Transcript 1. Which of the following is the most common cause of

1. Which of the following is the most common cause of
acute appendicitis?
A.
B.
C.
D.
E.
Fecalith
Foreign body
Tumor of the appendix
Lymphoid hyperplasia
Adhesive bands in the abdomen
Ans: D
The cause of the luminal obstruction that initiates the process
of appendicitis is postulated to involve lymphoid
hyperplasia, a condition that is especially common in the
teen years and correlates with the high incidence of
appendicitis in this age group. It is felt that either viral or
bacterial infections can precede an episode of appendicitis
and presumably initiate lymphoid hyperplasia and
subsequent luminal obstruction.
It is thought that approximately 30% of cases of acute
appendicitis in adults are linked to fecaliths.
2. Pelvic appendicitis is frequently associated with which
of the following physical signs?
A.
B.
C.
D.
Cervical motion tenderness
Psoas sign
Tenderness at McBurney’s point
Obturator sign
Ans: A, D
When the location of the appendix is deep within the pelvis,
there may be little or no abdominal findings. Proximity of
the inflamed appendix to the obturator internus muscle
may be associated with a positive obturator test
(suprapubic pain on internal and external rotation of the
thigh).
A peri-appendiceal inflammatory process and abscess in
continuity with the right adnexa may be associated with
cervical motion tenderness.
A psoas sign is not present in cases of pelvic appendicitis
because the psoas muscle does not lie in direct continuity
with the inflamed organ.
3. Typical patient with acute appendicitis will describe
the onset of symptoms in which of the following order?
A.
B.
C.
D.
Nausea/vomiting, fever, RLQ pain, periumbilical pain
and tenderness
Periumbilical pain, nausea/vomiting, RLQ pain and
tenderness, fever
Nausea/vomiting, periumbilical pain, RLQ pain and
tenderness, fever
Fever, periumbilical pain, nausea/vomiting, RLQ pain
and tenderness
Ans: B
Most patients with acute appendicitis will describe a
characteristic set of symptoms and these symptoms almost
always follow a precise temporal pattern. The initial
symptom is the periumbilical pain which is visceral in
nature. This is followed by nausea and/or vomiting. The
pain then shifts to the RLQ as the inflammatory process
involves the overlying parietal peritoneum. Fever then
ensues, and is usually of a low-grade nature, especially
early on in the course. Eventually, lab. tests will reveal a
leukocytosis, usually mild in nature. In those patients
where the symptoms do not follow this temporal pattern,
one must be suspicious of a diagnosis other than acute
appendicitis.
4. If one finds a normal appendix during laparotomy,
what must one do next?
A.
B.
C.
D.
Do not do anything and just close
Perform appendectomy and close
Seek other possible causes of abdominal pain
Inform pt.’s family of operative findings and ask their
opinions
Ans: C
5. Which of the following is/are possible differential
diagnosis at the time of negative laparotomy for
appendicitis?
A.
B.
C.
D.
E.
F.
G.
Crohn’s disease
Right-sided diverticulitis
Left-sided diverticulitis
Gynecologic disorders in case of a female
Neoplasms
Acute terminal ileitis
Meckel’s diverticulum
Ans: All of the above
If a normal appendix is found at the time of laparotomy, other causes for
the abdominal pain should be sought. The cecum and proximal
ascending colon should be examined for right-sided diverticulitis,
neoplasms, or other diseases. The terminal ileum should be examined
for Crohn’s disease or acute ileitis, and at least 2 feet of the ileum
proximal to the ileocecal valve should be inspected for the presence
of a Meckel’s diverticulum.
Occasionally, sigmoid diverticulitis may be mistaken for acute
appendicitis, especially when a redundant sigmoid colon reaches the
right side of the abdomen.
The fallopian tubes, ovaries, and uterus should also be carefully examined
in female patients.
6. A 40 year old male presents with a 7 day h/o abdominal pain. The
symptoms were fairly mild but have increased somewhat over the past
couple of days with localized pain in the RLQ. On exam, pt. is febrile
and has a tender mass in the RLQ. There is no tenderness elsewhere
in the abdomen. Which of the following is/are appropriate
management of this patient?
A.
B.
C.
D.
E.
IV hydration, antibiotics, CT-guided drainage, and interval
appendectomy at approximately 10 weeks
IV hydration, antibiotics, and urgent appendectomy through a
McBurney incision
IV hydration, antibiotics, and ileocecectomy via midline laparotomy
IV hydration, antibiotics, and interval appendectomy at
approximately 10 weeks
IV hydration, antibiotics, operative drainage of abscess through a
McBurney incision, and interval appendectomy at approximately 10
weeks
Ans: A, D
In patients who present with a prolonged history (greater than 5 days) and
have localized tenderness in the RLQ, perhaps with a palpable mass,
the likely diagnosis is a periappendiceal abscess/phlegmon. Such
patients have already “walled-off” the appendiceal inflammation and
are best treated initially with non-operative therapy, including IV
hydration and abx. A CT scan may be performed and if a large
collection/abscess is identified, then a CT-guided catheter can be
placed. In many patients, abx alone will be sufficient. Urgent
operation in these patients is associated with increased morbidity,
including the possible injury of surrounding structures, such as the
small intestine. Initial non-operative management is therefore
recommended, and an interval appendectomy can be performed once
the inflammatory process has completely resolved, usually at
approximately 10 weeks following the initial presentation.
7.
A.
B.
C.
D.
E.
Which of the following is/are true regarding
carcinoid tumors of the appendix?
It is the most common tumor of the appendix
Although its most common site of occurrence is GI tract,
it can also be found in bronchus, lung, ovaries, kidney,
and testicles
Regardless of tumor size, if the surgical margins are
clear, then simple appendectomy is the adequate surgical
treatment
Carcinoids are thought to derive from the
enteroendocrine cells within the appendiceal wall
Tumors that are 2 cm in size or larger should be treated
with formal right hemicolectomy
Ans: all of the above but C
Carcinoid tumors are of neural crest origin and are thought to
be derived from enteroendocrine cells in the appendiceal
wall. The prognosis of patients with appendiceal
carcinoid tumors is directly related to size. For tumors
greater than or equal to 2 cm, formal right hemicolectomy
is indicated in order to ensure adequate lymphatic
clearance. Smaller tumors can be safely treated by
appendectomy alone, assuming the surgical margins are
clear.