Appendicitis MCQs

December 18, 2011

QUESTION

With regard to the clinical course of appendicitis, which of the following statements is/are true?

a. The typical history is one of vague abdominal pain, followed by periumbilical pain and, later, right lower quadrant pain.

b. Nausea and vomiting usually precede the pain

c. Gross hematuria and pyuria are quite common

d. Most patients present with obstipation

ANSWER

The answer is A.

- Classically, abdominal pain, which begins in the periumbilical region and subsequently localizes to the right lower quadrant, is the hallmark of acute appendicitis.

- Distention of the appendix stimulates visceral afferent pain fibers, producing vague periumbilical pain of midgut origin.

- The inflammatory process eventually involves the serosa and the parietal peritoneum, producing the characteristic shift in pain to the right lower quadrant.

- Variations in the location of the appendix account for variations from the classic localization of somatic pain at McBurney’s point (eg. retrocecal appendix may cause flank or back pain).

- Atypical abdominal pain occurs in 45% of patients with proved appendicitis and is frequently found in elderly patients and patients receiving steroids or chronic antibiotic therapy.

- Anorexia is a faily constant symptom, and the diagnosis should be questioned if it is not present.

- Vomiting occurs in 75% of patients and typically follows the onset of pain.

- This sequence has diagnostic significance because, in 95% of patients, anorexia precedes the onset of pain and is followed by vomiting.

- Although many patients have vomiting, they have only one or two episodes

- This is in contrast to the profuse and frequent vomiting seen in patients with gastroenteritis.

- Variable patterns of bowel function may be seen and are usually not of diagnostic significance.

- Indeed, protracted diarrhea accompanied by vomiting is more suggestive of gastroenteritis than of appendicitis.

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QUESTION:
Which of the following statements regarding the pathogenesis of appendicitis is false?

a. Luminal obstruction is always the cause of acute appendicitis

b. Luminal obstruction leads to increased pressure and distention of the appendix

c. Obstruction of venous outflow and then arterial inflow results in gangrene

d. Obstruction of the lumen may occur from lymphoid hyperplasia, inspissated stool, or a foreign body

e. Viral or bacterial infections can precede an episode of appendicitis

ANSWER

The answer is A.

- In most instances of appendicitis, luminal obstruction leads to bacterial overgrowth, active mucus secretion, and increased luminal pressure.

- Increased pressures lead to decreased venous return and, later, decreased arterial inflow, which leads to gangrene, bacterial translocation, and perforation.

- The midportion of the antimesenteric border of the appendix has the poorest blood supply and most frequently shows evidence of perforation.

- The cause of the obstruction is usually lymphoid hyperplasia in younger patients and fecaliths in adults.

- Fecaliths are responsible for approximately 30% of cases in adults and have been identified in 90% of patients with gangrenous appendicitis with rupture.

- However, luminal obstruction does not occur in all cases, since in some patients the lumen of the appendix is patent on radiologic, gross, and histologic examination.

- The pathogenesis in these cases remains unclear.

- It is thought that either viral or bacterial infections, such as salmonella, shigella, or infectious mononucleosis, can precede appendicitis, probably secondary to lymphoid hyperplasia in the appendix and subsequent obstruction.

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QUESTION:

With regard to the natural history of acute appendicitis, which of the following statements is/are true?

a. Rupture occurs most frequently in adolescent girls because of the difficult in establishing the diagnosis and the consequent delay in operation.

b. Perforation rates are correlated with the severity of the inial illness.

c. Acute appendicitis does not resolve spontaneously.

d. Early antibiotic treatment decreases the incidence of perforation

e. None of the above is true.

ANSWER:

The answer is E.

- Although some episodes of acute appendicitis apparently resolve spontaneously and recurrent appendicitis is a recognized entity, the natural history of acute appendicitis is generally one of persistent obstruction leading the gangrene and perforation.

- Perforation occurs more commonly in patients at either end of the age spectrum, but clinical manifestations of the disease are not otherwise correlated with the risk of appendiceal rupture.

- Prompt appendectomy therefore is indicated when the diagnosis is made, because it is the only certain way of preventing perforation and its attendant morbidity.

- Antibiotics are indicated for prophylaxis of infectious complications.

- Nevertheless, antibiotics do not alter the natural history of the disease.

- Antibiotics should be directed against aerobic and anaeroebic enteric bacteria, since they are most commonly involved in bacterial invasion of the appendix.

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QUESTION:
A previously healthy 15 year old boy is brought to the emergency room with complaints of about 12h of progressive anorexia, nausea, and pain of the right lower quadrant. On physical examination, he is found to have a rectal temperature of 38.18C (100.58F) and direct and rebound abdominal tenderness localizing to McBurney’s point as well as involuntary guarding in the right lower quadrant. At operation through a McBurney-type incision, the appendix and cecum are found to be normal, but the surgeon is impressed by the marked edema of the terminal ileum, which also has an overlying fibrinopurulent exudate. Which of the following is the most appropriate next step?

a. Close the abdomen after culturing the exudate

b. Perform a standard appendectomy

c. Resect the involved terminal ileum

d. Perform an ileocolic resection

e. Perform an ileocolostomy to bypass the involved terminal ileum

ANSWER:
The answer is b. (Brunicardi, pp1076-1081, 1127)

Patients with regional enteritis usually have a chronic and slowly progressive course with intermittent symptom-free periods.

The usual symptoms are anorexia, abdominal pain, diarrhea, fever, and weight loss.

Extraintestinal syndromes that may be seen include ankylosing spondylitis, polyarthritis, erythema nodosum, pyoderma gangrenosum, gallstones, hepatic fatty infiltration, and fibrosis of the biliary tract, pancreas, and retroperitoneum.

However, in about 10% of patients, especially those who are young, the onset of the disease is abrupt and may be mistaken for acute appendicitis.

Appendectomy is indicated in such patients as long as the cecum at the ase of the appendix is not involved; otherwise, the risk of fecal fistula must be considered.

Interestingly, about 90% of patients who present with the acute appendicitis-like form of regional enteritis will not progress to development of the full-blown chronic disease.

Thus, resection or bypass of the involved areas is not indicated at this time.

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QUESTION:
You perform laparoscopy on a 25 year old man for presumed appendicitis and find terminal ileitis not involving the cecal area. The ileitis area is non-obstructing. The most appropriate next step in management is:

a. Appendectomy

b. Close

c. Place a drain

d. Ileal resection

ANSWER:
- The answer is a. Patients with presumed appendicitis but isntead have terminal ileitis not involving the cecum should undergo appendectomy so that confusion of ileitis with appendicitis will not occur in the future. Also, gross appendicitis may not be apparent at time of operation. You are there – take it out.

- If the cecum is involved in the ileitis, leave the appendix (high risk for leak).

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QUESTION:
A 28 year old woman who is 15 weeks pregnant has new onset of nausea, vomiting, and right-sided abdominal pain. She has been free of nausea since early in her first trimester. The pain has become worse over the past 6h. Which of the following statements regarding appendicitis during pregnancy is correct?

a. Appendicitis is the most prevalent extrauterine indication for celiotomy during pregnancy

b. Appendicitis occurs more commonly in pregnant women than in nonpregnant women of comparable age

c. Suspected appendicitis in a pregnant woman should be managed with a period of observation due to the risks of laparotomy to the fetus

d. Noncomplicated appendicitis results in a 20% fetal mortality and premature labor rate

e. The severity of appendicitis correlates with increased gestational age of the fetus

ANSWER
The answer is a. (Mahmoodian, pp19-24)

Appendicitis complications approximately 1 in 1700 pregnancies at an incidence comparable with that in nonpregnant women matched for age.

It is the most prevalent extrauterine indication for laparotomy in pregnancy.

The duration of gestation does not influence the severity of the disease, but the diagnosis does become more difficult as the pregnancy progresses.

By the twentieth week of gestation, the appendix often lies at the level of the umbilicus and more lateral than usual.

Pregnancy should not delay surgery if appendicitis is suspected; appendiceal perforation greatly increases the chance of premature labor and fetal mortality (approxiately 20% for each).

In contrast negative laparotomy under general anesthesia and nonperforated appendicitis are asociated with very low risk to both the fetus and the mother (less than 1% and 5%, respectively.)

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REVIEW OF APPENDICITIS

- Number one cause of surgical abdominal emergency.
- Lifetime risk is 7%, peak incidence between 10-30 years. 250,000cases/yr in US.
- Blood supply: appendiceal art from ileocolic. 66% are anterior or retrocecal intraperitoneal, 33% are retroperitoneal.
- Mortality 0.6% in non-perforated, 5% with perforations.
- In adults, cause is from to a fecolith. In kids, lymphoid hyperplasia accounts for 60% of cases.

Diagnosis:
- non-specific periumbo abd pain->anorexia/vomiting->RLQ pain, tenderness->fever->WBC. Classic history occurs in only 50% of patients. Atypical presentation occurs in the elderly and <3yrs old. Symptoms more than 24-36 hrs is rare in non-perforated appendicitis.
- Physical findings: tenderness at McBurney’s point, with cough (Dunphy’s sign). Rovsing’s sign=push on left, hurts on right. Obturator sign=pain after flex hip, internal rotate hip=pelvic appendicitis. Psoas sign=extend hip=retrocecal appendicitis..

Workup:
WBC: elevated in 90% of cases
UA: can have a mild hematuria, pyuria and proteinuria due to proximity to the ureter. be sure to r/o kidney stone, UTI.
LFTs r/o cholecystitis
amylase/ lipase r/o pancreatitis
cervical exam, GC, chlam: in young women r/o PID
UPreg: in all women chilbearing age r/o preg, ectopic. Criteria: >6mm, noncompressible, tender. 85-95% sensitivity, 92% specificity.
US: helpful in young women and children. Should in women include endovaginal US exam to eval ovaries and tubes.
CT: sens 95% spec 95%, accuracy 95%. get CTs in all women, men >40, children if US not helpful. Obviously this is controversial but recent surgical literature shows early CT cuts the negative appy rate to <4% without increasing rates of perforated appendicitis (AJS 188 (2004) 748-754) AND is cost effective when consider total cost of neg appys, unecessary admits, etc. Protocol: 5mm cuts with oral, IV+rectal contrast.
Fecalith seen 10-20% of the time. Other findings include: mesenteric fat stranding, target sign, free pelvic fluid, sentinel loop focal ileus, obliterated right psoas shadow. An appendix diameter >6 mm.

Don’t forget about 2 other diagnostic tools: admit for observation (12-24h) and diagnostic laparoscopy.

DDX
IBD, cecal tics, Meckel’s, endometriosis, TOA, ovarian torsion, Crohn’s, infection ileocecitis (Yersina, Campylobacter, Salmonella, acute chole or PUD with right gutter fluid, mesenteric adenitis with viral URI, Henoch- Schonlein purpura (+/- nephritis), typhlitis, pyelonephritis, UTI, kidney stone, DU, GB, cancer, gastroenteritis, ectopic preg, PID…

Treatment
Zosyn or cefotetan to cover GN and GP and anerobes.
early, non-perf: appy, treated overnight with abx, DC the next day. Gangrenous or perf: appy, needs 5 days of abx.
Phlegmon 10-14 days of abx and interval appy at 6wks to 3mos if stable.
Abscess gets IR drain and interval appy if contained, but may need to go to OR if uncontrolled abdominal sepsis. Sometimes the abscess may not be accessible to drainage due to bowel loops anteriorly–either a posterior transgluteal approach or antibiotics alone can be done. If the abscesses are multiloculated or complex->OR to break up. Interval appy somewhat controversial; most recommend it because 20% recurrence rate and allows r/o tumors (carcinoid, etc)
lap vs. open: studied in 27 prosp RCTs: cochrane review 2002 of 45 studies: 50% reduction in wound infections (7% to 3.4%), 14 min longer operations, less pain on visual score, LOS reduction by 0.7 days, return to activity better by 3-6 days, but higher rate of postop abcess (2.4% vs 1%).
good for: obese, women, athletes, unclear diagnosis.

Always ask about previous abdominal operations to decide whether Hasson cannula is needed, and look at the CT scan yourself so that the location of the appendix, presence of a fecalith will be known intraoperatively.

COMPLICATIONS
Mortality down from 25% to 1% in last 50 yrs. Wound infections, SBO, abscesses, nec fasc. In pregnancy, maternal mortality is 1-2%, but fetal demise is 2-9%, up to 35% with perforation.

SOURCES
ABSITE KILLER Q&A