Appendicitis and Diverticular Disease Flashcards
Appendicitis is _____
the inflammation of the inner lining of the vermiform appendix, with the potential to spread or rupture
Appendicitis pathophysiology
● The best explanation is obstruction of the lumen of the appendix. This can be
due to inflammation from infection, fibrosis, fecaliths, or neoplasia blocking the
lumen.
● Blockage leads to increased pressure in the appendix, occlusion of small vessels,
and stasis of lymphatic flow. The wall then becomes ischemic and necrotic
● Intestinal bacterial overgrowth can then occur
Appendicitis S/S
● The initial symptom is most commonly
periumbilical pain that later migrates to RLQ
● Most common symptoms:
○ RLQ Abdominal pain (most common)
○ Nausea +/- vomiting (61-92%)
○ Anorexia (75%)
Appendicitis diagnosis
● Labs often reveal (but not specific) Leukocytosis (neutrophilia)
● CT scan with contrast is the most specific test for appendicitis.
● Ultrasound is the recommended and safer
diagnostic tool for children and pregnant women.
Appendicitis management
● IV fluids should be started, especially if signs of dehydration or sepsis.
● Keep Pt NPO and consult General Surgery.
● Analgesics and antiemetics are indicated PRN.
● Appendectomy remains the only curative
treatment of acute appendicitis at this time.
○ Open (less common) or Laparoscopic
● IV antibiotics should be administered before and after surgery (usually Cephalosporin).
indication for Non-surgical Management for Appendicitis
Localized appendicitis without findings of diffuse peritonitis, hemodynamically instability, or imaging evidence of large abscess,
perforation, or tumor.
Non-surgical Management of appendicitis
○ Most protocols involve initial intravenous antibiotics for one to three days, followed by oral antibiotics for a total of 7 to 10 days.
○ The initial IV antibiotics can potentially be given in the ER, with oral antibiotics given outpatient with close clinic follow-up
○ Fluoroquinolone (Cipro or levo) or second/third-generation cephalosporin
(like Rocephin) +
○ Metronidazole or Augmentin
Laparascopic Appendectomy
● Laparoscopic Appendectomy has been performed hundreds of thousands of
times since first introduced in 1987.
● It is successful in 90-94% of cases.
○ 6-10% are converted to an open
procedure secondary to rupture or
unusual anatomy making laparoscopic
approach difficult
T/F Laparoscopic appendectomy is also safe in pregnancy.
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Advantages and disadvantages to an appendectomy
● Advantages of laparoscopic technique over open technique include cosmetic satisfaction and decrease in rate of post-op wound infection.
● Disadvantages of laparoscopic technique include increased cost of surgery and increased operating time by about 20 minutes over open
appendectomy
Colonic Diverticulosis
Diverticula are small sac-like protrusions or outpouchings
through the wall of the intestine.
● Colonic Diverticulosis is the presence of diverticula
Epidemiology of Colonic Diverticulosis
● Incidence increases with age, and is found in around 60% of people by age 60
● Areas that have adopted a more “Western” lifestyle have a higher incidence of diverticulosis
● In western countries, it more likely left-sided, while in Asia, it
is predominantly right-sided
Diverticulosis pathogenesis
● Diverticula occur at weak spots in the colon wall, where capillaries (vasa recta) penetrate the circular muscular layer.
● They are most often acquired (pulsion) diverticula in the left colon. The
hypothesized cause is abnormal colonic motility, with exaggerated segmentation contractions
● This causes higher intraluminal pressure,
potentially leading to herniation of the
mucosa/submucosa through the intestinal wall
Diverticulosis risk factors
● Older age is the biggest risk factor. The number and size also increases with age
● Male gender, smoking, and elevated BMI increase risk.
Diverticulosis presentation
● In most cases, diverticulosis is uncomplicated and asymptomatic, often
discovered incidentally during colonoscopy
● Most are found in the sigmoid colon (over 70%), with the rest occurring in the
descending, transverse, and ascending colon. They are rarely in the cecum.
Up to 10% of patients with diverticulosis develop _____
diverticular bleeding
Treatment for Diverticulosis
Aimed at reducing risk of complications
● Decrease the risk of diverticulitis: Smoking cessation, weight management,
increased physical activity, and decreased red meat, fat, and refined grains
_____ is the most common cause of acute lower
GI bleeding and occurs more commonly in the right colon.
Diverticular bleeding
Diverticular Bleeding pathogenesis and risk factors
Pathogenesis - Over time, the capillaries (vasa recta) associated with a
diverticulum become more prominent and exposed. Bleeding occurs when there
is rupture of those vessels.
Risk factors - Chronic use of NSAIDs, Aspirin,
and antiplatelet meds, and Hypertension.
Diverticular Bleeding symptoms
- Painless, often large volume, hematochezia.
The blood is usually maroon colored or bright red, depending
on the location of the diverticulum
Diverticular bleeding diagnosis
Colonoscopy is preferred. If unstable, CT Angio can be performed
Diverticular Bleeding treatment
Often, the bleeding itself is self-limited. Regardless, most patients will
require hospitalization for fluid/blood resuscitation.
● If active bleeding is still noted during colonoscopy (up to ⅓ of patients), then
clipping, banding, or electrical cautery can be performed at that time.
Recurrence is common in both the short and long term.
Diverticulitis
Diverticulitis is inflammation of one or more adjacent colonic diverticula.
Diverticulitis risk factors
● Lifestyle: Obesity, low physical activity, smoking, diets
high in red meat, fats, and refined grains, and diets low in
fruits, veggies, and dietary fiber.
● Others: Immunosuppression, NSAIDs, genetics
● Incidence increases with age. It most commonly occurs after age 60, but can
occur in younger patients as well.
