First Aid For Surgery - Appendix

Front 1

Mesoappendix

Back 1

Mesentery that suspends the appendix from terminal ileum; contains the appendicular artery [a branch of the ileocolic artery, which is a branch of the SMA]

Front 2

Mesoappendix

Back 2

Mesentery that suspends the appendix from terminal ileum; contains the appendicular artery [a branch of the ileocolic artery, which is a branch of the SMA]

Front 3

Appendicitis pain

Back 3

Initial dull, diffuse [visceral] pain that occurs at the onset of acute appendicitis is a result of the stimulation of visceral affect stretch fibers. These nerve endings fire as a result of the sudden-onset distention, and the pain is commonly felt around the umbilicus [T10]

Front 4

When does the pain of appendicitis shift from visceral to somatic pain?

Back 4

The shift from dull, diffuse [visceral] pain to sharp, localized [somatic] RLQ pain occurs when the inflamed serosa contracts the parietal peritoneum, causing peritoneal irritation. This pain is felt in the area directly overlying the appendix

Front 5

Sequence of events in acute appendicitis

Back 5

(1) Luminal OBSTRUCTION: lymphoid hyperplasia in younger patients, fecalith in older patients; (2) DISTENTION and increased intraluminal pressure: appendiceal mucosa continues to secrete normally despite being obstructure; the resident bacteria multiply rapidly, further increasing intraluminal pressure; (3) Venous congestion: intraluminal pressure eventually exceeds capillary and venule pressures; arteriolar blood continues to flow in, causing vascular congestion and engorgement; (4) Impaired blood supply renders mucosa ischemic and suspectiple to BACTERIAL INVASION; (5) INFLAMMATION and ISCHEMIA progress to involve the serosal surface of the appendix

Front 6

Signs of Appendicitis

Back 6

(1) Direct rebound tenderness, maximal at McBurney's point; (2) Leukocytosis; (3) Rovsing's sign: palpation pressure exerted over LLQ causes pain in RLQ; (4) Iliopsoas sign: pain on extension at right hip (patient gets relief by flexing right thigh at hip, relaxing psoas); (5) Obturator sign: pelvic pain on internal rotation of right thigh

Front 7

Great mimicker of appendicitis

Back 7

Yersinia enterolytica can cause mesenteric adenitis and is a great mimicker of appendicitis.

Front 8

Differential diagnosis of appendicitis

Back 8

(1) Gastrointestinal Conditions: gastroenteritis, mesenteric adenitis, Meckel's diverticulum, Intussusception, Typhoid fever, Primary peritonitis; (2) GU conditions: ectopic pregnancy, PID, ovarian torsion/cyst/tumor, UTI/pyelonephritis, Ureteral stone

Front 9

Diagnosis of Appendicitis

Back 9

(1) LABS: leukocytosis with left shift; consider perf or abscess if WBC > 18k; (2) UA: helpful in ruling out GU causes - note: RBCs, WBCs may be present 2/2 extension of appendiceal inflammation to the ureter - however, significant hematuria or pyuria and bacteriuria from a catherized specimen should suggest underlying urinary tract pathology

Front 10

Best imaging modality for acute appendicitis

Back 10

Abdominal CT with contrast: very sensitive (95-98%) and somewhat specific (83-90%); useful in identifying several other inflammatory processes that may present similarly to appendicitis. Positive findings include: (1) dilation of appendix to >6mm diameter; (2) thickening of appendiceal wall (edema); (3) preiappendiceal streaking (densities with perimesenteric fat); (4) presence of appendicolith

Front 11

Use of ultrasound in acute appendicitis

Back 11

Sensitivity = 85%, specificity = 92% for diagnosing acute appendicitis; positive findings: (1) enlarged (>6mm), noncompressible appendix; especially useful in ruling out gynecologic pathology

Front 12

Where is the pain sometimes felt in pregnant patients with acute appendicitis?

Back 12

RUQ - the enlarged uterus may push appendix up!

Front 13

Carcinoid of appendix

Back 13

Relatively low-grade neuroendocrine tumor - may cause nausea, diarrhea, flushing [FDR: flushing, diarrhea, right-heart failure]; (1) The appendix is the most common site of carcinoid tumors in GI tract; (2) Carcinoid is the 2nd MC type of appendiceal tumor (commonest being mucinous adenocarcinoma)

Front 14

Diagnosis of appendiceal carcinoid

Back 14

Increased urinary 5-HIAA and increased serum serotonin

Front 15

Treatment of appendiceal carcinoid

Back 15

Size is the major determinant of treatment and malignant potential! (1) Tumors <2cm treated with appendectomy; (2) Tumors >2cm are treated with right hemicolectomy; (3) Serotonin antagonists (cyproheptadine) or somatostatin analogues (octreotide) can be used for symptoms of carcinoid syndrome

Front 16

Mucinous tumors of the appendix

Back 16

(1) Can rupture, causing PSEUDOMYXOMA PERITONEI with mucin implants on peritoneal surfaces and omentum; (2) More common in women 3:2; (3) Complications include bowel obstruction and perforation; (4) Have been associated with migratory thrombophlebitis

Front 17

Adenocarcinoma of appendix

Back 17

(1) Colon cancer that arises from appendix is VERY rare-almost never diagnosed preop; (2) Rapid spread to regional lymph nodes, ovaries, and peritoneal surfaces; (3) If confined to appendix and local lymph nodes, right hemicolectomy is treatment of choice

Front 18

Appendiceal abscess

Back 18

Signs and symptoms are similar to acute appendicitis - increasing RLQ pain, tender, fluctuant RLQ mass palpable on rectal examination, anorexia, fever, localizing peritonitis, and leukocytois. Dx: CT scan. Tx: Percutaneous of operative drainage