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Clin Med 3 > Appendix > Flashcards

Appendix Flashcards

1
Q

What is the appendix?

A

Under-developed distal cecum

Located where tenia join at cecum

True diverticula - outpouch of the distal cecum

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2
Q

Most common location of Appendix?

A

McBurney’s point - RLQ

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3
Q

When does appendicitis most frequently occur? Age?

A

2nd and 3rd decades of life

Incidence highest in 10-19 year old age group

Male > Female

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4
Q

Pathogenesis of Appendicitis

A

Inflammation -> Ischemia -> Perforation -> Peritonitis/Abscess

-pts usually present BEFORE perf and abscess

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5
Q

Appendicitis pathogenesis related to what?

A

An obstructed process at the lumen of the appendix

  • obstruction by fecolith, stricture, foreign body
  • dietary factors (low fiber, highly refined CHO) - junk food
  • bacterial proliferation
  • obstruction by tumor
  • infective trigger and seasonal variation
  • lymphoid hyperplasia
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6
Q

What organisms are involved in gangrenous and perforated appendicitis?

A

E. Coli, Peptostrepto, B. Fragilis, and Pseudomonas

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7
Q

Common presentation of appendicitis

A

Periumbilical pain that moves to right iliac fossa pain

Colicky (waning) pain that changes to dull constant pain

Periumbilical pain -> 1 or 2 episodes of vomiting -> right iliac fossa pain

ALSO HAVE ANOREXIA AND NAUSEA PROGRESSION

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8
Q

Hx workup for appendicitis

A
  • abd pain
  • N/V
  • low grade fever
  • anorexia
  • malaise
  • diarrhea
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9
Q

Family hx and appendicitis

A

1/3 of children have a 1st degree relative with similar story

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10
Q

Appendicitis Physical Work-up

A

FEVER IS LOW GRADE

  • McBurney’s Point Tenderness
  • Rovsing’s sign
  • Psoas Sign (RLQ pain with passive right hip extension)
  • Obturator Sign
  • Pointing Sign
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11
Q

Appendicitis Lab Workup

A

CBC w/diff

Electrolytes

LFT’s

Urinalysis

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12
Q

Appendicitis Imaging

A

Abd X-ray

U/S - let’s you know if inflammation at site of appendix

CT scan

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13
Q

Appendicitis Tx

A
  • NOTHING BY MOUTH (NPO)
  • TREATMENT IS SURGICAL (but have to prepare)

To prepare do IVF and IV Abx broad spectrum (3rd ceph or Gentamycin or Metro+Flagyl)

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14
Q

When do you NOT operate for Appendicitis?

A

Peritonitis

Presence of appendicular mass

Resolved - elective at a later time

IF NO SX’S DON’T OPERATE

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15
Q

What must you do before appendicitis surgery?

A

Need to stabilize pt - give IVF and broad spectrum Abx

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16
Q

Appendicitis/Appendectomy complications

A
  • perforation
  • abscess intro-abdominal
  • fecal fistula
  • DVT
  • Hernia

Complications of surgery:

  • bleeding
  • wound infection (MOST COMMON)
  • bowel injury
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17
Q

What is the most common complication of appendix surgery?

A

Wound infection

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18
Q

What is the blood supply of the small intestine?

A

Superior Mesenteric Artery

-source of blood supply for Duodenum, jejunum, ileum, cecum, ascending colon and proximal 2/3 transverse colon

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19
Q

Superior Mesenteric artery supplies what?

A

Duodenum, jejunum, ileum, cecum, ascending colon, and proximal 2/3 transverse colon

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20
Q

Signs of Small Bowel Obstruction

A
  • Abd distention
  • Tinkering bowel sounds
  • possible bilious vomiting
  • colicky central abd pain
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21
Q

Evidence of small bowel strangulation/ischemia or perforation

A

Peritonism and fever

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22
Q

When does a small bowel obstruction occur?

A

When the normal flow of intestinal contents is interrupted

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23
Q

what is the most common cause of SBO in the U.S.?

A

Postop adhesions

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24
Q

What is the most common cause of SBO in developing world?

A

Hernias

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25
Q

Other causes of SBO

A

Malignant tumors (primary and metastatic deposits)

Intussusception (bowel folds in on itself)

Volvulus (bowel twists)

Crohn’s disease

Gallstones (gallstone ileum) - can come out and cause SBO

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26
Q

What are the types of SBO?

A

Intraluminal (w/in the lumen)

Intramural

Extramural

Simple
Closed Loop
Strangulated

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27
Q

What causes intraluminal SBO?

A
  • foreign bodies
  • bezoars
  • gallstones
  • parasites
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28
Q

What causes intramural SBO?

A

Inflammation causes a stricture

Crohn’s

Intussusception

Volvulus

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29
Q

What causes extramural SBO?

A

Something on outside that may clamp down and cause SBO

  • bands/adhesions
  • hernia
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30
Q

What is a simple SBO?

A

Above the obstruction:
-peristalsis increases -> intestine dilates -> reduction in peristaltic strength -> flaccidity and paralysis

Below the obstruction:
-normal peristalsis and absorption until it becomes empty and it contracts and becomes immobile

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31
Q

Strangulated SBO

A

Leads to impaired venous return and increased congestion

Have impaired arterial blood supply

Free peritoneal fluid

Edema of the intestinal wall

Ischemia and gangrene

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32
Q

What is abdominal distention? What is the gas and fluids from?

A

Distention = the accumulation of GAS AND FLUIDS

Gas -> swallowed air, bacterial overgrowth, diffusion from blood

Fluids -> ingested fluids, saliva, gastric and intestinal juices, bile and pancreatic secretions

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33
Q

What does a distended abdomen sound like?

A

Tympanic

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34
Q

SBO hx of pt

A
  • abd pain
  • N/V
  • no passage of flatus/stool
  • prior surgery
  • prior SBO
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35
Q

SBO PE signs

A
  • abd distention

- abd tenderness

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36
Q

What will CBC w/diff be for SBO?

A

Elevated WBC suggests ischemia, lower Hgb and MCV could suggest tumor

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37
Q

What will Chem 7 look like for SBO?

A
  • electrolyte losses, acute renal failure
  • elevated LFTs
  • amylase - pancreatitis w/ileus
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38
Q

What will ABG show for SBO?

A

Metabolic status of patient, evidence of intestinal ischemia

-metabolic acidosis is a LATE CHANGE

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39
Q

Lactate and SBO

A

Will be elevated if necrosis or perforation, but can be misleading and need to follow it

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40
Q

SBO and imaging

A
  • abd x-ray

- CT SCAN WITH ORAL CONTRAST

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41
Q

SBO and CT scan contrast to use?

A

DO CT CAN WITH ORAL CONTRAST THAT IS WATER SOLUBLE ONLY!!!

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42
Q

What is CT scan w/contrast for SBO useful in identifying?

A

Useful in identifying pts with SBO that are unlikely to resolve with conservative measures

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43
Q

If the CT contrast fails to reach cecum by 4 hrs, what does that indicate?

A

Surgical intervention is likely necessary

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44
Q

After give contrast for CT scan for SBO imaging, when is surgery necessary?

A

When the contrast fails to reach the cecum by 4 hrs

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45
Q

Can the CT contrast for SBO be therapeutic?

A

Yes, in adhesional SBO due to osmolar effect

-can help adhesion and resolve the SBO

46
Q

what are the indications for urgent surgery in SBO?

A

Evidence of strangulation:

  • Peritonism
  • Leukocytosis

Perforation

Irreducible hernia

47
Q

SBO treatment

A

NPO - give bowel rest

IVF - IMPORTANT

Abx if have perf, sick, or going to OR

NGT - to evacuate the stomach

Surgery (lap procedures best)

48
Q

NGT tx for SBO

A

To evacuate the stomach (not the jejunum)

Decreases nausea, vomiting, distention, aspiration

49
Q

what does NGT tx for SBO decrease?

A

nausea, vomiting, distention, aspiration

50
Q

when do you not take a pt to surgery for SBO?

A
  • post-op
  • carcinomatosis - little deposits of cancer and pts get a lot of SBOs
  • recurrent SBO
  • post-radiation
51
Q

adhesion tx for SBO

A

conservative at first

52
Q

volvulus tx for SBO

A

derotate and operate

53
Q

abscess or peritonitis tx for SBO

A

drain and treat

54
Q

mesenteric ischemia tx for SBO

A

operate (go to OR b/c have necrotic bowel now)

55
Q

intussusception tx for SBO

A

Pneumatic or Barium reduction then OR

-Use air to help bowel unfold on itself

56
Q

what is ileus? what do you hear on auscultation?

A

GUT HAS STOPPED MOVING

hear NO bowel sounds on auscultation

57
Q

what do you start with when treating ileus?

A

Start with correction of underlying medical conditions, electrolytes, acid base abnormalities

58
Q

what do most treatments of ileus involve?

A

watchful waiting with supportive treatment

59
Q

what study may you need to do for ileus tx?

A

May need to do a contrast study to rule out any mechanical obstruction if not improving

60
Q

what should you stop the use of when have ileus?

A

Discontinue any medication which slow the gut (ex: opiates)

61
Q

what meds/what should be treated when have ileus?

A

Consider NSAIDs, treat pain, and reduce inflammation

Emesis and distention - use NGT for decompression

62
Q

what is mesenteric ischemia?

A

Ischemia of the small bowel, usually secondary to an acute cause involving the SMA or SMV

63
Q

what is ischemic colitis?

A

Ischemia of the colon, rarely with a known acute precipitating cause

64
Q

what is the most common etiology of ischemic bowel disease?

A

SMA occlusion
-Embolism: MI, A-fib, Endocarditis, Valve d/o

-Thrombosis: Atherosclerosis – plaque rupture

65
Q

ischemic bowel disease etiologies

A

SMA Occlusion

Nonocclusive Mesenteric Ischemia (NOMI)

Mesenteric Venous Thrombosis (MVT)

66
Q

Nonocclusive Mesenteric Ischemia (NOMI)

A

cause of ischemic bowel disease

Atherosclerosis + shock + vasopressors

No blockage, just no blood flow to small bowel

67
Q

Mesenteric Venous Thrombosis (MVT)

A

cause of ischemic bowel disease

Primary clotting disorder -> clot off mesenteric vein

68
Q

what is the classical presentation of ischemic bowel disease?

A

Rapid onset of severe, unrelenting periumbilical pain

***Pain out of proportion to findings on physical exam

69
Q

what is the imaging test of choice for ischemic bowel disease?

A

Mesenteric angiography – TEST OF CHOICE!!!

-Can identify the type of Acute Mesenteric Ischemia

70
Q

ischemic bowel disease imaging

A

Plain films
-Thumb printing, thickened bowel (<40% sensitivity – not sensitive)

CT
-Thickened/dilated bowel, intramural hematoma, pneumatosis (64% sensitivity)

  • **Mesenteric angiography – TEST OF CHOICE!!!
  • Can identify the type of Acute Mesenteric Ischemia
71
Q

ischemic bowel disease treatment

A

Resuscitation with fluids/blood products

Anticoagulation (If there’s a clot causing obstruction)

Infusion of a vasodilator (if trying to increase blood flow)

  • Glucagon systemically OR
  • Papverine through a catheter
72
Q

infarcted bowel disease signs?

A

peritoneal signs, fever

73
Q

infarcted bowel disease tx

A

EMERGENT LAPAROTOMY

  • restore interrupted blood flow w/arteriotomy or bypass graft
  • resection of infarcted bowel
  • second look in 24-48hrs
  • vasodilators and pressor use
74
Q

what is the most frequent form of mesenteric ischemia?

A

ischemic colitis

75
Q

what part of colon does ischemic colitis affect?

A

watershed areas

  • rectosigmoid junction
  • left colon (splenic flexure)

Not a lot of blood flow to these areas so any disruption even to one vessel could be catastrophic

76
Q

ischemic colitis common in who?

A

elderly population

77
Q

common presentation of ischemic colitis

A

LEFT SIDED PAIN OUT OF PROPORTION IN OLDER PATIENT

78
Q

ischemic colitis etiologies

A
  • Low-flow state (hypotension)
  • Embolus (A-fib) – sets you up for clots
  • Post MI (hypotension, mural thrombus)
  • Post AAA reconstruction
  • Closed loop construction – left side with intact ileocecal valve
  • Volvulus
  • Mesenteric Vein Thrombosis
79
Q

what is the most common hx for a pt with ischemic colitis?

A

abdominal pain

80
Q

what is dx of ischemic colitis based off of?

A

clinical setting

  • PE
  • Labs (r/o that it’s not from infectious cause)
81
Q

ischemic colitis labs for dx

A
  • Rule out that it’s not from infectious cause (entero or invasive bacteria)
  • Stool cultures for suspected infectious cause
  • Metabolic acidosis
  • Elevated white count >20,000
82
Q

what is the study for choice for ischemic colitis?

A

CT

  • May be normal initially
  • Thickening of bowel wall in segmental pattern and mesenteric stranding in area that is ischemic
  • Pneumatosis and gas in mesenteric veins in advanced stages
83
Q

ischemic colitis tx

A

Supportive

  • IVR, bowel rest, empiric abx (mod-severe cases)
  • NGT (ileus)
  • hold meds that can promote ischemia (ex: clotting meds)
  • optimize cardiac and pulmonary function

Laparotomy w/resection

84
Q

what is toxic megacolon?

A

Total or segmental non-obstructive colonic dilatation plus systemic toxicity

-Grossly inflamed colon usually due to infection

BAD AND VERY RARE

85
Q

toxic megacolon etiologies

A
  • IBD – Crohn’s, UC
  • Bacterial – C. Diff, Salmonella, Shigella, Campylobacter, Yersinia
  • Parasitic – E. histolytica, Cryptosporidium
  • Viral – CMV colitis
86
Q

toxic megacolon pathogenesis

A

Mucosal inflammation leads sequentially to the release of inflammatory mediators and bacterial products, increased inducible nitric oxide synthase, generation of excessive nitric oxide, and colonic dilatation

Severe inflammation of the smooth muscle layer which paralyzes the colonic smooth muscle, thereby leading to dilatation

87
Q

possible precipitating agents of toxic megacolon

A
  • Hypokalemia
  • Antimotility agents
  • Opiates
  • Anticholinergics
  • Antidepressants
  • Barium enema and colonoscopy
88
Q

dx of toxic megacolon

A

Abdominal distention and acute or chronic diarrhea

Radiographic evidence of colonic distention with at least 3 of the following:

  • Fever >38 C
  • HR >120 beats/min
  • WBC >10,500/microL
  • Anemia

At least one of the following:

  • Dehydration
  • Altered sensorium
  • Electrolyte disturbances
  • Hypotension
89
Q

toxic megacolon imaging

A

x-ray and CT scan

90
Q

toxic megacolon labs

A

CBC, Chem 7, stool WBC and cultures including C. diff

91
Q

what is the first line tx of toxic megacolon?

A

Non-operative

92
Q

what is the non-operative tx of toxic megacolon?

A
  • Includes fluid resuscitation
  • Correction of lab abnormalities
  • Antibiotics broad spectrum for IBD (Vanco and Flagyl for C Diff)
  • Intravenous corticosteroids (IBD)
  • NPO
  • Bowel decompression with a NGT if needed
93
Q

who is surgery reserved for, for treatment of toxic megacolon?

A

Surgery reserved for patient who don’t improve on non-operative management

94
Q

what is the surgery of choice for toxic megacolon?

A

subtotal colectomy with end-ileostomy (up to 50% mortality)

95
Q

what is the 4th leading cause of cancer mortality? most common in? age?

A

pancreatic cancer

M>F

rarely seen before age 45

96
Q

pancreatic cancer risk factors

A
  • Chronic pancreatitis (a lot of insult to the pancreas)
  • Smoking
  • Diabetes mellitus
  • Family history
97
Q

pancreatic cancer pt hx

A

Jaundice – tumors in the head of the pancreas

Weight loss

Pain – tumors in body and tail of the pancreas
(If tumor in head, no complaints of pain – JUST JAUNDICE)

Recent onset of atypical DM

98
Q

pt with jaundice has tumor where in pancreas?

A

head of the pancreas

99
Q

pt with pain has tumor where in pancreas?

A

body and tail of the pancreas

100
Q

pancreatic cancer physical exam

A

Palpable mass/Ascites late in disease

Courvoisier’s sign (non-tender palpable gallbladder with jaundice)

101
Q

what is Courvoisier’s sign?

A

sign for pancreatic cancer

-non-tender palpable gallbladder with jaundice

102
Q

pancreatic cancer labs

A

LFTs and cancer antigen 19-9 test

103
Q

pancreatic cancer imaging

A
  • CT scan
  • MRI
  • Ultrasound
  • EUS (endoscopic ultrasound)
104
Q

what is the treatment of choice for pancreatic cancer?

A

SURGERY - ONLY CURATIVE APPROACH

done for stage I-IIB

105
Q

types of surgery of pancreatic cancer

A

Whipple (tumor in head)

Distal pancreatectomy (tumor in body or tail)

106
Q

what is the most common pathology of pancreatic cancer?

A

ductal adenocarcinoma

107
Q

at the time of dx of pancreatic cancer, what as occurred?

A

metastasis to peripancreatic lymph nodes

108
Q

common places of pancreatic cancer metastasis?

A

Metastases to the liver (up to 80%), peritoneum (60%), lungs and pleura (50-70%), and adrenal glands (25%)

109
Q

can you resect pancreatic tumor after stage IIb?

A

no!!!

110
Q

benign pancreatic tumors

A

Serous cystadenoma -> cured by surgical removal alone

111
Q

premalignant pancreatic lesions

A

Intraductal papillary-mucinous neoplasms (IPMN)

Mucinous Cystadenoma

-Remove them, not cancer, but high likelihood that will become malignant

112
Q

endocrine tumors of pancreas

A
  • Gastrinoma
  • Insulinoma
  • VIPoma
  • Glucagonoma
  • Somatostatinomas

Clin Med 3 (21 decks)

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