Surgery Marrow Pg 211-220 (GIT)
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Questions and Answers

Which imaging technique is considered inconclusive for diagnosing appendicitis in pregnancy?

  • Ultrasound (USG) (correct)
  • Electrocardiogram (ECG)
  • X-ray
  • Computed Tomography (CT)

    • Laparoscopic appendicectomy is contraindicated during the first trimester of pregnancy.

    False

    What can untreated or perforated appendicitis increase the risk of during pregnancy?

    Fetal loss or preterm labor

    The characteristic mass formed over the inflamed appendix in appendicular lump is created by the omentum and the ______.

    <p>bowel</p> Signup and view all the answers

    Match the following trimesters with their corresponding treatment for appendicitis:

    <p>First trimester = Laparoscopic appendicectomy Second trimester = Laparoscopic cholecystectomy for cholecystitis Third trimester = Laparoscopic appendicectomy All trimesters = Laparoscopic appendicectomy</p> Signup and view all the answers

    Which type of polyp has a 'tube-like' appearance?

    <p>Tubular polyp</p> Signup and view all the answers

    Villous polyps in children are primarily located in the stomach.

    <p>False</p> Signup and view all the answers

    What are the two main types of polyps mentioned?

    <p>Tubular and Villous</p> Signup and view all the answers

    A pedunculated polyp is resembled by a stalk, while a ______________ polyp extends directly from the mucosal surface.

    <p>sessile</p> Signup and view all the answers

    Match the management technique with the type of polyp:

    <p>Pedunculated polyp = Resected by snare around polyp Not a Pedunculated polyp = Injection of saline to raise the polyp Complete excision = Elimination of the entire polyp</p> Signup and view all the answers

    Which condition does NOT belong to the differential diagnosis for infants and children?

    <p>Ureteric colic</p> Signup and view all the answers

    The Modified Alvarado Score includes the assessment of the shift of white blood cell count to the left.

    <p>False</p> Signup and view all the answers

    What are the two types of appendectomy mentioned in the management section?

    <p>Open appendectomy and laparoscopic appendectomy</p> Signup and view all the answers

    Patients with suspected appendicitis should be kept _____ until further assessment is made.

    <p>nil per oral (NPO)</p> Signup and view all the answers

    Match the following management strategies with their descriptions:

    <p>Nil per oral (NPO) = Prevent intake of food or drink IV fluids = Maintain hydration IV antibiotics = Cover anaerobic and aerobic bacteria Pain killers = Relieve pain in patients</p> Signup and view all the answers

    What is the most common type of tumor found in the appendix?

    <p>Carcinoid tumor</p> Signup and view all the answers

    Fever with chills and rigors indicates a worsened condition in patients with an appendicular tumor.

    <p>True</p> Signup and view all the answers

    What is the primary surgical intervention recommended after six weeks for an appendicular tumor?

    <p>Interval appendectomy</p> Signup and view all the answers

    The most common site for a neuroendocrine tumor in the appendix is the ______.

    <p>tip</p> Signup and view all the answers

    Match the clinical features with their corresponding situation:

    <p>Asymptomatic = Neuroendocrine tumor of appendix Acute right iliac fossa pain = Appendicitis Fever with chills = Worsened condition Decrease in pulse rate = Recovery</p> Signup and view all the answers

    Which incision is also known as the bikini incision?

    <p>Lanz Incision</p> Signup and view all the answers

    In an open appendicectomy, McBurney's incision involves cutting through muscle.

    <p>False</p> Signup and view all the answers

    List the first two structures encountered during an open appendicectomy.

    <p>Skin, Superficial fascia</p> Signup and view all the answers

    During a laparoscopic appendicectomy, the appendix is located at the junction of the three _______.

    <p>taenia coli</p> Signup and view all the answers

    Match the following steps in laparoscopic appendicectomy with their descriptions:

    <p>Locate the appendix = Identifying the connection of taenia coli Ligate the appendicular artery = Securing blood supply before removal Crush the base = Creating a secure cut area Cut the appendix = Removing the appendix from its attachment</p> Signup and view all the answers

    What is the surgical procedure indicated for a tumor greater than 2 cm located close to the base of the cecum?

    <p>Right hemicolectomy</p> Signup and view all the answers

    A tumor larger than 2 cm located near the base of the cecum does not require any surgical intervention.

    <p>False</p> Signup and view all the answers

    What is the primary surgical option for tumors that are greater than 2 cm and close to the cecum?

    <p>Right hemicolectomy</p> Signup and view all the answers

    A tumor extending from the mucosal surface is described as a ______________ polyp.

    <p>sessile</p> Signup and view all the answers

    Match the following conditions with their appropriate treatments:

    <p>Tumor &gt; 2 cm close to cecum = Right hemicolectomy Appendicitis = Appendectomy Colorectal polyp (pedunculated) = Polypectomy Diverticulitis = Bowel resection</p> Signup and view all the answers

    What is a common clinical feature of pseudomyxoma peritonei?

    <p>Progressive abdominal distention</p> Signup and view all the answers

    HIPEC stands for Hyperthermic Intraperitoneal Chemotherapy.

    <p>True</p> Signup and view all the answers

    Name one type of neoplasm that can cause pseudomyxoma peritonei.

    <p>Appendiceal mucinous neoplasm</p> Signup and view all the answers

    Pseudomyxoma peritonei can be primarily associated with a mutation in _____ gene.

    <p>BRCA</p> Signup and view all the answers

    Match the following treatments with their descriptions:

    <p>Debulking surgery = R1/R2 resection Omentectomy = Removal of the omentum Total abdominal hysterectomy (TAH) = Surgical removal of the uterus and cervix Appendicectomy = Surgical removal of the appendix</p> Signup and view all the answers

    What should be done if the base of an inflamed appendix is encountered during surgery?

    <p>Use a linear stapler if the caecal base is healthy.</p> Signup and view all the answers

    Pelvic abscess is the most common complication following appendicectomy.

    <p>False</p> Signup and view all the answers

    What is the risk factor associated with children that can complicate appendicitis?

    <p>Underdeveloped greater omentum</p> Signup and view all the answers

    In the presence of appendicolith, there is a quick risk of ______________.

    <p>perforation</p> Signup and view all the answers

    Match each complication with its description:

    <p>Bleeding = From appendicular artery Stump appendicitis = Inflammation of the appendix stump Wound infection = Most common post-operative complication Pelvic abscess = Results in fever and pelvic diarrhoea</p> Signup and view all the answers

    What is the pathognomonic sign of Peutz-Jeghers Syndrome?

    <p>Perioral melanosis</p> Signup and view all the answers

    Hamartomatous polyps are always premalignant.

    <p>False</p> Signup and view all the answers

    What is the most common type of polyp?

    <p>Hyperplastic polyp</p> Signup and view all the answers

    Juvenile Polyposis Syndrome is caused by a mutation in the ______ gene.

    <p>SMAD</p> Signup and view all the answers

    Match the type of polyp with its main characteristic:

    <p>Inflammatory Polyp = Seen in ulcerative colitis Hyperplastic Polyp = Not premalignant and most common Hamartomatous Polyp = Autosomal dominant Juvenile Polyp = Single polyp, not premalignant</p> Signup and view all the answers

    What is the most common clinical presentation associated with colorectal polyps?

    <p>Intussusception</p> Signup and view all the answers

    Cowden Syndrome is associated with an increased risk of pancreatic cancer.

    <p>False</p> Signup and view all the answers

    What gene mutation is associated with Cowden Syndrome?

    <p>PTEN</p> Signup and view all the answers

    The condition characterized by macrocephaly and multiple hamartomatous GI polyps is known as __________.

    <p>Myre Smith Syndrome</p> Signup and view all the answers

    Match the following syndromes with their associated features:

    <p>Cowden Syndrome = Skin lesions, PTEN gene mutation Cronkhite-Canada Syndrome = Koilonychia, ectodermal dysplasia Myre Smith Syndrome = Macrocephaly, penile pigmentation Hamartomatous Polyps = Not pre-malignant</p> Signup and view all the answers

    Study Notes

    Appendicitis in Pregnancy

    • Rebound tenderness, guarding, and rigidity are common signs of appendicitis
    • Ultrasound and MRI are often inconclusive in diagnosing appendicitis during pregnancy
    • Untreated or perforated appendicitis increases the risk of fetal loss and preterm labor
    • Laparoscopic appendicectomy is the preferred treatment in all trimesters
    • Conservative management may be considered in the first and third trimesters
    • Laparoscopic cholecystectomy is the treatment for cholecystitis in the second trimester

    Adenomatous Polyp

    • Tubular, villous, and tubulovillous are common types of polyps
    • Increased size and number of polyps increase the risk of conversion
    • Villous polyps occur in the rectum and cause mucous secretion leading to metabolic acidosis and hypokalemia
    • Bleeding and pain are common clinical findings
    • Polyps are resected using a snare, either by removing the stalk in pedunculated types or lifting the polyps from the underlying muscle layer in non-pedunculated types

    Mantrel Scoring System/ALVARADO Score

    • The score is used to assess the likelihood of appendicitis
    • Pain migration to the right lower quadrant, anorexia, nausea & vomiting, tenderness in the right lower quadrant, rebound pain, elevated temperature, leukocytosis, and a shift in white blood cell count to the left are all scored
    • The modified Alvarado score does not consider the shift of white blood cells to the left
    • A higher score indicates a higher probability of appendicitis

    Differential Diagnosis

    • Infants & Children: Mesenteric adenitis, Meckel's diverticulitis, and intussusception
    • Adults & Elderly: Ureteric colic, bowel obstruction, torsion, gastroenteritis
    • Adult Females: Mittelschmerz, endometriosis, pelvic inflammatory disease, ectopic pregnancy

    Management of Appendicitis

    • Conservative: NPO, IV fluids, IV antibiotics, pain killers
    • Definitive: Open appendectomy, laparoscopic appendectomy
    • Definitive treatment is indicated in cases where conservative management is contraindicated
    • Open appendectomy has a higher recurrence rate than laparoscopic appendectomy

    Ochsner Sherren Regime

    • This regime is based on non-operative expectation
    • It involves NPO, IV fluids, intravenous antibiotics, and painkillers
    • The patient's vitals, including temperature, size of the lump, and the level of pain are monitored
    • Improvement is indicated by a decreased pulse rate, fever, size of the lump, and total leukocyte count
    • Worsening is indicated by an increased pulse rate, fever with chills and rigors, size of the lump, and total leukocyte count
    • After six weeks of successful non-operative management, an interval appendectomy can be performed

    Appendicular Tumour

    • Neuroendocrine tumors/carcinoid tumor are the most common type of appendicular tumors
    • Most occur at the tip of the appendix
    • Patients usually present with asymptomatic signs
    • Other common presentations include pain and features of appendicitis
    • Immunohistochemical staining for Synaptophysin and Chromogranin A is used for diagnosis

    Extraperitoneal Drainage

    • A pigtail catheter is used to perform extraperitoneal drainage

    Open Appendicectomy

    • McBurney's, Rutherford Morrison's, and Lanz incisions are commonly used
    • Structures encountered during the procedure include: skin, superficial fascia, external oblique aponeurosis, muscles, pre-peritoneal fat, and peritoneum

    Lap Appendicectomy

    • Ports are commonly placed in the infra-umbilical, left iliac fossa, and suprapubic regions
    • The procedure involves locating the appendix, ligating the appendicular artery, crushing and transfixing the base, cutting the appendix, and closing the opening in layers

    Pseudomyxoma Peritonei

    • It is characterized by the filling of the peritoneal cavity with mucin-like substance
    • It can be secondary to appendiceal or ovarian mucinous neoplasms, as well as primary peritoneal cancer with BRCA mutation
    • Progressive abdominal distention and bowel obstruction are common clinical features
    • Mucin deposits are evident on CECT
    • Treatment involves debulking and cytoreductive surgery, including appendicectomy, right hemicolectomy, omentectomy, stripping of peritoneum, and removal of mucin
    • Hyperthermic intraperitoneal chemotherapy (HIPEC) can be used to enhance chemotherapy efficacy

    Appendicectomy Procedures and Complications

    • The appendix might not be located, in which case the taenia coli should be used to identify it
    • If the appendix is not inflamed, the last two feet of the ileum should be examined for Meckel's diverticulum
    • In case of inflamed appendix base, the base should not be crushed and should be buried using a purse string suture or linear stapler
    • A gangrenous base and adjacent caecal wall necessitate a right hemicolectomy
    • Appendicitis in Crohn's disease should be assessed to determine the state of the caecum
    • Complications of appendicectomy include bleeding from the appendicular artery, wound infection, injury to the right iliohypogastric nerve, portal pyaemia, pelvic abscess, Stump appendicitis, and appendicular perforation

    Colorectal Polyps

    • Polyps can present with pain, obstruction, and bleeding
    • Inflammatory polyps are pseudopolyps associated with ulcerative colitis and are not premalignant
    • Hyperplastic polyps are the most common type, occur in the 6th-7th decade, are not premalignant, and are diagnosed and managed by colonoscopy
    • Hamartomatous polyps can be single (not premalignant) or part of syndromes such as Peutz-Jeghers or Juvenile Polyposis (both are premalignant)

    Cowden Syndrome

    • It is characterized by hamartomatous polyps, autosomal dominant inheritance, PTEN gene mutation, multiple polyps, and skin lesions like lipomas and ganglioneuromas
    • It carries an increased risk of breast, thyroid, and uterine cancers

    Myre Smith/Banayan-Riley-Ruvalcaba Syndrome

    • It involves multiple GI hamartomatous polyps, macrocephaly, hypothyroidism, and penile pigmentation

    Cronkhite-Canada Syndrome

    • It is associated with multiple GI polyps, ectodermal dysplasia, and features like koilonychia, Plummer-Vinson syndrome, and alopecia

    Clinical Presentation of Colorectal Polyps

    • Intussusception is the most common presentation, caused by the polyp acting as a pathological lead point
    • Bleeding is another common symptom
    • The presence of polyps increases the risk of pancreatic, thyroid, and periampullary cancers

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    Description

    This quiz covers critical aspects of diagnosing and managing appendicitis during pregnancy, including common symptoms and treatment options across trimesters. It also delves into adenomatous polyps, their types, clinical findings, and the risks associated with them. Test your knowledge on these important medical topics!

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