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Surgery > Appendicitis (Schwartz 11ed) > Flashcards

Appendicitis (Schwartz 11ed) Flashcards

1
Q

What causes appendictis in Pediatrics?

A

Luminal obstruction due to lymphoid hyperplasia

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2
Q

What causes appendicitis in adults?

A

Fecaliths, fibrosis, foreign bodies and neoplasia

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3
Q

How long is the appendix?

A

6-9cm

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4
Q

What is the location of the appendix (majority)?

A

Intraperitoneal and retrocecal

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5
Q

Other locations of the appendix?

A

Pelvic 30%

Retroperitoneal 7%

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6
Q

Incidence based on age and sex?

A

20-30 years old

Higher in men (8.6%) compared to women (6.7%)

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7
Q

Most common aerobic and Anaerobic bacteria in appendicitis?

A

Bacteroides fragilis

E. Coli

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8
Q

What are the 3 Lab parameters that help in predicting perforation?

A

C-reactive protein
Bilirubin
Pro-calcitonin

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9
Q

2 most common complications of appendicitis aside from perforation?

A

Abscess

Enterocutaneous fistula

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10
Q

What is the most common presentation of appendiceal carcinoma?

A

Appendicitis

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11
Q

What are the 2 other presentations of appendiceal carcinoma?

A

Ascites

Palpable mass

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12
Q

True or false? Does single-incision appendectomy improve clinical and cosmetic outcomes?

A

False

Has not been shown to improve outcomes both clinically and cosmetically

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13
Q

What is the classic sign of appendicitis?

A

Migratory RLQ pain

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14
Q

What is the cause of migratory RLQ pain?

A

Inflammation of the visceral peritoneum which progress to the parietal peritoneum

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15
Q

Location of the McBurney’s point?

A

1/3 of the anterior superior iliac spine (ASIS) and umbilicus

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16
Q

What is the Physical sign in appendicitis where there is pain on RLQ area after gentle release on the LLQ area?

A

Rovsing’s sign

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17
Q

What is the Physical sign in appendicitis where there is pain with coughing?

A

Dunphy’s sign

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18
Q

What is the Physical sign in appendicitis where there is pain with internal rotation of the hip?

A

Obturator’s sign

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19
Q

What is the Physical sign in appendicitis where there is pain with flexion of the hip?

A

Iliopsoa’s sign

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20
Q

What are the 2 initial appropriate lab parameters on initial work-up obtained for acute appendicitis?

A

WBC count

C- reactive protein

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21
Q

Level of leukocytosis in acute appendicitis?

A

10,000 cells/mm3

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22
Q

Level of leukocytosis for gangrenous and perforated appendicitis?

A

More than or equal to 17,000 cells/mm3

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23
Q

Most sensitive & specific imaging modality for acute appendicitis?

A

Contrast-enhanced CT scan (2-4Msv)

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24
Q

CT-scan findings in acute appendicitis?

A

Enlarged lumen
Double wall thickness > 6mm
Wall thickening > 2mm
Peri-appendiceal fat stranding

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25
Q

Best imaging modality for pediatric patients with appendicitis?

A

Graded-compression ultrasound

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26
Q

Graded-compression ultrasound normal findings?

A

Easily compressible appendix

Less than <5mm AP diameter

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27
Q

Graded-compression ultrasound positive findings?

A

AP diameter > or = to 6mm

Pain with compression

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28
Q

Delaying surgery by less than 12 hours is acceptable if the following 3 are present?

A

Symptoms less than <48 hours
Non-perforated
Non-gangrenous

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29
Q

Which is true of Laparoscopic appendectomy, lower superficial wound infection rates or lower intra-abdominal infection rates?

A

Lower superficial wound infection rates

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30
Q

Which is true of open appendectomy, lower superficial wound infection rates or lower intra-abdominal infection rates?

A

Lower intra-abdominal infection rates

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31
Q

Time administered for pre-op antibiotics in acute appendicitis?

A

30-60 min prior to skin incision

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32
Q

What are the antibiotics used for uncomplicated appendicitis?

A

Cefoxitin
Ampicillin sulbactam
Cefazolin with metronidazole

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33
Q

What are the antibiotics used for complicated appendicitis?

A

Piptazo monotherapy

Cephalosporin with metronidazole

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34
Q

What is the duration of post-op antibiotics?

A

Less than < 4days (STOP-IT trial)

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35
Q

Oblique type of skin incision?

A

McBurney’s incision

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36
Q

Transverse type of skin incision?

A

Rocky Davi’s incision

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37
Q

Incision for perforated appendicitis with phlegmon?

A

Lower midline laparotomy incision

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38
Q

Best position for open appendectomy?

A

Position the bed on Trendelenburg with Left side down

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39
Q

What is the approach for accessing the peritoneum during open appendectomy?

A

Muscle-splitting approach

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40
Q

What to identify and trace for locating the appendix?

A

Anterior Taenia “Tinea Liberia” of cecum

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41
Q

What is the blood supply of the appendix?

A

Appendicular branch of the Ileo-colic artery

42
Q

Surgical technique to secure base of appendix?

A

Z-stitch or purse-string

43
Q

Patient positioning in Lap Appendectomy?

A

Supine

Left arm tucked

44
Q

Bed positioning in Lap appendectomy?

A

Trendelenburg

Left side down

45
Q

Technique used in lap appendectomy?

A

Hasson Technique (peri-umbilical fashion)

46
Q

Upon negative exploration on lap or open appendectomy, do you remove or not remove the appendix?

A

Remove the appendix (to reduce future diagnostic dilemma)

47
Q

Is incidental appendectomy advocated? Yes or NO?

A

Not advocated

Risk of adhesions and complications is high than future appendicitis

48
Q

Which age group in pediatrics has higher rates of perforation,

Infants & young children?
Or
School-aged children?

A

Infants and young children (51-100%)

49
Q

3 Symptoms of appendicitis in neonates?

A

Irritability
Abdominal distention
Lethargy

50
Q

2 Parameters in Pediatric Appendicitis Score (PAS) with a max score of 2?

A 
Pain with coughing, percussion or hopping 
RLQ pain (not tenderness)
51
Q

Percentage chance of patients with PAS score of less than (<2)?

A

1-2.4% chance of appendicitis

52
Q

Percentage chance of patients with PAS score of less than (>7)?

A

78-96% chance of appendicitis

53
Q

What is the best management option for children with appendicitis? (uncomplicated)

A

Laparoscopic appendectomy “preferred”

54
Q

What is the best management option for appendicitis with no mass or abscess formation?

A

URGENT appendectomy (less than 12 hours symptoms)

55
Q

For cases of perforation, how many additional days (not including the 4 days in STOP IT trial) are required for IV antibiotics to be administered?

A 
3 days (at least) 
5 days (APSA guidelines)  - preferably
56
Q

In older adults with appendicitis, what is the reason why these patients often present with perforation or abscess formation?

A

Older adults have diminished inflammation (or inflammatory response)

57
Q

What to do first in older patients with appendicitis?

A

Obtain definitive imaging first!!!

Contrast enhanced CT-scan

58
Q

In pregnant patients with appendicitis, on what trimester/trimesters they are usually present?

A

1st and 2nd trimester of pregnancy

59
Q

At What age does postpartum appendicitis occur?

A

Age more than or equal to 35

Geriatric pregnancies

60
Q

Imaging of choice for appendicitis in pregnant women?

A

Ultrasound

61
Q

Alternative Imaging of choice for appendicitis in pregnant women?

A

MRI

62
Q

In pregnant patients with appendicitis, is the point of maximal tenderness consistent at RLQ area?

A

No!

Usually it is displaced

63
Q

In pregnant patients with appendicitis, which has higher fetal rate loss with regards to the management?

Laparoscopic appendectomy ?

Or

Open appendectomy?

A

Laparoscopic Appendectomy at 7%

Open at 3 % only

64
Q

In pregnant patients with appendicitis, what is the fetal rate loss if there is appendiceal perforation?

A

36%

65
Q

Symptoms and findings for Chronic or recurrent appendicitis?

A

RLQ pain not associated with febrile illness

On imaging:
+ appendicolith
+ dilated appendix

66
Q

What is the mortality rate of appendectomy (%)?

A

Less than 1%

67
Q

STOP IT trial recommended number of days for IV antibiotics to be administered?

A

4 days

68
Q

For patients with wound infections post appendectomy, what is the best management option?

A

Simple wound opening and packing

69
Q

For patients with deep space abscess post appendectomy, what is the best management option?

A

Percutaneous drainage and antibiotics

70
Q

What is the initial step in the management of fistula post appendectomy?

A

Conservative management

71
Q

What do you call a complication from an incompletely excised appendiceal stump?

A

Stump appendicitis

72
Q

To prevent stump appendicitis, the stump length post excision should be how many centimeters?

A

Less than 0.5cm stump length

More than 0.5cm = high risk for stump appendicitis

73
Q

What is the optimal management for stump appendicitis?

A

Re-excision of the appendiceal base

74
Q

What is appendiceal critical view?

A

Appendix at 10 o’clock
Taenia coli at 3 o’clock
Terminal ileum at 6 o’clock

75
Q

What is the incidence rate of appendiceal neoplasm in all appendectomy specimens?

A

1%

76
Q

What are the 3 types of neoplasms that occur in the appendix?

A

Carcinoids (GEP-NET’s)
Mucinous
Adenocarcinomas

77
Q

What type of appendiceal neoplasm that is relatively indolent in nature and can develop hepatic and nodal Mets?

A

Gastro-entero-pancreatic Neuro-endocrine tumor (GEP-NET) OR carcinoids

78
Q

What is the management option for a less than 1cm appendiceal tumor?

A

Negative margin appendectomy

79
Q

What is the management option for a more than 2cm appendiceal tumor?

A

Right hemicolectomy

80
Q

What is the management option for a 1-2 cm appendiceal tumor?

A

No consensus on completion colectomy as of now

81
Q

What are the 3 indications for Right colectomy?

A

Mesenteric invasion
Enlarged nodes
Positive or unclear margins

82
Q

What lab parameter is being measured for appendiceal tumors?

A

Chromogranin - A

83
Q

What type of appendiceal tumor that has the poorest prognosis?

A

Adenocarcinoma

84
Q

What type of appendiceal tumor that is an adenocarcinoid with both adenocarcinoma and neuroendocrine features?

A

Goblet cell carcinoma

85
Q

What type of appendiceal tumor that has high risk for peritoneal recurrence?

A

Goblet cell carcinoma

86
Q

What is the Best management option for goblet cell carcinoma with no evidence of Mets?

A

Right hemicolectomy

87
Q

What type of appendiceal tumor that has a diameter of 2.5cm or more?

A

Lymphomas (non-Hodgkin)

Rare (1-3%)

88
Q

What type of appendiceal tumor that has a high propensity for early perforation?

A

Adenocarcinoma

89
Q

What is the most common presentation of adenocarcinoma in the appendix?

A

Appendicitis

Others:
Ascites
Palpable mass
Neoplasm

90
Q

What is the survival rate for adenocarcinoma in the appendix?

A

55% 5 year survival rate

91
Q

What is the best management option for adenocarcinoma?

A

Formal Right hemicolectomy

92
Q

What type of appendiceal tumor that has a significant risk for synchronous and metachronous neoplasm?

A

Adenocarcinoma

93
Q

What type of appendiceal tumor that is round, well encapsulated, appears cystic and have low attenuation on imaging? And is usually “incidental” in nature

A

Appendiceal mucocele

94
Q

Best management option for appendiceal mucoceles?

A

Surgical excision without capsular disruption

“To avoid intraperitoneal spread” & development of Psudomyxoma Peritonei (nearly certain in adenocarcinoma)

95
Q

What to do if with high suspicion for mucinous neoplasm of the appendix?

A

Systematic examination of peritoneum
Do a peritoneal cancer index score of mucin
Biopsy

96
Q

In what type of appendiceal tumor do patients are prone to development of pseudomyxoma peritonei syndrome?

A

Appendiceal mucinous neoplasm

97
Q

What are other primary tumors that can cause pseudomyxoma peritonei syndrome aside from mucinous appendiceal tumors?

A

Primary tumors that occur in the

Gastric
Ovarian
Pancreatic
Colorectal

98
Q

What chemo drug is used in HIPEC?

A

Metomycin

99
Q

What is the standard of care for patients with Pseudomyxoma Peritonei Syndrome (PSP) from appendiceal primaries?

A

Cytoreductive surgery

HIPEC (hyperthermic intraperitoneal chemotherapy)

100
Q

What does HIPEC involves?

A

Parietal & peritoneal peritonectomies
Intraperitoneal administration of heated chemotherapy in the abdomen (42 degree celcius/108 degree Fahrenheit)
Using metomycin

Surgery (2 decks)

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