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Surgery Clerkship - Procedures > Appendix > Flashcards

Appendix Flashcards

1
Q

What vessel provides blood supply to the appendix?

A

Appendiceal artery (branch of the ileocolic artery)

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2
Q

Name the mesentery of the appendix. What does it contain?

A

Mesoappendex (contains the appendiceal artery)

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3
Q

How can the appendix be located if the cecum has been identified?

A

Follow the teniae coli down to the appendix; the teniae converge on the appendix

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4
Q

What is appendicitis?

A

Inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop with resultant inflammation that can lead to necrosis and perforation

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5
Q

Causes of appendicitis?

A

Lymphoid hyperplasia

Fecalith (aka appendicolith)

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6
Q

Lifetime incidence of acute appendicitis in the US?

A

~7%

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7
Q

Most common cause of emergent abdominal surgery in the US?

A

Acute appendicitis

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8
Q

Classical presentation of appendicitis?

A

Periumbilical pain (intermittent and crampy) -> N/V -> anorexia -> pain migrates to RLQ (constant and intense), usually in <24 hours

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9
Q

Why does periumbilical pain occur?

A

Referred pain

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10
Q

Why does RLQ pain occur?

A

Peritoneal irritation

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11
Q

What are the signs/symptoms of appendicitis?

A

Signs of peritoneal irritation may be present (guarding, muscle spasm, rebound tenderness, obturator, psoas signs), low-grade fever (high grade if perf occurs), RLQ hyperesthesia

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12
Q

Define - obturator sign.

A

Pain upon internal rotation of the leg with the hip and knee flexed; seen in patients with pelvic appendicitis

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13
Q

Define - psoas sign.

A

Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance; classically seen in retrocecal appendicitis

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14
Q

Define - Rovsing’s sign.

A

Palpation or rebound pressure of the LLQ results in pain in the RLQ; seen in appendicitis

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15
Q

Define - McBurney’s point.

A

Point 1/3 from the ASIS to the umbilicus (often the point of max tenderness)

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16
Q

DDx for appendicitis? (everyone)

A

Everyone: Meckel’s, Crohn’s disease, perforated ulcer, pancreatitis, mesenteric lymphadenitis, constipation, gastroenteritis intusussception, volvulus, tumors, UTI (eg., cystitis), pyelonephritis, torsed epiplociae, cholecystitis, cecal tumor, diverticulitis (floppy sigmoid)

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17
Q

DDx for appendicitis? (females)

A

Ovarian cyst, ovarian torsion, tuboovarian abscess, mittelschmerz, PID, ectopic pregnancy, rupture pregnancy

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18
Q

What labs should be performed in suspected appendicitis?

A

CBC: increased WBC (>10000 in >90% of cases), most often with a “left shift”
UA to evaluate for pyelo or renal calculus

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19
Q

Can you have an abnormal UA in appendicitis?

A

Yes; mild hematuria and pyuria are common in appendicitis with pelvic inflammation, resulting in inflammation of the ureter

20
Q

What additional tests can be performed if the dx of appendicitis is not clear?

A

Spiral CT, U/S (may see a large, non-compressible appendix or fecalith)

21
Q

In acute appendicitis, what classically precedes vomiting?

A

Pain (in gastroenteritis, the pain classically follows vomiting)

22
Q

What radiographic studies are often performed?

A

CXR to rule out RML or RLL pneumonia, free air

AXR: abdominal films are usually non-specific, but calcified fecalith present in ~5% of cases

23
Q

What are the CT scan findings with acute appendicitis?

A

Periappendiceal fat stranding, appendiceal diameter >6 mm, periappendiceal fluid, fecalith

24
Q

Preoperative prep for appendicitis?

A

Rehydration with IV fluids (LR)

Preoperative ABX with antibiotic coverage (appendix is considered part of the colon)

25
Q

Rx for non-perforated acute appendicitis?

A

Prompt appendectomy to prevent perforation, 24 hours of ABX, discharge home usually on POD #1

26
Q

Rx for perforated acute appendicitis?

A

IV fluid resuscitation
Prompt appendectomy
All pus is drained with post-op ABX continued for 3-7 days; wound left open in most cases after closing the fascia (heal by secondary intention or delayed primary closure)

27
Q

How is an appendiceal abscess that is diagnosed pre-operatively treated?

A

Percutaneous drainage of the abscess, antibiotic administration, ad elective appendectomy ~6 weeks later

28
Q

If a normal appendix is found upon exploration, should you take out the normal appendix?

A

Yes

29
Q

How long after removal of a non-ruptured appendix should ABX continue post-operatively?

A

24 hours

30
Q

Which antibiotic is used for non-perforated appendicitis?

A

Anaerobic coverage -> cefoxitin, cefotetan, unasyn, cipro, flagyl

31
Q

Which antibiotic is used for a perforated appendix?

A

Broad-spectrum ABX (eg, amp/cipro/clinda, Zosyn)

32
Q

How long do you give ABX for perforated appendicitis?

A

Until the patient has a normal WBC count and is afebrile, ambulating, and eating a regular diet (usually 3-7 days)

33
Q

What is the risk of perforation?

A

~25% by 24 hours from onset of symptoms, 50% by 36 hours, 75% by 48 hours

34
Q

What is the most common general surgical abdominal emergency in pregnancy?

A

Appendicitis (~1/1750); appendix may be in the RUQ because of the enlarged uterus

35
Q

Possible complications of appendicitis?

A

Pelvic abscess
Liver abscess
Free perforation
Portal pylethrombophlebitis (very rare)

36
Q

What % of negative appendectomies is acceptable?

A

Up to 20%

37
Q

Who is at risk of dying from acute appendicitis?

A

Very old and very young patients

38
Q

What bacteria are associated with mesenteric adenitis that can closely mimic acute appendicitis?

A

Y. enterocolitica

39
Q

What are the layers of the abdominal wall during a McBurney incision?

A 
Skin
Subcutaneous fat
Scarpa's fascia
External oblique
Internal oblique
Transversus muscle
Transversalis fascia
Preperitoneal fat
Peritoneum
40
Q

If you find Crohn’s disease in the terminal ileum, will you remove the appendix?

A

Yes, if the cecal/eappendiceal base is not involved

41
Q

If the appendix is normal, what do you inspect intraoperatively?

A

Terminal ileum: Meckel’s diverticulum, Crohn’s disease, intussusception

Gyne - cysts, torsion, etc

Groin - hernia, rectus sheath hematoma, adenopathy (adenitis)

42
Q

What is the most common appendceal tumor?

A

Carcinoid tumor

43
Q

What s the treatment of appendiceal carcinoid <1.5 cm?

A

Appendectomy (if not through the bowel wall)

44
Q

Rx appendiceal carcinoid >1.5 cm?

A

R hemicolectomy

45
Q

What percentage of appendiceal carcinoids are malignant?

A

<5%

46
Q

DDx - appendiceal tumor?

A

Carcinoid
Adenocarcinoma
Malignant mucoid adenocarcinoma

47
Q

What type of appendiceal tumor can cause the dreaded pseudomyxoma peritonei if the appendix ruptures?

A

Malignant mucoid adenocarcinoma

Surgery Clerkship - Procedures (17 decks)

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