MOD6-SURG2-T4-Diseases of the Appendix and Meckel's Diverticulum PDF

SURG2 SURGERY 2 Diseases of the Appendix and Meckel's Diverticulum TRANS 4...

SURG2 SURGERY 2 Diseases of the Appendix and Meckel's Diverticulum TRANS 4 MODULE 6 Dr. Maria Conception Ortillo-General, MD, FPCS, FPSGS September 13, 2024 LECTURE OUTLINE 1. MCBURNEY’S POINT Also known as point tenderness I Anatomy of the Appendix When patient can point exact location of pain, primarily at the A. Physical Findings of Acute Appendicitis McBurney’s point, then it is highly likely that we are dealing with a B. Rule of Diagnostics in Assessing patients with Acute case of acute appendicitis Appendicitis Patient is the one who tells you C. Management Plan To elicit point tenderness, ask the patient to cough or do the II Appendicitis in Pregnancy valsalva maneuver, then ask where the exact location of pain is A. Management Plan felt. III Appendicitis in the Older Age Group A. Diagnosis B. Differential Diagnosis C. Diagnostics D. Management IV Malignancies of the Appendix V Anatomy of Meckel’s Diverticulum A. Diseases of Meckel’s Diverticulum VI Summary Figure 1. McBurney’s Point Video Lecture on Diseases of the Appendix and Meckel's Diverticulum LECTURE OBJECTIVES 2. ROVSING’S SIGN 1. Diagnose diseases of the appendix and Meckel’s diverticulum from the simplest presentation to the most complex. When the tip of the appendix is anterior in location (known as good 2. Structure an appropriate management plan for the common morning appendix) diseases involving these two anatomic structures. To elicit, apply pressure on LLQ. 3. Collaborate with other subspecialties for a more comprehensive When there is pain in RLQ, this indicates (+) Rovsing’s sign and better patient management. 🧠 Must Know 📖 Book 📝 Previous Trans I. ANATOMY OF THE APPENDIX Anatomic location of the base of the appendix is constant ○ In the posteromedial aspect of the cecum ○ Part of the midgut Knowing the anatomic location, one can easily correlate: ○ The pathognomonic signs and symptoms of acute appendicitis ○ Why it is periumbilical pain shifting to the right lower quadrant Figure 2. Rovsing’s Sign (RLQ) Video Lecture on Diseases of the Appendix and Meckel's Diverticulum ○ Associated with anorexia, nausea, and vomiting ○ Fever usually manifests when pain shifts to the RLQ 3. PSOAS SIGN When the tip of the appendix is retrocecal, the most common Doctor’s Notes location, you elicit a positive psoas sign Periumbilical Pain: Due to the dermatomal level To elicit, flex the hip ○ Vague pain because it cannot be localized → Visceral Pain Shift to RLQ: becomes localized → Parietal Pain All dermatomal pain will start at the midline Dermatomal Levels Recap: ○ Foregut: T8-T10 ○ Midgut: T11-T12 ○ Hindgut: L1-L2 Abdominal Pain: from distention Figure 3. Psoas sign NOTE: During your 2nd year physical diagnosis, you were taught Video Lecture on Diseases of the Appendix and Meckel's Diverticulum how to examine a patient presenting with RLQ pain. Now is the time to recall these learnings and have a better understanding as you 4. OBTURATOR SIGN apply these concepts in the cases we will discuss. When the tip of the appendix is pelvic in location, the obturator sign is positive. A. PHYSICAL FINDINGS OF ACUTE APPENDICITIS The primary physical findings suggesting acute uncomplicated Doctor’s Notes appendicitis is direct rebound tenderness on the RLQ. Appendix Locations Maneuvers used in assessing patients suspected to have acute ○ Retrocecal: (+) Psoas Sign appendicitis: ○ Pelvic: (+) Obturator Sign ○ Anterior: Rovsing’s Sign Group 5B | Diseases of the Appendix and Meckel's Diverticulum 1 of 6  NOTE: Quinolones cannot be given to the 15 y/o because it causes premature closure of the growth plate, predisposing the patient to be stunted. Avoid quinolones for patients 70 years of age. B. DIFFERENTIAL DIAGNOSIS However, we also need to think of differentials: Doctor’s Notes ○ Perforated viscus from carcinoma Foregut Microflora: Gram (+) Organisms and Anaerobes ○ Peptic ulcer Midgut Microflora: Gram (-) Organisms; Anaerobes ○ Diverticulitis ○ E. Coli ○ Bacteroides Fragilis: Metronidazole ○ C. Diff: Vancomycin/Clindamycin C. DIAGNOSTICS ○ Gram (-): In this case do we need further diagnostics? Aminoglycosides (Gentamicin, Amikacin); To diagnose this condition, NO because he has a frank surgical Cephalosporins (2nd and 3rd gen); abdomen. 2nd: Cefuroxime; Cefoxitin However, referral to a cardiologist is in order for risk stratification, 3rd: Ceftriaxone; Ceftazidine to assess his cardiopulmonary function, renal and liver function, to Quinolones (Ciprofloxacin) – Cannot be given to children tell us what are the risks when a surgical intervention is performed