Surgical Recall: 45 - Appendix

Front 1

What vessel provides blood supply to the appendix?

Back 1

Appendiceal artery - branch of ileocolic artery

Front 2

Name the mesentery of the appendix?

Back 2

Mesoappendix (contains the appendiceal artery)

Front 3

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

Back 3

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

Front 4

What is appendicitis?

Back 4

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

Front 5

What are the causes of appendicitis?

Back 5

- Lymphoid hyperplasia

- Fecalith (aka appendicolith)

- Rare: parasite, foreign body, tumor (eg, carcinoid)

Front 6

What ist he lifetime incidence of acute appendicitis in the US?

Back 6

~7%

Front 7

What is the most common cause of emergent abdominal surgery in the US?

Back 7

Acute appendicitis

Front 8

How does appendicitis classically present?

Back 8

Classic chronologic order:

1. Periumbilical pain (intermittent and crampy)

2. Nausea / vomiting

3. Anorexia

4. Pain migrates to RLQ (contant and intense pain), usually in <24 hours

Front 9

Why does periumbilical pain occur?

Back 9

Referred pain

Front 10

Why does RLQ pain occur with appendicitis?

Back 10

Peritoneal irritation

Front 11

What are the signs / symptoms of appendicitis?

Back 11

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

Front 12

What is the Obturator sign?

Back 12

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

Front 13

What is the Psoas sign?

Back 13

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

Front 14

What is the Rovsing's sign?

Back 14

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

Front 15

What is the Valentino's sign?

Back 15

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

Front 16

What is McBurney's point?

Back 16

Point 1/3 from the ASIS to the umbilicus (often the point of maximal tenderness)

Front 17

What is the differential diagnosis in general for patients suspected of having appendicitis?

Back 17

- Meckel's diverticulum

- Crohn's disease

- Perforated ulcer

- Pancreatitis

- Mesenteric lymphadenitis

- Constipation

- Gastroenteritis

- Intussusception

- Volvulus

- Tumors

- UTI (eg, cystitis)

- Pyelonephritis

- Torsed epiploicae

- Cholecystitis

- Cecal tumor

- Diverticulitis (floppy sigmoid)

Front 18

What is the differential diagnosis for FEMALE patients suspected of having appendicitis?

Back 18

- Ovarian cyst

- Ovarian torsion

- Tuboovarian abscess

- Mittelschmerz

- Pelvic inflammatory disease (PID)

- Ectopic pregnancy

- Ruptured pregnancy

Front 19

What lab tests should be performed on patients suspected of having appendicitis?

Back 19

- CBC: increased WBC (<10,000/mm3 in >90% of cases), most often with a "left shift"

- U/A: to evaluate for pyelonephritis or renal calculus

Front 20

Can you have an abnormal urinalysis with appendicitis?

Back 20

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

Front 21

Does a positive urinalysis rule out appendicitis?

Back 21

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

Front 22

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

Back 22

- Spiral CT

- U/S (may see a large, non-compressible appendix or fecalith)

- AXR

Front 23

In acute appendicitis, what classically precedes vomiting?

Back 23

Pain (in gastroenteritis, the pain classically follows vomiting)

Front 24

What radiographic studies are performed in patients suspected of having appendicitis?

Back 24

- CXR: to rule out RML or RLL pneumonia, free air

- AXR: abdominal films are usually non-specific, but calcified fecalith present in about 5% of cases

Front 25

What are the radiographic signs of appendicitis on AXR?

Back 25

- Fecalith

- Sentinel loops

- Scoliosis away from the right because of pain

- Mass effect (abscess)

- Loss of psoas shower

- Loss of preperitoneal fat stripe

- Ver rarely a small amount of free air is perforated

Front 26

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

Back 26

Only ~5%

Front 27

What are the CT findings with acute appendicitis?

Back 27

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

Front 28

What are the preoperative medications / preparation for a patient with appendicitis?

Back 28

1. Rehydration with IV fluids (LR)

2. Pre-operative antibiotics with anaerobic coverage (appendix is considered part of the colon)

Front 29

What is a lap appy? When is it indicated?

Back 29

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

Front 30

What is the treatment for non-perforated acute appendicitis?

Back 30

Non-perforated:

- Prompt appendectomy (prevents perforation)

- 24 hours of antibiotics

- Discharge home usually on POD #1

Front 31

What is the treatment for perforated acute appendicitis?

Back 31

Perforated:

- IV fluid resuscitation and prompt appendectomy

- All pus is drained with post-op antibiotics continued for 3-7 days

- Wound is left open in most cases of perforation after closing the fascia (heals by secondary intention or delayed primary closure

Front 32

How is an appendiceal abscess that is diagnosed preoperatively treated?

Back 32

Usually by percutaneous drainage of the abscess, antibiotic administration, and elective appendectomy ~6 weeks later (aka interval appendectomy)

Front 33

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

Back 33

Yes

Front 34

How long after removal of a non-ruptured appendix should antibiotics continue post-operatively?

Back 34

For 24 hours

Front 35

Which antibiotic is used for non-perforated appendicitis?

Back 35

Anaerobic coverage:

- Cefoxitin

- Cefotetan

- Unasyn

- Cipro

- Flagyl

Front 36

Which antibiotic is used for a perforated appendix?

Back 36

Broad-spectrum antibiotics:

- Ampicillin / Ciprofloxacin / Clindamycin OR

- Zosyn

Front 37

How long do you give antibiotics for perforated appendicitis?

Back 37

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

Front 38

What is the risk of perforation with acute appendicitis?

Back 38

~25% by 24 hours from onset of symptoms

~50% by 36 hours

~75% by 48 hours

Front 39

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

Back 39

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

Front 40

What are the possible complications of appendicitis?

Back 40

- Pelvic abscess

- Liver abscess

- Free perforation

- Portal pylethrombophlebitis (very rare)

Front 41

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

Back 41

~15%

Front 42

What percentage of negative appendectomies is acceptable?

Back 42

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

Front 43

Who is at risk of dying from acute appendicitis?

Back 43

Very old and very young patients

Front 44

What bacteria are associated with "mesenteric adenitis" that can closely mimic acute appendicitis?

Back 44

Yersinia enterolytica

Front 45

What is an "incidental appendectomy"?

Back 45

Removal of normal appendix during abdominal operation for different procedure

Front 46

What are complications of an appendectomy?

Back 46

- SBO

- Enterocutaneous fistula

- Wound infection

- Infertility with perforation in women

- Increased incidence of right inguinal hernia

- Stump abscess

Front 47

What is the most common post-op complication of appendectomy?

Back 47

Wound infection

Front 48

What is the difference between a McBurney's incision and a Rocky-Davis incision?

Back 48

- McBurney's is angled down (follows ext oblique fibers)

- Rocky-Davis is straight across (transverse)

Front 49

What are the layers of the abdominal wall during a McBurney incision?

Back 49

1. Skin

2. Subcutaneous fat

3. Scarpa's fascia

4. External oblique

5. Internal oblique

6. Transversus abdominis muscle

7. Transversalis fascia

8. Pre-peritoneal fat

9. Peritoneum

Front 50

What are the steps in a lap appy?

Back 50

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 appendix from the abdomen

5. Irrigate and aspirate until clear

Front 51

Do you routinely get peritoneal cultures for acute appendicitis (non-perforated)?

Back 51

No

Front 52

How can you find the appendix after identifying the cecum?

Back 52

Follow the taenia down to where they converge on the appendix

Front 53

Which way should your finger sweep trying to find the appendix?

Back 53

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

Front 54

How do you get to a retrocecal and retroperitoneal appendix?

Back 54

Divide the lateral peritoneal attachments of the cecum

Front 55

Why use electrocautery on the exposed mucosa on the appendiceal stump?

Back 55

To kill the mucosal cells so they do not form a mucocele

Front 56

If you find Crohn's disease in the terminal ileum, will you remove the appendix?

Back 56

Yes, if the cecal / appendiceal base is not involved

Front 57

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

Back 57

- Terminal ileum: Meckel's diverticulum, Crohn's disease, intussusception

- Gynecologic: cysts, torsion, etc

- Groin: hernia, rectus sheath hematoma, adenopathy (adenitis)

Front 58

Who first described the classic history and treatment for acute appendicitis?

Back 58

Reginal Fitz

Front 59

Who performed the first appendectomy?

Back 59

Harry Hancock in 1848 (McBurney popularized the procedure in 1880s)

Front 60

Who performed the first lap appy?

Back 60

Dr. Semm (GYN) in 1983

Front 61

What is the most common appendiceal tumor?

Back 61

Carcinoid tumor

Front 62

What is the treatment of appendiceal carcinoid less than 1.5 cm?

Back 62

Appendectomy (if not through the bowel wall)

Front 63

What is the treatment of appendiceal carcinoid greater than 1.5 cm?

Back 63

Right hemicolectomy

Front 64

What percentage of appendiceal carcinoids are malignant?

Back 64

<5%

Front 65

What is the differential diagnosis of appendiceal tumor?

Back 65

- Carcinoid

- Adenocarcinoma

- Malignant mucoid adenocarcinoma

Front 66

What type of appendiceal tumor can cause the dreaded pseudomyxoma peritonei if the appendix ruptures?

Back 66

Malignant mucoid adenocarcinoma

Front 67

What is a "mittelschmerz"?

Back 67

Pelvic pain caused by ovulation

Front 68

Should one remove the normal appendix with Crohn's disease found intra-operatively?

Back 68

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