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Anatomy
Appendix
Pathophys
Treatment
Complications
100
1) The artery supplying the appendix is a branch off what artery
Ileocolic
100
Describe the obturator sign and what it tells you about location of the appendix?
Pain on internal rotation of the hip suggestive of pelvic appendix
100
Inciting event of acute diverticulitis
Microperforation of diverticuli
100
At what point following diverticulitis is a colonoscopy performed and why?
At least 6 weeks to allow perforation to heal and it is to rule out malignancy
100
Most common site of diverticular bleed
Right colon, diverticulosis is most common cause of LGIB, diverticulum erodes into vasa recta and causes bleeding, most spontaneously resolve
200
2) Most common location of the appendix
Retrocecal
200
The WBC is normal in approximately how many people presenting with acute appendicitis?
1/3 and even higher if pt presents prior to 24 hours of pain
200
Two mechanisms of obstruction in diverticular disease
Acute diverticulitis with acute inflammation and edema. Following multiple bouts of diverticulitis with chronic scar and thickening of colon wall SBO from inflammation caused by diverticulitis
200
Most common reason to have recurrent diverticulitis after resection with anastomosis is?
Having a colo-sigmoid resection instead of a colo-rectal anastomosis. The retained sigmoid puts patient at continued risk for diverticulitis
200
Presence of a mesenteric abscess that reaches toward to pelvis is a Hinchey class what?
Hinchey 2. 1 = pericolonic abscess, 3 = purulent peritonitis, 4 = feculent peritonitis
300
3) Where is McBurneys point?
1/3 the distance from ASIS to umbilicus in RLQ
300
CT criteria for acute appendicitis
Enlarged appendix (>6mm in diameter) wall thickening (>2mm) and periappendiceal fat stranding
300
Diet frequently associated with development of diverticulosis and why?
“low residue diet” high in processed carbohydrates and low in fiber leads to constipation and increased luminal pressure
300
Test of choice for patient with suspected colo-vesicle fistula?
CT scan, a colonoscopy should be done prior to any surgical resection but will often fail to demonstrate a fistulous connection
300
What is the most common complication of diverticulitis?
Abscess formation
400
What is the water shed area of the colon? And what does that mean?
The splenic flexure, it is between two blood supplies off the SMA and IMA
400
Rate of negative appendectomy in era of CT scans?
What is 5%
400
Pneumaturia, fecaluria and recurring UTI are classic signs of what? And the most common cause of this is what?
Colo-vesicle fistula from diverticulitis (crohns is second most common reason for entero-vesicle fistula)
400
What are the classic three stages of Hartmanns procedure?
1 is division of colon and colostomy. 2 is resection of diseased portion. 3 is anastomosis for return of bowel continuity
400
About what is the usual minimum size of an abscess to undergo CT guided drainage?
2 cm is the lower limit on average
500
Portion of the colon and location in wall where diverticuli are most often found?
Sigmoid and near vasa recta
500
Treatment for carcinoid tumor, 1.8cm in tip of the appendix?
Appendectomy. For carcinoids if < 2cm and in tip or body then treatment is appendectomy . if >2cm or involving base treatment is Rt Hemicolecomy
500
Classic description of sequence of onset of symptoms in patient with acute appendicitis?
Periumbilical pain -> nausea/vomiting -> RLQ pain -> fever
500
5) Patient with acute diverticulitis is admitted and started on abx and NPO. They are failing to progress and pain increasing. Repeat CT shows several small pelvic abscess with scant extraluminal air. Decision is made for surgical intervention. Describe at least 2 options for surgical approach in this patient?
Hartmanns procedure with resection and end colostomy. Also a resection with primary anastomosis and diverting ileostomy
500
During which acute attack of diverticulitis is a person most likely to require emergent surgery?
Their first