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GI > W3 Appendicitis > Flashcards

W3 Appendicitis Flashcards

1
Q

What vessel supplies blood to the appendix?

A

Appendicular artery

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2
Q

What does the appendicular artery branch from?

A

Ileocolic artery

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3
Q

What is the ileocolic artery a branch of?

A

Superior Mesenteric Artery

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4
Q

What age groups is appendicitis typical of?

A
  • Childhood/young adulthood

- elderly

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5
Q

Where is McBurney’s Point?

A

1/3 of the distance from the right anterior iliac spine to the umbilicus

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6
Q

What does McBurney’s Point correspond to?

A

Roughly corresponds to most common location of base of appendix where it is attached to caecum

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7
Q

List some causes of appendicitis.

A
  • faecolith sitting at base of appendix
  • viral (usually in clusters)
  • bacterial trigger
  • parasites
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8
Q

Describe pathological changes that occur in appendicitis in appendix.

A
  • mucosal inflammation
  • lymphoid hyperplasia
  • obstruction of lumen (due to inflammation)
  • build up of mucous and exudate
  • venous obstruction
  • ischaemia (due to pressure build up) and bacterial invasion through wall
  • perforation
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9
Q

What can cause lumen obstruction in appendicitis?

A
  • faecolith

- lymphoid hyperplasia

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10
Q

Describe pathological changes that can occur in the abdomen in appendicitis?

A
  • inflammation in appendix causes greater omentum to stick to it
  • inflammatory mass can form with greater omentum and small bowel
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11
Q

What is phlegmonous mass in appendicitis?

A

A mass made of greater omentum and small bowel loops that walls off inflamed appendicitis

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12
Q

What can burst appendix cause?

A

Peritonitis

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13
Q

What factors make peritonitis more likely in appendicitis?

A
  • age (very young or very old)
  • immunosuppressed e.g. on steroids
  • previous surgical removal of greater omentum
  • diabetes
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14
Q

What sort of diagnosis is appendicitis?

A

Clinical diagnosis

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15
Q

What are the typical symptoms of appendicitis?

A
  • central abdominal pain that migrates to RIF (sore coming over bumps/cough/laugh)
  • lack of appetite (anorexia)
  • nausea (maybe vomit once or twice)
  • usually haven’t opened bowels
  • flushed
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16
Q

What is ileus?

A
  • When peristalsis stops, functional problem not a structural problem causing it
  • obstruction of GI tract
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17
Q

Why might patient with appendicitis not have opened their bowels that day?

A

They can get a degree of ileus due to inflammation

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18
Q

What can be found in rectal exam of patient with appendicitis?

A

Rectal tenderness

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19
Q

What are the clinical signs of appendicitis?

A
  • mild pyrexia
  • tachycardic
  • localised pain in RIF
  • guarding in RIF
  • rebound
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20
Q

What is an alternative to testing for rebound on patient’s abdomen?

A

Tap on fingers like percussion and if painful

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21
Q

What are the specific signs of appendicitis?

A
  • Rosving’s sign
  • Psoas test
  • Obturator
  • Pointing
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22
Q

What is Rosving’s Sign?

A

When you press on the left side the patient experiences pain on the right.

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23
Q

What is the Psoas test?

A

Patient keeps right hip flexed to lift inflamed appendix off the psoas muscle.

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24
Q

What is the Obturator test?

A

If appendix is touching obturator internus muscle, flexing the hip and internally rotating it will cause pain .

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25
Q

What is the pointing test?

A
  • Where did the pain start and where is it now?

- usually umbilicus out to RIF

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26
Q

How can retrocaecal appendicitis present?

A
  • flushed
  • bad breath -> faetor due to rotting tissue inside
  • no intra-abdominal peritonitis so pain may not be present or severe
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27
Q

How can pelvic appendicitis present symptomatically?

A
  • pain
  • diarrhoea
  • frequent micturition
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28
Q

How can post ileal appendicitis present symptomatically and why these symptoms?

A
  • diarrhoea
  • vomiting
  • due to local irritation at the terminal ileum
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29
Q

How can appendicitis present differently in obese patients and what can be challenging?

A
  • no anorexia
  • examining abdomen difficult e.g. testing for guarding/rebound
  • operating challenging
30
Q

What can be different/challenging in diagnosing appendicitis in elderly people?

A
  • usually very advanced

- less reliable history e.g. dementia

31
Q

What can be different/challenging in diagnosing appendicitis in children?

A

-getting reliable history

32
Q

What can be different/challenging in diagnosing appendicitis in pregnant women?

A
  • pain can be due to stretching of organs
  • appendix shifts up and out and high so pain potentially in different place
  • imaging challenging
33
Q

List the differential diagnosis of abdominal pain in children. (6) (excluding appendicitis)

A
  1. Gastroenteritis
  2. Mesenteric adenitis
  3. Meckel’s diverticulum
  4. Intussusception
  5. Henoch-Schonlein Purpura
  6. Lobar pneumonia
34
Q

What is mesenteric adenitis and why is it typically painful in children?

A
  • Inflamed lymph glands in the abdomen due to viral infection
  • pain in children due to stretching of peritoneum which is tighter in children than adults
35
Q

What is gastroenteritis?

A

Irritation of lining of stomach and intestines characterised by nausea, vomiting, diarrhoea and cramps.

36
Q

What is intussusception?

A

When a segment of intestine slips into (infolds into) an adjacent segment of intestine usually causing bowel obstruction.

37
Q

What is Henoch-Schonlein Purpura and what clinical presentation is it characterised by and what is the microscopic hallmark of the disease?

A
  • small blood vessels inflammation in skin, joints, bowels, kidney
  • purpuric rash on ankles
  • deposition of IgA in walls of involved blood vessels
38
Q

List the differential diagnosis of abdominal pain in adults. (6) (excluding appendicitis)

A
  1. Terminal ileitis
  2. Ureteric colic
  3. Acute pyelonephritis
  4. Perforated ulcer
  5. Pancreatitis
  6. Rectus sheath haemotoma
39
Q

What is ureteric colic and what causes the colicky pain?

A
  • When a urinary stone blocks part of the urinary tract

- dilation, stretching and spasm of the ureter

40
Q

What is pyelonephritis?

A

Inflammation of the kidney

41
Q

What usually causes pyelonephritis?

A

Bacterial infection

42
Q

What is a rectus sheath haematoma?

A

An accumulation of blood in the rectus sheath

43
Q

What causes a rectus sheath haematoma?

A
  • rupture of epigastric artery

- muscular tear

44
Q

List differential diagnosis of abdominal pain in women. (4) (excluding appendicitis)

A
  1. Mittelschmerz
  2. Ovarian cyst
  3. Ectopic pregnancy
  4. Salpingitis
45
Q

List differential diagnosis of abdominal pain in elderly patients. (3) (excluding appendicitis)

A
  1. Sigmoid Diverticulitis
  2. intestinal obstruction
  3. carcinoma of the caecum
46
Q

List 3 rare differential diagnosis of abdominal pain.

A
  1. Porphyria
  2. Diabetic Ketoacidosis
  3. Typhlitis
47
Q

What is Mittelschmerz?

A

Abdominal pain in between periods usually associated with ovulation.

48
Q

What is salpingitis?

A

Inflammation of the fallopian tubes.

49
Q

What can cause salpingitis?

A

Bacterial infection

50
Q

Why is sigmoid diverticulitis a differential diagnosis of abdominal pain in elderly people?

A

Sigmoid can flip onto right side due to being a bit old and floppy.

51
Q

What is porphyria?

A

Group of genetic diseases that is characterised by accumulation of porphyrin in body.

52
Q

What is typhlitis?

A

Inflammation of caecum

53
Q

What is typhlitis also known as?

A

Neutropenic enterocolitis

54
Q

List appropriate investigations for appendicitis.

A
  • ultrasound (especially useful in women and kids)
  • Abdominal Xray (not encouraged)
  • bloods (particularly CRP and WCC)
  • urinalysis (including HCG)
55
Q

Describe the Alvarado score. (MANTRELS)

A 
M - Migration of pain to RIF
A - Anorexia
N - Nausea
T - tenderness in RLQ
R - Rebound pain
E - elevated temp.
L - Leukocytosis
S - Shift of white blood cell count to left
56
Q

What does “shift of white blood cell count to left” mean?

A

That there is an increase in the number of immature leukocytes in the peripheral blood.

57
Q

What is the appropriate management for appendicitis?

A
  • analgesia
  • antipyretic
  • theatre
  • antibiotics
58
Q

What are the two ways in which appendicectomy can be carried out?

A
  • laparascopically

- laparotomy

59
Q

What is the treatment for appendix mass?

A
  • Antibiotics first line and then sometimes appendicectomy later
  • can operate but worst time to operate
60
Q

When does an appendix mass occur?

A

When people don’t come to hospital

61
Q

Why not operate on appendix mass until treated?

A

Very messy, everything is inflamed and there is a lot of pus and blood

62
Q

When would you operate on patient with appendix mass as first line?

A
  • antibiotics don’t work
  • tachycardia
  • worsening pain
  • increase in size
  • vomiting or copious NG aspirates
  • ileus
63
Q

What is an appendix abscess?

A
  • When an appendix mass matures
  • presents delayed
  • usually liquid ball of pus
64
Q

How is appendix mass usually managed?

A

Radiological drain

65
Q

List some complications of appendicectomy. (10)

A
  • pelvic abscess
  • wound infection
  • intra-abdominal abscess
  • ileus
  • respiratory
  • DVT/PE
  • Portal pyaemia
  • Faecal fistula
  • adhesions
  • right sided inguinal hernia (in open appendicectomy)
66
Q

What is portal pyaemia?

A

Condition involving collection of pus in the portal venous system due to inflammation and patients can become septic

67
Q

What is a faecal fistula?

A

When abscess ruptures out through the abdominal wall and poo comes out onto their skin

68
Q

What is carcinoid of the appendix a tumour of?

A

Tumour of the Crypts of Lieberkuhn

69
Q

What does the metastatic risk of carcinoid of the appendix relate to?

A

Size of the tumour

70
Q

What is a carcinoid?

A
  • Tumour of the neuroendocrine system
  • often in digestive tract
  • slow-growing tumour
71
Q

What protein do carcinoids of the appendix stain for?

A

Chromagrannin

72
Q

What is treatment for carcinoid of the appendix?

A
  • if <1cm appendicectomy

- if >2cm right hemicolectomy

GI (29 decks)

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