Ch. 20 RLQ Abdominal Pain

Question 1

What is the differential dx of acute appendicitis in an adult?

Answer 1

1. IBD
2. Pancreatitis
3. Cholecystitis
4. Appendicitis
5. Gastroenteritis
6. Nephrolithiasis
7. Perforated duodenal ulcer (Valentino’s syndrome)
8. Pyelonephritis
9. Sigmoid diverticulitis
10. Cecal diverticulitis
11. Meckel’s diverticulitis

Question 2

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

IBD

Answer 2

History and Physical:

• Abdominal pain, severe cramps, weight loss, bloody diarrhea, anemia
• enterocutaneous fistula/anal fissures (Crohn’s), toxic megacolon (UC)

Mimicking Features:

• Crohn’s can present with RLQ pain due to inflammation limited to ileocecal region (regional enteritis)

Question 3

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Pancreatitis

Answer 3

H&P:

• Epigastric pain radiating to the back
• N/V/F
• Anorexia
• Tachycardia
• Cholelithasis
• Gallstones
• Alcohol abuse

Mimicking Features:

• Predominantly epigastic pain
• With severe pancreatitis, ascites forms –> may track down R paracolic gutter (depressions found between colon and abdominal wall) causing RLQ pain

Question 4

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Cholecystitis

Answer 4

H&P:

• RUQ pain radiating to back
• N/V/F
• Palpation of RUQ during inspiration stops inspiration 2/2 pain (Murphy’s sign)

Mimicking Features:

• Though pain is typically RUQ, a large inflamed gallbladder may cause RLQ pain

Question 5

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Gastroenteritis

Answer 5

H&P:

• N/V/F
• Vomiting
• Watery diarrhea (viral)
• Blood diarrhea (certain bacteria)
• Myalgia

Mimicking features:

• May cause diffuse abdominal tenderness and marked leukocytosis

Question 6

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Nephrolithiasis

Answer 6

H&P

• Colicky flank pain that may radiate to inner thigh or genitals
• N/V
• Dysuria
• Hematuria

Mimicking Features:

• Ureteral pain may refer to RLQ

Question 7

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Perforated duodenal ulcer (Valentino’s syndrome)

Answer 7

H&P

• Sudden onset of epigastric pain
• Rigid abdomen
• Hx of dyspepsia, NSAID use, recurrent ulcers, H. pylori infection

Mimicking features:

• Initial pain is epigastric, then diffuse, but duodenal perforation may seal –> enteric contents may track down R paracolic gutter –> RLQ pain

Question 8

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Pyelonephritis

Answer 8

H&P:

• CVA tenderness
• Fever
• Pain on urination
• Vomiting

Mimicking features:

• Renal and ureteral pain –> refer to RLQ

Question 9

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Sigmoid diverticulitis

Answer 9

H&P:

• Pain in LLQ
• F/N
• Diarrhea
• Leukocytosis
• Constipation
• Common in elderly (acquired)

Mimicking features:

• Large, floppy, redundant sigmoid colon may lie in RLQ, thus presenting w/ RLQ instead of LLQ pain

Question 10

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Cecal diverticulitis

Answer 10

H&P:

• Congenital solitary diverticulum

Mimicking features:

• Identical to appendicitis

Question 11

What clues on history and physical might direct you towards a specific diagnosis for… How can other diagnoses be confused with appendicitis?

Meckel’s diverticulitis

Answer 11

H&P:

• “Rule of 2’s”:
  
  • Males 2x more common
  • Ocurrs within 2 ft of ileocecal value
  • 2 types of tissue (pancreatic, gastric)
  • Found in 2% of population
  • Can present at 2 y/o (with painless rectal bleeding)

Mimicking Features:

• Identical to appendicitis, in an adult, a Meckel’s diverticulum can become infected (Meckel’s diverticulitis) and present with RLQ pain

Question 12

Differential dx of appendicitis in women (4) + corresponding clues on H&P

Answer 12

1. PID
   
   1. Neisseria gonorrhoeae or Chlamydia infection
   2. Purulent cervical discharge
   3. Cervical motion tenderness (chandelier sign)
   4. Adnexal tenderness
   5. Dysuria
2. Ruptured ectopic
   
   1. Typically presents 6-8 wks after last normal menstrual period
   2. Abdominal pain
   3. Amenorrhea
   4. Vaginal bleeding
   5. Breast tenderness
   6. Anemia (rarely hemorrhagic shock)
3. Ovarian Torsion
   
   1. Acute onset of severe pelvic pain
   2. Adnexal mass
   3. Hx of ovarian cysts
4. Mittelschmerz
   
   1. Physiologic recurrent mid-cycle pain (mild/unilateral)
   2. Duration ranges few hrs to few days
   3. Normal pelvic exam

Question 13

Differential dx of appendicitis in a child (5) + what clues on H&P?

Answer 13

1. Mesenteric lymphadenitis
   
   1. Concomitant or recent URI
   2. High fever
   3. Enlarged, inflamed, tender lymph nodes in small bowel mesentery
   4. Generalized abdominal pain
2. Yersinia enterocolitica (pseudoappendicitis)
   
   1. RLQ pain
   2. Fever
   3. Vomiting
   4. Bloody diarrhea
   5. History of sick contacts (e.g. infected children at daycare)
3. Pneumococcal pneumonia
   
   1. N/V
   2. Diffuse abdominal pain
4. Gastroenteritis
   
   1. N/V
   2. Watery diarrhea (viral)
   3. Bloody diarrhea (certain bacteria)
   4. Myalgia
   5. Fever
5. Intussusception
   
   1. N/V
   2. Crampy abdominsl pain
   3. “Red currant jelly” stool
   4. “Sausage-shaped mass in abdomen” - 12 month old infant

Question 14

What do you want to r/o in women with acute appendicitis presentation?

Answer 14

Ectopic pregnancy w/ beta-hCG pregnancy test

Question 15

H&P

What is usually the first sx of appendicitis and what is the classic sequence of symptoms?

Answer 15

In >95% cases, ANOREXIA = first sx

Sequence: anorexia –> vague, periumbilical abdominal pain –> vomiting –> shift to localized RLQ pain

Question 16

H&P

What is the significant of absent bowel sounds?

Answer 16

Paralytic ileus 2/2 inflamed/infected bowel

Question 17

What is a Hamburger Sign?

Answer 17

B/c majority of pts w/ acute appendicitis will have anorexia, if patient is hungry, acute appendicitis is less likely.

Inquire about pt’s favorite food (e.g., hamburger, pizza) and ask if pt would like to eat it. Patients with TRUE anorexia will decline their favorite food (+hamburger sign)

Question 18

Signs of appendicitis (4)

Answer 18

1. Psoas - RLQ pain on passive extension of R hip or active flexion of R hip
2. Rovsing’s - RLQ pain w/ palpation of LLQ
   
   1. Compression in LLQ stretches abdomainl wall triggering pain in inflamed underlying RLQ parietal peritoneum
3. Obturator - RLQ pain on internal rotation of hip
4. McBurney’s - Tenderness to palpation at McBurney’s point (1/3 distance along imaginary line drawn from anterior superior iliac spine to umbilicus)*** incision point for open appendectomies

Question 19

Pathophysiology:

What explains the transition from periumbilical pain to RLQ pain in appendicitis?

Answer 19

Autonomic nerves (S & PS) supply visceral peritoneum while parietal peritoneum has somatic innervation (from spinal nerves).

Early on in appendiceal inflammation, only VISCERAL peritoneum affected (VAGUE in periumbilical region)… as inflammation progresses, PARIETAL peritoneum becomes affected –> SHARP, SEVERE type of pain localized to region of appendiceal inflammation as RLQ

Question 20

Is the appendix considered foregut, midgut, hindgut?

How does that influence where visceral pain in the abdomen is perceived?

Answer 20

Appendix, small bowel (distal to ligament of Treitz), cecum, ascending colon, 2/3 transverse colon = derived from MIDGUT

In contrast, pain in foregut - esophagus –> distal duodenum) usually perceived in epigastrium

Question 21

Why is hyperesthesia of the skin a sign of acute appendicitis?

Answer 21

Cutaneous hyperesthesia, a sensation derived from the T10 to L1 nerve roots, is often an early although inconsistent sign of appendicitis. Lightly touching the patient with the stethoscope creates this uncomfortable sensation.

Question 22

What is a closed-loop obstruction?

Answer 22

Develops when a loop of bowel is obstructed at two points –> no outlet for bowel contents and pressure

As pressure continues to build, loop of bowel will continue to distend –> blood supply to loop compromised –> ischemia and infarction

Question 23

How does a closed-loop obstruction pertain to acute appendicitis?

Answer 23

Common etiology:

• Fecalith (in adults)
• Lymphoid hyperplasia (children)

Since appendix = blind loop, this creates a closed-loop obstruction

Appendiceal mucosa continues to secrete mucus –> bacteria multiply rapidly –> appendix distends rapidly –> intraluminal P exceeds venous but not arteriolar pressure –> vascular congestion ensues until arteriolar supply compromised as well –> ischemia and gangrene –> performation occurs at antimesenteric border just beyond point of obstruction (tension is high)

Question 24

Appendiceal Obstruction: lymphoid hyperplasia in children

Answer 24

Lymphoid hyperplasia obstructs appendiceal lumen (most often as a result of preceding viral infection)

Question 25

Other causes of appendiceal obstruction

Answer 25

* Inspissated (thickened/congealed) barium (impacted bariolith) after radiological studies * Tumors (adenocarcinoma of the appendix) * Ingested seeds * Parasites (Ascaris lumbricoides, Enterobius vermicularis)

Question 26

Retrocecal Appendix

Answer 26

In pts with retrocecal appendix, palpation of inferior lumbar (Petit) triangle --\> pain Floor of triangle = internal abdominal oblique Inferior border = iliac crest Margins = latissimus dorsi and external abdominal oblique

Question 27

Workup: Critical lab values

Answer 27

* **Leukocytosis with left shift** (inc. in immature white cells, called band cells) * **Elevated CRP** (marker for inflammation) * All women of childbearing age - beta-hCG pregnancy test to r/o ectopic pregnancy

Question 28

Workup: Significance of WBCs in urine w/o bacteria... how might this mislead the clinician?

Answer 28

Few WBCs can be seen in urine (pyuria) w/ ureteral or bladder irritation by inflammed appendix --\> can mislead to thinking **cystitis** However, bacteriuria (bacteria in urine) should not be present in catheterized urine specimen

Question 29

Workup: If classic presentation, no further imaging. When would imaging be indicated? How should the use of imaging studies differ b/w adults and kids? Men and women?

Answer 29

U/S - identify thick-walled, noncompressible tubular structure (dilated appendix) in RLQ * Peritoneal fluid and/or abscess can be seen in advanced cases * U/S useful to r/o gynecologic pathology in women * U/S useful for children b/c: * Children are more vulnerable to effects of radiation * Children have less periappendiceal fat so appendix not as readily visualized on CT scan CT scan utilized in adult men and nonpregnant women when dx unclear * Periappendiceal fat stranding * Appendiceal diameter \> 6 mm

Question 30

Workup: Plain abdominal X-ray finding that is highly suggestive of appendicitis

Answer 30

Calcified fecalith in RLQ

Question 31

Mgmt: Definitive tx

Answer 31

Surgical removal (appy) w/ either a laparoscopic or open approach

Question 32

Laparoscopic or open appy?

Answer 32

Laparoscopic: * Slightly decreased post-op pain * Faster return to normal activity * Rate of wound complications lower (but rate of post-op intra-abdominal abscess higher) * Surgery length longer, more $$

Question 33

What is the role of pre- and postop abx for acute non-perforated appendicitis? for perforated appendicitis?

Answer 33

Non-perforated: * single dose preop abx to reduce infectious complications * abx should not exceed 24 hrs postop Perforated: * single dose preop abx to reduce infectious complications * IV abx given until pt's fever and leukocytosis have resolved (typically takes 3-5 days)

Question 34

Mgmt How should you proceed if you are performing a laparoscopic appy and you discover that the appendix appears to be normal? Do you remove the appendix anyway? Any contraindications?

Answer 34

Rate of finding normal appendix during procedure = 10% (elderly, infants, young women) Remove it anyway... that way, if RLQ pain occurs in future, can r/o accute appendicitis Contraindication: in case of regional enteritis (Crohn's) involving cecum... appendix should not be removed b/c of high risk of developing cecal fistula

Question 35

Pts with appendicitis and \>5 day hx of RLQ pain

Answer 35

Appendix most likely ruptured --\> either infection spreads to cause diffuse peritonitis or body (with help of omentum) walls off perforation to create localized abscess Confirm with CT scan... treat first with IV antibiotics If large abscess seen, drain percutaneously

Question 36

1. What vessel provides blood supply to appendix? 2. How can the appendix be located if the cecum has been IDed?

Answer 36

1. What vessel provides blood supply to appendix? **appendiceal a.** 2. How can the appendix be located if the cecum has been IDed? **Follow taenia coli down to the appendix; taeniae converge on appendix**

Question 37

A 59 y/o woman presents with RLQ pain, N/V. She undergoes an uncomplicated lap appy. Post-op, the pathology reveals a **2.5 cm mucinous adenocarcinoma with lymphatic invasion.** Staging workup, including colonoscopy, CXR, CT scan of abdomen and pelvis, is negative. What is the most appropriate next step in her mgmt?

Answer 37

**R hemicolectomy** Pts with appendiceal adenocarcinoma, a rare neoplasm accounting for less than 0.5% of GI tumors, should undergo formal R hemicolectomy. Often affecting older pts, they may present with symptoms mimicking those of acute appendicitis.