1. Which of the following is the most common cause of acute appendicitis?

1. 1. Which of the following is the most common cause of acute appendicitis? • Fecalith • Foreign body • Tumor of the appendix • Lymphoid hyperplasia • Adhesive bands in the abdomen

2. Ans: D The cause of the luminal obstruction that initiates the process of appendicitis is postulated to involve lymphoid hyperplasia, a condition that is especially common in the teen years and correlates with the high incidence of appendicitis in this age group. It is felt that either viral or bacterial infections can precede an episode of appendicitis and presumably initiate lymphoid hyperplasia and subsequent luminal obstruction. It is thought that approximately 30% of cases of acute appendicitis in adults are linked to fecaliths.

3. 2. Pelvic appendicitis is frequently associated with which of the following physical signs? • Cervical motion tenderness • Psoas sign • Tenderness at McBurney’s point • Obturator sign

4. Ans: A, D When the location of the appendix is deep within the pelvis, there may be little or no abdominal findings. Proximity of the inflamed appendix to the obturator internus muscle may be associated with a positive obturator test (suprapubic pain on internal and external rotation of the thigh). A peri-appendiceal inflammatory process and abscess in continuity with the right adnexa may be associated with cervical motion tenderness. A psoas sign is not present in cases of pelvic appendicitis because the psoas muscle does not lie in direct continuity with the inflamed organ.

5. 3. Typical patient with acute appendicitis will describe the onset of symptoms in which of the following order? • Nausea/vomiting, fever, RLQ pain, periumbilical pain and tenderness • Periumbilical pain, nausea/vomiting, RLQ pain and tenderness, fever • Nausea/vomiting, periumbilical pain, RLQ pain and tenderness, fever • Fever, periumbilical pain, nausea/vomiting, RLQ pain and tenderness

6. Ans: B Most patients with acute appendicitis will describe a characteristic set of symptoms and these symptoms almost always follow a precise temporal pattern. The initial symptom is the periumbilical pain which is visceral in nature. This is followed by nausea and/or vomiting. The pain then shifts to the RLQ as the inflammatory process involves the overlying parietal peritoneum. Fever then ensues, and is usually of a low-grade nature, especially early on in the course. Eventually, lab. tests will reveal a leukocytosis, usually mild in nature. In those patients where the symptoms do not follow this temporal pattern, one must be suspicious of a diagnosis other than acute appendicitis.

7. 4. If one finds a normal appendix during laparotomy, what must one do next? • Do not do anything and just close • Perform appendectomy and close • Seek other possible causes of abdominal pain • Inform pt.’s family of operative findings and ask their opinions

8. Ans: C

9. 5. Which of the following is/are possible differential diagnosis at the time of negative laparotomy for appendicitis? • Crohn’s disease • Right-sided diverticulitis • Left-sided diverticulitis • Gynecologic disorders in case of a female • Neoplasms • Acute terminal ileitis • Meckel’s diverticulum

10. Ans: All of the above If a normal appendix is found at the time of laparotomy, other causes for the abdominal pain should be sought. The cecum and proximal ascending colon should be examined for right-sided diverticulitis, neoplasms, or other diseases. The terminal ileum should be examined for Crohn’s disease or acute ileitis, and at least 2 feet of the ileum proximal to the ileocecal valve should be inspected for the presence of a Meckel’s diverticulum. Occasionally, sigmoid diverticulitis may be mistaken for acute appendicitis, especially when a redundant sigmoid colon reaches the right side of the abdomen. The fallopian tubes, ovaries, and uterus should also be carefully examined in female patients.

11. 6. A 40 year old male presents with a 7 day h/o abdominal pain. The symptoms were fairly mild but have increased somewhat over the past couple of days with localized pain in the RLQ. On exam, pt. is febrile and has a tender mass in the RLQ. There is no tenderness elsewhere in the abdomen. Which of the following is/are appropriate management of this patient? • IV hydration, antibiotics, CT-guided drainage, and interval appendectomy at approximately 10 weeks • IV hydration, antibiotics, and urgent appendectomy through a McBurney incision • IV hydration, antibiotics, and ileocecectomy via midline laparotomy • IV hydration, antibiotics, and interval appendectomy at approximately 10 weeks • IV hydration, antibiotics, operative drainage of abscess through a McBurney incision, and interval appendectomy at approximately 10 weeks

12. Ans: A, D In patients who present with a prolonged history (greater than 5 days) and have localized tenderness in the RLQ, perhaps with a palpable mass, the likely diagnosis is a periappendiceal abscess/phlegmon. Such patients have already “walled-off” the appendiceal inflammation and are best treated initially with non-operative therapy, including IV hydration and abx. A CT scan may be performed and if a large collection/abscess is identified, then a CT-guided catheter can be placed. In many patients, abx alone will be sufficient. Urgent operation in these patients is associated with increased morbidity, including the possible injury of surrounding structures, such as the small intestine. Initial non-operative management is therefore recommended, and an interval appendectomy can be performed once the inflammatory process has completely resolved, usually at approximately 10 weeks following the initial presentation.

13. Which of the following is/are true regarding carcinoid tumors of the appendix? • It is the most common tumor of the appendix • Although its most common site of occurrence is GI tract, it can also be found in bronchus, lung, ovaries, kidney, and testicles • Regardless of tumor size, if the surgical margins are clear, then simple appendectomy is the adequate surgical treatment • Carcinoids are thought to derive from the enteroendocrine cells within the appendiceal wall • Tumors that are 2 cm in size or larger should be treated with formal right hemicolectomy

14. Ans: all of the above but C Carcinoid tumors are of neural crest origin and are thought to be derived from enteroendocrine cells in the appendiceal wall. The prognosis of patients with appendiceal carcinoid tumors is directly related to size. For tumors greater than or equal to 2 cm, formal right hemicolectomy is indicated in order to ensure adequate lymphatic clearance. Smaller tumors can be safely treated by appendectomy alone, assuming the surgical margins are clear.