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surgery oral stuff > RLQ > Flashcards

RLQ Flashcards

1
Q

Abdominal exam for RLQ

A

Focal pain at Mcburney’s point
Rovsing’s sign
Psoas sign
Obturator sign

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2
Q

Rovsing’s

A

push on LLQ –> mov’t of abdominal contents to RLQ –> peritoneal inflammation

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3
Q

Psoas

A

flex hip –> pain

suggests retrocecal appendix

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4
Q

Obturator sign

A

adduct hip –> pain

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5
Q

Labs for RLQ pain

A 
CBC (elevated WBC)
UA (hematuria suggestive of stone)
HCG - r/o pregnancy
Lactate - eval perfusion
General belly pain labs: lipase/amylase, bili, LFTs
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6
Q

Imaging:

A

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

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7
Q

DDx:

A 
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
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8
Q

Appendicitis symptoms

A

periumbilical pain localizing to mcburney’s point

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9
Q

why diffuse pain and localizing to specific point?

A

initial pain due to inflammation of visceral peritoneum (autonomic nerves which refers pain to midline of abdomen)

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10
Q

cheeseburger sign

A

anorexia

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11
Q

management of appendicitis (not ruptured)

A

appendectomy (open vs. laparoscopic; laparoscopic = less pain, faster recovery, quicker return to work, better cosmesis)
24 hrs of a/b
d/c POD1

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12
Q

appendicitis perforation management

A

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)

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13
Q

phlegmon

A

diffuse inflammatory process with formation of suppurative/purulent exudate or pus (walled-off, but more viscous than abscess)

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14
Q

phlegmon/abscess management

A

percutaneous drain, fluids, bowel rest, antibiotics

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15
Q

what kind antibiotics?

A

anerobes / gram-negs

cipro/flagyl, augmentin (amoxicillin-clavulanate), zosyn (piperacillin-tazobactam)

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16
Q

blood supply to appendix

A

SMA –> iliocolic –> appendiceal artery (supplies the mesoappendix)

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17
Q

management of complicated appendectomy?

A

high rate of post-op complications if surgery
treat w/ antibiotics
elective appendectomy at later date

18
Q

approach to surgery of appendix

A

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

19
Q

what is the fold/ligament of treves?

A

terminal ileum at the ileocecal junction - this antimesenteric fat fold is the only nonmesenteric fat over the course of the entire small bowel.

20
Q

how can the appendix be located if the cecum has been identified?

A

teania coli all converge on the appendix

21
Q

what is the mesentery of the appendix

A

mesoappendix (contains the appnediceal artery)

22
Q

what vessel provides blood supply to appendix?

A

appendiceal artery - branch of the ileocolic artery

23
Q

valentino’s sign

A

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)

24
Q

where is mcburney’s point?

A

1/3 distance from ASIS to the umbilicus

25
Q

pathophysiology of the appendix

A

obstruction of the appendiceal lumen - closed loop –> inflammation that may lead to necrosis / perforation

26
Q

how might you have abnl UA w/ appendicitis?

A

mild hematuria / pyuria 2/2 to pelvic inflammation –> ureter inflammation

27
Q

what seen on imaging of appendicitis?

A

large non-compressible appendix / fecalith

28
Q

how to differentiate acute appnedicitis vs. gastroenteritis?

A

in gastroenteritis, vomiting first then pain

in appendicitis, pain then vomiting

29
Q

CT findings of acute appendicitis

A

periappendiceal fluid
appendiceal diamter > 6 mm
periappendiceal fat stranding

30
Q

what are preop meds/prep?

A

IV fluids - rehydration

pre-op a/b (anaerobic coverage)

31
Q

what is risk of perforation?

A

25% by 24 hrs
50% by 36 hrs
75% by 48 hrs

32
Q

complications of appendicitis:

A

abscess, perforation, portal pylethrombophlebitis

33
Q

what is bacteria gastroenteritis (mesenteric adenitis)

A

yersinia enterolytica

34
Q

compliccations of appendectomy?

A

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)

35
Q

what are the layers of the abdominal wall?

A

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

36
Q

what is the significance of the arcuate line of rectus sheath / douglas line?

A

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

37
Q

how do you get to a retrocecal / retroperitoneal appendix

A

divide the lateral peritoneal attachmentss of the cecum

38
Q

how do you prevent tearing of the mesoappendix?

A

mesoappendix lies medially

finger sweep lateral to medial along the lateral peritoneum

39
Q

why use electrocautery on exposed mucosa on the appendiceal stump?

A

kill mucosal cells so they do not form a mucocele

40
Q

if the appendix is normal, what do you inspect intraoperatively?

A

terminal ileum - meckle’s diverticulum, crohn’s, intussusception
gynecologic - cysts, torsion
groin - hernia, rectus sheath hematom, adenopathy/adenitis

surgery oral stuff (4 decks)

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