Surgery Oral Exam: Acute Appendicitis

Front 1

Acute Appendicitis: H&P: classic presentation

Back 1

Classic chronologic order:
1. Periumbilical pain (intermittent andcrampy)
2. Nausea/vomiting
3. Anorexia
4. Pain migrates to RLQ (constant andintense pain), usually in 24 hours

Front 2

Acute Appendicitis: peritoneal signs

Back 2

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

Front 3

Acute Appendicitis: Differential Diagnosis:

Back 3

Everyone?
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)
Females?
Ovarian cyst, ovarian torsion, tuboovarianabscess, mittelschmerz, pelvic inflamma-
tory disease (PID), ectopic pregnancy,
ruptured pregnancy

Front 4

Acute Appendicitis: What lab tests should be performed?

Back 4

CBC: increased WBC (10,000 per mm3in 90% of cases), most often with a
“left shift”
Urinalysis: to evaluate for pyelonephritis
or renal calculus

Front 5

Acute appendicitis: imaging/ findings

Back 5

Spiral CT, U/S (may see a large,
noncompressible appendix or fecalith),AXR
CT findings:Periappendiceal fat stranding,
appendiceal diameter 6 mm,periappendiceal fluid, fecalith
AXR findings: 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) asmall amount of free air if perforated

Front 6

Acute Appendectomy: management and intervention

Back 6

Preop: IVF and ABX w. anaerobes coverage (Anaerobic coverage: Cefoxitin®, Cefotetan®, Unasyn®, Cipro®, and Flagyl®)
Op: lap appy

Front 7

Acute Appendicitis: management and intervention exceptions:

Back 7

Nonperforated—prompt appendectomy(prevents perforation), 24 hours of
antibiotics, discharge home usually on
POD #1
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 thefascia (heals by secondary intention or
delayed primary closure)
Appendiceal abscess:Usually by percutaneous drainage of theabscess, antibiotic administration, and
elective appendectomy 6 weeks later

Front 8

Acute Appendicitis: management and intervention: What ABXs should be used for perforated appendix?

Back 8

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