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Surgery Rotation > EOR GI part 5- SBO, appendicitis > Flashcards

EOR GI part 5- SBO, appendicitis Flashcards

1
Q

What is the #1 cause of SBO around the world?

A

Hernias

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2
Q

What is the #1 cause of SBO in children?

A

Hernias

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3
Q

What are the signs of strangulated bowel with SBO?

A 
Fever
Severe/continuous pain
Hematemesis
Shock
Gas in the bowel wall or portal vein
Abdominal free air
Peritoneal signs
Acidosis (increased lactic acid)
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4
Q

What are the clinical parameters that will lower the threshold to operate on a partial SBO?

A

Increasing WBC
Fever
Tachycardia/tachypnea
Abdominal pain

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5
Q

What is an absolute indication for operation with partial SBO?

A

Peritoneal signs

Free air on AXR

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6
Q

What condition commonly mimics SBO?

A

Paralytic ileus (AXR reveals gas distention throughout, including the colon)

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7
Q

What is the DDx of paralytic (nonobstructive) ileus?

A

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

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8
Q

What tumor classically causes SBO due to mesenteric fibrosis?

A

Carcinoid tumor

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9
Q

What is appendicitis?

A

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

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10
Q

What are the causes of appendicitis?

A

Lymphoid hyperplasia, fecalith (aka, appendicolith)

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11
Q

What is the lifetime incidence of acute appendicitis in the US?

A

~7%

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12
Q

What is the MCC of emergent abdominal surgery in the US?

A

Acute appendicitis

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13
Q

How does appendicitis classically present?

A

Classic chronologic order:

  1. Periumbilical pain (intermittent and crampy)
  2. Nausea/vomiting
  3. Anorexia
  4. Pain migrates to RLQ (constant and intense pain), usually in 24 hours
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14
Q

Why does periumbilical pain present in appendicitis?

A

Referred pain

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15
Q

Why does RLQ pain occur in appendicitis?

A

Peritoneal irritation

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16
Q

What are the S/sx of appendicitis?

A

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

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17
Q

Obturator sign

A

Pain upon internal rotation of the leg with the hip and knee flexed
Seen in pts with pelvic appendicitis

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18
Q

Psoas sign

A

Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance
Seen classically in retrocecal appendicitis

19
Q

Rovsing’s sign

A

Palpation or rebound pressure of the LLQ results in pain in the RLQ
Seen in appendicitis

20
Q

McBurney’s point

A

Point one third from the anterior superior iliac spine to the umbilicus (often the point of maximal tenderness)

21
Q

What is the DDx for appendicitis in everyone?

A 
Meckel's diverticulum
Crohn's dz
Perforated ulcer
Pancreatitis
Mesenteric lymphadenitis
Constipation
Gastroenteritis
Intussusception
Volvulus
Tumors
UTI
Pyelonephritis
Torsed epiplocae
Cholecystitis
Cecal tumor
Diverticulitis
22
Q

What is the DDx for appendicitis in females?

A 
Ovarian cyst
Ovarian torsion
Tuboovarian abscess
Mittelschmerz
PID
Ectopic pregnancy
Ruptured pregnancy
23
Q

What labs should be performed for appendicitis?

A

CBC: increased WBC (>10,000 in >90% of cases), most often with a left shift
UA: to evaluate for pyelonephritis or renal calculus

24
Q

Can you have an abnormal UA with appendicitis?

A

Yes; mild hematuria and pyuria are common in appendicitis with pelvic inflammation, resulting in inflammation of the ureter

25
Q

What additional tests can be performed if the dx is not clear with appendicitis?

A

Spiral CT

U/s (may see a large, noncompressible appendix or fecalith)

26
Q

In acute appendicitis, what classically precedes vomiting?

A

Pain (in gastroenteritis, the pain classically follows vomiting)

27
Q

What radiographic studies are often performed in appendicitis?

A

CXR: to rule out RML or RLL PNA, free air
AXR: abdominal films are usually nonspecific, but calcified fecalith present in ~5% of cases

28
Q

What are the CT scan findings with acute appendicitis?

A

Periappendiceal fat stranding
Appendiceal diameter >6 mm
Periappendiceal fluid
Fecalith

29
Q

What are the preop meds/preparation for appendicitis?

A

Rehydration with IV fluids (LR)

Preop abx with anaerobic coverage (appendix is considered part of the colon)

30
Q

What is a lap appy?

A

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

31
Q

What is the tx for acute nonperforated appendicitis?

A

Prompt appendectomy (prevents perforation)
24 hrs of abx
D/c home usually on POD #1

32
Q

What is the tx for perforated acute appendicitis?

A

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)

33
Q

How is an appendiceal abscess that is dx-ed preoperatively treated?

A

Percutaenous drainage of the abscess
Abx administration
Elective appendectomy ~6 wks later

34
Q

If a nl appendix is found upon exploration, should you take out the nl appendix (I guess for an abscess?)

A

Yes

35
Q

How long after removal of a nonruptured appendix should abx continue postoperatively?

A

For 24 hrs

36
Q

Which antibiotic is used for nonperforated appendicitis?

A 
Cefoxitin
Cefotetan
Unasyn
Cipro
Flagyl
37
Q

What antibiotic is used for a perforated appendix?

A

Broad-spectrum abx (e.g., amp/Cipro/clinda or a PCN such as Zosyn)

38
Q

How long do you give abx for perforated appendicitis?

A

Until the pt has a normal WBC count and is afebrile, ambulating, and eating a regular diet (usually 3-7 days)

39
Q

What is the risk of a perforated appendix?

A

~25% by 24 hrs from onset of sx

~50% by 36 hrs and ~75% by 48 hrs

40
Q

What are the possible complications of appendicitis?

A

Pelvic abscess
Liver abscess
Free perforation
Portal pylethrombophlebitis (very rare)

41
Q

What percentage of negative appendectomies is acceptable?

A

Up to 20%; taking out some nl appendixes is better than missing a case of acute appendicitis that eventually ruptures

42
Q

Who is at risk of dying from acute appendicitis?

A

Very old and very young pts

43
Q

What bacteria are associated with “mesenteric adenitis” that can closely mimic acute appendicitis?

A

Yersinia enterocolitica

Surgery Rotation (19 decks)

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