Appendicitis, Diverticulitis Steiner Flashcards
What is the MC surgical procedure performed on an emergent basis in the western world?
Appendectomy
When is the maximal incidence of appendicitis?
2nd and 3rd decades (teens and 20s)
Which gender is more affected by appendicitis?
- Up to age 25 males are 2:1
- After age 25 incidence is equal
What is the pathophys of appendicitis?
Appendiceal obstruction
What is the MC cause of appendicitis in children?
Submucosal hyperplasia of lymphoid follicles
What is the MC cause of appendicitis in adults?
Fecalith
What are the MC infectious agents of appendicitis?
Anerobes 3x greater (E. coli 80%) than aerobes
What is a retrocecal appendix and how does appendicitis pain present for this?
- Behind cecum or ileum
- Pain is low and only felt locally RLQ (no visceral pain)
- Muscular rigidity of abdomen is less than would be expected
What is a pelvic appendix and how does appendicitis present for this?
- Located lower down in RLQ (pelvis)
- Often overlooked dx bc when it ruptures, visceral pain diminishes and moves, false impression that pt is getting better
Presentation of appendicitis
- Visceral peri-umbilical pain initially
- Anorexia
- Low grade fever
- 25% of pts present with NO prior visceral pain and only localized symptoms
- Often less than 24 hrs from onset of symptoms to pt presentation in clinic
Why do appendicitis pts present with N/V?
As appendiceal distension increases there is venous congestion
Why does appendicitis pain become parietal over some time?
- Inflammation spreads to parietal peritoneum
- Pain becomes well localized to RLQ
What are Cope’s pearls for presentation of appendicitis?
Symptoms present in a “march of events” (occur in order usually):
- Pain (epigastric or periumbilical)
- Anorexia
- Pain and tenderness (RLQ)
- Fever
- Leukocytosis
When does appendicitis pain usually occur?
Middle of the night and may awaken pt out of sleep
When should diagnosis of appendicitis be made?
Before the pt develops leukocytosis
What do some appendicitis pts experience with a BM?
- “Downward urge” = sense that a BM will provide relief
- In reality, it is usually a small amount of stool and flatus with NO relief
Vomiting is less common in which type of appendicitis?
Retrocecal
Which type of appendicitis is more likely to be missed in diagnosis?
Pelvic appendix
What condition does a pelvic appendicitis present more like?
Gastroenteritis
How does pelvic appendicitis present?
- Diffuse pain, vomiting and diarrhea
- Tenderness on DRE
What differentiates ectopic pregnancy from appendicitis?
The classic “march of events” is altered
All females with acute abdominal pain require what?
Pelvic exam
What is the MC non-gynecological surgical emergency during pregnancy?
Appendicitis
When is surgery indicated in a pregnant patient with appendicitis?
As soon as diagnosis is made
Why must surgery be immediate in a pregnant pt w/appendicitis?
Death of fetus can occur with diffuse peritonitis or perforation
How does WBC present in appendicitis?
- Leukocytosis 10,000+ with 75+% neutrophils
- Can be normal in older adults
- Normal pregnancy can result in 15-20,000 WBC
What will cause an increase in neutrophils when evaluating for appendicitis?
Perforation
When is U/S most useful in evaluating appendicitis?
In females of childbearing age
*U/S is very operator dependent too
When are abdominal CTs used to evaluate appendicitis?
Reserved for complex or atypical cases
How is gastroenteritis ruled out in appendicitis?
- N/V precedes pain
- Usually WBC normal
How is mesenteric lymphadenitis ruled out in appendicitis?
- Usually younger than 20 yo
- No rebound tenderness or muscular rigidity
- Can be a/w URI
How is Meckel’s diverticulitis ruled out in appendicitis?
Looks like appendicitis but almost always occurs in infants (who rarely get appendicitis)
How is pyelonephritis ruled out in appendicitis?
- High fever
- Rigors
- CV angle pain and tenderness
How is ureteral colic (renal stone) ruled out in appendicitis?
- Flank pain radiating into groin
- Little or no localized abdominal tenderness
What condition is often indistinguishable from appendicitis?
Pelvic inflammatory disease
Does diagnosis of appendicitis require radiologic evaluation?
NO
How can PID be distinguished from appendicitis?
Cervical motion tenderness on pelvic exam (Chandelier’s sign) + milky vaginal discharge
Pre-op treatment of appendicitis
- Isotonic IV fluid
- Anti-pyretic
- NG suction if pt has peritonitis
Pharmacology tx of appendicitis
Broad spectrum abx initiated pre-op
Pharmacology tx of ruptured appendix
- Triple abx
- Continued for 3-5 days after surgery
Describe appendectomy
- Open procedure (usually not first choice)
- For pts w/peritonitis or who need exploration (questioned diagnosis)
Describe laparoscopic appendectomy
- Decreased post op pain
- Shorter hospital stay
- Faster recovery
- Cost and post op complications are the SAME as open procedure
Which features of laparoscopic appendectomy are no different than open appendectomy?
Cost and post-op complications are SAME as open procedure
Describe drainage of appendiceal abscess
- Controversial
- Treated w/systemic abx followed by elective appendectomy in 6-12 wks
Incidental appendectomy
- Removal of appendix after it has been visualized in some surgery
- Even if it is normal
- Often worth the risk when already in surgery
Complications of appendicitis and appendectomy
- Perforation (presents w/severe pain and fever)
- Post op infection (reduce risk w/pre-op abx)
- Intra-abdominal or pelvic abscess (occurs w/perforation)
How is a perforated appendix best treated?
Appendectomy + peritoneal lavage
How is an intra-abdominal or pelvic abscess treated?
Percutaneous CT (or US) guided aspiration
What are diverticula?
Outpouching of colonic and submucosal through weaknesses in muscle wall of colon
What is diverticulosis?
Presence of diverticula WITHOUT inflammation
What is diverticulitis?
Clinical term used to describe presence of symptomatic diverticula
What is the MC acquired pathology of the colon?
Diverticulitis
What populations are most affected by diverticulitis?
- Western world
- Age
What type of diverticulitis is MC in Western world?
Left sided (sigmoid)
What type of diverticulitis is MC in Africa/Asia?
Right sided
Where are diverticula MC found?
Sigmoid colon
Pathophys of diverticulitis
- MC accepted theory is too little fiber in diet
- Small hard stools lead to high intraluminal pressure and tension to propel out
- Forming diverticula
Types of diverticulitis
- Uncomplicated
- Complicated
- Hemorrhagic
- Giant colonic
- Right sided
Uncomplicated diverticulitis
- Often treated as outpt
- Abx
- May recur
Complicated diverticuitis
- A/w abscess, obstruction, perforation, fistula
- All require admission and emergency surgery
Hemorrhagic diverticulitis
- Can result in massive hemorrhage
- MC in elderly
- Bleeding stops spontaneously in 80% pts
Hemorrhagic diverticulitis is MC in which population?
Elderly
Giant colonic diverticulum
Very rare
Right sided diverticulitis
- Similar to L sided but symptoms on the R
- Found in Asians and Africans, younger pts
L sided diverticulitis symptoms
- Visceral pain starts in hypogastric region
- Anorexia, N/V (but less than w/appendicitis)
- Pain now shifts to LLQ
- Bowel change
- Fever (usually higher than appendicitis)
R sided diverticulitis presentation
Younger pts mistaken for appendicitis
Treatment of diverticulitis with abscess
- If 2+ cm, CT guided percutaneous drainage or open laparotomy, IV abx
- If less than 2 cm, just IV abx
Treatment of diverticulitis with perforation
Open laparotomy (2 stage)
Treatment of diverticulitis with obstruction
- Partial: conservative tx (NG, NPO)
- Complete: surgery w/resection of colon
What is the MC fistula with diverticulitis?
Colovesicular
Treatment of diverticulitis with fistula
- Identify anatomy of fistula (colovesicular, colovaginal)
- Surgery
Diverticulitis labs
Leukocytosis at 11-25,000 WBC (higher than appendicitis)
What can you look for on CT to diagnose diverticulitis?
- Presence of diverticula
- Inflamed colon in region
- Thickened colonic wall
- Free air from perforation, abscess, fistulas
Treatment of first occurrence of uncomplicated diverticulitis
- Broad spectrum abx to cover anaerobes (Augmentin, Metro+Cipro, Bactrim)
- 7 to 10 days until pt is afebrile for 3-5 days
- Clear liquid diet
Which types of diverticulitis require a one stage surgery and why?
- Perforation, obstruction, fistulas
- To deal with life threatening emergency!
- Elective reanastomoses of colon
Complications of diverticulitis
- Fistula, abscess, perforation
- Colonic stricture
- Sepsis
- Multiple recurrences
How many recurrences of diverticulitis before surgery? What type of surgery?
- 3rd recurrence
- Elective 1 stage hemi-colectomy w/colonic end to end anastomosis (resulting in normal bowel function)
What is the key finding in mesenteric ischemia?
Pain is out of proportion to amount of tenderness palpated
abdominal findings are “underwhelming” considering pt’s subjective complaint of severe pain
Pathophys of mesenteric ischemia
May result from superior mesenteric artery thrombosis or embolus (from A-fib)
Which populations suffer from mesenteric ischemia?
- Elderly
- Those with associated vascular disease
How does mesenteric ischemia present?
- Sudden onset of severe constant abdominal pain (epigastric or periumbilical)
- A/w discharge of intestinal contents (vomiting, diarrhea)
Gold standard to diagnose mesenteric ischemia
Angiography of mesenteric circulation (BUT may not be needed)
How is mesenteric ischemia diagnosed?
CTA or MRA
How does CBC present in mesenteric ischemia?
Elevated WBC with left shift
Treatment of mesenteric ischemia
If possible, surgical embolectomy should be performed to restore circulation (revasc) w/autologous aortic graft
What is the prognosis of mesenteric ischemia?
Poor - many of these pts are old, compromised with diffuse vascular disease, develop multi-system failure and go on to die
Chronic mesenteric ischemia presentation
- Pts have time to develop some collateral circulation
- Develop “intestinal angina”
What is intestinal angina?
- Abdominal pain a/w eating
- Occurs with chronic mesenteric ischemia
What happens to pts with chronic mesenteric ischemia who have cardiac outflow problems too?
- Results in low flow to the gut from chronically depleted intravascular volume
- Can develop shock
What is the standard of tx for mesenteric ischemia?
Restore circulation (could be anti-embolic tx or bypass)
Pts with acute mesenteric ischemia often have a history of what?
Chronic mesenteric ischemia
What happens when there are multiple blockages in mesenteric ischemia but one artery is restored by treatment?
Pt can get better
Define acute abdomen
- Sudden or recent onset of unexpected abdominal pain
- Usually w/in 24-72 hrs of pt presentation
Does every acute abdomen require surgical intervention?
NO
What is the visceral peritoneum innervated by?
ANS bilaterally
What is the parietal peritoneum innervated by?
Somatic nervous system unilaterally
What does referred pain result from?
Central neural pathways common to both somatic nerves and visceral organs
Where does biliary tract pain typically refer to?
Right shoulder and scapula
Where does diaphragmatic or “sub-phrenic” pain refer to?
Ipsilateral shoulder
How should acute onset pain persisting for more than 6 hrs be evaluated?
As a potential surgical acute abdomen
What does very sudden (within seconds) abdominal pain suggest?
Perforation or rupture (ulcer, AAA)
What should be considered with acute abdominal pain that begins rapidly and accelerates within minutes?
- Colic sources (stones)
- Inflammatory (appendicitis, diverticulitis)
- Ischemic (mesenteric ischemia, volvulus)
What should be considered with acute abdominal pain that is more gradual in onset but increases in intensity over several hours?
- Inflammatory (appendicitis, cholecystitis)
- Obstructive (urinary retention, bowel)
- Mechanical (ectopic preg, tumor)
Describe colicky pain
- Builds to a crescendo
- Caused by hyperperistalsis of smooth muscle contraction against an obstruction
- Followed by a period of minimal or absent pain
Patients with peritonitis note pain is worse with:
Movement
Patients with peritonitis prefer to:
Lie still
What is the hallmark of peritonitis?
Anorexia
Treatment of peritonitis
- Driven by diagnosis
- Many will require surgical eval
