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Clin Med II - GI > Appendicitis, Diverticulitis Steiner > Flashcards

Appendicitis, Diverticulitis Steiner Flashcards

1
Q

What is the MC surgical procedure performed on an emergent basis in the western world?

A

Appendectomy

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2
Q

When is the maximal incidence of appendicitis?

A

2nd and 3rd decades (teens and 20s)

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3
Q

Which gender is more affected by appendicitis?

A
  • Up to age 25 males are 2:1

- After age 25 incidence is equal

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4
Q

What is the pathophys of appendicitis?

A

Appendiceal obstruction

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5
Q

What is the MC cause of appendicitis in children?

A

Submucosal hyperplasia of lymphoid follicles

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6
Q

What is the MC cause of appendicitis in adults?

A

Fecalith

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7
Q

What are the MC infectious agents of appendicitis?

A

Anerobes 3x greater (E. coli 80%) than aerobes

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8
Q

What is a retrocecal appendix and how does appendicitis pain present for this?

A
  • 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
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9
Q

What is a pelvic appendix and how does appendicitis present for this?

A
  • 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
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10
Q

Presentation of appendicitis

A
  • 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
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11
Q

Why do appendicitis pts present with N/V?

A

As appendiceal distension increases there is venous congestion

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12
Q

Why does appendicitis pain become parietal over some time?

A
  • Inflammation spreads to parietal peritoneum

- Pain becomes well localized to RLQ

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13
Q

What are Cope’s pearls for presentation of appendicitis?

A

Symptoms present in a “march of events” (occur in order usually):

  1. Pain (epigastric or periumbilical)
  2. Anorexia
  3. Pain and tenderness (RLQ)
  4. Fever
  5. Leukocytosis
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14
Q

When does appendicitis pain usually occur?

A

Middle of the night and may awaken pt out of sleep

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15
Q

When should diagnosis of appendicitis be made?

A

Before the pt develops leukocytosis

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16
Q

What do some appendicitis pts experience with a BM?

A
  • “Downward urge” = sense that a BM will provide relief

- In reality, it is usually a small amount of stool and flatus with NO relief

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17
Q

Vomiting is less common in which type of appendicitis?

A

Retrocecal

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18
Q

Which type of appendicitis is more likely to be missed in diagnosis?

A

Pelvic appendix

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19
Q

What condition does a pelvic appendicitis present more like?

A

Gastroenteritis

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20
Q

How does pelvic appendicitis present?

A
  • Diffuse pain, vomiting and diarrhea

- Tenderness on DRE

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21
Q

What differentiates ectopic pregnancy from appendicitis?

A

The classic “march of events” is altered

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22
Q

All females with acute abdominal pain require what?

A

Pelvic exam

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23
Q

What is the MC non-gynecological surgical emergency during pregnancy?

A

Appendicitis

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24
Q

When is surgery indicated in a pregnant patient with appendicitis?

A

As soon as diagnosis is made

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25
Q

Why must surgery be immediate in a pregnant pt w/appendicitis?

A

Death of fetus can occur with diffuse peritonitis or perforation

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26
Q

How does WBC present in appendicitis?

A
  • Leukocytosis 10,000+ with 75+% neutrophils
  • Can be normal in older adults
  • Normal pregnancy can result in 15-20,000 WBC
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27
Q

What will cause an increase in neutrophils when evaluating for appendicitis?

A

Perforation

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28
Q

When is U/S most useful in evaluating appendicitis?

A

In females of childbearing age

*U/S is very operator dependent too

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29
Q

When are abdominal CTs used to evaluate appendicitis?

A

Reserved for complex or atypical cases

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30
Q

How is gastroenteritis ruled out in appendicitis?

A
  • N/V precedes pain

- Usually WBC normal

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31
Q

How is mesenteric lymphadenitis ruled out in appendicitis?

A
  • Usually younger than 20 yo
  • No rebound tenderness or muscular rigidity
  • Can be a/w URI
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32
Q

How is Meckel’s diverticulitis ruled out in appendicitis?

A

Looks like appendicitis but almost always occurs in infants (who rarely get appendicitis)

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33
Q

How is pyelonephritis ruled out in appendicitis?

A
  • High fever
  • Rigors
  • CV angle pain and tenderness
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34
Q

How is ureteral colic (renal stone) ruled out in appendicitis?

A
  • Flank pain radiating into groin

- Little or no localized abdominal tenderness

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35
Q

What condition is often indistinguishable from appendicitis?

A

Pelvic inflammatory disease

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36
Q

Does diagnosis of appendicitis require radiologic evaluation?

A

NO

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37
Q

How can PID be distinguished from appendicitis?

A

Cervical motion tenderness on pelvic exam (Chandelier’s sign) + milky vaginal discharge

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38
Q

Pre-op treatment of appendicitis

A
  • Isotonic IV fluid
  • Anti-pyretic
  • NG suction if pt has peritonitis
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39
Q

Pharmacology tx of appendicitis

A

Broad spectrum abx initiated pre-op

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40
Q

Pharmacology tx of ruptured appendix

A
  • Triple abx

- Continued for 3-5 days after surgery

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41
Q

Describe appendectomy

A
  • Open procedure (usually not first choice)

- For pts w/peritonitis or who need exploration (questioned diagnosis)

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42
Q

Describe laparoscopic appendectomy

A
  • Decreased post op pain
  • Shorter hospital stay
  • Faster recovery
  • Cost and post op complications are the SAME as open procedure
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43
Q

Which features of laparoscopic appendectomy are no different than open appendectomy?

A

Cost and post-op complications are SAME as open procedure

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44
Q

Describe drainage of appendiceal abscess

A
  • Controversial

- Treated w/systemic abx followed by elective appendectomy in 6-12 wks

45
Q

Incidental appendectomy

A
  • Removal of appendix after it has been visualized in some surgery
  • Even if it is normal
  • Often worth the risk when already in surgery
46
Q

Complications of appendicitis and appendectomy

A
  1. Perforation (presents w/severe pain and fever)
  2. Post op infection (reduce risk w/pre-op abx)
  3. Intra-abdominal or pelvic abscess (occurs w/perforation)
47
Q

How is a perforated appendix best treated?

A

Appendectomy + peritoneal lavage

48
Q

How is an intra-abdominal or pelvic abscess treated?

A

Percutaneous CT (or US) guided aspiration

49
Q

What are diverticula?

A

Outpouching of colonic and submucosal through weaknesses in muscle wall of colon

50
Q

What is diverticulosis?

A

Presence of diverticula WITHOUT inflammation

51
Q

What is diverticulitis?

A

Clinical term used to describe presence of symptomatic diverticula

52
Q

What is the MC acquired pathology of the colon?

A

Diverticulitis

53
Q

What populations are most affected by diverticulitis?

A
  • Western world

- Age

54
Q

What type of diverticulitis is MC in Western world?

A

Left sided (sigmoid)

55
Q

What type of diverticulitis is MC in Africa/Asia?

A

Right sided

56
Q

Where are diverticula MC found?

A

Sigmoid colon

57
Q

Pathophys of diverticulitis

A
  • MC accepted theory is too little fiber in diet
  • Small hard stools lead to high intraluminal pressure and tension to propel out
  • Forming diverticula
58
Q

Types of diverticulitis

A
  • Uncomplicated
  • Complicated
  • Hemorrhagic
  • Giant colonic
  • Right sided
59
Q

Uncomplicated diverticulitis

A
  • Often treated as outpt
  • Abx
  • May recur
60
Q

Complicated diverticuitis

A
  • A/w abscess, obstruction, perforation, fistula

- All require admission and emergency surgery

61
Q

Hemorrhagic diverticulitis

A
  • Can result in massive hemorrhage
  • MC in elderly
  • Bleeding stops spontaneously in 80% pts
62
Q

Hemorrhagic diverticulitis is MC in which population?

A

Elderly

63
Q

Giant colonic diverticulum

A

Very rare

64
Q

Right sided diverticulitis

A
  • Similar to L sided but symptoms on the R

- Found in Asians and Africans, younger pts

65
Q

L sided diverticulitis symptoms

A
  1. Visceral pain starts in hypogastric region
  2. Anorexia, N/V (but less than w/appendicitis)
  3. Pain now shifts to LLQ
  4. Bowel change
  5. Fever (usually higher than appendicitis)
66
Q

R sided diverticulitis presentation

A

Younger pts mistaken for appendicitis

67
Q

Treatment of diverticulitis with abscess

A
  • If 2+ cm, CT guided percutaneous drainage or open laparotomy, IV abx
  • If less than 2 cm, just IV abx
68
Q

Treatment of diverticulitis with perforation

A

Open laparotomy (2 stage)

69
Q

Treatment of diverticulitis with obstruction

A
  • Partial: conservative tx (NG, NPO)

- Complete: surgery w/resection of colon

70
Q

What is the MC fistula with diverticulitis?

A

Colovesicular

71
Q

Treatment of diverticulitis with fistula

A
  • Identify anatomy of fistula (colovesicular, colovaginal)

- Surgery

72
Q

Diverticulitis labs

A

Leukocytosis at 11-25,000 WBC (higher than appendicitis)

73
Q

What can you look for on CT to diagnose diverticulitis?

A
  • Presence of diverticula
  • Inflamed colon in region
  • Thickened colonic wall
  • Free air from perforation, abscess, fistulas
74
Q

Treatment of first occurrence of uncomplicated diverticulitis

A
  • 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
75
Q

Which types of diverticulitis require a one stage surgery and why?

A
  • Perforation, obstruction, fistulas
  • To deal with life threatening emergency!
  • Elective reanastomoses of colon
76
Q

Complications of diverticulitis

A
  • Fistula, abscess, perforation
  • Colonic stricture
  • Sepsis
  • Multiple recurrences
77
Q

How many recurrences of diverticulitis before surgery? What type of surgery?

A
  • 3rd recurrence

- Elective 1 stage hemi-colectomy w/colonic end to end anastomosis (resulting in normal bowel function)

78
Q

What is the key finding in mesenteric ischemia?

A

Pain is out of proportion to amount of tenderness palpated

abdominal findings are “underwhelming” considering pt’s subjective complaint of severe pain

79
Q

Pathophys of mesenteric ischemia

A

May result from superior mesenteric artery thrombosis or embolus (from A-fib)

80
Q

Which populations suffer from mesenteric ischemia?

A
  • Elderly

- Those with associated vascular disease

81
Q

How does mesenteric ischemia present?

A
  • Sudden onset of severe constant abdominal pain (epigastric or periumbilical)
  • A/w discharge of intestinal contents (vomiting, diarrhea)
82
Q

Gold standard to diagnose mesenteric ischemia

A

Angiography of mesenteric circulation (BUT may not be needed)

83
Q

How is mesenteric ischemia diagnosed?

A

CTA or MRA

84
Q

How does CBC present in mesenteric ischemia?

A

Elevated WBC with left shift

85
Q

Treatment of mesenteric ischemia

A

If possible, surgical embolectomy should be performed to restore circulation (revasc) w/autologous aortic graft

86
Q

What is the prognosis of mesenteric ischemia?

A

Poor - many of these pts are old, compromised with diffuse vascular disease, develop multi-system failure and go on to die

87
Q

Chronic mesenteric ischemia presentation

A
  • Pts have time to develop some collateral circulation

- Develop “intestinal angina”

88
Q

What is intestinal angina?

A
  • Abdominal pain a/w eating

- Occurs with chronic mesenteric ischemia

89
Q

What happens to pts with chronic mesenteric ischemia who have cardiac outflow problems too?

A
  • Results in low flow to the gut from chronically depleted intravascular volume
  • Can develop shock
90
Q

What is the standard of tx for mesenteric ischemia?

A

Restore circulation (could be anti-embolic tx or bypass)

91
Q

Pts with acute mesenteric ischemia often have a history of what?

A

Chronic mesenteric ischemia

92
Q

What happens when there are multiple blockages in mesenteric ischemia but one artery is restored by treatment?

A

Pt can get better

93
Q

Define acute abdomen

A
  • Sudden or recent onset of unexpected abdominal pain

- Usually w/in 24-72 hrs of pt presentation

94
Q

Does every acute abdomen require surgical intervention?

A

NO

95
Q

What is the visceral peritoneum innervated by?

A

ANS bilaterally

96
Q

What is the parietal peritoneum innervated by?

A

Somatic nervous system unilaterally

97
Q

What does referred pain result from?

A

Central neural pathways common to both somatic nerves and visceral organs

98
Q

Where does biliary tract pain typically refer to?

A

Right shoulder and scapula

99
Q

Where does diaphragmatic or “sub-phrenic” pain refer to?

A

Ipsilateral shoulder

100
Q

How should acute onset pain persisting for more than 6 hrs be evaluated?

A

As a potential surgical acute abdomen

101
Q

What does very sudden (within seconds) abdominal pain suggest?

A

Perforation or rupture (ulcer, AAA)

102
Q

What should be considered with acute abdominal pain that begins rapidly and accelerates within minutes?

A
  • Colic sources (stones)
  • Inflammatory (appendicitis, diverticulitis)
  • Ischemic (mesenteric ischemia, volvulus)
103
Q

What should be considered with acute abdominal pain that is more gradual in onset but increases in intensity over several hours?

A
  • Inflammatory (appendicitis, cholecystitis)
  • Obstructive (urinary retention, bowel)
  • Mechanical (ectopic preg, tumor)
104
Q

Describe colicky pain

A
  • Builds to a crescendo
  • Caused by hyperperistalsis of smooth muscle contraction against an obstruction
  • Followed by a period of minimal or absent pain
105
Q

Patients with peritonitis note pain is worse with:

A

Movement

106
Q

Patients with peritonitis prefer to:

A

Lie still

107
Q

What is the hallmark of peritonitis?

A

Anorexia

108
Q

Treatment of peritonitis

A
  • Driven by diagnosis

- Many will require surgical eval

Clin Med II - GI (17 decks)

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