Appendicitis (Schwartz 11ed) Flashcards
1
Q
What causes appendictis in Pediatrics?
A
Luminal obstruction due to lymphoid hyperplasia
2
Q
What causes appendicitis in adults?
A
Fecaliths, fibrosis, foreign bodies and neoplasia
3
Q
How long is the appendix?
A
6-9cm
4
Q
What is the location of the appendix (majority)?
A
Intraperitoneal and retrocecal
5
Q
Other locations of the appendix?
A
Pelvic 30%
Retroperitoneal 7%
6
Q
Incidence based on age and sex?
A
20-30 years old
Higher in men (8.6%) compared to women (6.7%)
7
Q
Most common aerobic and Anaerobic bacteria in appendicitis?
A
Bacteroides fragilis
E. Coli
8
Q
What are the 3 Lab parameters that help in predicting perforation?
A
C-reactive protein
Bilirubin
Pro-calcitonin
9
Q
2 most common complications of appendicitis aside from perforation?
A
Abscess
Enterocutaneous fistula
10
Q
What is the most common presentation of appendiceal carcinoma?
A
Appendicitis
11
Q
What are the 2 other presentations of appendiceal carcinoma?
A
Ascites
Palpable mass
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
13
Q
What is the classic sign of appendicitis?
A
Migratory RLQ pain
14
Q
What is the cause of migratory RLQ pain?
A
Inflammation of the visceral peritoneum which progress to the parietal peritoneum
15
Q
Location of the McBurney’s point?
A
1/3 of the anterior superior iliac spine (ASIS) and umbilicus
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
17
Q
What is the Physical sign in appendicitis where there is pain with coughing?
A
Dunphy’s sign
18
Q
What is the Physical sign in appendicitis where there is pain with internal rotation of the hip?
A
Obturator’s sign
19
Q
What is the Physical sign in appendicitis where there is pain with flexion of the hip?
A
Iliopsoa’s sign
20
Q
What are the 2 initial appropriate lab parameters on initial work-up obtained for acute appendicitis?
A
WBC count
C- reactive protein
21
Q
Level of leukocytosis in acute appendicitis?
A
10,000 cells/mm3
22
Q
Level of leukocytosis for gangrenous and perforated appendicitis?
A
More than or equal to 17,000 cells/mm3
23
Q
Most sensitive & specific imaging modality for acute appendicitis?
A
Contrast-enhanced CT scan (2-4Msv)
24
Q
CT-scan findings in acute appendicitis?
A
Enlarged lumen
Double wall thickness > 6mm
Wall thickening > 2mm
Peri-appendiceal fat stranding
25
Best imaging modality for pediatric patients with appendicitis?
Graded-compression ultrasound
26
Graded-compression ultrasound normal findings?
Easily compressible appendix
| Less than <5mm AP diameter
27
Graded-compression ultrasound positive findings?
AP diameter > or = to 6mm
| Pain with compression
28
Delaying surgery by less than 12 hours is acceptable if the following 3 are present?
Symptoms less than <48 hours
Non-perforated
Non-gangrenous
29
Which is true of Laparoscopic appendectomy, lower superficial wound infection rates or lower intra-abdominal infection rates?
Lower superficial wound infection rates
30
Which is true of open appendectomy, lower superficial wound infection rates or lower intra-abdominal infection rates?
Lower intra-abdominal infection rates
31
Time administered for pre-op antibiotics in acute appendicitis?
30-60 min prior to skin incision
32
What are the antibiotics used for uncomplicated appendicitis?
Cefoxitin
Ampicillin sulbactam
Cefazolin with metronidazole
33
What are the antibiotics used for complicated appendicitis?
Piptazo monotherapy
| Cephalosporin with metronidazole
34
What is the duration of post-op antibiotics?
Less than < 4days (STOP-IT trial)
35
Oblique type of skin incision?
McBurney’s incision
36
Transverse type of skin incision?
Rocky Davi’s incision
37
Incision for perforated appendicitis with phlegmon?
Lower midline laparotomy incision
38
Best position for open appendectomy?
Position the bed on Trendelenburg with Left side down
39
What is the approach for accessing the peritoneum during open appendectomy?
Muscle-splitting approach
40
What to identify and trace for locating the appendix?
Anterior Taenia “Tinea Liberia” of cecum
41
What is the blood supply of the appendix?
Appendicular branch of the Ileo-colic artery
42
Surgical technique to secure base of appendix?
Z-stitch or purse-string
43
Patient positioning in Lap Appendectomy?
Supine
| Left arm tucked
44
Bed positioning in Lap appendectomy?
Trendelenburg
| Left side down
45
Technique used in lap appendectomy?
Hasson Technique (peri-umbilical fashion)
46
Upon negative exploration on lap or open appendectomy, do you remove or not remove the appendix?
Remove the appendix (to reduce future diagnostic dilemma)
47
Is incidental appendectomy advocated? Yes or NO?
Not advocated
| Risk of adhesions and complications is high than future appendicitis
48
Which age group in pediatrics has higher rates of perforation,
Infants & young children?
Or
School-aged children?
Infants and young children (51-100%)
49
3 Symptoms of appendicitis in neonates?
Irritability
Abdominal distention
Lethargy
50
2 Parameters in Pediatric Appendicitis Score (PAS) with a max score of 2?
```
Pain with coughing, percussion or hopping
RLQ pain (not tenderness)
```
51
Percentage chance of patients with PAS score of less than (<2)?
1-2.4% chance of appendicitis
52
Percentage chance of patients with PAS score of less than (>7)?
78-96% chance of appendicitis
53
What is the best management option for children with appendicitis? (uncomplicated)
Laparoscopic appendectomy “preferred”
54
What is the best management option for appendicitis with no mass or abscess formation?
URGENT appendectomy (less than 12 hours symptoms)
55
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?
```
3 days (at least)
5 days (APSA guidelines) - preferably
```
56
In older adults with appendicitis, what is the reason why these patients often present with perforation or abscess formation?
Older adults have diminished inflammation (or inflammatory response)
57
What to do first in older patients with appendicitis?
Obtain definitive imaging first!!!
| Contrast enhanced CT-scan
58
In pregnant patients with appendicitis, on what trimester/trimesters they are usually present?
1st and 2nd trimester of pregnancy
59
At What age does postpartum appendicitis occur?
Age more than or equal to 35
| Geriatric pregnancies
60
Imaging of choice for appendicitis in pregnant women?
Ultrasound
61
Alternative Imaging of choice for appendicitis in pregnant women?
MRI
62
In pregnant patients with appendicitis, is the point of maximal tenderness consistent at RLQ area?
No!
| Usually it is displaced
63
In pregnant patients with appendicitis, which has higher fetal rate loss with regards to the management?
Laparoscopic appendectomy ?
Or
Open appendectomy?
Laparoscopic Appendectomy at 7%
| Open at 3 % only
64
In pregnant patients with appendicitis, what is the fetal rate loss if there is appendiceal perforation?
36%
65
Symptoms and findings for Chronic or recurrent appendicitis?
RLQ pain not associated with febrile illness
On imaging:
+ appendicolith
+ dilated appendix
66
What is the mortality rate of appendectomy (%)?
Less than 1%
67
STOP IT trial recommended number of days for IV antibiotics to be administered?
4 days
68
For patients with wound infections post appendectomy, what is the best management option?
Simple wound opening and packing
69
For patients with deep space abscess post appendectomy, what is the best management option?
Percutaneous drainage and antibiotics
70
What is the initial step in the management of fistula post appendectomy?
Conservative management
71
What do you call a complication from an incompletely excised appendiceal stump?
Stump appendicitis
72
To prevent stump appendicitis, the stump length post excision should be how many centimeters?
Less than 0.5cm stump length
More than 0.5cm = high risk for stump appendicitis
73
What is the optimal management for stump appendicitis?
Re-excision of the appendiceal base
74
What is appendiceal critical view?
Appendix at 10 o’clock
Taenia coli at 3 o’clock
Terminal ileum at 6 o’clock
75
What is the incidence rate of appendiceal neoplasm in all appendectomy specimens?
1%
76
What are the 3 types of neoplasms that occur in the appendix?
Carcinoids (GEP-NET’s)
Mucinous
Adenocarcinomas
77
What type of appendiceal neoplasm that is relatively indolent in nature and can develop hepatic and nodal Mets?
Gastro-entero-pancreatic Neuro-endocrine tumor (GEP-NET) OR carcinoids
78
What is the management option for a less than 1cm appendiceal tumor?
Negative margin appendectomy
79
What is the management option for a more than 2cm appendiceal tumor?
Right hemicolectomy
80
What is the management option for a 1-2 cm appendiceal tumor?
No consensus on completion colectomy as of now
81
What are the 3 indications for Right colectomy?
Mesenteric invasion
Enlarged nodes
Positive or unclear margins
82
What lab parameter is being measured for appendiceal tumors?
Chromogranin - A
83
What type of appendiceal tumor that has the poorest prognosis?
Adenocarcinoma
84
What type of appendiceal tumor that is an adenocarcinoid with both adenocarcinoma and neuroendocrine features?
Goblet cell carcinoma
85
What type of appendiceal tumor that has high risk for peritoneal recurrence?
Goblet cell carcinoma
86
What is the Best management option for goblet cell carcinoma with no evidence of Mets?
Right hemicolectomy
87
What type of appendiceal tumor that has a diameter of 2.5cm or more?
Lymphomas (non-Hodgkin)
| Rare (1-3%)
88
What type of appendiceal tumor that has a high propensity for early perforation?
Adenocarcinoma
89
What is the most common presentation of adenocarcinoma in the appendix?
Appendicitis
Others:
Ascites
Palpable mass
Neoplasm
90
What is the survival rate for adenocarcinoma in the appendix?
55% 5 year survival rate
91
What is the best management option for adenocarcinoma?
Formal Right hemicolectomy
92
What type of appendiceal tumor that has a significant risk for synchronous and metachronous neoplasm?
Adenocarcinoma
93
What type of appendiceal tumor that is round, well encapsulated, appears cystic and have low attenuation on imaging? And is usually “incidental” in nature
Appendiceal mucocele
94
Best management option for appendiceal mucoceles?
Surgical excision without capsular disruption
“To avoid intraperitoneal spread” & development of Psudomyxoma Peritonei (nearly certain in adenocarcinoma)
95
What to do if with high suspicion for mucinous neoplasm of the appendix?
Systematic examination of peritoneum
Do a peritoneal cancer index score of mucin
Biopsy
96
In what type of appendiceal tumor do patients are prone to development of pseudomyxoma peritonei syndrome?
Appendiceal mucinous neoplasm
97
What are other primary tumors that can cause pseudomyxoma peritonei syndrome aside from mucinous appendiceal tumors?
Primary tumors that occur in the
Gastric
Ovarian
Pancreatic
Colorectal
98
What chemo drug is used in HIPEC?
Metomycin
99
What is the standard of care for patients with Pseudomyxoma Peritonei Syndrome (PSP) from appendiceal primaries?
Cytoreductive surgery
| HIPEC (hyperthermic intraperitoneal chemotherapy)
100
What does HIPEC involves?
Parietal & peritoneal peritonectomies
Intraperitoneal administration of heated chemotherapy in the abdomen (42 degree celcius/108 degree Fahrenheit)
Using metomycin
