RLQ Flashcards
Abdominal exam for RLQ
Focal pain at Mcburney’s point
Rovsing’s sign
Psoas sign
Obturator sign
Rovsing’s
push on LLQ –> mov’t of abdominal contents to RLQ –> peritoneal inflammation
Psoas
flex hip –> pain
suggests retrocecal appendix
Obturator sign
adduct hip –> pain
Labs for RLQ pain
CBC (elevated WBC) UA (hematuria suggestive of stone) HCG - r/o pregnancy Lactate - eval perfusion General belly pain labs: lipase/amylase, bili, LFTs
Imaging:
For classic presentation + healthy male, 90% sensitivity w/ good exam (10-15% acceptable failure rate)
Non-classic presentation - CT higher sensitivity
Peds - U/S
KUB to r/o obstruction
DDx:
INFECTIOUS -appendicitis -Gastroenteritis -Ileitis (yersinia, campylobacter, salmonella) INFLAMMATORY -IBD ISCHEMIA -mesenteric ischemia OBSTRUCTION -SBO/volvulus/intussusception MEDICAL Typhilitis OTHER ORGANS: -Nephrolithiasis/UTI -GU: testicular/ovarian torsion, Cyst rupture, PID, ectopic pregnancy -Inguinal/abdominal wall hernia
Appendicitis symptoms
periumbilical pain localizing to mcburney’s point
why diffuse pain and localizing to specific point?
initial pain due to inflammation of visceral peritoneum (autonomic nerves which refers pain to midline of abdomen)
cheeseburger sign
anorexia
management of appendicitis (not ruptured)
appendectomy (open vs. laparoscopic; laparoscopic = less pain, faster recovery, quicker return to work, better cosmesis)
24 hrs of a/b
d/c POD1
appendicitis perforation management
IV fluid resuscitation
prompt appendectomy
post-op a/b for 3-7D
wound left open after closing fascia (will heal by 2/2 intention / delayed primary closure)
phlegmon
diffuse inflammatory process with formation of suppurative/purulent exudate or pus (walled-off, but more viscous than abscess)
phlegmon/abscess management
percutaneous drain, fluids, bowel rest, antibiotics
what kind antibiotics?
anerobes / gram-negs
cipro/flagyl, augmentin (amoxicillin-clavulanate), zosyn (piperacillin-tazobactam)
blood supply to appendix
SMA –> iliocolic –> appendiceal artery (supplies the mesoappendix)
management of complicated appendectomy?
high rate of post-op complications if surgery
treat w/ antibiotics
elective appendectomy at later date
approach to surgery of appendix
1) identify the appendix
2) isolate blood supply / staple mesoappendix
3) staple / transect appendix at the base of the appendix
4) removal from abdomen
5) irrigate / aspiration until clear
what is the fold/ligament of treves?
terminal ileum at the ileocecal junction - this antimesenteric fat fold is the only nonmesenteric fat over the course of the entire small bowel.
how can the appendix be located if the cecum has been identified?
teania coli all converge on the appendix
what is the mesentery of the appendix
mesoappendix (contains the appnediceal artery)
what vessel provides blood supply to appendix?
appendiceal artery - branch of the ileocolic artery
valentino’s sign
RLQ pain/peritonitis from succus draining down to the RLQ form a perfrom a perforcated gastric / duodenal ulcer (paracolic gutters) - may be mistaken for appendix-like pain (but diff. origin)
where is mcburney’s point?
1/3 distance from ASIS to the umbilicus
pathophysiology of the appendix
obstruction of the appendiceal lumen - closed loop –> inflammation that may lead to necrosis / perforation
how might you have abnl UA w/ appendicitis?
mild hematuria / pyuria 2/2 to pelvic inflammation –> ureter inflammation
what seen on imaging of appendicitis?
large non-compressible appendix / fecalith
how to differentiate acute appnedicitis vs. gastroenteritis?
in gastroenteritis, vomiting first then pain
in appendicitis, pain then vomiting
CT findings of acute appendicitis
periappendiceal fluid
appendiceal diamter > 6 mm
periappendiceal fat stranding
what are preop meds/prep?
IV fluids - rehydration
pre-op a/b (anaerobic coverage)
what is risk of perforation?
25% by 24 hrs
50% by 36 hrs
75% by 48 hrs
complications of appendicitis:
abscess, perforation, portal pylethrombophlebitis
what is bacteria gastroenteritis (mesenteric adenitis)
yersinia enterolytica
compliccations of appendectomy?
SBO, enterocutaneous fistula, wound infection, infertility w/ perforation in women, stump abscess, incr. incidence of right inguinal hernia (3 categories: 1) poor healing - infxn, fistula, abscess; 2) poor healing in long-term - hernia. 3) adhesions - SBO)
what are the layers of the abdominal wall?
1) skin
2) subqfat/camper’s
3) scarpa’s fascia
4) external oblique
5) interal oblique
6) transversus muscle
7) transversalis fascia
8) preperitoneal fat
9) peritoneum
what is the significance of the arcuate line of rectus sheath / douglas line?
superior to the arcuate line - internal oblique aponeurosis splits to cover the rectus abdominus
inferior to the arcuate line - the internal oblique / transversus abdominis aponeurosis merge and pass anteriorly/superficially to the rectus muscle
how do you get to a retrocecal / retroperitoneal appendix
divide the lateral peritoneal attachmentss of the cecum
how do you prevent tearing of the mesoappendix?
mesoappendix lies medially
finger sweep lateral to medial along the lateral peritoneum
why use electrocautery on exposed mucosa on the appendiceal stump?
kill mucosal cells so they do not form a mucocele
if the appendix is normal, what do you inspect intraoperatively?
terminal ileum - meckle’s diverticulum, crohn’s, intussusception
gynecologic - cysts, torsion
groin - hernia, rectus sheath hematom, adenopathy/adenitis
