Diseases of Small Bowel and Appendix

Question 1

incidence of appendicitis

Answer 1

rare in infancy
peaks in childhood and young adults
peaks again in elderly

Question 2

aetiology of appendicitis

Answer 2

obstruction of lumen with faecolith
bacterial
viral
parasites

Question 3

pathology of appendicitis

Answer 3

lumen may or may not be occluded 
mucosal inflammation 
lymphoid hyperplasia 
obstruction 
build up of mucus and exudate 
venous obstruction 
ischaemia - bacterial invasion through wall 
perforation 
small bowel adheres 
phlegmonous mass
peritonits

Question 4

symptoms of appendicitis

Answer 4

anorexia
nausea +/- vomiting
rectal tenderness
+/- fever

Question 5

signs of appendicitis

Answer 5

mild Pyrexia 
mild tachycardia 
central abdominal pain, later localised pain in right iliac fossa 
guarding 
rebound 
rosving's
psoas
obturator

Question 6

rosving’s sign

Answer 6

pressing on the left causes pain on the right

Question 7

psoas sign

Answer 7

patient keep the right hip flexed as this lefts an inflamed appendix off the posts

Question 8

obturator signs

Answer 8

if appendix is touching obturator internus, flexing the hip and internally rotating with cause pain

Question 9

special cases of appendicitis

Answer 9

retrocacal appendix 
pelvic appendix 
postileal
the obese
the elderly
children
pregnancy

Question 10

retrocaecal appendix

Answer 10

may be very few signs

Question 11

pelvic appendix

Answer 11

diarrhoea

frequency of micturition

Question 12

postilieal apendicitis

Answer 12

rare
diarrhoea
vomiting

Question 13

differential diagnosis of appendicitis in children

Answer 13

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

Question 14

differential diagnosis of appendicitis in adults

Answer 14

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

Question 15

differential diagnosis of appendicitis in the elderly

Answer 15

Sigmoid diverticulitis
Intestinal obstruction
Carcinoma of the caecum

Question 16

differential diagnosis of appendicitis in woman

Answer 16

Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregnancy

Question 17

rare differential diagnosis of appendicitis

Answer 17

Pophyria
Diabetic ketoacidosis
typhilitis

Question 18

tests for appendicitis

Answer 18

it is a clinical diagnosis;
ultrasound - first line
AXR - exclude other causes 
FBC
urinalysis
Alvarado score

Question 19

describe the Alvarado score

Answer 19

MANTRELS;
migration of pain to lower right quadrant 
anorexia 
nausea and vomiting 
tenderness in right lower quadrant 
rebound pain 
elevated temperature 
leukocytosis 
shift of white blood cell count to left

Question 20

management of appendicitis

Answer 20

analgesia (pain)
antipyretics (reduce fever)
appendicectomy
antibiotics

Question 21

treatment of an appendix mass

Answer 21

antibiotics - first line

can choose whether or not to operate

Question 22

complications of surgical intervention of appendicitis

Answer 22

tachycardia
worsening pain
increase in pain
vomiting or copious NG aspirates (ileus)

Question 23

describe an appendix abscess

Answer 23

not an appendix mass
usually has liquidised
usually delayed

Question 24

treatment of appendix abscess

Answer 24

radiological drains

Question 25

complications of appendix abscess

Answer 25

Pelvic abscess
Wound infection
Intra-abdominal abscess
Ileus
Respiratory
DVT/PE
Portal pyaemia
Faecal fistula
Adhesions
Right sided inguinal hernia

Question 26

describe carcinoid of the appendix

Answer 26

appears in crypts of Lieberkuhn
metastatic risk relates to size
stains for chromagrannin

Question 27

obstruction of the small bowel

Answer 27

proximal bowel will dilate and develop altered motility

swells due to build up of fluid and gas

Question 28

where does the gas come from that causes the small bowel to swell

Answer 28

anaerobic and aerobic metabolism that occurs with the overgrowth of organisms in the obstructed bowel - nitrogen and hydrogen sulphide

Question 29

where may the small bowel be obstructed

Answer 29

within the lumen
within the wall
outside the wall

Question 30

what may cause the lumen of the small bowel to be obstructed

Answer 30

gallstone
food
bezoar

Question 31

what may cause the inside wall of the small bowel to be obstructed

Answer 31

tumour
Crohn’s disease
radiation

Question 32

what may cause the outside wall of the small bowel to be obstructed

Answer 32

adhesions

herniation

Question 33

symptoms of obstruction of the small bowel

Answer 33

look for a cause of obstruction (groins both femoral and inguinal) - scars, hernias
pain 
constipation
vomiting 
burping 
abdominal distension 
borborygmi

Question 34

tests for obstruction of small bowel

Answer 34

urinalysis 
bloods
gases
AXR
CT
gastrograffin studies

Question 35

treatment for obstruction of small bowel

Answer 35

analgesia 
fluids + K+
catheterise 
NG tube (ryles, not feeding)
anti-thromboembolism measures

Question 36

causes of mesenteric ischaemia

Answer 36

embolus - from AF (forms in left atrium and sticks in narrow Superior mesenteric artery)
thrombosis (arterial and venous) - Virchow’s triad

Question 37

chronic mesenteric ischaemia

Answer 37

superior mesenteric artery affected
cramps
‘angina of the gut’
atherosclerosis

Question 38

acute mesenteric ischaemia

Answer 38

small bowel usually infarcts - dies

colon lives due to marginal artery

Question 39

presentation of mesenteric ischaemia

Answer 39

pain out of proportion to clinical findings
acidosis
lactate elevated
elevated WBC

Question 40

tests for mesenteric ishcaemia

Answer 40

blood gases

CT angiogram

Question 41

treatment for mesenteric ischaemia

Answer 41

very quick treatment required
resect in non-viable
re-anastomose or staple and planned return
superior mesenteric artery embolectomy