Chapter 44: Appendix- Appendicits

Question 1

What is it?

Answer 1

Inflammation of the appendix caused by obstruction of the appendiceal lumen,producing a closed loop with resultant inflammation that can lead to necrosis andperforation

Question 2

What are the causes?

Answer 2

Lymphoid hyperplasia, fecalith (a.k.a. “appendicolith”)

Question 3

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

Answer 3

≈7%!

Question 4

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

Answer 4

Acute appendicitis

Question 5

How does appendicitis classically present?

Answer 5

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

Question 6

Why does periumbilical pain occur?

Answer 6

Referred pain

Question 7

Why does RLQ pain occur?

Answer 7

Peritoneal irritation

Question 8

What are the signs/symptoms?

Answer 8

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

Question 9

Obturator sign

Answer 9

• Pain upon internal rotation of the leg with the hip and knee flexed
• seen inpatients with pelvic appendicitis

Question 10

Psoas sign

Answer 10

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

Question 11

Rovsing’s sign

Answer 11

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

Question 12

McBurney’s point

Answer 12

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

Question 13

What is the differential diagnosis for everyone

Answer 13

• 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)

Question 14

What is the differential diagnosis for females

Answer 14

• Ovarian cyst
• ovarian torsion
• tuboovarian abscess
• mittelschmerz
• pelvicinflammatory disease (PID)
• ectopic pregnancy
• ruptured pregnancy

Question 15

What lab tests should be performed?

Answer 15

1. CBC: increased WBC (>10,000 per mm3 in >90% of cases)
   
   • most often with a“left shift”
2. Urinalysis: to evaluate for pyelonephritis or renal calculus

Question 16

Can you have an abnormal urinalysis with appendicitis?

Answer 16

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

Question 17

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

Answer 17

Spiral CT scan

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

Question 18

In acute appendicitis, what classically precedes vomiting?

Answer 18

Pain

(in gastroenteritis, the pain classically follows vomiting)

Question 19

What radiographic studies are often performed?

Answer 19

1. CXR: to rule out RML or RLL pneumonia, free air
2. AXR: abdominal films are usually nonspecific, but calcified fecalith present in≈5% of cases

Question 20

What are the CT scan findings with acute appendicitis?

Answer 20

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

Question 21

What are the preoperative medications/preparation?

Answer 21

1. Rehydration with IV fluids (LR)
2. Preoperative antibiotics with anaerobic coverage (appendix is considered partof the colon)

Question 22

What is a lap appy?

Answer 22

Laparoscopic appendectomy;

• used in most cases in women (can see adnexa)
• if patient has a need to quickly return to physical activity
• obese

Question 23

What is the treatment for nonperforated acute appendicitis?

Answer 23

Nonperforated—

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

Question 24

What is the treatment for perforated acute appendicitis?

Answer 24

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)

NOTE: Check first aid

Question 25

How is an appendiceal abscess that is diagnosed preoperatively treated?

Answer 25

* Percutaneous drainage of the abscess * antibiotic administration * elective appendectomy ≈6 weeks later (a.k.a. “interval appendectomy”)

Question 26

If a normal appendix is found upon exploration, should you take out the normal appendix?

Answer 26

Yes

Question 27

How long after removal of a NONRUPTURED appendix should antibiotics continue postoperatively?

Answer 27

For 24 hours

Question 28

Which antibiotic is used for NONPERFORATED appendicitis?

Answer 28

**Anaerobic coverage**: * Cefoxitin® * Cefotetan® * Unasyn® * Cipro® * Flagyl

Question 29

What antibiotic is used for a PERFORATED appendix?

Answer 29

**Broad-spectrum antibiotics:** * amp/Cipro®/clinda or * a penicillin such as Zosyn®

Question 30

How long do you give antibiotics for perforated appendicitis?

Answer 30

**Until the patient has a** : 1. normal WBC count 2. afebrile 3. ambulating 4. eating a regular diet *(usually 3 to 7 days)*

Question 31

What is the risk of perforation?

Answer 31

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

Question 32

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

Answer 32

Appendicitis (about 1/1750) appendix _may be in the RUQ_ because of theenlarged uterus)

Question 33

What are the possible complications of appendicitis?

Answer 33

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

Question 34

What percentage of negative appendectomies is acceptable?

Answer 34

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

Question 35

Who is at risk of dying from acute appendicitis?

Answer 35

Very old and very young patients

Question 36

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

Answer 36

Yersinia enterocolitica