibiotics with gram- negative and anaerobic coverage. Options include:
(a) Ampicillin-sulfabactam (Unasyn) 3g IV every 6 hours
(b) Ertapenem (Invanz) 1g as a single dose (Relative Contraindication in patients
with a history of seizures)
(c) Metronidazole (Flagyl) 500mg IV every 6 hours AND ciprofloxacin (Cipro)
400mg IV every 12 hours OR levofloxacin (Levaquin) 750mg IV every 24 hours.
(2) IV Access (fluid bolus if patient has evidence of hypovolemia).
(3) Pain Control: NSAIDs, Tylenol or morphine acceptable.
(4) NPO (Sips with meds okay)
(5) Monitor I&O, maintain urine output of 1000 ml/day
(6) PROPAQ monitor

Question 13

Initial Care

Answer 13

(1) The treatment goal for appendicitis is ABD surgery and prevention of further infection.
(2) Delay in treatment could lead to gangrene and perforation (within 36 hours) with a potential onset of peritonitis.

Question 14

Complications

Answer 14

(1) Perforation: May present as a sudden increase in pain followed by temporary relief of pain.
(2) Sepsis
(3) Peritonitis
(4) Death (low mortality rate, 1%)

Question 15

Disposition

Answer 15

(1) MEDEVAC

(2) Refer to surgery for appendectomy