Diverticular diseases and appendicitis

Question 1

What is the lifetime risk of developing appendicitis?

Answer 1

7-8%. 4% chance of having appendicitis by age 20

Question 2

At what age does it become uncommon to have appendicitis?

Answer 2

Age 50

Question 3

Pathophysiology of appendicitis

Answer 3

1. Obstruction of lumen (stool, lymphoid hyperplasia, foreign body, carcinoid tumor)
2. Production of mucus (continued production)
3. Intraluminal hypertention
4. Lymphatic obstruction/venous congestion
5. Edema and local inflammation
6. Arterial obstruction, ischemia, gangrene, perforation

Question 4

Describe the classic presentation of appendicitis

Answer 4

1. Pain and appendix swells. Stretch receptors transmit pain impulses along mesenteric nerves to T10
2. Umbilical pain, constant, mild, gradual
3. 4-8 hrs later, pain move to RLQ, with focused peritoneal signs

Question 5

What are the three main Sx of appendicitis

Answer 5

1. Pain
2. Anorexia (No desire for favorite food)
3. Tenderness

Question 6

Where is mcburney’s point? how do you elicit it?

Answer 6

It’s 2/3rds of the distance from the umbilicus to the anterior superior spine. Elicit it by applying pressure (or spontaneous pain)

Question 7

What are additional ancillary signs of appendicitis? How do you elicit them?

Answer 7

Rovsings (Pressure on left=rebound pain on right)
Psoas (straight leg raise against resistance)
Obturator (intorting or extorting the hip)

Question 8

What is an acute abdomen?

Answer 8

Peritonitis

Question 9

What are the physical exam findings of peritonitis?

Answer 9

tenderness, guarding, rebound tenderness

Question 10

What’s on your differential for appendicitis (non repro)?

Answer 10

Gastroenteritis
Pyelonephritis
Cholecystitis
Pancreatitis
Crohn's
Cecal diverticulitis
Meckle's diverticulitis

Question 11

What are the reproductive differentials?

Answer 11

Ectopic pregnancy
Torsed ovary
Ruptured ovarian cyst
Pelvic Inflammatory disease

Question 12

What could confound the diagnosis of appendicitis?

Answer 12

1. very young
2. elderly
3. narcotics
4. steroids
5. antibiotic

Question 13

Why labs would you get in someone with appendicitis?

Answer 13

WBC
Urinalysis
Lipase
Beta-HCG

Question 14

What imaging studies would you want in appendicitis?

Answer 14

CT scan. Look for a dilated appendix. Also, wall thickening and fat stranding around the appendix

Question 15

Do you need a CT scan in order to diagnose appendicitis?

Answer 15

No…if presenting with all the classic signs. If ambigious, get a CT

Question 16

What are the benefits vs the risks of laparoscopic vs open appendectomy?

Answer 16

Laparoscopic takes longer AND...
-Higher risk of abscess
-BUT lower wound infection rate
-Slightly milder pain
Both are still used

Question 17

Can you treat acute non-perforated appendicitis with only Abx?

Answer 17

You should not do this. Surgery is the standard of care because outcomes are much worse with Abx alone.

Question 18

What are your options if a patient presents with a perforated appendicitis?

Answer 18

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.

Question 19

What percentage of americans have diverticula by age 60? What percentage develop symptoms?

Answer 19

50% have diverticula by age 60

10% develop symptoms

Question 20

How does diverticulitis present?

Answer 20

LLQ abdominal pain, constant and gradual onset

Question 21

What imaging would you want in diverticulitis?

Answer 21

CT if long duration of symptoms, high fever, and leukocytosis. However, Abx is usually enough based on symptomology

Question 22

What labs would you want with diverticulitis?

Answer 22

CBC, UA

Question 23

What do you do if someone with diverticulitis has fever or leukocytosis?

Answer 23

Admit them and get a CT. Treat with broad spectrum antibiotics. Follow up with a colonoscopy to rule out cancer

Question 24

How do you manage complicated diverticulitis? perforation/obstruction/large abscess

Answer 24

For perforation and obstruction: Resection and colostomy

For large abscess: Resection and colostomy OR CT percutaneous drainage, followed by bowel prep, resection, and anastamosis