Appendicitis/cholecystitis Flashcards
Peritoneum
general
regions and folds
Broad serous membranous sac surrounded by connective tissue that holds the digestive organs within the abdominal cavity in place
Composed of two regions:
Parietal peritoneum: lines the abdominal wall
Visceral peritoneum: envelops the abdominal organs
Five major peritoneal folds:
Greater omentum, lesser omentum, falciform ligament, mesentery, mesocolon
Watery fluid acts as a lubricant to minimize friction between surfaces
Appendix
general
Also referred to as the vermiform appendix or cecal appendix
Finger-like, blind-ended tube extending from the cecum in the right lower quadrant
Appendix
functions
Contains lymphoid tissue and is a primary site for IgA production, which is vital for maintaining homeostasis of the intestinal flora
Rich in biofilms and continuously sheds healthy bacteria into the intestinal lumen
Can be used as a replacement bladder
appendix
Position of the free-end of the appendix is highly variable and can be categorized into seven main locations:
Pre-ileal– anterior to the terminal ileum –1 or 2 o’clock
Post-ileal– posterior to the terminal ileum – 1 or 2 o’clock
Sub-ileal– parallel with the terminal ileum – 3 o’clock
Pelvic– descending over the pelvic brim – 5 o’clock
Subcecal– below the cecum – 6 o’clock
Paracecal– alongside the lateral border of the cecum – 10 o’clock
Retrocecal– behind the cecum – 11 o’clock
Variable location of the appendix causes variations in the clinical presentation, making diagnosis challenging
retrocecal most common
Acute Appendicitis
general
Acute inflammation of the vermiform appendix
One of the most common causes of acute abdominal pain in adults and children
Affects ~6% of the population
Commonly occurs between 10-30 years of age
Most common:
Acute surgical problem in the pediatric population
Non-obstetric surgical emergency during pregnancy
appendicitis
Etiology
Luminal obstruction
Fecalith
Lymphoid hyperplasia
Tumors (benign or malignant)
appendicitis
patho
Obstruction of appendiceal orifice
Mucus accumulation and luminal distention:
Bacterial overgrowth (aerobes andanaerobes):
Escherichia coli
Peptostreptococcus
Pseudomonas
Bacteroides fragilis
Increase in transmural pressure →thrombosisand occlusion of small vessels
Ischemiaandnecrosis(gangrene)
Eventualperforation
Perforation contained by the greater omentum → appendiceal abscess
Perforation into the abdominal cavity → peritonitis
appendicitis
Classic signs
Appear in < 50% of patients
McBurney point tenderness
Psoas sign
Obturator sign
Rovsing sign
appendicitis
classic symptoms
Abdominal pain
Periumbilical pain that later migrates to the RLQ (24 hours)
Localized rigidity
↑ pain with cough or movement
Low-grade fever
Nausea/vomiting
Anorexia → dehydration
appendicitis
McBurney Point
Point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitis
2/3 of the way between umbilicus and ASIS (2/3 down) on right side
appendicitis
psoas sign
An increase in pain caused by passive extension of the right hip joint while applying counter resistance to the right hip (asterisk)
Indicates a retrocecal orientation of the appendix
can also be done by having them attempt to raise right leg against resistance
appendicitis
obturator sign
Pain caused by passive internal rotation of the flexed right thigh
better for more anterior position of appendix
Appendicitis
Rovsing sign
Palpation of the left lower quadrant of the abdomen followed by quick release causes increased pain felt in the right lower quadrant
rebound/ referred tenderness
appendicitis
Clinical Dx
can be made if classic symptoms and signs are present
appendicitis
Labs
Atypical or equivocal findings:
Labs:
Pregnancy test
Perform on all females of reproductive age
CBC
Leukocytosis (12,000-15,000/mcL) with left shift
appendicitis
imaging
Ultrasound - children and pregnant women
Contrast-enhanced CT scan of the abdomen and pelvis unless contraindicated
Laparoscopy
Can be used for diagnosis and definitive treatment of appendicitis
Enlarged appendix with an appendicolith (yellow arrow)
Appendicolith (white arrow) with a large abscess (dashed blue line) containing a foci of air (red arrow)
appendicitis
The Alvarado score is the best studied clinical decision rule in adults and children
Imaging is not required for diagnosis if theAlvarado scoreis very low (< 4) or high (> 7)
Interpretation:
0–4: Appendicitis is less likely
5–6: Appendicitis is possible; imaging evaluation needed
7–8: Appendicitis is probable → surgical consultation
9–10: Appendicitis is highly likely → surgical consultation
Appendicitis
Supportive Tx
NPO
IV fluids
Analgesics: NSAIDs or opioids
Nausea/vomiting control
appendicitis
Abx
30-60 minutes prior to incision
First-generationcephalosporin or fluoroquinolone + anaerobic coverage
cefazolin- metronidazole
ciprofloxacin–metronidazole
appendicitis
Surgical Tx
Open or laparoscopic appendectomy
Open – lower rate of intraabdominal infections
Laparoscopic – lower rate of wound infections
Pericolic abscess formation
Drain the abscess by ultrasound-guided percutaneous catheter or by open operation (with appendectomy to follow)
Acute Cholecystitis
general and types
Inflammation of the gallbladder
♀ > ♂
Peak incidence is 40-50 years
Types:
Calculous - 95%
Gallbladder inflammation as a complication of cholelithiasis (gallbladder)
Acalculous – 5%
Gallbladder inflammation due to gallbladder stasis and ischemia
More common in critically ill and/or immunocompromisedpatients
calc is due to stone. Acalc no stone
cholecystitis
RF (6 F’s)
pregnancy or hormone therapy
older age
natice american/hispanic
obesity:rapid gain or loss
Diabetes
cholecystitis
patho
Cystic duct obstruction leads to bile stasis
Stasis triggers the release of inflammatory enzymes that damage the gallbladder mucosa
Mucosal damage causes more fluid to be secreted into the gallbladder lumen than is absorbed leading to an increase in intraluminal pressure
Increased pressure results in distention which further the release of inflammatory mediators (prostaglandins and lysolecithin)
As inflammation increases, mucosal damage worsens leading to ischemia
cholecystitis
complications
Bacterial classification
Bacterial infection can ensue (gram-negative bacteria: E. coli, Enterococcus, Klebsiella)
Complications: gangrene (20%) and perforation (20%)
cholecystitis
S/Sx
Boas sign
Abdominal pain
Severe, sudden right upper quadrant pain
Often triggered by a fatty meal
Duration > 6 hours
Radiation of pain to the right lower scapula (Boas’ sign)
Nausea/Vomiting (75%)
Fever – low grade
Murphy’s sign
cholecystitis
Murphy’s sign
Develops within 2-3 hours
Deep inspiration exacerbates pain during palpation of the RUQ subcostal region and halts inspiration
cholecystitis
Dx and labs
Acute cholecystitis should be suspected based on signs and symptoms
Labs
Performed, but not diagnostic
CBC: leukocytosis with left shift (12,000-15,000/cmL)
Lipase: > 3x normal suggests common bile duct obstruction
Liver tests:
Elevation ofbilirubinandalkaline phosphataseshould raise suspicion for complications (cholangitis, choledocholithiasis)
Mild elevation ofalanineaminotransferase (ALT) andaspartateaminotransferase (AST)
cholecystitis
imaging
Diagnostics
Ultrasound
Ultrasonographic Murphy’s sign (elicited with USprobepressing on the abdomen)
HIDA
cholecystitis
US findings
Findings:
Gallbladder wall thickening > 4 mm
Gallbladder wall edema
Pericholecystic fluid
Presence of gallstones
Air in the GB wall (indicative ofgangrene)
cholecystitis
Hepatobiliary iminodiacetic acid (HIDA) scan or cholescintigraphy
Performed if the ultrasound is equivocal
4 hour fast prior to the procedure
Uses a radioactive tracer to access the filling of the gallbladder
If the cystic duct is not obstructed, the tracer will be excreted in the bile
cholecystitis
CT scan of abdomen and pelvis
Used to identify extrabiliary abnormalities or complications of acute cholecystitis
best for when suspecting complications
not your “go to study”
Acute cholecystitis on ultrasound. The closed arrow points to gallbladder wall thickening. Open arrow points to stones in the gallbladder.
Acute cholecystitis with the fat stranding around the enlarged gallbladder.
Cholecystitis
Tx
supportive and Abx
Hospital admission
Supportive care
NPO
IV Hydration
Antiemetics
NG tube placed for vomiting or if an ileus is present
Analgesics
NSAIDs (ketorolac) or opioids
Antibiotics
Initiated to treat possible infection
Empiric coverage directed against gram-negative bacteria
Ceftriaxone 1-2 grams IV every 12-24 hours plus metronidazole 500 mg IV every 8 hours- best for pregnant or child
Piperacillin/tazobactam (Zosyn) 3.375-4.5 grams IV every 6 hours
cholecystitis
surgical Tx
Cholecystectomy
Definitive treatment
Early cholecystectomy (within 24-48 hours) is preferred
Approach:
Laparoscopic is thestandard of care(lower risk of infection, shorter hospital stay).
Open surgery: reserved for complicated cases
Chronic cholecystitis
General
Long-standing gallbladder inflammation resulting from gallstones and prior episodes of acute cholecystitis
Gallbladder becomes fibrotic and contracted
Not able to concentrate bile or empty normally
Chronic cholecystitis
S/Sx
Recurrent biliary colic, usually without fever
RUQ pain is often less intense
Chronic cholecystitis
Dx and Tx
Diagnosis
Ultrasound
Treatment:
Laparoscopic cholecystectomy
cholecystitis
Key points
- Acute cholecystitis is most often caused by gallstones (95%)
- In older patients, symptoms of cholecystitis may be nonspecific (malaise, anorexia, vomiting) and fever may be absent
- Diagnosed via ultrasound and, if results are equivocal, by HIDA scan
- Surgery (cholecystectomy) within 24-48 hours of admission (early) is preferable
cholecystitis
First line treatments include (5)
fasting, intravenous fluids, analgesics, antiemetics, and antibiotics
