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Review Question - QID 107823

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QID 107823 (Type "107823" in App Search)
A 23-year-old woman presents to the emergency department for evaluation of abdominal pain. She states that her pain started yesterday and was initially in the center of her abdomen. When she awoke today, she states that her pain was much worse and is now located in the right lower quadrant of her abdomen. She reports associated nausea and vomiting that started this morning as well as fevers. She denies any other symptoms. Her temperature is 102.2°F (39.0°F), pulse is 102, blood pressure is 115/70 mmHg, and respirations are 18/min. On exam there is tenderness to palpation in the right lower quadrant with guarding and rebound tenderness. An abdominal CT scan is obtained as shown in Figure A. Which of the following best describes the pathophysiology of this patient's condition?
  • A

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

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0/3

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

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

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

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3/3

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

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  • A

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This patient with migratory right lower quadrant abdominal pain, fever, nausea and vomiting likely has acute appendicitis. The pathophysiology of acute appendicitis involves obstruction of the lumen of the appendix by a fecolith or lymphoid hyperplasia resulting in elevated intraluminal pressure and subsequent ischemia.

Acute appendicitis is a common cause of the acute abdomen and is the most common reason for unplanned abdominal surgery in the United States. Appendicitis occurs in patients across a wide spectrum of age. Appendicitis develops as the lumen of the appendix becomes obstructed. In children, lymphoid hyperplasia often leads to obstruction, while a fecolith is a more common source of obstruction in adults. As intraluminal pressure mounts within the vermiform appendix, it becomes engorged, and stimulates the visceral afferent nerve fibers entering the spinal cord at the T8-T10 level, leading to vague periumbilical referred pain. Well localized pain occurs later in the course, once the inflammation begins to involve the adjacent parietal peritoneum. Similarly, the presence of the the psoas sign is indicative of a retrocecal appendix, which when the psoas muscle is flexed, results in peritonitis at this point. The obturator sign is indicative of an abdominal appendix, with a similar mechanism as the psoas sign, but this time involving the inflamed, draped appendix over the right obturator internus.

Howell et al. discuss the evaluation and management of patients with suspected appendicitis. They conclude that any female of childbearing age should be first screened of the possibility of pregnancy, with qualitative B-HCG being an appropriate modality. In children, acute appendicitis should be first explored with a right lower quadrant ultrasound (US). US should be used to confirm acute appendicitis, but not exclude it. In children without a definitive diagnosis after US, computed tomography is appropriate. Interestingly, Anderson et al. found that the addition of oral contrast to IV contrast in computed tomography did not significantly improve the sensitivity or specificity of the scan with regards to acute appendicitis.

Korndorffer et al. discuss the recommendations regarding surgical approaches to appendectomies. In general, they conclude that laparoscopic appendectomy is a reasonable approach for uncomplicated and complicated appendicitis. Laparoscopic appendectomies has a lower rate of of postoperative wound infection, and shorter recovery periods when compared to open appendectomy. As such, the laparoscopic approach should be attempted when considered prudent. Of note, Walsh et al. found a higher rate of fetal loss when pregnant patients underwent a laparoscopic approach, as compared to an open approach. Thus, open appendectomy appears to be a safer option for pregnant patients.

Figure A shows a markedly dilated appendix with thickened wall and adjacent fat stranding, characteristic of acute appendicitis.

Incorrect Answers:
Answer 1: Implantation of zygote within the fallopian tubes leading to tubular dilation and rupture describes the pathophysiology of ruptured ectopic pregnancy. While this condition may also present with lower quadrant abdominal pain, vaginal bleeding and a history of missed menstrual period would be expected.

Answer 3: Rotation of adnexa about ligamentous structures leading to venous and arterial compromise describes the pathophysiology of ovarian torsion. While this condition may also present with lower quadrant abdominal pain, pain is typically very sudden in onset. A migratory pattern of pain developing over the course of several days would be atypical.

Answer 4: Telescoping of hollow viscus into adjacent segment due to a lead point resulting in vascular compromise describes the pathophysiology of intusussecption. This condition is more common in younger children and is characterized by colicky abdominal pain.

Answer 5: Viral infection with hyperplasia of lymphoid tissue, and inflammation of mesenteric nodes describes the pathophysiology of mesenteric adenitis. This is a common mimic of acute appendicitis that can be differentiated with this patient's history of migratory abdominal pain and imaging findings.

Bullet Summary:
Acute appendicitis develops due to luminal obstruction by a fecolith or lymphoid tissue leading to venous outflow obstruction and subsequent ischemia.

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