Updated: 8/15/2017

Appendicitis

Topic
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Questions
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Snap Shot
  • 24-year-old presents with nausea, vomiting, constipation, and periumbilical pain that settles in the lower right quadrant. On Physical Exam she has tenderness and guarding in the lower right quadrant.
Introduction
  • Increased frequency 10-30 years of age
  • More common in US due to low fiber diet
  • Most common etiologies are 
    • lymphoid hyperplasia
    • fecolith obstruction
Presentation
  • Symptoms
    • loss of appetite, nausea, vomiting
    • fever
    • pain moves from periumbilical area to LRQ
    • diarrhea only with retrocecal appendicitis
  • Physical exam 
    • Blumberg sign
      • rebound tenderness at McBurney's point
    • Psoas/Obturator sign
      • raise the patient's right leg with the knee flexed
      • rotate the leg internally at the hip
      • increased abdominal pain indicates a positive obturator sign
    • Rovsing's sign
      • pressure over the descending colon causes pain in the RLQ
Evaluation
  • Labs
    • absolute neutrophillic leukocytosis and left shift
    • always perform pregnancy test
  • Physical Exam
    • perform rectal exam, tenderness suggests inflamed posterior appendix
  • Imaging 
    • Abdominal US first in pediatric and pregnant patients to spare ionizing radiation 
    • Abdominal CT scan in adults or pediatric patients without a diagnostic US
Differential
  • PID, ovarian torsion, gyn disorders, volvulus, gastroenteritis, ectopic pregnancy, pyelonephritis, diverticulits, colorectal cancer, IBD, cholecystitis, Meckel's, mesenteric ischemia
Treatment
  • Laparoscopic Appendectomy
  • CT guided drainage of abscess
Prognosis, Prevention, and Complications
  • Perforation
  • Peritonitis
  • Periappendiceal abscess
  • Pylephlebitis (inflammation of the portal vein)
  • Septicemia
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M2.GI.4694) A 23-year-old college student presents to the emergency room with severe abdominal pain, nausea, vomiting, and anorexia for the last 24 hours. She reports that she was in her usual state of health, until yesterday when she began to have abdominal pain which she describes near her belly button. This morning, she woke up with her pain much increased, and shifted to the right lower quadrant. Vitals are T 102.0 F HR 98 bpm BP 138/94 mmHg RR 18 Sat 100%. Exam is notable for exquisite right lower quadrant pain that is worse with rebound. When the examiner presses on the left lower quadrant, the patient complains of pain in the right lower quadrant. Psoas signs is present, with a negative obturator sign. Lab studies show a white blood cell count of 15.3, beta HCG is negative. Abdominal CT with contrast is shown in Figure A. Which of the follow pathophysiologies most likely lead to this patient's condition? Review Topic

QID: 107823
FIGURES:
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Telescoping of hollow viscus into adjacent segment due to a lead point resulting in vascular compromise

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Rotation of adnexa about ligamentous structures leading to venous and arterial compromise

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Implantation of zygote within the fallopian tubes leading to tubular dilation and rupture

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Luminal obstruction of hollow viscus by fecolith or lymphoid tissue leading to venous outflow obstruction

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5

Viral infection with hyperplasia of lymphoid tissue, and inflammation of mesenteric nodes

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M2

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PREFERRED RESPONSE 4

(M3.GI.26) A 12-year-old boy is brought in by his mother to the emergency department. He has had abdominal pain, fever, nausea, vomiting, and loss of appetite since yesterday. At first, the mother believed it was just a "stomach flu," but she is growing concerned about his progressive decline. Vitals include: T 102.3 F, HR 110 bpm, BP 120/89 mmHg, RR 16, O2 Sat 100%. Abdominal exam is notable for pain over the right lower quadrant. What is the next best step in management in addition to IV hydration and analgesia? Review Topic

QID: 103317
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Abdominal CT scan with IV and PO contrast

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Abdominal CT scan with IV contrast

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Upright and supine abdominal radiographs

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Right lower quadrant ultrasound

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Abdominal MRI with gadolinium contrast

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M2

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PREFERRED RESPONSE 4
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