Appendix and GB

Question 1

Describe arterial supply of appendix

Answer 1

Aorta—>SMA—>ileocolic—> appendiceal

Question 2

What causes appendicitis?

Answer 2

OBSTRUCTION of the appendiceal lumen (usually lymphoid hyperplasia or fecalith)

Question 3

Most common cause of emergent abd surgery in US?

Answer 3

Acute appendicitis

Question 4

What kind of appendicitis is a positive obturator sign suggestive of?

Answer 4

Pelvic

Question 5

What kind of appendicitis is a positive psoas sign suggestive of?

Answer 5

Retrocecal

Question 6

How can you differentiate gastroenteritis from appendicitis based on sx chronicity?

Answer 6

Gastroenteritis vomiting usually precedes abd pain

In appendicitis the pain usually precedes vomiting

Question 7

What CT findings indicate acute appendicitis?

Answer 7

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

Question 8

Which bacteria is associated with mesenteric adenitis(which mimics appendicitis)?

Answer 8

Yersinia enterocolitica

Question 9

Most common type of appendiceal tumor

Answer 9

Carcinoid

Question 10

How do you treat appendiceal carcinoid?

Answer 10

<1.5cm appendectomy

>1.5cm right hemicolectomy

Question 11

What type of appendiceal tumor can cause the dreaded pseudonymous peritonei if the appendix rupture?

Answer 11

Malignant mucous Adenocarcinoma

Question 12

What are the small ducts that drain bile directly into the gallbladder from the liver?

Answer 12

Ducts of Luschka

Question 13

Which artery is susceptible to injury in cholecystectomy?

Answer 13

Right hepatic artery

Question 14

What stimulates the gallbladder emptying?

Answer 14

CCK and vagal input

Question 15

What is the source of CCK?

Answer 15

Duodenal mucosal cells

Question 16

At what level of serum bilirubin does one start to get jaundice?

Answer 16

2.5

Question 17

Classically what is thought to be the anatomic location where one first finds evidence of jaundice?

Answer 17

Under the tongue (UV rays break down bili at other sites)

Question 18

What causes itching in obstructive jaundice?

Answer 18

Bile salts in dermis (not bilirubin!)

Question 19

Signs and sx of obstructive jaundice include:

Answer 19

Yellowing of skin
Dark urine
Clay colored stools
Itching
Loss of appetite 
Nausea

Question 20

What is Klatskin’s tumor?

Answer 20

Cholangiocarcinoma of bile duct at junction of right and left hepatic

Question 21

What is a biloma?

Answer 21

An intraperitoneal bile fluid collection

Question 22

What lab results are associated with obstructive jaundice?

Answer 22

Elevated alk phos and bili. Without elevated LFTs

Question 23

What is the incidence of cholelithiasis?

Answer 23

10% of the population will develops gallstones

Question 24

What are the big 4 risk factors for cholelithiasis?

Answer 24

Female
Fluffy
Forty
Fertile

Question 25

Most gallstones are this type

Answer 25

Cholesterol (75%)

Question 26

What causes brown gallstones?

Answer 26

Billiary tract infection

Question 27

What causes black gallstones?

Answer 27

Cirrhosis and hemolysis

Question 28

What percentage of pts with gallstones are asymptotic?

Answer 28

80%

Question 29

What are indications for cholecystectomy in the asymptotic pt?

Answer 29

Sickle cell dz
Calcifies gallbladder
Pt is a child

Question 30

What is first line management for choledocholithiasis?

Answer 30

ERCP with papillotomy and retrieval of stone

Question 31

What medications dissolve a cholesterol gall stone?

Answer 31

Chenodeoxycholic avid, ursodeoxycholic acid. (Takes >6m and if pt stops meds stones recur)

Question 32

What is charcot’s triad and what does it indicate?

Answer 32

Fever/chills
RUQ pain
Jaundice

Cholangitis

Question 33

What is reynold’s pentad and what does it indicate?

Answer 33

Fever/chills
RUQ pain
Jaundice
AMS
Shock

Cholangitis

Question 34

What is suppurations cholangitis?

Answer 34

Severe infection with sepsis - “pus under pressure”