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Appendix > Appendix > Flashcards

Appendix Flashcards

1
Q

How do we locate the base of the appendix?

A

follow taeniae coli to confluence on cecum

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2
Q

In what instance do we find the appendix in the LLQ?

A

situs inversus

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3
Q

Situs inversus is a rare genetic condition where we have transposition of abdominal organs, and appendix is found where?

A

LLQ

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4
Q

When do we see appendix positioned in LUQ?

A

instance of midgut malrotation (midgut fails to rotate or incompletely rotates arounds SMA)

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5
Q

Blood supply of appendix?

A

appendicular branch of ileo-colic artery

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6
Q

Innervation of appendix?

A

SNS: superior mesenteric plexus, PSNS: vagus

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7
Q

What are the layers of the appendix?

A

outer serosa–>muscularis layer–> submucosa + mucosa

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8
Q

Appendix is an immunological organ secreting what?

A

IgA

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9
Q

Lifetime risk of developing appendicitis?

A
  1. 6% males

6. 8 % females

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10
Q

Main causes of acute appendicitis?

A

obstruction of lumen; fecalith vs hypertrophied lymph tissue

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11
Q

What causes umbilical pain in appendicitis?

A 
lumen gets obstructed-->
closed loop obstruction-->
distention of lumen-->
visceral afferent stretch fibers-->
vague dull umbilical pain
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12
Q

Pathophysiology of appendicitis?

A 
obstructed lumen
continued distention
bacterial overgrowth
venous compromise
arterial compromise 
perforation
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13
Q

What causes the RLQ abdominal pain assc with appendicitis?

A

inflammation that ultimately reaches serosal layer of appendix and then the peritoneum

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14
Q

What two bugs commonly found in appendicitis?

A

bacteroides fragilis

e. coli

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15
Q

Pts with perforated appendicitis or gangrene tend to have what bug more?

A

bacteroides

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16
Q

Describe the pain of appendicitis:

A

initially diffuse umbilical visceral pain

becomes more localized to RLQ as peritoneum involved

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17
Q

Psoas sign?

A

pain with right hip extension

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18
Q

Obturator sign?

A

pain with right hip flexion and internal rotation

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19
Q

Rovsign’s sign?

A

RLQ tenderness with palpation of LLQ

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20
Q

For uncomplicated appendicitis, it is unusual to have what?

A

leukocytosis >18 K

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21
Q

Most widespread scoring system for appendicitis?

A

ALVARADO score

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22
Q

Role of abdominal xrays in appendicitis work up?

A

can show fecaliths, but rarely helpful

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23
Q

CT vs US in diagnosing appendicitis, which is more sensitive and specific?

A

CT

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24
Q

What does appendix look like on US?

A

blind-ending non-peristaltic bowel loop originating from cecum

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25
Q

Rate of misdiagnosis of appendicitis is?

A

15%

higher in women > men

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26
Q

What dx process most often confused for appendicitis in pediatric pts?

A

acute mesenteric adenitis (self-limited dx)

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27
Q

Differential dx in women who present with appendicitis?

A 
PID
ruptured follicle
twisted ovarian cyst
endometriosis 
ectopic
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28
Q

Incidence rate of appendicitis in immunocompromised HIV pts?

A

0.5% (higher than 0.1-0.2% in general population)

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29
Q

Compared to general population, HIV pts with appendicitis tend to have higher rates of?

A

perforation during surgical exploration

due to delay in presentation, low CD4

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30
Q

Gold standard for treatment of uncomplicated appendicitis?

A

appendectomy

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31
Q

Role of urgent vs emergent surgery for uncomplicated appendicitis?

A

emergent group had time from presentation to OR <12 hrs

urgent group 12-24 hrs

no statistically significant increase in complicated appendicitis between the two groups

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32
Q

What’s complicated appendicitis?

A

perfed appy commonly assc. with phlegmon or abscess

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33
Q

Which pts have highest rates of perforations?

A

children < 5 yrs

> 65 yrs

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34
Q

Conservative management vs early intervention for complicated appendicitis?

A

36% morbidity of early surgery

11% morbidity of conservative tx (fluids, abx, NPO, drainage)

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35
Q

What’s an interval appendectomy?

A

performing appendectomy after initial successful non-operative management in pts who are asymptomatic

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36
Q

What are your two incisions for an open appendectomy?

A

Rocky-Davis tranverse incision

McBurney oblique incision

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37
Q

Does placing drains for complicated and uncomplicated appendicitis have any benefit?

A

not supported by clinical trials

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38
Q

Do we irrigate in complicated appendicitis?

A

NO, can suction

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39
Q

If we don’t find appendicitis when we open the abdomen what do we do?

A

check for Crohn’s

check for Meckel’s

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40
Q

What’s Valentino’s appendicitis?

A

perforated duodenal ulcer presenting as appendicitis

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41
Q

Positioning for laparoscopic appendectomy?

A

pt supine, left arm tucked, possible Foley

surgeon + assistant stand to pt’s left, facing RLQ

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42
Q

Port-placement for lap. appy?

A

12 mm port at umbilicus

2 5 mm ports, one LLQ, one suprapubic

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43
Q

Benefits of laparoscopic v open appendectomy;

A

fewer SSI
less pain
shorter length of stay

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44
Q

Risk of intra-abdominal abscesses with laparoscopic vs open appendectomy?

A

higher in laparoscopic approach

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45
Q

Whats NOTES?

A

natural orifice transluminal endoscopic surgery

appendectomy thru vagina or gastrostomy

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46
Q

Appendiceal perforation rates in kids <5 yrs old?

A

45%

underdeveloped greater omentum can’t contain perforation

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47
Q

Antibiotic treatment for appendicitis in pediatric pts?

A

24-48 hrs in cases of non-perforated appendicitis

perforated appendicits–> abx until WBC normal, afebrile for 24 hrs

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48
Q

What’s perf rate of appendicitis in elderly?

A

50-70%

also increases with age >80

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49
Q

Most common non-gyn surgical emergency during pregnancy?

A

appendicitis

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50
Q

Incidence of appendicitis during pregnancy?

A

1/766 births

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51
Q

When does appendicitis occur during pregnancy?

A

anytime, but rare during 3rd trimester

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52
Q

What’s the most consistent sign seen in acute appendicitis during pregnancy?

A

right sided abdominal pain

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53
Q

Why is leukocytosis not helpful in appendicitis during pregnancy?

A

physiologic leukocytosis of pregnancy

can be as high as 16 K

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54
Q

Risk of fetal loss and risk of early delivery after appendectomy in pregnancy?

A

fetal loss 4%

early delivery 7%

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55
Q

Most common site for SSI in laparoscopic appendectomy?

A

umbilical port

56
Q

What’s stump appendicitis?

A

failure to remove entire appendix on initial procedure

present with sxs of recurrent appendicitis 9 yrs after initial procedure

57
Q

To prevent stump appendicitis, the appendiceal stump should be how long?

A

no longer than 0.5 cm

stump appendicitis noted only in stumps >0.5cm

58
Q

Why do we commonly performed appendectomy during Ladd’s procedure for malrotation?

A

cecum is displaced in LUQ, can complicate subsequent diagnosis of appendicitis

59
Q

What’s the prevalence of identifying a mass in the appendix during surgery?

A

less than 1%

60
Q

What are the most common appendix lesions identified during surgery?

A

appendiceal carcinoids

appendiceal adenomas

61
Q

This is a firm, yellow, bulbar mass in the appendix:

A

carcinoid of appendix

62
Q

What is the most common site of gastrointestinal carcinoid?

A

appendix–> then small bowel –>rectum

63
Q

Majority of appendiceal carcinoids found where?

A

tip of appendix

64
Q

Malignant potential of appendiceal carcinoid related to what?

A

size

tumors < 1 cm rarely extending outside appendix

65
Q

Treatment for carcinoids of appendix < 1 cm?

A

appendectomy

66
Q

When do we do a right hemicolectomy for appendiceal carcinoids?

A

tumors > 1 - 2 cm located at base
involving the mesentery
lymph node mets

67
Q

Primary adenocarcinoma of appendix is rare, has 3 subtypes:

A

mucinous adenocarcinoma

colonic adenocarcinoma

adenocarcinoid

68
Q

Recommended treatment for all pts with appendix adenocarcinoma is?

A

right hemi-colectomy

69
Q

What’s a mucocele of the appendix?

A

intraluminal accumulation of mucoid material

cause obstructive dilatation

70
Q

What causes mucoceles?

A

retention cysts
mucosal hyperplasia
cystadenomas
cystadenocarcinomas

71
Q

What do you do once you see a mucocele on laparoscopy?

A

convert to laparotomy

this ensures that a benign process does not convert to a malignant one by having the mucocele rupture

72
Q

Surgical management of appendiceal mucocele?

A

appendectomy
wide resection of meso-appendix
appendix lymph nodes
inspect base of appendix

73
Q

When do we perform a right hemi-colectomy or ileo-cecectomy for mucocele of appendix?

A

pts with positive margin at base of appendix or

positive peri-appendiceal nodes

74
Q

What is pseudomyxoma peritonei?

A

diffuse gelatinous fluid assc. with mucinous implants of peritoneal surfaces

(more common in females)

75
Q

Origin of majority of cases of pseudomyxomas?

A

appendix

76
Q

Tx for pseudomyxomas?

A

surgical debulking

remove all gross disease and omentum

appendectomy routinely done

hysterectomy b/l salpingo-oopherectomy done

77
Q

Lymphoma of the appendix is?

A

extremely rare

presents as appendicitis

78
Q

Tx for appendiceal lymphoma contained to appendix?

A

appendectomy

79
Q

Tx for appendiceal lymphoma that extends to mesentery or cecum?

A

R- hemicolectomy

80
Q

Does appendiceal lymphoma need adjuvant chemo?

A

If it’s confined to the appendix NO

81
Q

CT findings that should raise suspicion for lymphoma of appendix?

A

appendix diameter > 2.5 cm

surrounding soft tissue thickening

82
Q

Blood supply of appendix?

A

appendiceal artery, branch of ileo-colic

83
Q

Embryologically the appendix is derived from?

A

midgut

84
Q

Most common location we find the appendix is?

A

retrocecal

85
Q

Major cause of acute appendicitis?

A 
luminal obstruction
(fecalith, lymphoid hyperplasia, seeds, parasites, neoplasm)
86
Q

What causes the peri-umbilical visceral pain associated with appendicitis?

A

luminal obstruction causing luminal distention

87
Q

Most common aerobic bug found in perforated appendicitis cultures?

A

E.coli

88
Q

Most common anaerobic bug found in perforated appendicitis cultures?

A

bacteroides fragilis

89
Q

Typical presentation of appendicitis?

A

Periumbilical pain followed by anorexia and nausea

90
Q

Where is McBurney’s point?

A

1/3 of the distance from ASIS to umbilicus

91
Q

What’s Dunphy’s sign?

A

when someone with suspected appendicitis coughs and they have pain

92
Q

What diameter do we usually need on CT imaging to classify as dilated appendix suspicious for appendicitis?

A

7mm

93
Q

Perforations in acute appendicitis tend to happen more in what pt population?

A

very young

very old

94
Q

How do you distinguish appendicitis vs intussusception in younger kids?

A

intussusception pain is colicky, with pain-free periods, and no peritonitis

95
Q

For open appendectomy we performed what type of incision?

A

Rocky-Davis- tranverse RLQ incision

McArthurt-McBurney- oblique RLQ incision

96
Q

For open appendectomies, once the appendix is removed and the stump is sutured, what do we do with the appendiceal stump?

A

performed a Z stitch (absorbable purse string suture)

stump is inverted into fold of cecal wall

97
Q

Wound infection rate after open appendectomy?

A

most cases, less than 5%

98
Q

Risk of recurrent appendicitis after non-operative management is?

A

15-25%

99
Q

For interval appendectomies we perform it how long after a bout of appendicitis?

A

6 weeks

100
Q

Mortality after appendectomy is?

A

less than 1 %

101
Q

Most common complications seen after appendectomy?

A

SSI

abscesses

102
Q

Most common appendiceal neoplasms?

A

carcinoid vs mucinous?

103
Q

What’s an appendiceal mucocele?

A

obstruction of appendix lumen

distention of appendix caused by intraluminal accumulation of mucoid material

104
Q

What is pseudomyxoma peritonei?

A

mucoceles that have ruptured spread epithelial cells within mucoid fluid throughout the peritoneal cavity

105
Q

Appendiceal carcinoids are neuroendocrine tumors that express what marker?

A

S-100

106
Q

What cell type do appendiceal carcinoids come from?

A

enterochromaffin cell type

107
Q

Adenocarcinoma of appendix is found in what % of specimens?

A

1 %

108
Q

Factors associated with perforated appendicitis?

A

male sex
older age
lack of insurance
three or more comorbid conditions

109
Q

Most common complication after laparoscopic appendectomy?

A

SSI

usually if this happens, the incision should be opened and pus should be drained and cultured

110
Q

What is the most common appendiceal mass?

A

carcinoid 80%

111
Q

When do we perform right hemicolectomy for carcinoid appendiceal masses?

A 
mucosal cell origin
assc with mucin production
lymphovascular invasion
involvement of lymph nodes of appendix 
tumors > 2 cm, tumors located at base of appendix
112
Q

Percutaneous abscess drainages for complicated appendicitis is indicated for abscesses what size?

A

> 4 cm

113
Q

What causes the localizing RLQ pain in appendicitis?

A

parietal peritoneum becomes inflamed

114
Q

CT scan showed a 2cm cystic lesion in appendix. A pt had an appendectomy, path showed a high grade mucinous neoplasm of appendix, what to do next?

A

nothing, no need for a right hemi if lesion did not rupture, confined to the appendix, and is completely resected

right hemi after appendectomy recommended for mucinous adenocarcinoma of appendix

115
Q

Highest rates of appendicitis during pregnancy noted during what trimester?

A

2nd

lowest rate during 3rd trimester

116
Q

Most common symptom of appendicitis in pregnant women?

A

RLQ abdominal pain close to McBurney’s

however during 3rd trimester, appendix migrates cephalad due to expanding uterus; so pain can localize to mid or upper abdomen

117
Q

McBurney;s point tenderness may be less prominent during pregnancy?

A

gravid uterus lifts and stretches abdominal wall from appendix

118
Q

Leukocytosis during pregnancy?

A

can be a normal finding

can be as high as 17K during 3rd trimester and 30K during labor

119
Q

When do we see microscopic hematuria and pyuria in suspected pts with appendicitis?

A

when inflamed appendix is close to bladder/ureter

120
Q

Initial modality of choice for imaging appendix in pregnancy?

A

US

**MRI next test when US inconclusive

121
Q

US findings of appendicitis in pregnant pts?

A

non-compressible, blind-ending, tubular structure in RLQ

122
Q

Do we use gadolinium during MRI for pregnant pts suspected of acute appendicitis?

A

No

123
Q

How sensitive and specific is MRI for acute appendicits?

A

sensitivity 94%

specificity 97%

124
Q

Abx coverage for acute appendicitis?

A

gram negative + gram positive coverage (2nd generation cephalosporin)

coverage for anaerobes (clindamycin + metronidazole)

125
Q

Maternal morbidity in pregnant pts following appendectomy?

A

same as non-pregnant pts

126
Q

What is the risk of fetal demise in pregnant pts if appendix perforates?

A

fetal loss of 36% (perforated) v 1.5% (non-perforated)

if there is generalized peritonitis (fetal loss of 6 vs 2 %)

(early delivery 11 v 4 %)

127
Q

What’s an acceptable negative laparotomy rate for appendicitis in pregnant pts?

A

20-35 %

this is b/c morbidity associated with missed appendicitis in pregnancy is higher (fetal loss, early delivery)

128
Q

In a pregnant pt suspected of appendicitis who undergoes surgery, what do you do if appendix is normal?

A

remove it ; histological exam may reveal acute inflammation

excision avoids future trouble for intervention for suspected appendicitis

129
Q

Do pregnant pts who have undergone appendectomy have an increased risk of dehiscene of appendectomy site wounds during labor?

A

no increased risk if fascia closed appropriately.

130
Q

How do you manage a pregnant pt with suspected perforated appendicits?

A

depends if perforation is a; free perforation vs walled-off perforation

free perf–> causes dissemination of fecal material, pus, which increases risk of pre-term labor, and fetal loss–> need urgent laparotomy

walled-off perforation–> non-pregnant pts with sxs >5 days and have a contained perf can be initially treated with abx (will have a phlegmon or abscess on imaging)

most of these pts respond to IVF and abx, not advisable to operate on these pts due to increased morbidity bc of inflammation and dense adhesions

***for walled off perforations in pregnant women, not much evidence about conservative management

131
Q

Benefits of laparoscopic approach over open approach in appendectomy in pregnancy?

A

shorter hospital stay

lower overall complication rates

132
Q

Overall differences in laparoscopic vs open approach for appendectomy during pregnancy?

A

similar outcomes noted for operative times, birth weight, incidence of preterm birth, c-section delivery rates

133
Q

Benefits of open approach for appendectomy during pregnancy?

A

reduced risk of fetal loss vs laparoscopic approach

134
Q

When doing an open appy in pregnant ps, what type of incision do you make?

A

tranverse incision made over McBurney’s point or point of maximal tenderness

when dx is less clear; make a vertical midline incision; can diagnose other conditions that mimic appendicitis

135
Q

When doing a laparoscopic appendectomy during pregnancy, what trimester do we do it in?

A

can be performed successfully during all trimesters with few complications

136
Q

If performing a laparoscopic appendectomy, what modifications need to be made?

A

place pt in left lateral decubitus if in 2nd trimester

using CO2 insufflation of 10-12 mmHg

directly visualizing trocar placement

137
Q

Most common general surgical problem encountered during pregnancy?

A

appendicitis

Appendix (39 decks)

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