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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
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.
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
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.
– Abdominal Aortic Aneurysm .
– Acute Pancreatitis .
– Aortic Dissection .
– Appendicitis .
– Cholecystitis .
– Chronic Pancreatitis and Familial Pancreatitis:
– Colorectal Surgery .
– Duodenal Injuries, Duodenal Perforation, Duodenal Hematoma .
– Gastrointestinal Hormones .
– Hirschsprung’s Disease .
– Inguinal Hernias .
– Inguinal Hernia Repair .
– Liver Trauma, Liver Injury, Liver Laceration .
– Malrotation and Midgut Volvulus .
– Nutrition and Metabolism .
– Pancreatic Pseudocysts:
– Splenic Trauma, Splenic Injury, and Splenic Rupture .
– Transplantation .
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Categorised as: Appendicitis