Disease of the Small Bowel & Appendix

Question 1

Who usually gets appendicitis?

Answer 1

• Usually childhood/young adulthood
• Another peak in the elderly
• Rare in infancy

M:F ratio 3:2 before 25 years, then equal

Question 2

What are the possible causes of appendicitis?

Answer 2

• Unknown cause
• Obstruction of the lumen with faecolith
• Bacterial
• Viral (clustering of cases)
• Parasites

Question 3

Describe the macroscopic appearance of the appendix in appendicitis

Answer 3

• Lumen may or may not be occluded
• Mucosal inflammation
• Lymphoid hyperplasia
• Build up of mucus and exudate
• Venous obstruction
• Ischaemia..bacterial invasion through wall
• Perforation

Question 4

In what groups is peritonitis most likely fatal?

Answer 4

Increased Age
Immunosuppressed
Diabetes
Absence of omentum (previous surgery)

Question 5

What signs are classically seen in a patient presenting with appendicitis?

Answer 5

• Mild pyrexia (never high temp initially)
• Mild tachycardia
• Localised pain in RIF
• Guarding
• Rebound

Question 6

What specific signs can you illicit to aid a diagnosis of appendicitis?

Answer 6

• Rosving’s
  => Pressing on the left causes pain on the right
• Psoas
  Pt keeps right hip flexed as this lifts an inflamed appendix off the psoas muscle
• Obturator
  If appendix is touching obturator internus, flexing the hip and internally rotating will cause pain
• Pointing
  Where did it start, where it is now?
  => Diffuse RIF -> McBurney’s Point

Question 7

An appendix in the retrocaecal position may show very few signs of appendicitis. TRUE/FALSE?

Answer 7

TRUE

Question 8

A pelvic appendix may cause what symptoms?

Answer 8

diarrhoea

increased frequency of micurition

Question 9

What differential diagnoses must you consider in children who present with symptoms similar to that of appendicitis?

Answer 9

• Gastroenteritis
• Mesenteric adenitis
• Meckel’s diverticulum
• Intususseption
• Henoch-Schonlein Purpura
• Lobar pneumonia

Question 10

What differentials for appendicitis are more common in adults?

Answer 10

• Terminal ileitis
• Ureteric colic
• Acute pyelonephritis
• Perforated ulcer
• Pancreatitis
• Rectus sheath haemotoma

Question 11

If a women presents with symptoms typucal of appendicitis, what other differentials should you consider?

Answer 11

Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregnancy*

Question 12

What differential diagnoses of appendicitis should be considered in the elderly?

Answer 12

• Sigmoid diverticulitis
• Intestinal obstruction
• Carcinoma of the caecum

Question 13

What investigations can be used in the diagnosis of appendicitis?

Answer 13

• USUALLY A CLINICAL DIAGNOSIS
• USS useful in women and kids
• AXR to exclude other causes
• Bloods (important CRP, WCC)
• Urinalysis

Question 14

How is appendicitis managed?

Answer 14

• Analgesia
• Antipyretics
• Theatre (laparoscopic appendicectomy)
• Antibiotics

Question 15

An appendix abscess usually presents as a mass. TRUE/FALSE?

Answer 15

FALSE

• usually delayed
• liquified by this point
• needs radiological drainage

Question 16

What are the potential complications of appendicitis?

Answer 16

• Pelvic/intra-abdominal abscess
• Wound infection
• Ileus
• DVT/PE
• Faecal fistula
• Adhesions
• Right sided inguinal hernia

Question 17

Describe how Carcinoid of the appendix is treated with surgery depending on its size.

Answer 17

If < 1cm = appendicectomy alone

> 2cm completion right hemicolectomy

Question 18

A small bowel obstruction causes what symptoms?

Answer 18

Pain (colicky, central)
Absolute constipation
Vomiting (may be faeculent)
Burping
Abdominal distension

Question 19

What can cause a small bowel obstruction?

Answer 19

Within the lumen (gallstone, food, bezoar)

Within the wall (tumour, Crohn’s, Radiation)

Outside the wall (Adhesions, Herniation)

Question 20

If you suspect a small bowel obstruction you must look for the cause. TRUE/FALSE?

Answer 20

TRUE

Question 21

How does a small bowel obstruction look on an AXR?

Answer 21

• large distended loops of bowel

=> filled with gas

Question 22

HOw is small bowel obstruction treated?

Answer 22

• ABC
• Analgesia
• Fluids with Potassium
• They are usually hypokalaemic and alkalotic
• Catheterise
• NG tube (Ryles tube NOT feeding tube)
• Anticoagulation measures

Question 23

How long can you use drip and suck?

Answer 23

- Up to 72 hours is standard
Intervene earlier if:
- Strangulation
- Perforation
- Ischaemia

Question 24

HOw is small bowel obstruction managed surgically?

Answer 24

• Laparotomy (midline incision)
• Find obstruction by following collapsed or dilated bowel

Remember to give:

• Antibiotics
• Anticoagulation

Question 25

Describe the difference between acute and chronic mesenteric ischaemia?

Answer 25

Chronic = like angina of the guts

• cramps
• due to atherosclerosis

Acute = infarction occurs and bowel dies

Question 26

What is the common cause of SMA occlusion in mesenteric ischaemia?

Answer 26

Embolus usually from AF
Forms in left atrium
Sticks in a narrow SMA

Question 27

What symptoms and signs indicate a diagnosis of mesenteric ischaemia?

Answer 27

• Pain out of proportion
• Acidosis on gases (low pH, high H+ concentration)
• Lactate elevated
• CRP may be normal
• WCC may be up a bit

Question 28

What investigation may be used to visualise SMA occlusion?

Answer 28

CT angiography

Question 29

HOw is mesenteric ischaemia treated

Answer 29

• Resect if bowel is non-viable
• Re-anastomse or staple remaining bowel together
• If bowel is viable you can perform an SMA embolectomy

Question 30

What is Meckel’s Diverticulum?

Answer 30

• 2 feet IC valve
• 2% of population
• Presents before 2 years of age
• Remnant of the omphalomesenteric duct

Question 31

What complications can patient’s experience with Meckel’s Diverticulum?

Answer 31

• Bleed (haematochezia)
• Ulcerate/meckels diverticulitis
• Obstruction
• Malignant change (0.5%)