Chapter 44: Appendix- Appendicits Flashcards
What is it?
Inflammation of the appendix caused by obstruction of the appendiceal lumen,producing a closed loop with resultant inflammation that can lead to necrosis andperforation
What are the causes?
Lymphoid hyperplasia, fecalith (a.k.a. “appendicolith”)
What is the lifetime incidence of acute appendicitis in the UnitedStates?
≈7%!
What is the most common cause of emergent abdominal surgery inthe United States?
Acute appendicitis
How does appendicitis classically present?
- Periumbilical pain (intermittent and crampy)
- Nausea/vomiting
- Anorexia
- Pain migrates to RLQ
- (constant and intense pain)
- usually in <24 hours
Why does periumbilical pain occur?
Referred pain
Why does RLQ pain occur?
Peritoneal irritation
What are the signs/symptoms?
Signs of peritoneal irritation may be present:
- guarding
- muscle spasm
- rebound tenderness
- obturator and psoas signs
- low-grade fever (high grade if perforation occurs)
- RLQ hyperesthesia
Obturator sign
- Pain upon internal rotation of the leg with the hip and knee flexed
- seen inpatients with pelvic appendicitis
Psoas sign
- Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance
- seen classically in retrocecal appendicitis
Rovsing’s sign
- Palpation or rebound pressure of the LLQ results in pain in the RLQ
- seen in appendicitis
McBurney’s point
Point one third from the anterior superior iliac spine to the umbilicus (often the point of maximal tenderness)
What is the differential diagnosis for everyone
- Meckel’s diverticulum
- Crohn’s disease
- perforated ulcer
- pancreatitis
- mesenteric lymphadenitis
- constipation
- gastroenteritis
- intussusception
- volvulus
- tumors
- UTI (e.g., cystitis)
- pyelonephritis
- torsed epiploicae
- cholecystitis
- cecal tumor
- diverticulitis (floppy sigmoid)
What is the differential diagnosis for females
- Ovarian cyst
- ovarian torsion
- tuboovarian abscess
- mittelschmerz
- pelvicinflammatory disease (PID)
- ectopic pregnancy
- ruptured pregnancy
What lab tests should be performed?
- CBC: increased WBC (>10,000 per mm3 in >90% of cases)
- most often with a“left shift”
- Urinalysis: to evaluate for pyelonephritis or renal calculus
Can you have an abnormal urinalysis with appendicitis?
Yes; mild hematuria and pyuria are common in appendicitis with pelvicinflammation, resulting in inflammation of the ureter
What additional tests can be performed if the diagnosis is not clear?
Spiral CT scan
U/S (may see a large, noncompressible appendix or fecalith)
In acute appendicitis, what classically precedes vomiting?
Pain
(in gastroenteritis, the pain classically follows vomiting)
What radiographic studies are often performed?
- CXR: to rule out RML or RLL pneumonia, free air
- AXR: abdominal films are usually nonspecific, but calcified fecalith present in≈5% of cases
What are the CT scan findings with acute appendicitis?
- Periappendiceal fat stranding
- appendiceal diameter >6 mm
- periappendiceal fluid
- fecalith
What are the preoperative medications/preparation?
- Rehydration with IV fluids (LR)
- Preoperative antibiotics with anaerobic coverage (appendix is considered partof the colon)
What is a lap appy?
Laparoscopic appendectomy;
- used in most cases in women (can see adnexa)
- if patient has a need to quickly return to physical activity
- obese
What is the treatment for nonperforated acute appendicitis?
Nonperforated—
- prompt appendectomy (prevents perforation)
- 24 hours of antibiotics
- discharge home usually on POD #1
What is the treatment for perforated acute appendicitis?
Perforated—
- IV fluid resuscitation and prompt appendectomy
- all pus is drained with postoperative antibiotics continued for 3 to 7 days
- wound is left open in most cases of perforation after closing the fascia
- (heals by secondary intention or delayed primary closure)
NOTE: Check first aid
