EOR GI part 5- SBO, appendicitis Flashcards
What is the #1 cause of SBO around the world?
Hernias
What is the #1 cause of SBO in children?
Hernias
What are the signs of strangulated bowel with SBO?
Fever Severe/continuous pain Hematemesis Shock Gas in the bowel wall or portal vein Abdominal free air Peritoneal signs Acidosis (increased lactic acid)
What are the clinical parameters that will lower the threshold to operate on a partial SBO?
Increasing WBC
Fever
Tachycardia/tachypnea
Abdominal pain
What is an absolute indication for operation with partial SBO?
Peritoneal signs
Free air on AXR
What condition commonly mimics SBO?
Paralytic ileus (AXR reveals gas distention throughout, including the colon)
What is the DDx of paralytic (nonobstructive) ileus?
Postoperative ileus after abd surgery (normally resolves in 3-5 days)
Electrolyte abnormalities (hypokalemia is most common)
Medications (anticolinergic, narcotics)
Inflammatory intra-abdominal process
Sepsis/shock
Spine injury/spinal cord injury
Retroperitoneal hemorrhage
What tumor classically causes SBO due to mesenteric fibrosis?
Carcinoid tumor
What is appendicitis?
Inflammation of the appendix caused by obstruction of the appendiceal lumen, producing a closed loop with resultant inflammation that can lead to necrosis and perforation
What are the causes of appendicitis?
Lymphoid hyperplasia, fecalith (aka, appendicolith)
What is the lifetime incidence of acute appendicitis in the US?
~7%
What is the MCC of emergent abdominal surgery in the US?
Acute appendicitis
How does appendicitis classically present?
Classic chronologic order:
- Periumbilical pain (intermittent and crampy)
- Nausea/vomiting
- Anorexia
- Pain migrates to RLQ (constant and intense pain), usually in 24 hours
Why does periumbilical pain present in appendicitis?
Referred pain
Why does RLQ pain occur in appendicitis?
Peritoneal irritation
What are the S/sx of appendicitis?
Signs of peritoneal irritation may be present:
Guarding
Muscle spasm
Rebound tenderness
Obturator and Psoas signs
Low-grade fever (high grade if perf occurs)
RLQ hyperesthesia
Obturator sign
Pain upon internal rotation of the leg with the hip and knee flexed
Seen in pts with pelvic appendicitis
Psoas sign
Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance
Seen classically in retrocecal appendicitis
Rovsing’s sign
Palpation or rebound pressure of the LLQ results in pain in the RLQ
Seen in appendicitis
McBurney’s point
Point one third from the anterior superior iliac spine to the umbilicus (often the point of maximal tenderness)
What is the DDx for appendicitis in everyone?
Meckel's diverticulum Crohn's dz Perforated ulcer Pancreatitis Mesenteric lymphadenitis Constipation Gastroenteritis Intussusception Volvulus Tumors UTI Pyelonephritis Torsed epiplocae Cholecystitis Cecal tumor Diverticulitis
What is the DDx for appendicitis in females?
Ovarian cyst Ovarian torsion Tuboovarian abscess Mittelschmerz PID Ectopic pregnancy Ruptured pregnancy
What labs should be performed for appendicitis?
CBC: increased WBC (>10,000 in >90% of cases), most often with a left shift
UA: to evaluate for pyelonephritis or renal calculus
Can you have an abnormal UA with appendicitis?
Yes; mild hematuria and pyuria are common in appendicitis with pelvic inflammation, resulting in inflammation of the ureter
What additional tests can be performed if the dx is not clear with appendicitis?
Spiral CT
U/s (may see a large, noncompressible appendix or fecalith)
In acute appendicitis, what classically precedes vomiting?
Pain (in gastroenteritis, the pain classically follows vomiting)
What radiographic studies are often performed in appendicitis?
CXR: to rule out RML or RLL PNA, free air
AXR: abdominal films are usually nonspecific, but calcified fecalith present in ~5% of cases
What are the CT scan findings with acute appendicitis?
Periappendiceal fat stranding
Appendiceal diameter >6 mm
Periappendiceal fluid
Fecalith
What are the preop meds/preparation for appendicitis?
Rehydration with IV fluids (LR)
Preop abx with anaerobic coverage (appendix is considered part of the colon)
What is a lap appy?
Laparoscopic appendectomy: used in most cases in women (can see adnexa) or if pt has a need to quickly return to physical activity or is obese
What is the tx for acute nonperforated appendicitis?
Prompt appendectomy (prevents perforation)
24 hrs of abx
D/c home usually on POD #1
What is the tx for perforated acute appendicitis?
IV fluid resuscitation and prompt appendectomy
All pus is drained with postop abx continued for 3-7 days
Wound is left open in most cases of perforation after closing the fascia (heals by secondary intention or delayed primary closure)
How is an appendiceal abscess that is dx-ed preoperatively treated?
Percutaenous drainage of the abscess
Abx administration
Elective appendectomy ~6 wks later
If a nl appendix is found upon exploration, should you take out the nl appendix (I guess for an abscess?)
Yes
How long after removal of a nonruptured appendix should abx continue postoperatively?
For 24 hrs
Which antibiotic is used for nonperforated appendicitis?
Cefoxitin Cefotetan Unasyn Cipro Flagyl
What antibiotic is used for a perforated appendix?
Broad-spectrum abx (e.g., amp/Cipro/clinda or a PCN such as Zosyn)
How long do you give abx for perforated appendicitis?
Until the pt has a normal WBC count and is afebrile, ambulating, and eating a regular diet (usually 3-7 days)
What is the risk of a perforated appendix?
~25% by 24 hrs from onset of sx
~50% by 36 hrs and ~75% by 48 hrs
What are the possible complications of appendicitis?
Pelvic abscess
Liver abscess
Free perforation
Portal pylethrombophlebitis (very rare)
What percentage of negative appendectomies is acceptable?
Up to 20%; taking out some nl appendixes is better than missing a case of acute appendicitis that eventually ruptures
Who is at risk of dying from acute appendicitis?
Very old and very young pts
What bacteria are associated with “mesenteric adenitis” that can closely mimic acute appendicitis?
Yersinia enterocolitica
