Appendix

Question 1

A 34-year-old female is diagnosed with acute appendicitis and taken to the operating room where she undergoes an uneventful laparoscopic appendectomy. She is discharged home on postoperative day #1. The final pathology report demonstrates a 1.0 cm carcinoid tumor in the tip of the specimen. Which of the following is the MOST appropriate management strategy?

a. No further management is necessary
b. Recommend evaluation by an oncologist for possible adjuvant therapy
c. Recommend re-exploration with ileocecetomy
d. Recommend re-exploration with right colectomy

Answer 1

a. No further management is necessary

Question 2

A 46-year-old female patient undergoes a routine open appendectomy after presenting through the ER with classic appendicitis. On postoperative day 1, you note increasing redness and watery drainage from the wound. Closer examination shows crepitus around the wound edges with an associated bronze hue. Which of the following with the MOST likely pathogen causing the wound infection?

A. S. aureus

B. C. difficile

C. P. aeruginosa

D. S. epidermidis

E. S. pyogenes

Answer 2

E. S. pyogenes

Question 3

A 33-year-old female sustains a gunshot wound to the left lower quadrant. A CT scan demonstrates free air in the abdomen. You suspect an injury to the sigmoid colon. What is the MOST appropriate prophylactic antibiotic to be administered intravenously prior to surgery?

A. Cefoxitin

B. Neomycin plus erythromycin

C. Cefazolin

D. Metronidazole

E. Erythromycin

Answer 3

A. Cefoxitin

Question 4

A 29-year-old male presents with a 24h history of abdominal pain and anorexia. He initially described periumbilical pain but now states that the pain is most severe in his right lower quadrant. He is febrile and has a leukocytosis with slight left shift. Examination reveals tenderness of the RLQ and guarding. The patient is taken to the operating room without imaging studies with the working diagnosis of appendicitis. However, laparoscopic evaluation reveals a normal appendix and cecum with a significantly inflamed terminal ileum. Which of the following is the most appropriate next step?

A. Ileo-cecectomy

B. Right hemicolectomy

C. Appendectomy

D. Terminate the procedure and perform interval appendectomy in 6 weeks

E. Laparoscopic drain placement without appendectomy

Answer 4

C. Appendectomy

Question 5

A 34-year-old female is diagnosed with acute appendicitis and taken to the operating room where she undergoes an uneventful laparoscopic appendectomy. She is discharged home on postoperative day 1. The final pathology report demonstrates a 1.0cm carcinoid tumor in the tip of the specimen. Which of the following is the MOST appropriate management strategy?

A. No further management is necessary

B. Recommend evaluation by an oncologist for possible adjuvant therapy

C. Recommend re-exploration with ileocecectomy

D. Recommend re-exploration with right colectomy

Answer 5

A. No further management is necessary

Question 6

A 45-year-old female presents with a 24-hour history of abdominal pain and decreased appetite. She states that her pain began in in the periumbilical region and over the past few hours has migrated to her RLQ. PE reveals focal peritonitis in the RLQ with involuntary guarding and rebound tenderness. The patient is taken to the OR without any further imaging. Initial laparoscopic evaluation reveals an inflamed appendix. Diffusely occurring peritoneal implants are also observed. The appendix is removed and intraoperative pathology shows mucinous cystadenocarcinoma. Which of the ff is the most appropriate step?

A. No further surgical resection is necessary

B. Ileocecectomy

C. Right hemicolectomy

D. Right hemicolectomy and debulking of peritoneal implants

E. Total abdominal colectomy with end colostomy

Answer 6

D. Right hemicolectomy and debulking of peritoneal implants

Question 7

A 54-year-old female presents to the ER with abdominal pain over the past week. The pain has been intermittent but has not completely resolved. A CT scan is performed which shows a distended appendix with a 2cm cystic lesion. The appendix is removed and pathology describes a cystadenocarcinoma. What is the BEST next step in management?

A. No further intervention

B. Radiation therapy

C. Adjuvant chemotherapy

D. Right hemicolectomy

E. Intraperitoneal chemotherapy for pseudomyxoma peritonei

Answer 7

D. Right hemicolectomy

Question 8

A 33-year-old female who is 23 weeks pregnant presents to the ER. She complains of right-sided mid-abdominal pain and anorexia for the past 24h. She states that this pain is different from any other she has experienced in her pregnancy. VS are within normal limits. WBC count is 16,000 cells/mm3. UTZ is consistent with acute appendicitis. All of the ff are true regarding acute appendicitis in pregnancy EXCEPT:

A. Acute appendicitis is the most common surgical emergency during pregnancy

B. There is no association between appendectomy and subsequent fertility

C. Pain is most commonly located in the mid-right abdomen, not RLQ

D. Risk of fetal loss after removing a normal appendix is 25%

E. It may occur in any trimester

Answer 8

D. Risk of fetal loss after removing a normal appendix is 25%

Question 9

Which of the ff is the MOST common malignancy of the appendix?

A. Gastrointestinal stromal tumor

B. Adenocarcinoma

C. Carcinoid

D. Goblet cell carcinoma

E. Signet-ring cell carcinoma

Answer 9

B. Adenocarcinoma

Question 10

A 32-year-old male presents to the ER after 3 days of abdominal pain and nausea. On exam, the patient is febrile and has tenderness in his RLQ. A CT scan is performed showing inflamed appendix with free fluid in the RLQ, suspicious for a perforation. What is the MOST common bacteria isolated in a perforated appendix?

A. Bacteroides

B. Pseudomonas

C. Streptococcus

D. Clostridium

E. Fusobacterium

Answer 10

A. Bacteroides

*and E. Coli

Question 11

A 21-year-old male presents to the ER with a 5-day history of fever, nausea, vomiting, and anorexia. He admits to abdominal pain that has localized to the RLQ over the past 3 days. PE reveals tenderness between the umbilicus and anterior superior iliac spine on the right. The abdomen is otherwise soft. Lab evaluation demonstrates a leukocytosis of 19,000 cells/mcl. CT scan demonstrates an inflammatory process in the right lower quadrant with a 4.5cm fluid collection containing a calcified appearing nodule adjacent to the cecum. The remainder of the intestine and colon appear normal. What is the MOST appropriate management?

A. Broad spectrum IV antibiotics and observation with plans for interval appendectomy in 6-12 weeks

B. Broad spectrum antibiotics and CT guided percutaneous drainage of the fluid collection

C. Urgent laparoscopic appendectomy

D. Urgent laparotomy and right colectomy

Answer 11

B. Broad spectrum antibiotics and CT guided percutaneous drainage of the fluid collection

*phlegmon–> interval AP

Question 12

A 30-year-old woman presents with fever and lower abdominal pain. She undergoes surgery for presumed appendicitis but at operation the appendix is normal. In this patient:

A. If a ruptured Graafian follicle is found, the ovary and appendix should be removed.

B. If endometriomas of both ovaries are found, an appendectomy should still be carried out

C. All of the above

D. None of the above

Answer 12

D. None of the above

Question 13

At operation for presumed appendicitis, a 26-year-old patient was found to have a firm, yellow, bulbar mass at the tip of the appendix. You estimate its size to be 0.8cm. You should:

A. Perform a right hemicolectomy

B. Perform a cecectomy

C. Perform an appendectomy

D. Perform a wide excision of the appendix and mesoappendix, possible cecorrhaphy

Answer 13

C. Perform an appendectomy

Question 14

The initial diagnostic and therapeutic procedure of choice in patients with massive life-threatening LGIB with negative nasogastric tube aspirate is:

A. Urgent colonoscopy

B. Technetium-99 RBC scintigraphy

C. Mesenteric angiography

D. Exploratory laparotomy

Answer 14

C. Mesenteric angiography

Question 15

After an appendectomy, the patient comes back with a histopathology findings of lymphoma confined to the appendix, with negative lymph node involvement. What would be sound advice for this patient?

A. Abdominal and chest CT

B. Completion right hemicolectomy

C. Chemotherapy after a negative staging work up

D. Observe with close surveillance of every 3 months

Answer 15

A. Abdominal and chest CT

Question 16

Which of the following statements concerning appendiceal adenocarcinoma is true?

A. These tumors are most commonly found incidentally.

B. Treatment is by appendectomy with adjuvant chemotherapy

C. Perforation does not change prognosis.

D. Synchronous tumors are rare.

Answer 16

C. Perforation does not change prognosis.

Question 17

The incidence of appendectomy for acute appendicitis was decreasing in the United Status until the 1990s, at which point the frequency of appendectomy or nonperforated appendicitis began to rise. What is one potential explanation for this observation?

A. Increased use of diagnostic imaging and detection of appendicitis that otherwise would have resolved.

B. Increased incidence of obesity and the impact of periappendicular fat on luminal obstruction.

C. Increasing incidence of inflammatory bowel disease and the potential mitigation of ulcerative colitis symptoms seen with appendectomy.

D. Reimbursement patterns have changed in the United States, favoring aggressive surgical decision making.

Answer 17

Answer: A

While the true reason is unknown, some have suggested that the quality and usage of diagnostic imaging in the past 20 to 30 years has resulted in the detection of acute appendicitis that would have otherwise spontaneously resolved.

While appendectomy may mitigate the clinical symptoms of ulcerative colitis, this is likely not responsible for the broad reduction in observed appendectomy.

Obesity is not known to impact appendicitis incidence.

Reimbursement patterns should hopefully not impact surgical decision making so directly. (See Schwartz 10th ed., p. 1243.)

Question 18

What imaging finding would exclude appendicitis?

A. A computed tomographic (CT) scan with a nonvisualized appendix.

B. A barium enema where a short (2 cm) appendix was clearly identified.

C. An ultrasound study with a compressible appendix that is <5 mm in diameter.

D. A CT scan showing an edematous but retrocecal
appendix.

Answer 18

Answer: C

Graded compression ultrasonography is inexpensive and rapid. The appendix is identified as a nonperistaltic, blind ending loop of bowel.

The compressibility and anteroposterior dimensions are measured.

Thickening of the wall as well as periappendiceal fluid with a noncompressible appendix are suggestive of appendicitis while an easily compressible, narrow appendix excludes the diagnosis.

Failure to identify the appendix on imaging does not definitely rule out appendicitis.

A fecalith in the midappendix may allow proximal filling of the appendix with barium in the presence of appendicitis.

Sonographic sensitivity for appendicitis is 55 to 96% while specificity is 85 to 98%. (See Schwartz 10th ed., p. 1245.

Question 19

A 25-year-old man presents with migratory right lower quadrant (RLQ) pain, leukocytosis, and a CT scan consistent with acute, uncomplicated appendicitis. He is physiologically normal and it is 2 AM. You are planning an appendectomy, what difference might be expected in his outcome if his operation is delayed until the next morning?

A. Increased risk of an intra-abdominal abscess.

B. Increased risk of surgical-site infection.

C. Decreased operative time.

D. Increased risk of perforation.

E. No difference in perforation rates, surgical-site infection, abscess, conversion rate or operative time.

Answer 19

Answer: E

There have been three retrospective studies comparing urgent versus emergent appendectomy.

No difference was ound in the incidence of complicated appendicitis, surgical-site infections, abscess formation, or conversion to an open procedure.

While hospital length of stay was longer in the urgent group (as might be anticipated given the delay in definitive surgi- cal care) this was not statistically or clinically different rom the emergent group.

It may be safe in physiologically normal patients with uncomplicated appendicitis to wait 12 to 24 hours and book them as an “urgent” case.

(See Schwartz 10th ed., p. 1250.)

Question 20

A 55-year-old man has CT evidence of complicated appendicitis with a contained abscess in the RLQ. He is mildly tachycardic, afebrile, and normotensive with ocal RLQ tenderness but no peritonitis. What is the optimal approach to this patient?

A. Immediate laparotomy.

B. Laparoscopic exploration and abscess drainage.

C. Percutaneous drainage, intravenous (IV) fluids, bowel rest, and broad spectrum antibiotics.

D. IV fluids, bowel rest, and broad spectrum antibiotics.

Answer 20

Answer: C

Conservative management of the physiologically stable patient with complicated appendicitis has been shown to be associated with fewer overall complications, fewer bowel obstructions, fewer intra-abdominal abscesses, and fewer reoperations.

While patients with peritonitis or hemodynamic instability should proceed to the operating room, conservative management of more stable patients with complicated appendicitis is favored.

This may not necessarily be true in the pediatric population, however, as two prospective randomized trials in children demonstrate equivalent or superior outcomes with early operative intervention. (See Schwartz 10th ed., p. 1251.)

Question 21

A 23-year-old woman who is 28 weeks pregnant presents with right-sided abdominal pain, leukocytosis, and an abdominal ultrasound that does not visualize the appendix. What intervention would you recommend?

A. Exploratory laparoscopy.

B. Abdominal CT scan.

C. Abdominal magnetic resonance imaging (MRI) scan.

D. Serial clinical observations.

Answer 21

Answer: C

Appendicitis complicates 1/766 births and is rare in the third trimester. The rate of negative appendectomy in the pregnant patient appears to be about 25% higher than in nonpregnant patients.

This is not, however, a benign procedure as a negative appendectomy is associated with a 4% risk of fetal loss and a 10% risk of early delivery.

The American College of Radiology recommends the use of nonionizing radiation techniques as front-line imaging in pregnant women.

Serial examinations would be inappropriate as rates of fetal loss are considerably higher in patients with complicated appendicitis and the greatest opportunity to improve fetal outcomes is to improve diagnostic accuracy. (See Schwartz 10th ed., p. 1256.)

Question 22

A 34-year-old man presents to your clinic asking about an elective appendectomy. He has no history of appendicitis. What are possible indications or appendectomy in this patient?
A. Planned travel to far remote place with no surgical care.

B. Patients with Crohn disease where the cecum is free of gross disease.

C. As part of Ladd procedure.

D. All of the above.

Answer 22

Answer: D

Incidental appendectomy is generally not indicated.

A few select indications could be considered and they include children about to undergo chemotherapy, the disabled who cannot describe pain or react normally to pain, patients with Crohn disease when the cecum is free of macroscopic disease, and those patients planning to travel to remote areas with limited surgical care.

While part of the traditional teaching, the ubiquity of antibiotics and the evolving understanding of our ability to treat at least some appendicitis nonoperatively may further limit the indications for elective, incidental appendectomy. (See Schwartz 10th ed., p. 1257.)

Question 23

While reviewing pathology of a recent laparoscopic appendectomy, you note that in addition to acute appendicitis, the patient had a 1.5-cm carcinoid tumor located at the base of the appendix. The patient is otherwise healthy and recovering well from surgery. What would you recommend?

A. No additional therapy necessary.

B. Right hemicolectomy.

C. Radical appendectomy.

D. Adjuvant chemotherapy.

Answer 23

Answer: B

Appendiceal carcinoid is one of the most common neoplasms to identify in an appendectomy specimen.

Lesions that are <1 cm generally do not require additional therapy.

Lesions larger than 1 or 2 cm, involving the appendiceal base or with lymph node metastasis or mesenteric invasion warrant right hemicolectomy.

A radical appendectomy is not a described operation and adjuvant chemotherapy could be considered but only after definitive surgical care. (See Schwartz 10th ed., p. 1258.)

Question 24

An 8-year-old boy presents to the emergency department complaining of generalized abdominal pain or the past 24 hours. Laboratory tests reveal a leukocytosis of 13,000 and he is tender in the RLQ on physical examination. He is taken to the operating room for laparoscopic appendectomy. Removal of the appendix has been associated with a protective effect of which of the following?

A. Crohn colitis

B. Ulcerative colitis

C. Clostridium difficile

D. Carcinoid

Answer 24

Answer: B

The appendix is an immunologic organ involved in secretion of immunoglobulins.

An inverse association between appendectomy and development of ulcerative colitis has been reported.

Routine resection of the normal appendix to improve the clinical course of ulcerative colitis is not generally indicated. (See Schwartz 10th ed., p. 1243.)

Question 25

Which of the following physical signs is associated with the correct definition suggestive of acute appendicitis?

A. Rovsing sign: pain in the RLQ on palpation of the left lower quadrant

B. Dunphy sign: pain in the RLQ with palpation on the left

C. Obturator sign: pain with extension of the leg

D. Iliopsoas sign: pain on internal rotation of the right hip

Answer 25

Answer: A

Appendicitis usually starts with periumbilical pain that migrates to the RLQ.

Patients often have associated gastrointestinal symptoms such as anorexia, nausea, and vomiting.

On physical examination, patients often prefer to remain lying supine and often guard due to peritoneal irritation.

Rebound tenderness is when the examiner presses on the RLQ and the patient experiences a sudden pain upon removal of the hand.

Rovsing sign is RLQ pain that is induced by palpation of the left lower quadrant and is highly suggestive of a RLQ in lam- matory process.

Dunphy sign elicits pain with coughing and is related to inflammation of the peritoneum.

The obturator sign occurs with internal rotation of the right hip.

Lastly, the iliopsoas sign is pain with extension of the right hip, attributed to a retrocecal appendix. (See Schwartz 10th ed., p. 1244.)

Question 26

A 29-year-old woman presents with RLQ pain, fever, and leukocytosis. Prior to imaging studies the Alvarado score is used to determine the patient’s likelihood of having appendicitis. All of the following variables make up the Alvarado score EXCEPT

A. Anorexia

B. Left shift of neutrophils

C. Iliopsoas sign

D. RLQ pain

E. Fever

Answer 26

Answer: C

The Alvarado score is the most widespread scoring system useful for ruling out appendicitis and selecting patients for further imaging or intervention (Table 30-1).

The Alvarado score is calculated using RLQ tenderness, elevated temperature, rebound tenderness, migration of pain, anorexia,
nausea/vomiting, leukocytosis, and a left shift on leukocyte differential as predictive factors.

Several online calculators are freely available. (See Schwartz 10th ed., able 30-2, p. 1245.)

Question 27

A 34-year-old man undergoes an uneventful appendectomy for acute, nonperforated appendicitis. The pathology report notes reads: acute inflammation with a 1-cm adenocarcinoma of the midappendix. This patient should have

A. No further treatment

B. Chemotherapy

C. Regional radiation

D. Right hemicolectomy

E. Ileocecectomy

Answer 27

Answer: D

Primary adenocarcinoma of the appendix is rare. Three types of adenocarcinoma exist; mucinous, colonic, and adenocarcinoid.

The most common presentation of adenocarcinoma is acute appendicitis.

The recommended treatment for all patients diagnosed with adenocarcinoma is a formal right hemicolectomy.

Patients are at risk or both synchronous and metachronous neoplasms—half of which will originate in the GI tract. (See Schwartz 10th ed., p. 1258.)

Question 28

A 45-year-old woman presents with RLQ pain. A CT is performed. What finding on CT scan is most suggestive of appendiceal lymphoma?

A. Appendiceal diameter >2.5 cm or surrounding soft tissue thickening

B. Lack of contrast filling the appendix

C. 1-cm mass at the base of the appendix

D. Prominent aortic lymph nodes

Answer 28

Answer: A

Lymphoma of the appendix is uncommon. The most common types of appendiceal lymphoma in decreasing order are non-Hodgkin, Burkitt, and leukemia.

Findings on CT scan include appendiceal diameter of >2.5 cm or surrounding soft tissue thickening.

The management is confined to appendectomy. Right hemicolectomy is indicated if the tumor extends beyond the appendix onto the cecum or into the mesentery.

If requiring a right hemicolectomy, postoperatively the patient will require a staging workup and possible adjuvant chemotherapy. (See Schwartz 10th ed., p. 1259.)

Question 29

Which of the following is true regarding the location of the appendix?

A. The base of the appendix can always be found at the confluence of the cecal taenia.

B. The tip of the appendix is found in the pelvis in the majority of cases.

C. The appendix is often
retrocecal and extraperitoneal.

D. After the fifth gestational month of pregnancy, the appendix is shifted posteriorly and laterally by the gravid uterus.

E. The position of the tip of the appendix does not determine the symptoms of the patient with appendicitis.

Answer 29

ANSWER: A

COMMENTS: The appendix, along with the ileum and ascending colon, is a derivative of the midgut.

Following developmental rotation, the cecum becomes fixed in the right lower quadrant, and this determines the final location of the appendix.

The appendiceal orifice and therefore the base of the appendix are always found at the antimesenteric confluence of the cecal taeniae.

The anterior taenia, in particular, may be used as a landmark to find the appendix at surgery.

Although the base of the appendix is found in a constant location, the position of the tip varies.

The tip of the appendix is found retrocecally in the majority of patients (65%), in the pelvis in approximately 30%, and in a retroperitoneal position in approximately 7%.

In pregnancy, the gravid uterus tends to push the appendix superiorly and the tip medially.

The various locations of the tip of the inflamed appendix determine the location of physical findings produced by irritation of the parietal peritoneum, but the prodromal symptoms remain the same.

Question 30

Which of the following statements regarding the appendix is false?

A. The average length of an adult appendix is 9 cm.

B. The blood supply to the appendix is from the appendicular artery, a branch of the ileocolic artery.

C. Innervation of the appendix is derived from the somatic nervous system.

D. The appendix contains large amounts of lymphoid aggregates, but it has no significant exocrine function.

E. The lymphatic drainage of the appendix goes through the ileocolic nodes.

Answer 30

ANSWER: C

COMMENTS: The length of the appendix varies from 2 to 20 cm, with an average length of 9 cm in adults.

The blood supply to the appendix is from the appendicular artery, which is a branch of the ileocolic artery.

The innervation of the appendix, like other visceral organs, is derived from the autonomic nervous system.

As appendicitis progresses, irritation of the surrounding parietal peritoneum activates the somatic pain fibers, which localizes pain to the right lower quadrant.

The appendix contains large amounts of lymphoid tissue in aggregates but has no known significant exocrine function.

The lymphatic drainage of the appendix is the same as the cecum and follows that of the ileocolic nodes.

These nodes are often enlarged and hyperplastic in acute appendicitis.

Question 31

Which of the following statements regarding the pathogenesis of appendicitis is false?

A. The antimesenteric border has the poorest blood supply and is usually the site of the perforation.

B. Fecaliths are commonly responsible for appendicitis in children.

C. Viral or bacterial infections can precede an episode of appendicitis.

D. Obstruction of venous outflow and then arterial inflow results in gangrene.

E. Obstruction of the lumen may occur as a result of inspissated stool or a foreign body.

Answer 31

ANSWER: B

COMMENTS: In most instances of appendicitis, luminal obstruction leads to bacterial overgrowth, active secretion of mucus, and increased luminal pressure.

Increased pressure leads to decreased venous return and, later, decreased arterial inflow, which results in gangrene, bacterial translocation, and perforation.

The midportion of the antimesenteric border of the appendix has the poorest blood supply and most frequently shows evidence of perforation.

The cause of the obstruction is usually lymphoid hyperplasia in younger patients and fecaliths in adults.

Fecaliths are responsible for approximately 30% of cases in adults and have been identified in 90% of patients with gangrenous appendicitis with rupture.

However, luminal obstruction does not occur in all cases. In some patients, the lumen of the appendix is found to be patent during radiologic, gross, and histologic examinations.

The pathogenesis in these cases remains unclear. It is thought that either viral or bacterial infection, such as Salmonella, Shigella, or infectious mononucleosis, can precede appendicitis.

These infections probably cause lymphoid hyperplasia in the appendix and subsequent obstruction.

Question 32

A 27-year-old man has a 1-day history of right lower quadrant pain and leukocytosis. Probable nonperforated acute appendicitis is diagnosed. What is the best antibiotic and surgical management for this patient?

A. Operate and then await the results of peritoneal fluid cultures to tailor the selection of antibiotics.

B. Administer cefazolin perioperatively to reduce the risk of wound infection and then operate.

C. Begin ceftriaxone and metronidazole (Flagyl), monitor the patient with serial abdominal examinations, and operate if he fails to improve.

D. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery.

E. Begin clindamycin perioperatively, because Bacteroides fragilis is the most common organism involved in acute appendicitis, and proceed with surgery.

Answer 32

ANSWER: D

COMMENTS: Antibiotics play an important role in the treatment of appendicitis.

The flora of the normal appendix is similar to that of the colon. There is a mixture of aerobic (Escherichia coli, most common) and anaerobic bacteria (Bacteroides, most common).

If early nonperforated appendicitis is suspected, an appendectomy is warranted.

Perioperative antibiotics help prevent wound infection and should cover both anaerobes and aerobes.

Ceftriaxone plus metronidazole is the antibiotic regimen presented that is most appropriate.

Peritoneal cultures in patients with acute nonperforated appendicitis are frequently negative.

Peritoneal cultures in patients with perforated appendicitis usually reveal multiple colonic bacteria with predictable sensitivities.

Therefore antibiotic choice is not based on peritoneal cultures.

Currently, nonoperative management of appendicitis is controversial in the United States.

Most surgeons agree that appendectomy is preferred for nonperforated cases.

Question 33

A 62-year-old female presents with a 5-day history of right lower quadrant abdominal pain and nausea. A computed tomography (CT) of the abdomen and pelvis shows perfo- rated appendicitis with a 5-cm abscess. She was started on broad-spectrum antibiotics and underwent percutaneous drainage of the abscess. In 72 h she was afebrile, and her leukocytosis and symptoms had resolved. What should the next treatment step be?

A. Appendectomy prior to discharge

B. Continue broad-spectrum antibiotics until drain removal

C. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks

D. Interval appendectomy in 4 weeks

E. Ileocecectomy in 6 weeks

Answer 33

ANSWER: C

COMMENTS: Patients who present with perforated appendicitis with an abscess or phlegmon are best treated nonoperatively with broad-spectrum intravenous antibiotics and drainage of any intraabdominal abscess larger than 4 to 5 cm.

This decreases the morbidity and risk of injury to adjacent structures due to inflammation during appendectomy.

Most patients respond within 24 to 48 h. The duration of antibiotic treatment varies, but the maximum duration of course is 7 to 10 days.

Some physicians believe that once the patient is afebrile, tolerating a diet, and has resolution of leukocytosis, antibiotics are no longer needed. If the patient has persistent fever, leukocytosis, or ileus, antibiotics should be adjusted to cover Pseudomonas and the CT should be repeated.

Surgery may be warranted.

Interval appendectomy is somewhat controversial.

Recurrent appendicitis without appendectomy occurs in about 10% of patients, usually by 6 months.

Factors such as age, comorbidities, and prior abdominal operations should be considered in the decision to proceed with an interval appendectomy.

Surgery is usually performed 6 to 10 weeks after initial presentation.

Adults who have not had a recent colonoscopy should undergo one because up to 5% of patients have a cecal neoplasm.

Question 34

A 27-year-old man is suspected of having acute appendicitis. On physical examination his abdomen is soft and nondis- tended. He does not have pain with coughing or reproduction of tenderness in the right lower quadrant when palpated in the left lower quadrant. He experiences abdominal pain during extension of the right thigh while lying on his left side. He does not have pain with passive rotation of his right hip in a flexed position. Where do you suspect the location of the tip of his appendix to be?

A. Displaced to the right upper quadrant

B. Extraperitoneal and lying anterior to the cecum

C. In the pelvis

D. In the left lower quadrant

E. Retrocecal over the psoas muscle

Answer 34

ANSWER: E

COMMENTS: Variations in the location of the appendix can account for variations in the classic location of somatic pain.

McBurney’s point in the right lower quadrant, one-third of the distance between the anterior superior iliac spine and the umbilicus, is the typical site of maximal tenderness.

Pain exaggerated by coughing is called the Dunphy’s sign and is associated with peritoneal irritation.

The Rovsing’s sign is elicited by palpating the left lower quadrant that causes pain to be felt in the right lower quadrant, a finding suggestive of peritoneal irritation.

The psoas sign is elicited by extension of the right thigh with the patient lying in the left lateral decubitus position.

The stretched psoas muscle may irritate an inflamed overlying appendix and suggest retrocecal appendicitis.

The obturator sign is elicited with passive external rotation of the flexed right hip.

If positive, the obturator sign suggests that the inflamed tip is lying in the pelvis.

Question 35

With regard to appendicitis in the elderly, which statement is false?

A. Elderly patients tend to present later in the course of acute appendicitis.

B. Elderly patients have a higher rate of perforation because of omental atrophy.

C. Perforation has an associated mortality rate of 50%.

D. Appendicitis may mimic bowel obstruction.

E. Symptoms of appendicitis along with anemia should raise suspicion for a concomitant cecal neoplasm.

Answer 35

ANSWER: C

COMMENTS: Acute appendicitis in the elderly may not be accompanied by the typical signs and symptoms of appendicitis.

Fever, leukocytosis, and right lower quadrant pain may be minimal or absent.

The absence of typical symptoms often results in a delay in diagnosis and an increase in the perforation rate (up to 60%–90%).

A mortality rate of approximately 15% has been reported for perforated appendicitis in elderly patients.

The atrophic omentum is less capable of walling off a perforated appendix; therefore diffuse peritonitis or a distant intraabdomi- nal abscess is more common in elderly than in younger patients.

Physical examination is characterized by a paucity of findings.

Abdominal distention is prominent, and symptoms and signs mimicking bowel obstruction such as nausea and vomiting are not uncommon.

Occasionally, a patient has a painless palpable mass in the right lower quadrant because of a gangrenous appendix and a surrounding phlegmon.

Anemia, particularly in elderly patients, should raise suspicion for carcinoma of the cecum.

If found or strongly suspected, a right hemicolectomy may be appropriate.

Question 36

A 30-year-old, 28-week pregnant female presents to the emergency department with a 24-h history of right upper quadrant abdominal pain. The white blood cell (WBC) count is 18,000. An ultrasound was done showing a normal gallbladder and viable fetus. The appendix was not visualized. What is the next best step?

A. Obtain a CT abdomen/pelvis.

B. Treat with antibiotics in an attempt to avoid an operation.

C. Proceed with laparoscopy after delivery.

D. Obtain a magnetic resonance imaging (MRI) and proceed with an appendectomy if positive.

E. Admit the patient for serial abdominal examinations and repeat lab tests in the morning.

Answer 36

ANSWER: D

COMMENTS: Appendicitis occurs with equal frequency in both pregnant and nonpregnant women.

Peritonitis may result in fetal loss.

Diagnosing appendicitis during pregnancy can be difficult because abdominal pain, nausea, vomiting, and elevated WBC count are common during pregnancy.

Additionally, as the uterus enlarges, the location of the appendix is shifted superiorly and medially.

Delayed diagnosis and therefore delay in the treatment leading to perforated appendicitis increases the risk of fetal loss to about 30%.

Ultrasound is helpful in establishing the diagnosis.

In cases where ultrasound is equivocal, an MRI can be performed for further evaluation without the risk of radiation exposure to the developing fetus.

A fairly aggressive approach with early laparoscopic exploration is a reasonable option in pregnant women with suspected appendicitis.

The risk of maternal and/or fetal morbidity is quite low with a negative laparoscopy and appendectomy.

Question 37

You are performing a laparoscopic appendectomy on a 35-year-old male who presented with classic acute appendicitis. During the operation, you note that the appendix is necrotic and perforated at the base. What is the best way to proceed with the appendectomy?

A. Perform a limited cecal resection using a stapling device.

B. Staple across the necrotic base of the appendix making sure the perforation is closed.

C. Place an endoloop around the base of the appendix.

D. Irrigate and place a drain with plans to perform an interval appendectomy in 6 weeks.

E. Perform an ileocecectomy.

Answer 37

ANSWER: A

COMMENTS: Using the standard appendectomy technique of stapling across or placing an endoloop at the base of an appendix that is acutely inflamed and necrotic or perforated increases the risk for failure and subsequent leak or abscess markedly.

A limited cecal resection using a stapler or inverting the closed appendiceal stump and oversewing the cecal wall will decrease the risk of leak.

Inverting and oversewing the appendiceal stump laparoscopically requires advanced laparoscopic skills, and therefore a limited, stapled cecectomy through healthy appearing tissue is best during laparoscopy.

A formal ileocolic resection is rarely necessary.

Question 38

A 20-year-old woman is operated on through a right lower quadrant incision for presumed appendicitis, but the appendix is normal. At this point, which of the following would be an appropriate treatment?

A. Exploration and appendectomy if no other pathology is found

B. Exploration, treatment of any associated pathologic condition, as indicated, and avoiding removal of a healthy appearing appendix

C. Exploration and diverticulectomy if a Meckel’s diverticu- lum is present and is normal by inspection and palpation

D. Midline laparotomy for complete exploration if no pathology can be seen through the right lower quadrant incision

E. Exploration and ileal resection if the terminal ileum appears acutely inflamed

Answer 38

ANSWER: A

COMMENTS: If appendicitis is not found at the time of surgery, careful exploration for other pathologic conditions must be carried out.

The accuracy of a preoperative diagnosis of appendicitis should be at least 85% (90% in men and 70% in women).

In general, appendectomy is performed whether or not the appendix is inflamed, except when ileal or cecal Crohn’s disease is found. In this case, the bowel is not violated, and the patient is started on a medical therapy soon after surgery.

The pelvic organs, gallbladder, colon, and gastroduodenal areas should be inspected.

A laparoscopic approach may allow better evaluation of other areas than can be accomplished through a limited right lower quadrant incision.

The differential diagnosis of appendicitis is basically that of an acute abdomen.

The surgeon must be prepared to treat other pathologic entities should they be found.

Such differential diagnoses include acute mesenteric adenitis, gastroenteritis, diverticulitis, epiploic appendagitis, gynecologic problems, and cancer.

Acute mesenteric adenitis is most often confused with appendicitis in children.

Frequently, an upper respiratory tract infection precedes or is present at the onset of diffuse abdominal pain.

Generalized lymphadenopathy or relative lymphocytosis, when present, can be of help.

At surgery, the mesenteric lymph nodes are assessed. If they are enlarged, a biopsy is performed.

The lymph nodes are examined histologically for granulomas (including Crohn’s disease), and tissue is cultured for mycobacteria and Yersinia. Infection with Yersinia may cause mesenteric adenitis, ileitis, colitis, and acute appendicitis.

Acute gastroenteritis is characterized by cramping pain followed by watery stools, nausea, and vomiting.

Laboratory results are usually normal.

Diagnosis of a specific bacterial infection (e.g., Salmonella or typhoid fever) is made by stool culture.

The small intestine is inspected in a retrograde manner for evidence of inflammatory bowel disease or an inflamed Meckel’s diverticulum.

The incidence of perforation or peritonitis with Meckel’s diverticulitis is about 50%. Resection of a Meckel’s diverticulum is indicated if diverticulitis is present.

An asymptomatic Meckel’s diverticulum found incidentally during a laparotomy in adults may be removed with low risk in the absence of other pathology.

Diverticulitis of the cecum may be impossible to distinguish from acute appendicitis or cancer clinically.

Both may be manifested as a right lower quadrant mass with evidence of infection and peritonitis.

Sigmoid diverticulitis may also mimic appendicitis if a mobile, inflamed sigmoid colon is located in the right lower quadrant.

Epiploic appendagitis usually results from infarction of the appendage secondary to torsion.

The pain is short-lived and well- localized, recovery is fairly rapid, and patients do not appear ill.

If no pathology is found and a right lower quadrant incision is made, an appendectomy should be performed to eliminate potential confusion in the management of right lower quadrant abdominal pain in the future.

Question 39

With regard to appendicitis in immunocompromised patients, which of the following statements is false?

A. Immunocompromised patients with appendicitis often have a fever, a normal WBC count, and nonspecific abdominal pain.

B. Typhlitis often mimics acute appendicitis.

C. CT is particularly useful in immunocompromised patients.

D. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis.

E. Cytomegalovirus (CMV) infections and Kaposi sarcoma can occlude the appendiceal orifice and cause acute appendicitis.

Answer 39

ANSWER: D

COMMENTS: Appendicitis in immunocompromised patients can be difficult to diagnose.

These patients cannot mount the normal immune response to infection and so the signs and symptoms may be diffuse, vague, and blunted.

However, these patients may also progress to sepsis and critical illness.

Therefore a heightened level of awareness must be maintained.

The patient often has nonspecific findings on abdominal examination, fever, and a normal WBC count.

The differential diagnosis in an immunocompromised patient with abdominal pain includes CMV enteritis, typhlitis, and unusual infections, including those caused by mycobacteria, protozoal species, and fungi.

Typhlitis, or neutropenic colitis, often mimics appendicitis in these patients since the cecum is the most common location.

Treatment with antibiotics and recovery of immune function usually obviate surgery. CT can be particularly useful in helping establish the diagnosis.

Acute appendicitis secondary to luminal obstruction in a patient with acquired immunodeficiency syndrome (AIDS) may be the result of a fecalith, CMV bodies, or Kaposi sarcoma.

Approximately 30% of cases of acute appendicitis in patients with AIDS are caused by conditions particular to AIDS.

Question 40

A patient suspected of having acute appendicitis underwent exploration. An inflamed terminal ileum consistent with Crohn’s disease was found. Which of the following is true?

A. The normal appendix should always be removed.

B. All grossly involved bowel, including the appendix, should be resected.

C. An inflamed appendix, cecum, and terminal ileum should be resected.

D. Perforated bowel and advanced Crohn’s disease with obstruction should be resected.

E. Only the tip of the appendix should be resected if the base is found to be involved with Crohn’s disease.

Answer 40

ANSWER: D

COMMENTS: If a normal appendix is found at the time of laparotomy, other causes should be sought.

If Crohn’s disease is encountered and the cecum and base of the appendix are normal, an appendectomy should be performed.

If the base is involved with Crohn’s disease, appendectomy should be avoided as the rate of fistula formation is high after an appendectomy in patients with Crohn’s disease.

If the areas involved with Crohn’s disease are not complicated by perforation or obstruction, bowel resec- tion is not indicated, and medical therapy should be instituted.

However, in the setting of perforation or high-grade obstruction from a fibrotic segment, the involved bowel should be resected.

Ileostomy and deferred anastomosis may be appropriate in some cases.

Question 41

Which of the following is true regarding appendiceal
carcinoid tumors?

A. Carcinoid tumor is the second most common tumor of the appendix.

B. For tumors greater than 2 cm, a formal right hemicolectomy is indicated.

C. All tumors less than 2 cm that do not involve the appendiceal base can be treated with an appendectomy alone.

D. Nearly 75% of appendiceal carcinoid tumors are located in the proximal one-third of the appendix.

E. Carcinoid tumors arise from the smooth muscle within the appendiceal wall.

Answer 41

ANSWER: B

COMMENTS: Carcinoid tumors arise from neural crest cells and are derived from enteroendocrine cells.

Fifty percent of carcinoid tumors within the gastrointestinal cells arise within the appendix.

Nearly 75% of appendiceal carcinoid tumors are located in the distal one-third of the appendix.

Tumors less than 1 cm are usually treated with an appendectomy alone.

Treatment of tumors between 1 and 1.9 cm is based on the risk of recur- rence.

Tumors with poor prognostic indicators should be treated with a formal right hemicolectomy.

Thirty to sixty percent of appendiceal carcinoid tumors greater than 2 cm are associated with nodal disease or distant metastases.

Therefore all tumors greater than 2 cm should be treated with a formal right hemicolectomy.

Question 42

A 35-year-old male underwent a laparoscopic appendectomy. On final pathology, he was found to have a 1.4-cm carcinoid tumor in the mid-appendix with direct extension to the mesoappendix, negative margins, and no lymphovascular invasion. What is the best treatment plan?

A. No further treatment needed

B. Ileocecectomy

C. Right hemicolectomy

D. Medical treatment with octreotide

E. Chemotherapy

Answer 42

ANSWER: C

COMMENTS: Carcinoid tumors between 1 and 1.9 cm must be treated based on the risk of recurrence.

Poor prognostic indicators include high-grade lesions with a high mitotic rate, direct extension into the mesoappendix, lymph node involvement, lymphovascular invasion, positive margins, or mucin-producing tumors.

If any of these are present, a formal right hemicolectomy is warranted.

Octreotide is used for metastatic disease, and chemotherapy has very limited benefit for either local or metastatic carcinoid tumors.

Question 43

A 57-year-old male with a complaint of watery diarrhea underwent a colonoscopy and was found to have a mass within the appendiceal orifice. This was biopsied and the pathology was consistent with a carcinoid tumor. A CT of the chest, abdomen, and pelvis showed a 3-cm appendiceal base mass and two liver lesions. Which of the following is true?

A. Appendiceal carcinoid tumors with metastases to the liver are fast growing and have a 5-year survival rate of only 10%.

B. Octreotide decreases metastatic tumor progression and improves survival rates.

C. Carcinoid syndrome occurs when the primary tumor becomes larger than 2 cm and secretes hormones.

D. Hepatic resection of liver metastases is not recommended as a method for tumor debulking and symptom control.

E. Synchronous treatment with a right hemicolectomy and radiofrequency ablation of the liver metastases is appropriate.

Answer 43

ANSWER: E

COMMENTS: Rarely, appendiceal carcinoids are associated with liver metastases.

Appendiceal carcinoid tumors with metastases are slow growing and have 5- and 10-year survival rates approaching 60%.

Carcinoid syndrome occurs when the tumor produces hormones, most commonly serotonin, which reaches the systemic circulation.

Typically, carcinoid syndrome only occurs with gastrointestinal tumors when they metastasize to either the liver or the retroperitoneum.

The liver contains monoamine oxidase, which deactivates serotonin.

Therefore to develop carcinoid syndrome, the patient must have a tumor that does not drain primarily through the portal venous system. The clinical manifestations of the carcinoid syndrome include episodic flushing, wheezing, nonbloody watery diarrhea, abdominal pain, and right-sided heart failure.

Flushing is the most common symptom, occurring in 80% of patients with carcinoid syndrome, followed by watery diarrhea in 75% and cardiac manifestations in 60% to 70%.

Management of carcinoid syndrome is multimodal, using surgical, medical, and radiologic treatment.

Surgical debulking may improve symptoms and prolong life.

This includes excision of the primary tumor and debulking of hepatic metastases.

Hepatic artery embolization and radiofrequency ablation of hepatic metastases are also options for disease control and symptom relief.

Somatostatin analogues (octreotide) are effective at controlling symptoms and decreasing tumor progression, but no overall survival benefit has been demonstrated.

Question 44

When a mucocele of the appendix is found at the time of surgery, which of the following is an appropriate initial therapy?

A. Incisional biopsy with subsequent appendectomy if malignancy is confirmed by frozen section

B. Routine right hemicolectomy with lymph node dissection

C. Needle aspiration of cystic fluid for cytologic examination

D. Appendectomy

E. Closure and observation

Answer 44

ANSWER: D

COMMENTS: Appendectomy is an adequate treatment of a mucocele, but care must be taken to avoid rupture, because pseudomyxoma peritonei has been reported following rupture and peritoneal dissemination of the appendiceal contents, even if the appendix was free of cancer.

Histologically, mucoceles can be categorized as a benign type, which is the result of occlusion of the proximal lumen of the appendix, or a malignant type, which is a variant of a mucous papillary adenocarcinoma.

Treatment of an appendiceal adenocarcinoma is right hemicolectomy.

Question 45

Which of the following is true regarding adenocarcinoma of
the appendix?

A. Appendectomy is an adequate treatment for tumors less than 1 cm without lymph node involvement and clear margins.

B. Fifty percent of patients have metastatic disease at the time of diagnosis.

C. Right hemicolectomy is required for all appendiceal adenocarcinomas.

D. A second primary adenocarcinoma is rarely found elsewhere in the gastrointestinal tract at the time of diagnosis.

E. Adenocarcinoma is the most common tumor of the appendix.

Answer 45

ANSWER: B

COMMENTS: Primary adenocarcinoma of the appendix is very rare. Approximately 50% of patients present with metastatic disease at the time of diagnosis.

Early lesions confined to the mucosa or submucosa (T0–T1) may be treated with a simple appendectomy as long as there are clear margins.

Any more invasive lesions require a formal right hemicolectomy.

Staging and treatment for appendiceal adenocarcinoma are similar to colon adenocarcinoma.

A second primary adenocarcinoma is found in 35% of patients with an appendiceal adenocarcinoma, most often involving other areas of the gastrointestinal tract.

Therefore thorough evaluation of the abdominal cavity and bowel should be performed at the time of operation.

Question 46

During an exploratory laparotomy on a 46-year-old male with a small bowel obstruction, mucinous ascites is found throughout the abdomen along with a large cystic-appearing appendiceal mass. What is the most likely diagnosis?

A. Malignant peritoneal mesothelioma

B. Appendiceal carcinoid tumor

C. Perforated acute appendicitis

D. Metastatic melanoma

E. Pseudomyxoma peritonei

Answer 46

ANSWER: E

COMMENTS: Pseudomyxoma peritonei is malignant mucinous ascites that usually arises from a ruptured ovarian or mucinous appendiceal adenocarcinoma.

The peritoneal surfaces are coated with a diffuse, mucus-secreting tumor that often fills the peritoneal cavity.

It may cover any of the abdominal cavity surfaces including the abdominal wall, liver, spleen, bowel, uterus, ovaries and tubes, bladder, and diaphragm.

It occurs in equal frequency in men and women and is most common between the ages of 40 and 50 years.

Patients are often asymptomatic until they have advanced disease.

Symptoms are nonspecific and may include abdominal pain, bloating, distention, loss of appetite and weight, and wasting.

CT scanning often does not identify the problem.

Vague thickening or nodularity of surfaces and ascites may be seen.

The diagnosis is usually made at laparotomy.

Treatment involves debulking resection of as much of the tumor as possible (cytoreduction) and heated intraperitoneal chemotherapy.

Cytoreduction includes omentectomy, stripping of the involved peritoneum, resection of involved organs, and right hemicolectomy.

Successful cytoreduction leaves no residual tumor nodules larger than 2 mm to allow for better penetration of the intraperitoneal chemotherapy.

These operations may be very long and tedious.

For best results, these patients should be treated at a center and by surgeons that specialize in peritoneal malignancies.

Complication rates are high (25%–35%), but significant prolongation of life is possible in many patients.

The best approach for the operating surgeon who is not prepared to do a formal cytoreduction operation is to establish the diagnosis by the least invasive procedure (appendectomy or biopsies), relieve any intestinal obstruction, close, and refer the patient to a specialized center.

Question 47

A 17-year-old female model presents to the emergency room with a 1-day history of lower abdominal
pain. On examination she is most tender in the right
lower quadrant (RLQ) and also has pelvic tenderness. White blood cell (WBC) count is 13,000 and
temperature is 100.6°F. A provisional diagnosis of
uncomplicated appendicitis is made and laparoscopic appendectomy is offered.
1. Regarding laparoscopic appendectomy which
of the following is TRUE?
(A) It can be performed safely with minimal
morbidity compared to open technique.
(B) Length of hospital stay is longer than
with open technique.
(C) Procedure cost is less than with open
technique.
(D) Return to full feeding is less than with
open technique.
(E) Wound complication rate is greater with
open technique.

Answer 47

1. (C) In uncomplicated appendicitis laparoscopic
   appendectomy can be performed with similar
   outcomes to an open technique. Studies reveal
   hospital stay and return to full feeding is similar. Wound complication and overall complication rates are the same. Procedure cost are higher
   owing to the use of additional equipment.

Question 48

2. Possible advantages of the laparoscopic techniques include all except?
   (A) Post hospital recovery is longer.
   (B) More scar formation.
   (C) Not allow thorough inspection of the
   peritoneal contents.
   (D) Longer operative time.
   (E) No treatment for nonappendical disease.

Answer 48

2. (D) Laparoscopic appendectomy does present
   the surgeon with several advantages.
   Although in hospital recovery is similar to the
   open technique, posthospital recovery can be
   shorter in uncomplicated appendicitis. In cases
   where the diagnosis of appendicitis is less certain the laparoscopic approach confers several
   advantages. In addition to accurately diagnosing appendicitis, the laparoscopic approach
   allows the surgeon the ability to inspect the
   entire abdominal cavity when a normal appendix is found. The laparoscopic approach can
   also be used to treat other intra-abdominal
   surgical pathologies and, therefore, reduces
   the need for extending or converting to a conventional laparotomy incision. Laparoscopic
   technique does result in a longer operative
   time for appendectomy with higher operative
   cost. Cosmesis is generally better with the
   laparoscopic technique owing to smaller
   wound size.

Question 49

3. At open operation a normal appendix is found.
   What is the most common procedure a surgeon should do if he finds a normal appendix?
   (A) Evaluate the pelvis for tuboovarian
   abscess pelvic inflammatory disease,
   malignancy or etopic pregnancy
   (B) Removal of appendix
   (C) Evaluate the terminal ileum and cecum
   for signs of regional or bacterial enteritis
   (D) Evaluate the upper abdomen for
   cholecystitis or perforated duodenal ulcer
   (E) Evaluate for Meckel’s diverticulum

Answer 49

3. (B) The normal appendix should be removed to
   avoid future diagnostic confusion and appendicitis. The entire abdomen should be explored
   for other potential causes of the clinical presentation. If found, other pathologies, which are the
   cause of the presentation, may be treated surgically, either laparoscopically or open if indicated.

Question 50

38. A 79-year-old man has had abdominal pain for
    4 days. An operation is performed, and a gangrenous appendix is removed. The stump is
    inverted. Why does acute appendicitis in elderly
    patients and in children have a worse prognosis?
    (A) The appendix is retrocecal.
    (B) The appendix is in the preileal position.
    (C) The appendix is in the pelvic position.
    (D) The omentum and peritoneal cavity
    appear to be less efficient in localizing
    the disease in these age groups.
    (E) The appendix is longer in these age
    groups.

Answer 50

38. (D) The omentum and peritoneal cavity seem
    to be less efficient in localizing the disease in
    these age groups. Appendicitis has a particularly high-complication rate in infants and
    the elderly. Delay in establishing the accurate
    diagnosis in these two age groups also contributes to a worse prognosis.

Question 51

39. A 12-year-old boy complains of pain in the
    lower abdomen (mainly on the right side).
    Symptoms commenced 12 hours before admission. He had noted anorexia during this period.
    Examination revealed tenderness in the right
    iliac fossa, which was maximal 1 cm below Mc
    Burney’s point. In appendicitis, where does the
    pain frequently commence?
    (A) In the right iliac fossa and remains there
    (B) In the back and moves to the right iliac
    fossa
    (C) In the rectal region and moves to the
    right iliac fossa
    (D) In the umbilical region and then moves
    to the right iliac fossa
    (E) In the right flank

Answer 51

39. (D) In appendicitis, patients frequently note
    that the pain commences in the umbilical
    region and moves later to the right iliac fossa.
    Pain in the iliac fossa occurs when the overlying parietal peritoneum is involved. Patients
    with appendicitis typically indicate that they
    have anorexia. 70–80% of patients with appendicitis have vomiting.

Question 52

40. On examination, patients presenting with appendicitis typically show maximal tenderness over
    which of the following?
    (A) Inguinal region
    (B) Immediately above the umbilicus
    (C) At a point between the outer one-third
    and inner two-thirds of a line between
    the umbilicus and the anterior superior
    iliac spine
    (D) At a point between the outer two-thirds
    and inner one-third of a line between
    the umbilicus and the anterior superior
    iliac spine
    (E) At the midpoint of a line between the
    umbilicus and the anterior superior iliac
    spine

Answer 52

40. (C) This is McBurney’s point and often indicates
    the region where maximal tenderness can be
    elicited. In addition to tenderness, guarding and
    percussion tenderness should be sought to verify
    whether localized and/or general peritonitis exists.

Question 53

41. What is the mortality rate from acute
    appendicitis?
    (A) In the general population, it is 4/10,000
    (B) After rupture, appendicitis is 4–5%
    (C) For nonruptured appendicitis, it is 2%
    (D) It is 80% if an abscess has formed
    (E) It has increased in the past 40 years

Answer 53

41. (B) The mortality rate from appendicitis is
    4/1,000,000 in the general population, which is a
    20-fold decline from that reported 50 years ago.
    The mortality rate for ruptured appendicitis is
    4–5% but increases to 9% in infants and 15% in
    patients above 65 years of age and those with
    serious underlying medical illness. The high rate
    of perforation is partly due to physician delay in
    establishing the diagnosis of acute appendicitis.
    The mortality rate of 0.1% in patients with nonruptured appendicitis highlights the fact that the
    condition remains a potentially lethal disease.
    The diagnosis of acute appendicitis is nearly
    always determined on clinical grounds without
    need to request a CT scan (Fig. 6–4).

Question 54

42. A 29-year-old woman presents to her physician’s office with pain in the right iliac fossa.
    Examination reveals tenderness in this region.
    Her last menstrual cycle was 2 weeks previously and findings on gynecologic examination
    and leukocyte count are normal. A provisional
    diagnosis of acute appendicitis is made. She
    should be informed that operations to treat this
    condition reveal acute appendicitis in what percentage of cases?
    (A) A small percentage of cases
    (B) 50–89% of cases
    (C) 90–99% of cases
    (D) More than 99% of cases
    (E) No reliable statistics are available

Answer 54

42. (C) If the surgeon’s records indicate that all operations on the appendix are abnormal, there is a
    real danger that a true appendicitis will be
    missed and that the criteria chosen are too rigid.
    On the other hand, if the rate of normal appendices removed is increased, the criteria selected
    for operation require further defining. Good clinical observation and appropriate laparoscopy in
    female patients will help achieve the goal of optimal incidence of accuracy with emergency
    appendectomy. After unwarranted appendectomy, complications include persistent pain from
    adhesions, inadvertent visceral trauma at operation, and small-bowel obstruction. In older
    patients in particular, the usual diverse complications of operations occur.

Question 55

43. A 28-year-old man is admitted to the emergency
    department complaining of pain in the umbilical
    region that moves to the right iliac fossa. Which
    is a corroborative sign of acute appendicitis?
    (A) Referred pain in the right side with
    pressure on the left (Rovsing)sign
    (B) Increase of pain with testiculalr
    elevation
    (C) Relief of pain in lower abdomen with
    extension of thigh
    (D) Relief of pain in lower abdomen with
    internal rotation of right thigh
    (E) Hyperanesthesia in the right lower
    abdomen

Answer 55

43. (A) Rousing’s sign is corroborative of acute
    appendicitis. The other signs are corroborative
    of appendicitis. Hyperesthesia is a useful sign
    provided that it is performed objectively. The
    area of hyperesthesia is a triangular area (base
    placed upward) in the right lower abdomen.

Question 56

44. A 28-old-male from Kosovo, who lives alone,
    presents with diarrhea. On examination he manifests clear wasting and malnutrition. His hematocrit (HCT) is 28%, serum albumin reduced to
    2.8 g%, and the blood analysis shows a macrocytic anemia. The emergency department physician is unable to secure an accurate history of the
    nature of multiple previous operations he had
    undergone before his arrival in the United States
    several months previously. What is the likely
    diagnosis that explains these features?
    (A) Blind loop syndrome
    (B) Diverticulitis of the sigmoid colon
    (C) Carcinoma of the left colon
    (D) Gastric ulcer
    (E) Carcinoid syndrome

Answer 56

44. (A) The presence of a blind loop leads to malabsorption with steatorrhea, macrocytic
    anemia, and malabsorption. A blind loop is
    likely to occur if an antiperistaltic loop is created, and it is more than 3–6 inches in length.
    The antiperistaltic loop causes failure of adequate emptying of intestinal contents; this leads
    to stasis and overgrowth of bacteria.