Diverticular diseases and appendicitis Flashcards
What is the lifetime risk of developing appendicitis?
7-8%. 4% chance of having appendicitis by age 20
At what age does it become uncommon to have appendicitis?
Age 50
Pathophysiology of appendicitis
- Obstruction of lumen (stool, lymphoid hyperplasia, foreign body, carcinoid tumor)
- Production of mucus (continued production)
- Intraluminal hypertention
- Lymphatic obstruction/venous congestion
- Edema and local inflammation
- Arterial obstruction, ischemia, gangrene, perforation
Describe the classic presentation of appendicitis
- Pain and appendix swells. Stretch receptors transmit pain impulses along mesenteric nerves to T10
- Umbilical pain, constant, mild, gradual
- 4-8 hrs later, pain move to RLQ, with focused peritoneal signs
What are the three main Sx of appendicitis
- Pain
- Anorexia (No desire for favorite food)
- Tenderness
Where is mcburney’s point? how do you elicit it?
It’s 2/3rds of the distance from the umbilicus to the anterior superior spine. Elicit it by applying pressure (or spontaneous pain)
What are additional ancillary signs of appendicitis? How do you elicit them?
Rovsings (Pressure on left=rebound pain on right)
Psoas (straight leg raise against resistance)
Obturator (intorting or extorting the hip)
What is an acute abdomen?
Peritonitis
What are the physical exam findings of peritonitis?
tenderness, guarding, rebound tenderness
What’s on your differential for appendicitis (non repro)?
Gastroenteritis Pyelonephritis Cholecystitis Pancreatitis Crohn's Cecal diverticulitis Meckle's diverticulitis
What are the reproductive differentials?
Ectopic pregnancy
Torsed ovary
Ruptured ovarian cyst
Pelvic Inflammatory disease
What could confound the diagnosis of appendicitis?
- very young
- elderly
- narcotics
- steroids
- antibiotic
Why labs would you get in someone with appendicitis?
WBC
Urinalysis
Lipase
Beta-HCG
What imaging studies would you want in appendicitis?
CT scan. Look for a dilated appendix. Also, wall thickening and fat stranding around the appendix
Do you need a CT scan in order to diagnose appendicitis?
No…if presenting with all the classic signs. If ambigious, get a CT
What are the benefits vs the risks of laparoscopic vs open appendectomy?
Laparoscopic takes longer AND... -Higher risk of abscess -BUT lower wound infection rate -Slightly milder pain Both are still used
Can you treat acute non-perforated appendicitis with only Abx?
You should not do this. Surgery is the standard of care because outcomes are much worse with Abx alone.
What are your options if a patient presents with a perforated appendicitis?
Option 1: Immediate surgery–>remove and drain abscess. Delay primary wound closure. Prescribe antibiotics.
Option 2: Drain abscess percutaneously. Treat with antibiotics. Undergo elective appendectomy later on.
What percentage of americans have diverticula by age 60? What percentage develop symptoms?
50% have diverticula by age 60
10% develop symptoms
How does diverticulitis present?
LLQ abdominal pain, constant and gradual onset
What imaging would you want in diverticulitis?
CT if long duration of symptoms, high fever, and leukocytosis. However, Abx is usually enough based on symptomology
What labs would you want with diverticulitis?
CBC, UA
What do you do if someone with diverticulitis has fever or leukocytosis?
Admit them and get a CT. Treat with broad spectrum antibiotics. Follow up with a colonoscopy to rule out cancer
How do you manage complicated diverticulitis? perforation/obstruction/large abscess
For perforation and obstruction: Resection and colostomy
For large abscess: Resection and colostomy OR CT percutaneous drainage, followed by bowel prep, resection, and anastamosis
