Appendicitis Flashcards
What is appendicitis?
Inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop with resultant inflammation that can lead to nerosis and perforation
What are the causes of appendicitis?
Lymphoid hyperplasia, fecalith (appendicolith)
Rare: parasite, foreign body, tumor (carcinoid)
Lifetime incidence of acute appendicitis in US?
~7%
What is the classic presentation if appendicitis in chronologic order?
- Periumbilical pain (intermittent and crampy)
- nausea/vomiting
- anorexia
- pain migrates to RLQ (constant/intense pain) usually in <24 hours
Why does the periumbillical pain occur?
It is referred pain
Why does the RLQ pain occur?
Peritoneal irritation
What are the signs/sx of appendicitis?
Signs of peritoneal irritation: guarding, muscle spasm, rebound tenderness, obturator and psoas signs, low-grade fever (high-grade if perforation), RLQ hyperesthesia
What is the obturator sign?
Pain upon internal rotation of the leg with the hip and knee flexed
seen in patients with pelvic appendicitis
What is the psoas sign?
Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance
Seen classically with retrocecal appendicitis
What is Rovsing’s sign?
Palpation or rebound pressure of the LLQ results in pain in the RLQ
What is Valentino’s sign?
RLQ pain/peritonitis from succus draining down to the RLQ from a perforated gastric duodenal ulcer
What is McBurney’s point?
Point one third from the ASIS to the umbilicus (often point of maximal tenderness)
What are some DDx for everyone with possible appendicitis?
Meckel’s diverticulum
Chron’s
perforated ulcer
pancreatitis
mensenteric lymphadenitis
constipation
gastroenteritis
pyelonephritis/UTI
Diverticulitis
What are some Ddx for females with possible appendicitis?
Ovarian cyst
Ovarian torsion
Tuboovarian abscess
mittlelschmerz
PID
ectopic/ruptured PG
What labs should be performed with possible appendicitis?
CBC: increase WBC (usually >10,000 and with left shift)
UA to evaluate for Pyelo/renal calculus
Can you have an abnormal UA with appendicitis?
Yes!
Mild hematuria and pyuria are common if there is pelvic inflammation with the appendicitis leading to ureter inflammtion
What diagnostic tests can be performed if the diagnosis is not clear?
Spiral CT
U/S (may see large, noncompressible appedix or fecalith)
AXR
What classically precedes vomiting in appendicitis?
Pain
(in gastroenteritis- the pain usually FOLLOWS vomiting)
What radiographic studies are often performed with appendicitis?
CXR: to rule out RML or RLL pneumonia and free air
AXR: usually non-specific, but calcified fecalith in about 5% of cases
What are radiographic signs of appendicitis on AXR?
Fecalith
Sentinel loops
Scoliosis away from the right because of pain
Mass effect (abscess)
Loss of psoas shadow
Loss of preperitoneal fat stripe
rarely: free air if perforation
___% of cases a radiopaque fecalith will be on a ABX with appendicitis?
~5%
What are the preoperative meds/preps for appendicitis?
Rehydration with IV fluids (lactated ringers)
Preoperative antibiotics with anaerobic coverage
What is a lap appy?
Laparoscopic appendectomy: used in most cases in women (can see adnexa) or if patinet has a need to quickly return to physical activity, or is obese
Tx for non-perforated acute appendicitis?
Prompt appendectomy (to prevent perforation), 24 hours of antibiotics, discharge home usually on POD #1
What is the tx for perforated acute appendicitis?
IV fluid resusitation and prompt appendectomy
All pus is drained with postoperative antibiotics contimued for 3-7 days
Wound if left open in most cases after closing the fascia (heals secondary intentionor delayed primary closure)
How is an appendiceal abscess that is diagnosed preoperatively tx?
Percutaneous drainage of the abscess
Antibiotic admin
elective appendectomy ~ 6 weeks later (interval appendectomy)
If a normal appendix is found upon exploration, should you take out the normal appendix?
YES!
How long after removal of NUNRUPTURED appendix should antibiotics continue postoperatively?
24 hours
What antibiotics are used for NONPERFORATED appendictis?
Anaerobic coverage: Cefoxitin®, Cefotetan®, Unasyn®, Cipro®, and Flagyl®
What antibiotics are used for PERFORATED appendicitis?
Broad-spectrum antibiotics (e.g., Amp/Cipro®/Clinda or a penicillin such as Zosyn®)
How long do you give antibiotics for perforated appendicitis?
Until the patient has a normal WBC count and is afebrile, ambulating, and eating a regular diet
Usually 3-7 days
What is the risk of perforation?
~25% by 24 hours from onset of sx
~50% by 36 hours
~75% by 48 hours
Most common general surgical abdominal emergency in PG?
Appendicitis
1/1750
*may present in RUQ due to enlarged uterus
Possible complications of appendicitis?
Pelvic abscess
Liver abscess
Free perforation
Poral pylethrombophlebitis (VERY rare)
__% of the population has a retrocecal, retroperitoneal appendix?
~15%
What % of negative appendecotomies is acceptable?
Up to 20% - better than missing a case of acute appendicitis that can rupture
Who is at risk for dying from acute appendicitis?
Very young and very old patients
What bacteria is associated with “mesenteric adenitis” that can closely mimic acute appendicitis?
Yersinia enterolytica
What is an “incidental appendectomy”?
Removal of a normal appendix during abdominal operation for different procedure
Complications of appendectomy?
SBO
enterocutaneous fistula
wound infection
infertility with perforation in women
increased incidence of inguinal hernia
stump abscess
What is the most common postoperative appendectomy complication?
Wound infection
