Acute Appendicitis

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					Acute Appendicitis
• The incidence of appendectomy appears
  to be declining due to more accurate
  preoperative diagnosis.
• Despite newer imaging techniques, acute
  appendicitis can be very difficult to
• Acute appendicitis is thought to begin with
  obstruction of the lumen
• Obstruction can result from food matter,
  adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase
  intraluminal pressure
• Eventually the pressure exceeds capillary
  perfusion pressure and venous and
  lymphatic drainage are obstructed.
• With vascular compromise, epithelial
  mucosa breaks down and bacterial
  invasion by bowel flora occurs.
• Increased pressure also leads to arterial
  stasis and tissue infarction
• End result is perforation and spillage of
  infected appendiceal contents into the
• Initial luminal distention triggers visceral
  afferent pain fibers, which enter at the 10th
  thoracic vertebral level.
• This pain is generally vague and poorly
• Pain is typically felt in the periumbilical or
  epigastric area.
• As inflammation continues, the serosa and
  adjacent structures become inflamed
• This triggers somatic pain fibers,
  innervating the peritoneal structures.
• Typically causing pain in the RLQ
• The change in stimulation form visceral to
  somatic pain fibers explains the classic
  migration of pain in the periumbilical area
  to the RLQ seen with acute appendicitis.
• Exceptions exist in the classic
  presentation due to anatomic variability of
  the appendix
• Appendix can be retrocecal causing the
  pain to localize to the right flank
• In pregnancy, the appendix ca be shifted
  and patients can present with RUQ pain
• In some males, retroileal appendicitis can
  irritate the ureter and cause testicular pain.
• Pelvic appendix may irritate the bladder or
  rectum causing suprapubic pain, pain with
  urination, or feeling the need to defecate
• Multiple anatomic variations explain the
  difficulty in diagnosing appendicitis
• Primary symptom: abdominal pain
• ½ to 2/3 of patients have the classical
• Pain beginning in epigastrium or
  periumbilical area that is vague and hard
  to localize
• Associated symptoms: indigestion,
  discomfort, flatus, need to defecate,
  anorexia, nausea, vomiting
• As the illness progresses RLQ localization
  typically occurs
• RLQ pain was 81 % sensitive and 53%
  specific for diagnosis
• Migration of pain from initial periumbilical
  to RLQ was 64% sensitive and 82%
• Anorexia is the most common of
  associated symptoms
• Vomiting is more variable, occuring in
  about ½ of patients
            Physical Exam
• Findings depend on duration of illness
  prior to exam.
• Early on patients may not have localized
• With progression there is tenderness to
  deep palpation over McBurney’s point
            Physical Exam
• McBurney’s Point: just below the middle of
  a line connecting the umbilicus and the
• Rovsing’s: pain in RLQ with palpation to
• Rectal exam: pain can be most
  pronounced if the patient has pelvic
           Physical Exam
• Additional components that may be helpful
  in diagnosis: rebound tenderness,
  voluntary guarding, muscular rigidity,
  tenderness on rectal
            Physical Exam
• Psoas sign: place patient in L lateral
  decubitus and extend R leg at the hip. If
  there is pain with this movement, then the
  sign is positive.
• Obturator sign: passively flex the R hip
  and knee and internally rotate the hip. If
  there is increased pain then the sign is
            Physical Exam
• Fever: another late finding.
• At the onset of pain fever is usually not
• Temperatures >39 C are uncommon in
  first 24 h, but not uncommon after rupture
• Acute appendicitis should be suspected in
  anyone with epigastric, periumbilical, right
  flank, or right sided abd pain who has not
  had an appendectomy
• Women of child bearing age need a pelvic
  exam and a pregnancy test.
• Additional studies: CBC, UA, imaging
• CBC: the WBC is of limited value.
• Sensitivity of an elevated WBC is 70-90%,
  but specificity is very low.
• But, +predictive value of high WBC is 92%
  and –predictive value is 50%
• CRP and ESR have been studied with
  mixed results
• UA: abnormal UA results are found in 19-
• Abnormalities include: pyuria, hematuria,
• Presence of >20 wbc per field should
  increase consideration of Urinary tract
• Imaging studies: include X-rays, US, CT
• Xrays of abd are abnormal in 24-95%
• Abnormal findings include: fecalith,
  appendiceal gas, localized paralytic ileus,
  blurred right psoas, and free air
• Abdominal xrays have limited use b/c the
  findings are seen in multiple other
• Graded Compression US: reported
  sensitivity 94.7% and specificity 88.9%
• Basis of this technique is that normal
  bowel and appendix can be compressed
  whereas an inflamed appendix can not be
• DX: noncompressible >6mm appendix,
  appendicolith, periappendiceal abscess
• Limitations of US: retrocecal appendix
  may not be visualized, perforations may
  be missed due to return to normal
• CT: best choice based on availability and
  alternative diagnoses.
• In one study, CT had greater sensitivity,
  accuracy, -predictive value
• Even if appendix is not visualized,
  diagnose can be made with localized fat
  stranding in RLQ.
• CT appears to change management
  decisions and decreases unnecessary
  appendectomies in women, but it is not as
  useful for changing management in men.
        Special Populations
• Very young, very old, pregnant, and HIV
  patients present atypically and often have
  delayed diagnosis
• High index of suspicion is needed in the
  these groups to get an accurate diagnosis
• Appendectomy is the standard of care
• Patients should be NPO, given IVF, and
  preoperative antibiotics
• Antibiotics are most effective when given
  preoperatively and they decrease post-op
  infections and abscess formation
• There are multiple acceptable antibiotics
  to use as long there is anaerobic flora,
  enterococci and gram(-) intestinal flora
• One sample monotherapy regimen is
  Zosyn 3.375g or Unasyn 3g
• Also, short acting narcotics should be
  used for pain management
• Abdominal pain patients can be put in 4
• Group 1: classic presentation for Acute
  appendicitis- prompt surgical intervention
• Group 2: suspicious, but not diagnosed
  appendicitis- benefit from imaging and 4-
  6h observation with surgical consult if
  serial exam changes or imaging studies
• Group 3: remote possibility of appendicitis-
  observe in ED for serial exams; if no
  change and course remains benign patient
  can D/C with dx of nonspecific abd pain
• Patients are given instructions to return if
  worsening of symptoms, and they should
  be seen by PCP in 12-24 h
• Also advised to avoid strong analgesia
• Group 4: high risk population(including
  elderly, pediatric, pregnant and
  immunocomprimised)- require high index
  of suspicion and low threshold for imaging
  and surgical consultation
Ileitis, Colitis, and
             Crohn Disease
• Chronic granulomatous inflammatory
  disease of the GI tract.
• Can involve any part of GI tract from
  mouth to anus
• Ileum is involved in majority of cases
• Confined to colon in 20%
• Terms:regional enteritis, terminal ileitis,
  granulomatous ileocolitis
            Crohn Disease
• Etiology and pathogenesis are unknown.
• Infectious, genetic, environmental factors
  have been implicated.
• Autoimmune destruction of mucosal cells
  as a result of cross-reactivity to antigens
  from enteric bacteria.
           Crohn Disease
• Cytokines,including IL and TNF have been
  implicated in perpetuating the
  inflammatory response.
• Anti-TNF(remicade) drugs have shown
  efficacy in treating Crohn disease
           Crohn Disease
• Epidemiology: peak incidence is 15-22
  years old with a second peak 55-66years
• 20-30% increase in women
• More common in European
• 4 times more common in Jews than non-
• More common in whites vs blacks
• 10-15% have family hx
           Crohn Disease
• Pathology: most important is the
  involvement of all layers of the bowel and
  extension into mesenteric lymph nodes
• Disease has skip areas between involved
• Longitudinal deep ulcers and
  cobblestoning of mucosa are characteristic
• These result in fissures, fistulas, and
            Crohn Disease
• Clinical features: variable and
• Abd pain, anorexia, diarrhea, and weight
  loss are present in most cases
• 1/3 of patients develop perianal fissures or
  fistulas, abscesses, or rectal prolapse
            Crohn Disease
• Patients may present with lat
  complications including:
• Obstruction, crampy abd pain, obstipation,
  intraabdominal abscess with fever
• 10-20% have extraabdominal features
  such as: arthritis, uveitis, or liver disease
• Crohn’s should also be considered when
  evaluating FUO
           Crohn Disease
• Clinical course and manifestation depends
  of anatomic distribution.
• 30% involves only small bowel, 30% only
  colon, and 50% involves both
           Crohn Disease
• Recurrence rate is as high as 50% for
  those responding to medical management
• Rate is even higher for those requiring
• Incidence of hematochezia and perianal
  disease is higher when the colon is
            Crohn Disease
• Dermatologic complications: erythema
  nodosum and pyoderma gangrenosum
• Ocular: episcleritis and uveitis
• Hepatobiliary: pericholangitis, chronic
  hepatitis, primary sclerosing cholangitis,
  cholangiocarcinoma, pancreatitis,
            Crohn Disease
• Vascular: thromboembolic disease,
  vasculitis, arteritis
• Other: anemia, malnutrition, hyperoxaluria
  leading to nephrolithiasis, myeloplastic
  disease, osteomyelitis, osteonecrosis
            Crohn Disease
• Complications: >75% of patients will
  require surgery within the first 20 years
• Abscesses present with pain and
  tenderness, but may also have palpable
  masses or fever spikes
• Most common fistula sites are between
  ileum and sigmoid colon, cecum, another
  ileal segment, or the skin
           Crohn Disease
• Fistulas should be suspected when there
  is a change in bowel movement frequency,
  amount of pain or weight loss
• GI bleed is common, but only 1% develop
  life threatening hemorrhage.
• Toxic megacolon occurs in 6% of patients
  and results massive GI bleed 50% of the
            Crohn Disease
• Complications can also arise from the
  treatment of the disease
• Sulfasalazine, steroids,
  immunosuppressive agents, and
  antibiotics can cause leukopenia,
  thrombocytopenia, fever, infection,
  diarrhea, pancreatitis, renal insufficiency,
  liver failure.
            Crohn Disease
• Incidence of malignancy is 3 times higher
  in Crohn disease than in general
            Crohn Disease
• Diagnosis: history, Upper GI, air-contrast
  barium enema and colonoscopy
• Characteristic radiologic findings in small
  intestine include: segmental narrowing,
  destruction of normal mucosal pattern, and
            Crohn Disease
• Colonoscopy is most sensitive for patients
  with colitis
• Useful for detecting mucosal lesions,
  defining extent of involvement, occurrence
  of colon ca.
• Abd CT is most useful for acute
            Crohn Disease
• Findings of bowel wall thickening,
  mesenteric edema, local abscess
  formation suggest Crohn disease.
             Crohn Disease
• Differential Dx: lymphoma, ileocecal
  amebiasis, sarcoidosis, deep chronic
  mycotic infections involving GI tract, GI
  TB, Kaposi’s sarcoma, campylobacter,
  Yersinia, ulcerative colitis, C.diff, ischemic
            Crohn Disease
• Tx: relief of symptoms, induction of
  remission, maintenance of remission,
  prevention of complications, optimizing
  timing of surgery, and maintenance of
• Since the disease is virtually incurable,
  emphasis should be placed of relief of
  symptoms and preventing complications
            Crohn Disease
• Initial ED management: focus on severity
  of attack, identifying possible
  complications such as obstruction,
  hemorrhage, abscess, toxic megacolon.
• CBC, electrolytes, BUN/creatinine, and
  type and cross if appropriate
• Plain films may be useful for obstruction,
  perforation or toxic megacolon
           Crohn Disease
• Initial Tx: NPO, IVF resuscitation and
  correction of electrolytes
• NG decompression if indicated, broad
  spectrum atbx(ampicillin or a
  cephalosporin, aminoglycoside, and flagyl)
  should be used for suspected fulminant
  colitis or peritonitis
            Crohn Disease
• IV steroids: hydrocortisone 300mg qd,
  methylprednisone 48mg qd, or
  prednisolone 60mg qd should be used for
  severe disease
• Sulfasalazine 3-4g qd can be effective for
  mild-moderate cases, although it has
  many toxic side effects
             Crohn Disease
• Oral steroids are reserved for severe
  disease-prednisone 40-60mg qd
• Immunosuppressive drugs:
  6-MP or azathioprine are useful for steroid
  alternatives, healing fistulas, or in patients
  with contraindications to surgery
  Response to immunosuppressant agents
  takes 3-6 months
           Crohn Disease
• Flagyl and Cipro have been shown some
  improvement in perianal complications and
  fistulous disease.
• Medically resistant or moderate cases may
  benefit from anti-TNF(Remicade) 5 mg/kg
• Cellcept, etanercept, thalidomide, IL
  therapy may also be beneficial
           Crohn Disease
• Diarrhea can be controlled using imodium,
  lomotil, or questran
             Crohn Disease
• Disposition: patients with signs of
  fulminant colitis, peritonitis, obstruction,
  significant hemorrhage, dehydration,
  electrolyte/fluid imbalance should be
  hospitalized under the care of a surgeon
  or gastroenterologist
           Crohn Disease
• Patients with chronic disease can be
  discharged home as long as there are no
  serious complications.
• Alterations in maintenance therapy should
  be discussed with GI
• Close follow up should be secured.
          Ulcerative Colitis
• Chronic inflammatory disease of the colon.
• Inflammation is more severe from proximal
  to distal colon
• Rectum is involved in nearly 100%
• Characteristic symptom is bloody diarrhea
• Etiology remains unknown
          Ulcerative Colitis
• Epidemiology: similar to Crohn disease
• More prevalent in US and northern
• First degree relatives have 15 fold
  increase for UC and 3.5 fold increase for
  Crohn disease
          Ulcerative Colitis
• Pathology: involves mucosa and
• Mucosal inflammation and formation of
  crypt abscesses, epithelial necrosis, and
  mucosal ulceration
• Early stages mucosa membrane appears
  finely granular and friable
• Severe cases show large oozing
  ulcerations and pseudopolyps
            Ulcerative Colitis
• Clinical features:
• Mild: <4 bm per day, no systemic symptoms,
  and few extraintestinal manifestations. (account
  for 60% of all UC patients)
• Severe: frequent bm’s, anemia, fever, wt loss,
  tachycardia, low albumin, frequent
  extraintestinal manifestations. (accounts for 15%
  of all patients and 90% of mortality)
          Ulcerative Colitis
• Moderate: manifesations are less severe
  and respond well to treatment. Typically
  have left sided colitis, but can have
           Ulcerative Colitis
• Characterized by: intermittent attacks of
  acute disease with remission between
• Unfavorable prognosis and increased
  mortality is seen with higher severity and
  extent of disease, short interval between
  attacks, and onset of disease after 60
           Ulcerative Colitis
• Extraintestinal complications: arthritis,
  ankylosing spondylitis, episcleritis, uveitis,
  pyoderma gangrenosum, erythema
  nodosum, liver disease(similar to that
  found in Crohn disease)
          Ulcerative Colitis
• Complications: hemorrhage, toxic
  megacolon, perirectal abscesses and
  fistulas, colon ca, perforation
           Ulcerative Colitis
• Dx: lab findings are nonspecific.
• Diagnosis is made by Hx of abd cramps
  and diarrhea, mucoid stools, stool
  negative for ova/parasites, negative stool
• confirmation of disease by colonoscopy
  showing granular, friable, ulceration of the
  mucosa, and sometimes pseudopolyps
          Ulcerative Colitis
• Differential Dx: similar to that of Crohn
• Also be aware of STD’s when confined to
  the rectum
          Ulcerative Colitis
• Treatment:
• Severe UC: IV steroids, fluid replacement,
  electrolyte correction, broad spectrum
  atbx(amp and clindamycin or flagyl)
• Cyclosporine has been advocated for
  steroid refractory cases
• NG for toxic megacolon just as in crohn
           Ulcerative Colitis
• Mild to moderate: majority of cases can be
  treated as outpatient with daily prednisone
• Active proctitis, proctosigmoiditis, and left
  side colitis can be treated with 5-
  aminosalicylic acid enemas or topical
  steroid preparations
          Ulcerative Colitis
• Treatment is very similar to Crohn disease
• Other supportive measures include
  metamucil or other bulking agents
• Anti-diarrheals should be used with
  caution in case of toxic megacolon
          Ulcerative Colitis
• Disposition:Fulminant attacks should be
  hospitalized for aggressive IVF and
  elctrolyte correction.
• Complications should be managed with
  appropriate surgical or GI consult
• Mild-moderate: may be discharged with
  close follow up secured. Instructions on
  when to return should be given
   Pseudomembranous Colitis
• Inflammatory bowel disorder with
  membrane-like yellowish plaques of
  exudate overlie and replace necrotic
  intestinal mucosa
   Pseudomembranous Colitis
• Epidemiology:
• Clostridium Difficile- spore forming
  obligate anaerobic bacillus
• 3 types: neonatal, post-operative and
  antibiotic associated
• Risk factors: recent atbx, GI surgery,
  severe medical illness, advancing age
• Transmission: direct contact and objects
   Pseudomembranous Colitis
• Pathophysiology: 10-25% of hospital
  patients are colonized
• Diarrhea in recently hospitalized person
  should suggest C.difficile
• Broad spectrum atbx such as clindamycin,
  cephalosporins, amp/amox- alter gut flora
  and allow C.difficile to flourish
• However any atbx can lead to C.difficile
     Pseudomembranous Colitis
•   C. difficile produces
•   toxin A enterotoxin
•   toxin B cytotoxin
•   Toxins interact and produce the colitis and
    associated symptoms
   Pseudomembranous Colitis
• Clinical features: from frequent mucoid,
  watery stools to profuse toxic
  diarrhea(>20-30 stools/day), abdominal
  pain, fever, leukocytosis, dehydration,
• Stool exam may reveal fecal leukocytes
   Pseudomembranous Colitis
• Complications: severe electrolyte
  imbalance, hypotension, anasarca from
  low albumin, toxic megacolon, bowel
• Onset is typically 7-10 days after starting
  atbx therapy
   Pseudomembranous Colitis
• Extraintestinal complications are rare, but
  include: arthritis, visceral abscesses,
  cellulitis, necrotizing fasciitis,
  osteomyelitis, prostheitc device infection
   Pseudomembranous Colitis
• Diagnosis: hx of diarrhea that develops
  during or within 2 weeks of atbx treatment.
• Confirmed by stool for C.difficile toxin and
• Most labs use ELISA to detect C.difficile
  toxins even though there are many other
• 5-20% of patients require more than one
  stool to diagnose
   Pseudomembranous Colitis
• Treatment: d/c atbx, supportive IVF,
  electrolyte correction, flagyl 250 mg qid, or
  vancomycin 125-250mg po qid(alternative
• 25% of patients will respond to supportive
  measures only
• Severely ill patients should hospitalized
   Pseudomembranous Colitis
• Relapses occur in 10-20% of patients
• Use of anti-diarrheals should be avoided
• Surgery or steroids are rarely needed
   Pseudomembranous Colitis
• Disposition:
• Severe diarrhea, symptoms that persist
  despite outpatient management, or those
  with systemic response(fever,
  leukocytosis, severe abdominal pain)
  should be hospitalized
• Suspected perforation, toxic megacolon or
  failure to respond to medical treatment
  need a surgical consult
   Pseudomembranous Colitis
• For patients who are discharged whom:
  good oral intake must be encouraged.
  Flagyl or vancomycin are equally effective
  for treatment.
• Acute inflammation of the wall of a
  diverticulum and surrounding tissue
• Caused by either a micro- or
• Epidemiology:
• Acquire disease of the colon has become
  common in industrialized nations
• Approximately 1/3 of population will
  acquire diverticuli by age 50 and 2/3 by
  age 85
• Rare <20 years
• Diverticulitis is estimated in 10-25% of
  people with known diverticulosis
• Incidence increases with age
• Only 2-4 % are < 40
• Diverticulitis in younger age is associated
  with more complications requiring surgical
• Frequency is slightly higher in men, the
  incidence is on the rise in women
•   Pathophysiology:
•   Cause is not known
•   Low residue diets have been implicated
•   Acute complications: Inflammation(and
    associated complications) and Bleeding
• Inflammation is the most common
  complication of diverticulosis
• Mechanism was thought to occur when
  fecal material was inspissated in the neck
  of a diverticulum, resulting in bacterial
  proliferation, mucous secretion, and
• More commonly, it results from high
  pressure in the colon, erosion of
  diverticulum wall, microperforation, and
• Free perforation can occur with
  generalized peritonitis, but is uncommon
• Other complications: obstruction and
  fistula formation between the bladder and
• Clinical Features: most common symptom
  is pain.
• Described as steady, deep discomfort in
  the LLQ
• Other complaints: change in bowel habit,
  tenesmus, dysuria, frequency, UTI,
  distention, nausea, vomiting,
• Presentation may be indistinguishable for
  acute appendicitis
• Diverticulitis should always be considered
  in patient >50 with abdominal pain
• Perforation is characterized by sudden
  lower abdominal pain progressing general
  abdominal pain
• Physical exam: frequently fever of 38 C,
  localized abdominal tenderness, voluntary
  guarding, rebound, rectal tenderness on
  left side, possibly occult blood +,
• As always, Pelvic should be done with
• Watch for signs of peritonitis or perforation
• Diagnosis: typically suspected by Hx and
• Abdominal plain films can show partial
  SBO, free air, extraluminal air
• CT is procedure of choice. Demonstrates
  inflammation of pericolic fat, diverticula,
  thickening of bowel wall, peridiverticular
• Barium enema can be done, but are
  insensitive and may cause perforation due
  to the introduction of barium at high
• Routine labs include: CBC, electrolytes,
  BUN/creatinine, UA
• Sigmoidoscopy and colonoscopy are
  performed only after inflammation has
• Differential Dx:
• Similar to that of appendicititis, Crohn
  disease, UC, and C.difficile colitis
• Treatment:
• NPO, IVF, electrolyte correction, NG for
  obstruction, Broad spectrum atbx,
  observation for complications
• Outpatient management includes liquids
  only for 48 hours and oral
  antibiotics(Cipro, flagyl, bactrim, ampicillin)
• Disposition:
• Patients without signs of peritonitis or
  systemic infection maybe treated as
  outpatients with careful follow up
  arranged. Should be instructed to return
  for fever, increasing pain, unable to
  tolerate po.
• If patient shows signs of systemic
  infection, perforation or peritonitis then
  they should be hospitalized with a surgical
• 1. With a retrocecal appendix, the pain of
  acute appendicitis may localize to the right
  flank. (True or false)
• 2. Outpatient antibiotics is the standard
  treatment of acute appendicitis. (True or
• 3. Special populations of people that may have
  delayed diagnosis of acute appendicitis due to
  atypical presentation include:
• A.) very young patients
• B.) elderly patients
• C.) AIDS patients
• D.) Pregnant patients
• E.) all of the above
• 4. Crohn disease can involve:
• A.) any part of the GI tract(from mouth to
• B.) colon only
• C.) esophagus only
• D.) small intestine only
• 5. Ulcerative colitis and Crohn disease are
  both considered types of inflammatory
  bowel disease. (True or False)

• Answers: 1T, 2F, 3E, 4A, 5T

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