Diverticular Diseases and Appendicitis Flashcards
What causes appendicitis?
obstruction of lumen with:
• stool
• lymphoid hyperplasia
• foreign bodies
• carcinoid tumors
low daily fiber intake
What is the time course of appendicitis?
How does it progress?
- obstruction with continued production of mucus by the appendiceal mucosa
- leads to intraluminal HTN
- leads to lymphatic obstruction and venous congestion
- leads to edema and local inflammation
- finally causing arterial obstruction, ischemia, gangrene and perforation of the appendix
What are the chronological symptoms of appendicitis?
How are these symptoms produced specifically ?
1) appendix swells -> stretch receptors transmit pain along mesenteric nerves to T10 spinal nerve (supplies dermatome at the level of umbilicus) -> results in a gradual onset of constant, mild peri-umbilical pain
2) 4-8 hours: direct contact or inflammatory fluid hits the parietal peritoneum -> pain shifts from peri-umbilical to RLQ (hurts when going over bumps in car on way to hospital)
What is the history and physical of a patient with appendicitis?
History
- Pain (peri-umbilical -> RLQ)
- Anorexia (Lack of desire for favorite food. Vomiting possible, but unusual, almost always comes after pain)
- Tenderness (McBurneys’ point - 1/3 between ASIS and umbilicus)
Physical
- General: Lying still. Not writhing in pain.
- VS: T 38 C. (low grade fever early on)
- McBurney’s point (FOCAL pain)
- Guarding
- Rebound Tenderness (RT); refusal to hop.
What are 3 ancillary tests for appendicitis?
Rovsings - elicit RT in the RLQ by palpating the LLQ
Psoas - if flexing the thigh at the hip causes pain, this may be due to an inflamed appendix that is oriented retrocaecally and causing irritation to the iliopsoas
Obturator – if internal rotation of the hip causes pain, this may be due to an inflamed appendix that is oriented towards the pelvic region and causing irritation to the obturator internus
What is guarding?
tightening of abdominal wall muscles (can be voluntary vs. involuntary
What are some confounding Factors for making a diagnosis of appendicitis
- Very young
- Elderly
- Steroids/narcotics/antibiotics - can blunt the response of pain
What are some labs and imaging tests that you would perform on a patient who comes in with complaints in the RLQ and suspected appendicitis?
- WBC (1/3 of patients absolute number will be normal)
- Urinalysis, lipase (to r/o pyelonephritis pancreatitis)
- ß-HCG (r/o ectopic pregnancy)
Radiologic studies:
• US: may be useful in pregnant women
• CT: can be very useful in patients who do not present with typical findings of appendicitis; considered + if appendiceal diameter is > 6 mm. Also look for signs of appendicitis: wall thickening, mucosal enhancement, or peri-appendiceal fat stranding. Problem: radiation may increase cancer risk for kids
What is the standard of care for patients with appendicitis?
Would antibiotics help?
Surgery is the standard of care
• open appendectomy
• laparoscopic removal - longer, more $$$, and higher risk of intra-abdominal abscess but there is a lower risk of wound-infection rate and reduced post-op pain
antibiotics DO NOT help
What is a complication that can arise with appendicitis?
How would you treat this complication?
perforation of appendicitis with abscess that results in an acute abdomen
two treatment options:
• immediate surgery (remove appendix, drain abscess), followed by antibiotics – technically difficult with high complication rates
• drain abscess percutaneously, followed by antibiotics – high success rate but it does fail in 7% (need surgery), can miss cancer or Crohn’s disease, or it can recur in next year. Consider “interval” appendectomy (performed when all of the inflammatory processes have settled down)
What is diverticulum and how do they arise?
What are some causes of diverticula formation?
Where do they commonly arise?
diverticulum - out pouching of mucosa + serosa that develops at well-defined points of weakness (usually correspond to where the vasa recta penetrates the circular muscle layer of the colon). Note the muscular wall does not go into the diverticulum, thus the diverticula is very easy to pop
causes – usually a low fiber diet, which results in abnormal colonic motility and ultimately hardened stool forms. The intestine tries to move the stool out and the excess pressure causes these diverticula to form.
common sites: sigmoid colon – where the stool has already formed
What is this history and physical of a patient with diverticula look like?
What are some labs that you would order for a patient with suspected diverticulitis?
History
- LLQ abdominal pain, constant, gradual onset
Physical
- Vitals: T 37-39 C
- Tenderness to deep palpation in LLQ. Guarding
Labs:
- CBC, UA
- Radiologic studies: CT if long duration of symptoms, high fever, leukocytosis.
How would you treat a patient with diverticulitis?
If tender with no significant fever or leukocytosis: oral antibiotics.
if fever or leukocytosis: admit, CT, treat with IV antibiotics covering gram (-) bacteria and anaerobes. Once resolved, colonoscopy to rule-out cancer
What are some complications of diverticulitis? How are these managed?
Perforation: resection and colostomy (external bag for feces to leave body), followed by colostomy take-down (reversal)
**Obstruction: ** same
Large Abscess: Resection and colostomy or CT guided percutaneous drainage, followed by bowel prep, resection and primary anastamosis
What is an acute abdomen?
causes?
What is the physical exam like?
Acute abdomen = peritonitis (an acute inflammatory process in the abdomen)
physical exam = tenderness, guarding, rebound tenderness all over the abdomen
causes = perforated duodenal ulcer, perforated sigmoid colon due to diverticulitis, ruptured appendix
