Appendix

Question 1

Pathophysiology of appendicitis

Answer 1

• obstruction due to fecolith/calculi/lymphoid tissue/tumor
• swelling over mucosal/submucosal tissue
• bacterial translocation leading to necrosis and perforation

Question 2

Explain the mechanism behind traveling pain to RLQ

Answer 2

Visceral afferent nerves entering T8- T10 → vague abdominal pain

Further irritation of parietal peritoneum → localized RLQ pain

Question 3

Anatomical locations of appendix

Answer 3

Retrocolic and retrocecal 75%

Subcaecal and pelvic 20%

Retroileal and pre-ileal 5%

Question 4

Name the clinical signs of appendicitis

Answer 4

McBurney’s point of tenderness

Rovsing’s sign

Psaos stretch sign

Obturator sign

Question 5

What is alvarado’s score?

Answer 5

Predictor of appendicitis

5-6 compatible

7-8 probable

9-10 very probable

Question 6

Name some components of Alvarado’s score

Answer 6

MANTRELS

M- migration of pain to RIF

A-Anorexia

N- Nausea/vomiting

T-Tenderness in RIL

R-Rebound tenderenss

E-Elevated temperature

L- leucocytosis

S- shift of white cells to left

Question 7

CT features for appendicitis

Answer 7

Appendiceal diameter >7mm

Thickened appendiceal wall > 3mm

Periappendiceal stranding/fluid

Presence of fecolith

Question 8

CT accurancy for detection of appendicitis

Answer 8

90%

Sensitivity 95

Specificity 75-80%

Question 9

Should interval appendiectomy be offered for patient’s with delayed presentation?

Answer 9

pros: risk of recurrence, risk of ca
cons: risk of IA

Inform patient of option of option and offer IA selectively (>40

Question 10

Management for delayed presentation of appendicitis

Answer 10

• Control any component of sepsis
  
  • course of antibiotics
  • percutaneous drainage of any intraabdominal collection
• Offer elective colonoscopy for those > 40 in 6-8 weeks
• Discuss option of interval appendiectomy vs conservative management

Question 11

Complications of appendectomy

Answer 11

Wound infection

Bleeding

Pelvic abscess

Fecal fistula

Iatrogenic bowel injury

Adhesive IO

Mortality < 0.5%

Question 12

Name some appendiceal tumors of epithelial origin

Answer 12

Carcinoid: classical, tubular, globet cell

Adenoma: tubular, tubulovillous, serrated

Adenocarcinoma: intestinal, mucinous, signet ring

Question 13

Name some appendiceal tumors of non-epithelial origin

Answer 13

GIST

lymphoma

leiomyoma

leiomyosarcoma

neurofibroma

ganglioneuroma

Kaposi sarcoma

Question 14

Two patterns of appendiceal carcinoma

Answer 14

Mucinous

Intestinal

Question 15

DDX for appendiceal mucocele

Answer 15

Non-neoplastic

-simple mucoceles /retention cysts

Neoplastic

• serrated + hyperplastic polyps
• LAMN
• HAMN
• Mucinous adenocarcinoma

Question 16

LAMN

Answer 16

Low-grade appendiceal mucinous neoplasm

• true neoplasm with dysplastic epithelium
• produced abundant mucin
• exhibits an expansile growth with a ‘pushing’ border
• confined to muscular propria, not infiltrative

Question 17

HAMN

Answer 17

High-grade appendiceal mucinous neoplasm

• high grade dysplastic changes
• distinguished from LAMN only by degree of epithelial dysplasia

Question 18

Treatment of localized disease of appendiceal mucocele

Answer 18

Complete resection of lesion:

• standard appendectomy
• if base involved (partical cecectomy/ileocecetomy/right colectomy)

Question 19

Appendiceal specimen information to determine subsequent management after initial appendectomy

Answer 19

Any perforation

Margins of resection

Cytology

Appendiceal lymph nodes

Question 20

Treatment of ruptured lesions

Answer 20

• Appendectomy/Right Hemicolectomy
• Careful inspection of abdominal cavity with documentation
• Biopsy of any suspicious peritoneal lesions
• Thorough irrigation of abdomen and surgical wounds
• Referral of patients with gross peritoneal spread to specialized center

Question 21

Treatment of disseminated peritoneal disease

Answer 21

• Completion right hemicolectomy with lymphadenoectomy
• Cytoreductive surgery (CRS) + heated intraperitoneal chemotherapy (HIPEC)

Question 22

T4a LAMN/HAMN

Answer 22

acellular/cellular mucin on serosal surface of appendix/mesoappendix

Question 23

M1 LAMN

Answer 23

mucin involvement of distant peritoneal sites

a: acellular mucin in peritoneal sites
b: metastases confined to peritnoeum
c: metastases outside of peritoneum

Question 24

Recurrence rate of T4a LAMN

Answer 24

acellular: 3-7%
cellular: 33-78%

Question 25

Management for completely resected unruptured MACA

Answer 25

G1: observe

G2 + G3: completion right hemicolectomy

Question 26

Pseudomyxoma peritonei (PMP)

Answer 26

Deposits of mucin pools in peritoneum

Question 27

Mucin spreading invasive adenocarcinomas can be from

Answer 27

appendix

stomach/small/large bowel

fallopian tube/ovary

pancreas / gallbladder

breast