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Clinical Medicine II Exam 3 GI > Appendicitis > Flashcards

Appendicitis Flashcards

1
Q

Dependents is true diverticulum of what structure?

A

Cecum

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2
Q

The appendix contains what layers of the cecum?

A

All layers: mucosa, submucosa, muscularis and serosal covering

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3
Q

Where is the appendix located and where does it open into?

A

Located at the base of cecum, near ileocecal valve, opens into cecum

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4
Q

How is blood supplied to the appendix?

A

Appendiceal artery

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5
Q

Which part of the appendix is constant, and which part can migrate?

A

Attachment at base of cecum is constant, tip of appendix may migrate (retrocecal, subcecal, etc.)

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6
Q

At what age does appendicitis usually occur?

A

Most common in 2nd to 3rd decade of life, highest incidence 10 to 19 years of age

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7
Q

What age has the lowest incidence of appendicitis?

A

Less than nine years of age

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8
Q

What percent of the population will have appendicitis?

A

7 to 12%

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9
Q

Do males or females more commonly experience appendicitis?

A

Males more often than females

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10
Q

What is the most common indication for abdominal surgery in childhood?

A

Appendicitis

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11
Q

What is the most common indication for emergency abdominal surgery?

A

Appendicitis

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12
Q

What is the pathophysiology of appendicitis?

A

Similar to that of other inflammatory process is involving hollow visceral organs
Information of the appendiceal wall followed by :
Localized ischemia, perforation, development of contained abscess or generalized peritonitis

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13
Q

What is the primary cause of appendicitis?

A

Obstruction

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14
Q

How many patients with non-perforated appendicitis have obstruction identified?

A

1/3 of patients

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15
Q

Causes of obstruction leading to appendicitis?

A

1 Fecaliths (six times more common than calculi, but easily crushed)
2 Calculi (more often associated with perforation and abscess)
3 Lymphoid hyperplasia
4 Infectious causes
5 Benign or malignant tumors

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16
Q

What does obstruction of the appendix lead to?

A

Lumen becoming filled with mucus that distends the appendix, and increases Luminal and intramural pressure
This results in thrombosis inclusion of the small vessels in the appendiceal wall and status of lymphatic flow
Lymphatic and vascular compromise progresses, causing appendix to become ischemic and necrotic, and bacterial overgrowth occurs

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17
Q

What kind of luminal obstruction are young patients more likely to have?

A

Lymphoid follicular hyperplasia due to infection

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18
Q

What luminal obstruction is almost likely to occur in older patients?

A

Fibrosis, fecaliths, or neoplasm (carcinoid, adenocarcinoma, or mucocele)

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19
Q

What is the infection pathophysiology of appendicitis?

A

Aerobic organisms predominate early in the course, mixed infection more common late in the course

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20
Q

What are the common organisms in gangrenous and perforated appendix?

A

E. coli, Peptostreptococcus, Bacteroides fragilis, Pseudomonas

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21
Q

Risk factors for appendicitis?

A

Male sex, age, economic status, diet, genetics, season (summer MC), breast-feeding (diminishes risk)

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22
Q

Early symptoms of appendicitis are often subtle and vary depending on what?

A

Location of the tip of the appendix

23
Q

What is the most common symptoms of appendicitis?

A

Abdominal pain (50 to 60% has pain that starts and periumbilical area in migrates to the RLQ)

24
Q

Classic symptoms of appendicitis?

A

RLQ pain, anorexia, nausea and vomiting, fever occurs late

25
Q

Atypical presentation found in many patients with appendicitis?

A

Indigestion, flatulence, bowel irregularity, diarrhea, general malaise

26
Q

Clinical presentation of appendicitis in children?

A

Anorexia, periumbilical pain (early), migration of pain to RLQ (often within 24 hours of onset), pain with movement (such as walking or shifting position), vomiting (typically after onset of paint), fever (commonly 24 to 48 hours after onset), RLQ tenderness

27
Q

What is the clinical presentation of appendicitis in pregnant patients?

A

May have classic presentation
Or diarrhea, heartburn, malaise
* Less likely to have classic presentation than non-pregnant woman

28
Q

Why may physical exam for appendicitis be unrevealing in early stages?

A

Because visceral organs are not innervated with somatic pain fibers

29
Q

Physical exam regarding fever for appendicitis?

A

Low grade to 101°F early on that increases as inflammation progress

30
Q

Physical exam for tenderness with appendicitis?

A

Tenderness in right lower quadrant as inflammation progresses, due to involvement of overlying parietal peritoneum

31
Q

Rectal exam for appendicitis?

A

Positive with a retrocecal appendix

32
Q

What might a pelvic exam in females show if the patient has appendicitis?

A

Right adnexal area tenderness (adds to Ddx)

33
Q

Where is McBurney’s point?

A

2/3 of the way from umbilicus to ASIS

34
Q

What is Rovsing’s sign?

A

Pain elicited to the right lower quadrant when the left lower quadrant is palpated, indicative of acute appendicitis

35
Q

What is the psoas sign?

A

Right lower quadrant pain produced with extension of the hip due to inflammation of the peritoneum overlying the psoas muscle, and inflammation of the psoas muscles themselves

36
Q

What is the obturator sign?

A

Pain on passive internal rotation of the flexed thigh

37
Q

What is rebound tenderness?

A

Brief worsening of pain after releasing pressure while palpating, indicates possible peritonitis or ruptured appendix

38
Q

What is guarding?

A

When the abdominal muscles tense up during palpation, indicative of peritonitis or ruptured appendix

39
Q

Differential diagnosis for appendicitis sx of both male and females?

A

Appendicitis, perforated appendix, cecal diverticulitis, Meckel’s diverticulitis, acute ileitis, Crohn’s disease, torsion of the appendix testis or appendix epididymis, renal colic

40
Q

Differential diagnosis of appendicitis symptoms for males only?

A

Testicular torsion and epididymis

41
Q

Differential diagnosis for appendicitis symptoms for females only?

A

Tubo-ovarian abscess, pelvic inflammatory disease, ruptured ovarian cyst, Mittlezchmertz pain, ovarian and fallopian tube torsion, endometriosis, ovarian hyperstimulation syndrome (OHSS), ectopic pregnancy

42
Q

Labs for appendicitis work up?

A

CBC, CMP

43
Q

Expected findings for CBC with appendicitis?

A

Leukocytosis, 80% confirmed cases have increased white blood cells, bands and neutrophils
*WBC HIGHER, IF GANGRENE/PERF

44
Q

CMP findings in appendicitis?

A

Elevated bilirubin (total over 1 mg/dL) can be a marker for perforation, sensitivity 70% specificity 86%
not discriminatory: generally unhelpful
* Perforation may have significant dehydration/electrolyte abnormalities

45
Q

Which diagnostic imaging is preferred for appendicitis due to accuracy and lowest rates of non-diagnosis?

A

CT of abdomen and pelvis
-Can use low-dose radiation, contrast better
* also helps for planning

46
Q

What can you see on a CT of the abdomen and pelvis in appendicitis?

A

Enlarged double wall thickness greater than 6 mm
Wall thickening greater than 2 mm
Fat stranding
Wall enhancement
Appendicolith (minority)

47
Q

When is ultrasound preferred for appendicitis?

A

In children and pregnant women recommended over CT due to no radiation, no contrast, can perform at bedside

48
Q

Downsides to ultrasound for appendicitis?

A

Lower diagnostic accuracy than CT, graded compression of appendix causes pain in acute appendicitis

49
Q

What can be seen an ultrasound for appendicitis?

A

Noncompressible appendix with double wall thickness, diameter of greater than 6 mm
Focal pain over appendix with compression
Appendicolith
Increased echogenicity of inflamed periappendiceal fat
Fluid and right lower quadrant

50
Q

When can MRI be used for appendicitis?

A

Pregnant patients an older children who can cooperate
* recommended over CT for these populations

51
Q

Why is an MRI favorable for pregnant women and older children who can cooperate?

A

No radiation or contrast, good diagnostic accuracy comparable to CT and better than ultrasound

52
Q

Downsides to MRI for appendicitis?

A

Less tolerated due to claustrophobia, if patient is very young, if patient is very old, if there’s metal in the body

53
Q

Complications of appendicitis?

A

Untreated may cause perf, sepsis, chronic appendicitis
Recurrence (need for interval appy)
General surgical complications
Unexpected findings (neoplasm)

Clinical Medicine II Exam 3 GI (14 decks)

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