Surgery Marrow Pg 211-220 (GIT)

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

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!