Ch. 343 - Acute Appendicitis Flashcards by CM A

MC acute surgical condition in children

Acute appendicitis

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Mainstay of treatment of acute appendicitis

Prompt appendectomy

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T/F Incidence of appendicitis increases with age

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Appendicitis is diagnosed in ___% of children presenting to the ER for evaluation of abdominal pain

1-8%

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T/F Mortality rate of acute appendicitis is high

F, low, less than 1%

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T/F Morbidity rate of acute appendicitis is high

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T/F Children have a higher perforation rate of appendicitis than adults

T, 82% for children younger than 5, approaching 100% in infants

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Complications brought about by acute appendicitis

1) Perforation 2) Abscess formation 3) Peritonitis 4) Pylephlebitis (due to bacterial invasion of mesenteric veins to involve the portal vein and SMV) 5) Thrombosis 6) [Fistula formation>] Liver abscess and abscess formation in adjacent organs 7) Scrotal cellulitis and abscess through a patent processus vaginalis (congenital indirect inguinal hernia) 8) Small bowel obstruction

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Final common pathway of appendiceal inflammation and its complications

Invasion of the appendiceal wall by bacteria

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Factors implicated in the initiation of acute appendicitis

1) Luminal obstruction 2) Enteric infection 3) Blunt abdominal trauma 4) Cystic fibrosis (due to abnormally thickened mucus)

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Implicated in luminal obstruction that leads to acute appendicitis

1) Inspissated fecal material 2) Lymphoid hyperplasia 3) Ingested foreign body 4) Parasites 5) Tumors (e.g. carcinoid tumors of the appendix)

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Pathophy of acute appendicitis caused by luminal obstruction

Luminal obstruction > bacterial proliferation and continued secretion of mucus > elevated intraluminal pressure > lymphatic and venous congestion and edema > impaired arterial perfusion > ischemia of wall of appendix > bacterial invasion of appendiceal wall > necrosis

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Clinical disease progression of appendicitis

Simple appendicitis > gangrenous appendicitis > appendiceal perforation

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Acute appendicitis is most common at what age group

Teenagers/older children/specifically between 12 and 18 years old (less than 5% of cases in less than 5y/o, less than 1% of cases in less than 3 y/o)

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Why is acute appendicitis most common during teen years

Submucosal lymphoid follicles, which can obstruct appendiceal lumen, are few at birth but multiply steadily during childhood and peak in number during teen years

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T/F Majority of specimens from cases of acute appendicitis demonstrate luminal obstruction

F, less than 50%

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Pathophy of acute appendicitis caused by enteric infection

Mucosal ulceration > invasion of the appendiceal wall by bacteria

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Organisms implicated in acute appendicitis

Yersinia, Salmonella, Shigella, infectious mononucleosis (EBV), mumps, coxsackie B, adenovirus, Ascaris

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T/F Appendicitis is common in neonates

F, RARE, hence occurrence warrants diagnostic evaluation for CF and Hirschprung disease

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“A primary focus in the management of acute appendicitis is

Avoidance of sepsis and infectious complications

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Why is “Avoidance of sepsis and infectious complications” a primary focus in the management of acute appendicitis

Leads to increased morbidity

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T/F Bacteria can be cultured from the serial surface of the appendix before microscopic or gross perforation

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Localized abscess or inflammatory mass formed subsequent to perforation by the momentum and adjacent loops of bowel

Phlegmon

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Reason why young children are often unable to control local infection

Poorly developed omentum

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T/F Classic presentation of acute appendicitis represents majority of acute appendicitis cases in children

F, less than 50%; majority are atypical

Acute appendicitis in children typically begins with

Generalized malaise and anorexia

Appendiceal perforation in children is likely to occur within

48 hours of onset of illness

Consistently the primary and often first symptom of appendicitis in children

Abdominal pain, begins hours after onset of illness

Typical pain of appendicitis in children

1) Vague 2) Poorly localized 3) Unrelated to activity or position 4) Colicky 5) Periumbilical

Why is the pain of acute appendicitis characterized as such

There are no somatic pain fibers within the appendix, hence pain is due to visceral inflammation from a distended appendix

Why is the pain of acute appendicitis localized to the RLQ in the next 12-24 hours

Involvement of the adjacent peritoneal surfaces, which has somatic pain fibers

In 50% of the population, the appendix is located in a ___ position

Retrocecal

T/F Nausea and vomiting usually precedes abdominal pain in acute appendicitis

F, it usually follows the onset of abdominal pain

T/F Anorexia is a classic and consistent finding in acute appendicitis

T/F Symptoms of acute appendicitis includes diarrhea and urinary symptoms

T, particularly in cases of perforated appendicitis; may be misdiagnosed as AGE

T/F Appendicitis is often associated with constipation

T, due to adynamic ileus

Pain of appendicitis vs AGE

Constant (not cramping or relieved by defecation)

Emesis of appendicitis vs AGE

Bile-stained and persistent

Clinical course of appendicitis vs AGE

Worsens readily rather than demonstrating a waxing and waning pattern

T/F Fever of acute appendicitis is typically high-grade

F, typically low-grade unless perforation has occurred

T/F Fever is uncommon in acute appendicitis in children

F, it is common

The temporal progression fo symptoms of appendicitis occurs slowly

F, rapidly, in 24-48 hours

Perforation rate of acute appendicitis

>65%

T/F Following perforation is a period of less pain and acute symptoms

T, presumably with the elimination of pressure within the appendix

T/F If the omentum or adjacent intestine is able to wall off the infectious process, the evolution of illness is less predictable and delay in presentation is likely.

When several days have elapsed in the progression of appendicitis, patients often develop signs and symptoms of ___

Small bowel obstruction

If the appendix is at this position, appendicitis predictably evolves more slowly and patients are likely to relate 4-5 days of illness preceding evaluation.

Retrocecal

Appendicitis can mimic the symptoms of ___ and ___ if the appendix is retrocecal

1) Septic arthritis of the hip 2) Psoas muscle abscess

Hallmark of diagnosing acute appendicitis

Careful and thorough history and physical examination

T/F In many children, appendicitis can be confidently diagnosed based on history and physical examination alone

T/F Children with acute appendicitis rarely present

Typical appearance of children with early (18-36 hours) appendicitis

Mildly ill, move tentatively, hunched forward and, often, with a slight limp favoring the right side

Supine, children with appendicitis often lie quietly on their ___ side with their knees pulled

Right

Early appendicitis on auscultation

Normal or hyperactive bowel sounds

As appendicitis progresses to perforation, auscultation reveals

Hypoactive bowel sounds

T/F The judicious use of morphine analgesia to relieve abdominal pain does not change diagnostic accuracy or interfere with surgical decision making

The single most reliable finding in the diagnosis of acute appendicitis

Localized abdominal tenderness

McBurney described the classic point of localized tenderness in acute appendicitis, which is at the

Junction of the lateral and middle thirds of the line joining the right anterior–superior iliac spine and the umbilicus on the right

When the appendix is at this position, the tenderness on abdominal examination may be minimal and best appreciated on rectal examination

Appendix localized entirely in the pelvis

In acute appendicitis, the examination is best initiated in which region of the abdomen

LLQ

In acute appendicitis, abdominal examination is ideally conducted in what direction

Counterclockwise

Sign of appendicitis exhibited by abdominal pain when coughing

Dunphy sign

"Guarding" in acute appendicitis refers to

Voluntary or involuntary rigidity of the overlying rectus muscle

Sign of appendicitis exhibited by referred tenderness

Rovsing sign

Recommended way to test for rebound tenderness

Gentle finger percussion; deep palpation followed by sudden release is very painful and has demonstrated poor correlation with peritonitis; DRE is uncomfortable

Psoas sign

Pain with active right thigh flexion or passive extension of the hip

The sign of appendicitis that is typically positive in cases of retrocecal appendix

Psoas sign

Obturator sign

Adductor pain after internal rotation of the flexed thigh

The sign of appendicitis that is typically positive in cases of pelvic appendix

Obturator sign