APPENDICITIS

296 Section II / General Surgery

What lab tests should be performed?

Can you have an abnormal urinalysis with appendicitis?

CBC: increased WBC ( 10,000 per mm3 in 90% of cases), most often with a “left shift”

Urinalysis: to evaluate for pyelonephritis or renal calculus

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

Does a positive urinalysis rule out appendicitis?

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

In acute appendicitis, what classically precedes vomiting?

What radiographic studies are often performed?

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

Spiral CT, U/S (may see a large, noncompressible appendix or fecalith), AXR

Pain (in gastroenteritis, the pain classically follows vomiting)

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

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

What are the radiographic signs of appendicitis on AXR?

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

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) a small amount of free air if perforated

Only 5% of the time!

What are the CT findings with acute appendicitis?

Periappendiceal fat stranding, appendiceal diameter 6 mm, periappendiceal fluid, fecalith

What is a lap appy?

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

How is an appendiceal abscess that is diagnosed preoperatively treated?

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

Usually by percutaneous drainage of the abscess, antibiotic administration, and elective appendectomy 6 weeks later (a.k.a. interval appendectomy)

Yes

How long after removal of a NONRUPTURED appendix should antibiotics continue postoperatively?

Which antibiotic is used for NONPERFORATED appendicitis?

What antibiotic is used for a PERFORATED appendix?

For 24 hours

Anaerobic coverage: Cefoxitin®, Cefotetan®, Unasyn®, Cipro®, and Flagyl®

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

298 Section II / General Surgery

How long do you give antibiotics for perforated appendicitis?

What is the risk of perforation?

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

What are the possible complications of appendicitis?

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

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

25% by 24 hours from onset of symptoms, 50% by 36 hours, and75% by 48 hours

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

Pelvic abscess, liver abscess, free perforation, portal pylethrombophlebitis (very rare)

15%

What percentage of negative appendectomies is acceptable?

Who is at risk of dying from acute appendicitis?

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

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

Very old and very young patients

Yersinia enterolytica