Appendix Flashcards
How do we locate the base of the appendix?
follow taeniae coli to confluence on cecum
In what instance do we find the appendix in the LLQ?
situs inversus
Situs inversus is a rare genetic condition where we have transposition of abdominal organs, and appendix is found where?
LLQ
When do we see appendix positioned in LUQ?
instance of midgut malrotation (midgut fails to rotate or incompletely rotates arounds SMA)
Blood supply of appendix?
appendicular branch of ileo-colic artery
Innervation of appendix?
SNS: superior mesenteric plexus, PSNS: vagus
What are the layers of the appendix?
outer serosa–>muscularis layer–> submucosa + mucosa
Appendix is an immunological organ secreting what?
IgA
Lifetime risk of developing appendicitis?
- 6% males
6. 8 % females
Main causes of acute appendicitis?
obstruction of lumen; fecalith vs hypertrophied lymph tissue
What causes umbilical pain in appendicitis?
lumen gets obstructed--> closed loop obstruction--> distention of lumen--> visceral afferent stretch fibers--> vague dull umbilical pain
Pathophysiology of appendicitis?
obstructed lumen continued distention bacterial overgrowth venous compromise arterial compromise perforation
What causes the RLQ abdominal pain assc with appendicitis?
inflammation that ultimately reaches serosal layer of appendix and then the peritoneum
What two bugs commonly found in appendicitis?
bacteroides fragilis
e. coli
Pts with perforated appendicitis or gangrene tend to have what bug more?
bacteroides
Describe the pain of appendicitis:
initially diffuse umbilical visceral pain
becomes more localized to RLQ as peritoneum involved
Psoas sign?
pain with right hip extension
Obturator sign?
pain with right hip flexion and internal rotation
Rovsign’s sign?
RLQ tenderness with palpation of LLQ
For uncomplicated appendicitis, it is unusual to have what?
leukocytosis >18 K
Most widespread scoring system for appendicitis?
ALVARADO score
Role of abdominal xrays in appendicitis work up?
can show fecaliths, but rarely helpful
CT vs US in diagnosing appendicitis, which is more sensitive and specific?
CT
What does appendix look like on US?
blind-ending non-peristaltic bowel loop originating from cecum
Rate of misdiagnosis of appendicitis is?
15%
higher in women > men
What dx process most often confused for appendicitis in pediatric pts?
acute mesenteric adenitis (self-limited dx)
Differential dx in women who present with appendicitis?
PID ruptured follicle twisted ovarian cyst endometriosis ectopic
Incidence rate of appendicitis in immunocompromised HIV pts?
0.5% (higher than 0.1-0.2% in general population)
Compared to general population, HIV pts with appendicitis tend to have higher rates of?
perforation during surgical exploration
due to delay in presentation, low CD4
Gold standard for treatment of uncomplicated appendicitis?
appendectomy
Role of urgent vs emergent surgery for uncomplicated appendicitis?
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
What’s complicated appendicitis?
perfed appy commonly assc. with phlegmon or abscess
Which pts have highest rates of perforations?
children < 5 yrs
> 65 yrs
Conservative management vs early intervention for complicated appendicitis?
36% morbidity of early surgery
11% morbidity of conservative tx (fluids, abx, NPO, drainage)
What’s an interval appendectomy?
performing appendectomy after initial successful non-operative management in pts who are asymptomatic
What are your two incisions for an open appendectomy?
Rocky-Davis tranverse incision
McBurney oblique incision
Does placing drains for complicated and uncomplicated appendicitis have any benefit?
not supported by clinical trials
Do we irrigate in complicated appendicitis?
NO, can suction
If we don’t find appendicitis when we open the abdomen what do we do?
check for Crohn’s
check for Meckel’s
What’s Valentino’s appendicitis?
perforated duodenal ulcer presenting as appendicitis
Positioning for laparoscopic appendectomy?
pt supine, left arm tucked, possible Foley
surgeon + assistant stand to pt’s left, facing RLQ
Port-placement for lap. appy?
12 mm port at umbilicus
2 5 mm ports, one LLQ, one suprapubic
Benefits of laparoscopic v open appendectomy;
fewer SSI
less pain
shorter length of stay
Risk of intra-abdominal abscesses with laparoscopic vs open appendectomy?
higher in laparoscopic approach
Whats NOTES?
natural orifice transluminal endoscopic surgery
appendectomy thru vagina or gastrostomy
Appendiceal perforation rates in kids <5 yrs old?
45%
underdeveloped greater omentum can’t contain perforation
Antibiotic treatment for appendicitis in pediatric pts?
24-48 hrs in cases of non-perforated appendicitis
perforated appendicits–> abx until WBC normal, afebrile for 24 hrs
What’s perf rate of appendicitis in elderly?
50-70%
also increases with age >80
Most common non-gyn surgical emergency during pregnancy?
appendicitis
Incidence of appendicitis during pregnancy?
1/766 births
When does appendicitis occur during pregnancy?
anytime, but rare during 3rd trimester
What’s the most consistent sign seen in acute appendicitis during pregnancy?
right sided abdominal pain
Why is leukocytosis not helpful in appendicitis during pregnancy?
physiologic leukocytosis of pregnancy
can be as high as 16 K
Risk of fetal loss and risk of early delivery after appendectomy in pregnancy?
fetal loss 4%
early delivery 7%
Most common site for SSI in laparoscopic appendectomy?
umbilical port
What’s stump appendicitis?
failure to remove entire appendix on initial procedure
present with sxs of recurrent appendicitis 9 yrs after initial procedure
To prevent stump appendicitis, the appendiceal stump should be how long?
no longer than 0.5 cm
stump appendicitis noted only in stumps >0.5cm
Why do we commonly performed appendectomy during Ladd’s procedure for malrotation?
cecum is displaced in LUQ, can complicate subsequent diagnosis of appendicitis
What’s the prevalence of identifying a mass in the appendix during surgery?
less than 1%
What are the most common appendix lesions identified during surgery?
appendiceal carcinoids
appendiceal adenomas
This is a firm, yellow, bulbar mass in the appendix:
carcinoid of appendix
What is the most common site of gastrointestinal carcinoid?
appendix–> then small bowel –>rectum
Majority of appendiceal carcinoids found where?
tip of appendix
Malignant potential of appendiceal carcinoid related to what?
size
tumors < 1 cm rarely extending outside appendix
Treatment for carcinoids of appendix < 1 cm?
appendectomy
When do we do a right hemicolectomy for appendiceal carcinoids?
tumors > 1 - 2 cm located at base
involving the mesentery
lymph node mets
Primary adenocarcinoma of appendix is rare, has 3 subtypes:
mucinous adenocarcinoma
colonic adenocarcinoma
adenocarcinoid
Recommended treatment for all pts with appendix adenocarcinoma is?
right hemi-colectomy
What’s a mucocele of the appendix?
intraluminal accumulation of mucoid material
cause obstructive dilatation
What causes mucoceles?
retention cysts
mucosal hyperplasia
cystadenomas
cystadenocarcinomas
What do you do once you see a mucocele on laparoscopy?
convert to laparotomy
this ensures that a benign process does not convert to a malignant one by having the mucocele rupture
Surgical management of appendiceal mucocele?
appendectomy
wide resection of meso-appendix
appendix lymph nodes
inspect base of appendix
When do we perform a right hemi-colectomy or ileo-cecectomy for mucocele of appendix?
pts with positive margin at base of appendix or
positive peri-appendiceal nodes
What is pseudomyxoma peritonei?
diffuse gelatinous fluid assc. with mucinous implants of peritoneal surfaces
(more common in females)
Origin of majority of cases of pseudomyxomas?
appendix
Tx for pseudomyxomas?
surgical debulking
remove all gross disease and omentum
appendectomy routinely done
hysterectomy b/l salpingo-oopherectomy done
Lymphoma of the appendix is?
extremely rare
presents as appendicitis
Tx for appendiceal lymphoma contained to appendix?
appendectomy
Tx for appendiceal lymphoma that extends to mesentery or cecum?
R- hemicolectomy
Does appendiceal lymphoma need adjuvant chemo?
If it’s confined to the appendix NO
CT findings that should raise suspicion for lymphoma of appendix?
appendix diameter > 2.5 cm
surrounding soft tissue thickening
Blood supply of appendix?
appendiceal artery, branch of ileo-colic
Embryologically the appendix is derived from?
midgut
Most common location we find the appendix is?
retrocecal
Major cause of acute appendicitis?
luminal obstruction (fecalith, lymphoid hyperplasia, seeds, parasites, neoplasm)
What causes the peri-umbilical visceral pain associated with appendicitis?
luminal obstruction causing luminal distention
Most common aerobic bug found in perforated appendicitis cultures?
E.coli
Most common anaerobic bug found in perforated appendicitis cultures?
bacteroides fragilis
Typical presentation of appendicitis?
Periumbilical pain followed by anorexia and nausea
Where is McBurney’s point?
1/3 of the distance from ASIS to umbilicus
What’s Dunphy’s sign?
when someone with suspected appendicitis coughs and they have pain
What diameter do we usually need on CT imaging to classify as dilated appendix suspicious for appendicitis?
7mm
Perforations in acute appendicitis tend to happen more in what pt population?
very young
very old
How do you distinguish appendicitis vs intussusception in younger kids?
intussusception pain is colicky, with pain-free periods, and no peritonitis
For open appendectomy we performed what type of incision?
Rocky-Davis- tranverse RLQ incision
McArthurt-McBurney- oblique RLQ incision
For open appendectomies, once the appendix is removed and the stump is sutured, what do we do with the appendiceal stump?
performed a Z stitch (absorbable purse string suture)
stump is inverted into fold of cecal wall
Wound infection rate after open appendectomy?
most cases, less than 5%
Risk of recurrent appendicitis after non-operative management is?
15-25%
For interval appendectomies we perform it how long after a bout of appendicitis?
6 weeks
Mortality after appendectomy is?
less than 1 %
Most common complications seen after appendectomy?
SSI
abscesses
Most common appendiceal neoplasms?
carcinoid vs mucinous?
What’s an appendiceal mucocele?
obstruction of appendix lumen
distention of appendix caused by intraluminal accumulation of mucoid material
What is pseudomyxoma peritonei?
mucoceles that have ruptured spread epithelial cells within mucoid fluid throughout the peritoneal cavity
Appendiceal carcinoids are neuroendocrine tumors that express what marker?
S-100
What cell type do appendiceal carcinoids come from?
enterochromaffin cell type
Adenocarcinoma of appendix is found in what % of specimens?
1 %
Factors associated with perforated appendicitis?
male sex
older age
lack of insurance
three or more comorbid conditions
Most common complication after laparoscopic appendectomy?
SSI
usually if this happens, the incision should be opened and pus should be drained and cultured
What is the most common appendiceal mass?
carcinoid 80%
When do we perform right hemicolectomy for carcinoid appendiceal masses?
mucosal cell origin assc with mucin production lymphovascular invasion involvement of lymph nodes of appendix tumors > 2 cm, tumors located at base of appendix
Percutaneous abscess drainages for complicated appendicitis is indicated for abscesses what size?
> 4 cm
What causes the localizing RLQ pain in appendicitis?
parietal peritoneum becomes inflamed
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?
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
Highest rates of appendicitis during pregnancy noted during what trimester?
2nd
lowest rate during 3rd trimester
Most common symptom of appendicitis in pregnant women?
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
McBurney;s point tenderness may be less prominent during pregnancy?
gravid uterus lifts and stretches abdominal wall from appendix
Leukocytosis during pregnancy?
can be a normal finding
can be as high as 17K during 3rd trimester and 30K during labor
When do we see microscopic hematuria and pyuria in suspected pts with appendicitis?
when inflamed appendix is close to bladder/ureter
Initial modality of choice for imaging appendix in pregnancy?
US
**MRI next test when US inconclusive
US findings of appendicitis in pregnant pts?
non-compressible, blind-ending, tubular structure in RLQ
Do we use gadolinium during MRI for pregnant pts suspected of acute appendicitis?
No
How sensitive and specific is MRI for acute appendicits?
sensitivity 94%
specificity 97%
Abx coverage for acute appendicitis?
gram negative + gram positive coverage (2nd generation cephalosporin)
coverage for anaerobes (clindamycin + metronidazole)
Maternal morbidity in pregnant pts following appendectomy?
same as non-pregnant pts
What is the risk of fetal demise in pregnant pts if appendix perforates?
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 %)
What’s an acceptable negative laparotomy rate for appendicitis in pregnant pts?
20-35 %
this is b/c morbidity associated with missed appendicitis in pregnancy is higher (fetal loss, early delivery)
In a pregnant pt suspected of appendicitis who undergoes surgery, what do you do if appendix is normal?
remove it ; histological exam may reveal acute inflammation
excision avoids future trouble for intervention for suspected appendicitis
Do pregnant pts who have undergone appendectomy have an increased risk of dehiscene of appendectomy site wounds during labor?
no increased risk if fascia closed appropriately.
How do you manage a pregnant pt with suspected perforated appendicits?
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
Benefits of laparoscopic approach over open approach in appendectomy in pregnancy?
shorter hospital stay
lower overall complication rates
Overall differences in laparoscopic vs open approach for appendectomy during pregnancy?
similar outcomes noted for operative times, birth weight, incidence of preterm birth, c-section delivery rates
Benefits of open approach for appendectomy during pregnancy?
reduced risk of fetal loss vs laparoscopic approach
When doing an open appy in pregnant ps, what type of incision do you make?
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
When doing a laparoscopic appendectomy during pregnancy, what trimester do we do it in?
can be performed successfully during all trimesters with few complications
If performing a laparoscopic appendectomy, what modifications need to be made?
place pt in left lateral decubitus if in 2nd trimester
using CO2 insufflation of 10-12 mmHg
directly visualizing trocar placement
Most common general surgical problem encountered during pregnancy?
appendicitis
