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Section II General Surgery P203Surgical Recall Sixth > Appendix, C45 P293-301 > Flashcards

Appendix, C45 P293-301 Flashcards

1
Q

What vessel provides blood
supply to the appendix?
P293

A

Appendiceal artery—branch of the

ileocolic artery

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2
Q

Name the mesentery of the
appendix.
P293

A

Mesoappendix (contains the appendiceal

artery)

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3
Q

How can the appendix be
located if the cecum has
been identified?
P293

A

Follow the taenia coli down to the
appendix; The taeniae converge on the
appendix

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4
Q

What is it?

P294

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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5
Q

What are the causes?

P294

A

Lymphoid hyperplasia, fecalith
(a.k.a. appendicolith)
Rare—parasite, foreign body, tumor
(e.g., carcinoid)

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6
Q 
What is the lifetime
incidence of acute
appendicitis in the United
States?
P294
A

≈7%!

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7
Q

What is the most common
cause of emergent abdominal
surgery in the United States?
P294

A

Acute appendicitis

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8
Q

How does appendicitis
classically present?
P294

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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9
Q

Why does periumbilical pain
occur?
P294

A

Referred pain

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10
Q

Why does RLQ pain occur?

P294

A

Peritoneal irritation

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11
Q

What are the signs/symptoms?

P294

A 
Signs of peritoneal irritation may be
present: guarding, muscle spasm,
rebound tenderness, obturator and psoas
signs, low-grade fever (high grade if
perforation occurs), RLQ hyperesthesia
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12
Q

Define the following terms:
Obturator sign
P294

A

Pain upon internal rotation of the leg
with the hip and knee flexed; seen in
patients with pelvic appendicitis

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13
Q

Define the following terms:
Psoas sign
P295

A

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

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14
Q

Define the following terms:
Rovsing’s sign
P295

A

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

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15
Q

Define the following terms:
Valentino’s sign
P295

A

RLQ pain/peritonitis from succus
draining down to the RLQ from a
perforated gastric or duodenal ulcer

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16
Q

Define the following terms:
McBurney’s point
P295 (picture)

A

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

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17
Q

What is the differential diagnosis for:
Everyone?
P295

A

Meckel’s diverticulum, Crohn’s
disease, perforated ulcer, pancreatitis,
mesenteric lymphadenitis, constipation,
gastroenteritis, intussusception, volvulus,
tumors, UTI (e.g., cystitis), pyelonephritis,
torsed epiploicae, cholecystitis, cecal
tumor, diverticulitis (floppy sigmoid)

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18
Q

What is the differential diagnosis for:
Females?
P295

A

Ovarian cyst, ovarian torsion, tuboovarian
abscess, mittelschmerz, pelvic inflammatory
disease (PID), ectopic pregnancy,
ruptured pregnancy

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19
Q

What lab tests should be
performed?
P296

A

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

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20
Q

Can you have an abnormal
urinalysis with appendicitis?
P296

A

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

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21
Q

Does a positive urinalysis
rule out appendicitis?
P296

A

No; ureteral inflammation resulting from
the periappendiceal inflammation can
cause abnormal urinalysis

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22
Q

What additional tests can be
performed if the diagnosis is
not clear?
P296

A

Spiral CT, U/S (may see a large,
noncompressible appendix or fecalith),
AXR

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23
Q

In acute appendicitis, what
classically precedes vomiting?
P296

A

Pain (in gastroenteritis, the pain

classically follows vomiting)

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24
Q

What radiographic studies
are often performed?
P296

A 
CXR: to rule out RML or RLL
     pneumonia, free air
AXR: abdominal films are usually
    nonspecific, but calcified fecalith
    present in about 5% of cases
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25
Q

What are the radiographic
signs of appendicitis on AXR?
P296

A

Fecalith, sentinel loops, scoliosis away
from the right because of pain, mass effect
(abscess), loss of psoas shadow, loss of
preperitoneal fat stripe, and (very rarely) a
small amount of free air if perforated

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26
Q 
With acute appendicitis, in
what percentage of cases
will a radiopaque fecalith be
on AXR?
P296
A

Only ≈5% of the time!

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27
Q

What are the CT findings
with acute appendicitis?
P296

A

Periappendiceal fat stranding,
appendiceal diameter >6 mm,
periappendiceal fluid, fecalith

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28
Q

What are the preoperative
medications/preparation?
P297

A
  1. Rehydration with IV fluids (LR)
  2. Preoperative antibiotics with
    anaerobic coverage (appendix is
    considered part of the colon)
29
Q

What is a lap appy?

P297

A

Laparoscopic appendectomy; used in
most cases in women (can see adnexa) or
if patient has a need to quickly return to
physical activity, or is obese

30
Q

What is the treatment
for nonperforated acute
appendicitis?
P297

A

Nonperforated—prompt appendectomy
(prevents perforation), 24 hours of
antibiotics, discharge home usually on
POD #1

31
Q

What is the treatment for
perforated acute
appendicitis?
P297

A 
Perforated—IV fluid resuscitation and
prompt appendectomy; all pus is drained
with postoperative antibiotics continued
for 3 to 7 days; wound is left open in
most cases of perforation after closing the
fascia (heals by secondary intention or
delayed primary closure)
32
Q

How is an appendiceal
abscess that is diagnosed
preoperatively treated?
P297

A

Usually by percutaneous drainage of the
abscess, antibiotic administration, and
elective appendectomy ≈6 weeks later
(a.k.a. interval appendectomy)

33
Q 
If a normal appendix is
found upon exploration,
should you take out the
normal appendix?
P297
A

Yes

34
Q 
How long after removal of a
NONRUPTURED appendix
should antibiotics continue
postoperatively?
P297
A

For 24 hours

35
Q

Which antibiotic is used
for NONPERFORATED
appendicitis?
P297

A

Anaerobic coverage: Cefoxitin®,

Cefotetan®, Unasyn®, Cipro®, and Flagyl®

36
Q

What antibiotic is used for a
PERFORATED appendix?
P297

A

Broad-spectrum antibiotics (e.g.,
Amp/ Cipro®/Clinda or a penicillin such
as Zosyn®)

37
Q

How long do you give
antibiotics for perforated
appendicitis?
P298

A

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

38
Q

What is the risk of
perforation?
P298

A

≈25% by 24 hours from onset of
symptoms, ≈50% by 36 hours, and
≈75% by 48 hours

39
Q

What is the most common
general surgical abdominal
emergency in pregnancy?
P298

A

Appendicitis (about 1/1750; appendix
may be in the RUQ because of the
enlarged uterus)

40
Q

What are the possible
complications of
appendicitis?
P298

A

Pelvic abscess, liver abscess, free
perforation, portal pylethrombophlebitis
(very rare)

41
Q

What percentage of the
population has a retrocecal,
retroperitoneal appendix?
P298

A

≈15%

42
Q

What percentage of negative
appendectomies is
acceptable?
P298

A

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

43
Q

Who is at risk of dying from
acute appendicitis?
P298

A

Very old and very young patients

44
Q 
What bacteria are associated
with “mesenteric adenitis”
that can closely mimic acute
appendicitis?
P298
A

Yersinia enterolytica

45
Q

What is an “incidental
appendectomy”?
P298

A

Removal of normal appendix during
abdominal operation for different
procedure

46
Q

What are complications of
an appendectomy?
P298

A

SBO, enterocutaneous fistula, wound
infection, infertility with perforation in
women, increased incidence of right
inguinal hernia, stump abscess

47
Q

What is the most common
postoperative complication?
P298

A

Wound infection

48
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
What is the difference
between a McBurney’s
incision and a Rocky-Davis
incision?
P299
A 
McBurney’s is angled down (follows ext
oblique fibers), and Rocky-Davis is
straight across (transverse)
49
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
What are the layers of the
abdominal wall during a
McBurney incision?
P299
A
  1. Skin
  2. Subcutaneous fat
  3. Scarpa’s fascia
  4. External oblique
  5. Internal oblique
  6. Transversus muscle
  7. Transversalis fascia
  8. Preperitoneal fat
  9. Peritoneum
50
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
What are the steps in
laparoscopic appendectomy
(lap appy)?
P299
A
  1. Identify the appendix
  2. Staple the mesoappendix (or coagulate)
  3. Staple and transect the appendix at
    the base (or use Endoloop® and cut
    between)
  4. Remove the appendix from the
    abdomen
  5. Irrigate and aspirate until clear
51
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
Do you routinely get
peritoneal cultures
for acute appendicitis
(nonperforated)?
P299
A

No

52
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
How can you find the
appendix after identifying
the cecum?
P299
A

Follow the taeniae down to where they

converge on the appendix

53
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
Which way should your
finger sweep trying to find
the appendix?
P299
A

Lateral to medial along the lateral
peritoneum—this way you will not tear
the mesoappendix that lies medially!

54
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
How do you get to
a retrocecal and
retroperitoneal appendix?
P299
A

Divide the lateral peritoneal attachments

of the cecum

55
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
Why use electrocautery on
the exposed mucosa on the
appendiceal stump?
P299
A

To kill the mucosal cells so they do not

form a mucocele

56
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
If you find Crohn’s disease
in the terminal ileum, will
you remove the appendix?
P300
A

Yes, if the cecal/appendiceal base is not

involved

57
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
If the appendix is normal
what do you inspect
intraoperatively?
P300
A 
Terminal ileum: Meckel’s diverticulum,
    Crohn’s disease, intussusception
Gynecologic: Cysts, torsion, etc.
Groin: hernia, rectus sheath hematoma,
    adenopathy (adenitis)
58
Q 
CLASSIC INTRAOPERATIVE QUESTIONS
Who first described the
classic history and treatment
for acute appendicitis?
P300
A

Reginald Fitz

59
Q

CLASSIC INTRAOPERATIVE QUESTIONS
Who performed the first
appendectomy?
P300

A

Harry Hancock in 1848 (McBurney

popularized the procedure in 1880s)

60
Q

CLASSIC INTRAOPERATIVE QUESTIONS
Who performed the first lap
appy?
P300

A

Dr. Semm (GYN) in 1983

61
Q

APPENDICEAL TUMORS
What is the most common
appendiceal tumor?
P300

A

Carcinoid tumor

62
Q 
APPENDICEAL TUMORS
What is the treatment of
appendiceal carcinoid less
than 1.5 cm?
P300
A

Appendectomy (if not through the bowel

wall)

63
Q 
APPENDICEAL TUMORS
What is the treatment of
appendiceal carcinoid larger
than 1.5 cm?
P300
A

Right hemicolectomy

64
Q 
APPENDICEAL TUMORS
What percentage of
appendiceal carcinoids are
malignant?
P300
A

< 5%

65
Q 
APPENDICEAL TUMORS
What is the differential
diagnosis of appendiceal
tumor?
P300
A

Carcinoid, adenocarcinoma, malignant

mucoid adenocarcinoma

66
Q 
APPENDICEAL TUMORS
What type of appendiceal
tumor can cause the dreaded
pseudomyxoma peritonei if
the appendix ruptures?
P300
A

Malignant mucoid adenocarcinoma

67
Q

APPENDICEAL TUMORS
What is “mittelschmerz”?
P301

A

Pelvic pain caused by ovulation

68
Q 
APPENDICEAL TUMORS
Should one remove the
normal appendix with
Crohn’s disease found
intraoperatively?
P301
A

Yes, unless the base of the appendix is
involved with Crohn’s disease, the normal
appendix should be removed to avoid
diagnostic confusion with appendicitis in
the future

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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