Test 4-GI Part I (Abdominal Pain & Appendicitis

Abdominal Pain: ( Definition, epidemiology and etiology) (Buttaro, Chapter 126)

-Abdominal pain is a most challenging condition to diagnose in primary care. -Patient's often present abdominal pain that is very vague.

Pathophysiology:

-Several major mechanisms of abdominal pain, including pain from obstruction of a hollow viscus, capsular distention, peritoneal irritation, mucosal ulceration, vascular insufficiency, altered body motility, nerve injury, abdominal wall injury, and pain referred from an extra abdominal site.

Answers to questions

17. D 18. C 19. A 20. A 21.B 22.B 23.D 24.C 25.A

Which of the following best represents the peak ages for occurrence of acute appendicitis?

A. 1 to 20 years B. 20 to 40 years C. lO to 30 years D. 30 to 50 years

Clinical findings most consistent with appendiceal rupture include all of the following except:

A. abdominal discomfort less than 24 hours in duration. B. fever greater than 102°F (>38°C). C. palpable abdominal mass. D. marked leukocytosis with total WBC greater than 20,000/mm3.

All of the following are typically noted in a young adult with the diagnosis of acute appendicitis except:

A. epigastric pain. B. positive obturator sign. C. rebound tenderness. D. marked febrile response.

To support the diagnosis of acute appendicitis with suspected appendiceal rupture, you consider obtaining the following abdominal imaging study:

A. magnetic resonance image B. computed tomography (CT) scan C. ultrasound D. flat plate

Which of the following WBC forms is an ominous finding in the presence of severe bacterial infection?

A. neutrophil B. lymphocyte C. basophil D. metamyelocyte

The obturator sign can be best described as abdominal pain elicited by:

A. passive extension of the hip. B. passive flexion and internal rotation of the hip. C. deep palpation. D. asking the patient to cough.

The psoas sign can be best described as abdominal pain elicited by:

A. passive extension of the hip. B. passive flexion and internal rotation of the hip. C. deep palpation. D. asking the patient to cough.

In evaluating a patient with suspected appendicitis, the clinician considers that:

A. the presentation may differ according to the anatomical location of the appendix. B. this is a common reason for acute abdominal pain in elderly patients. C. vomiting before onset of abdominal pain is often seen. D. the presentation is markedly different from the presentation of pelvic inflammatory disease.

A 26-year-old man presents with acute abdominal pain. As part of the evaluation for acute appendicitis, you order a white blood cell (WBC) count with differential and anticipate the following results:

A. total WBCs, 4500 mm3; neutrophils, 35%; bands, 2%; lymphocytes, 45% B. total WBCs, 14,000 mm'; neutrophils, 55%; bands, 3%; lymphocytes, 38% C. total WBCs, 16,500 mm3; neutrophils, 66%; bands, 8%; lymphocytes, 22% D. total WBCs, 18,100 mm'; neutrophils, 55%; bands, 3%; lymphocytes, 28%

Diagnosis

Accurate diagnosis is highly dependent on history, physical examination, and appropriate laboratory and radiologic procedures. Allergies, medication history (including over-the counter drugs, vitamins, and supplements), surgical history, social and sexual history, last menstrual period, dietary history, last food or fluid ingested, and family history of abdominal pain are important considerations that should be elicited.

Appendicitis

An inflammatory disease of the wall of the appendix that may result in perforation with subsequent peritonitis. Diagnosis is primarily based on the history and physical examination.

Diseases that may cause acute abdominal pain include:

Appendicitis • Cholecystitis • Diverticulitis • Small bowel obstruction • Perforated peptic ulcer • Peritonitis • Ruptured ectopic pregnancy • Ruptured abdominal aortic aneurysm • Hypercalcemia • Superior mesenteric artery syndrome • Acute intermittent porphyria • Pelvic inflammatory disease (especially in female patients) Acute diseases of the chest, including myocardial infarction, congestive heart failure, pulmonary infarction, and pneumonia, may mimic primary disease of the abdomen.

Appendicitis-Physical Examination

DX requires a detail history and PE including pelvic exam in females. Low grade fever is usually present. Localized tenderness is a valuable physical finding, and the patient can often specify the painful spot with one finger. Localized tenderness is usually in the RLQ between the umbilicus and the anteriorsuperior iliac spine (McBurney's point). There may be signs of peritoneal irritation, including guarding, rebound tenderness and obturator and psoas sign. The psoas sign is elicited by asking the supine pt to raise the straightened right leg against resistance by the practitioner. The obturator sign is elicited by passive rotation of the right leg with the patient supine and the right hip and knee flexed.

Appendicitis-DX

Diagnosis based on History and PE. The health care provider should immediately refer patient with suspected acute appendicitis for surgical consultation/ER. Elevated WBC usually present, R/O ectopic pregnancy with ß-HCG. If CRP is normal with a pt c/o abdominal pain for more than 24 hours is not suggestive of appendicitis, finding is even greater if WBCs are not elevated. Ultrasound can be done but CT scan has increased specificity and sensitivity.

Appendicitis-Complications

Gangrene Perforation with peritonitis Abscess formation Septicemia Urinary retention Small bowel obstruction Fistula Inguinal hernia

Appendicitis-DD

Gastroenteritis Mesenteric lymphadenitis Acute salpingittis Mitteschmerz Ruptured ectopic pregnancy Ureteral colic Perforated Peptic ulcer Basilar pneumonia

Location of Pain:

Right Upper Abdominal Quadrant pain: generally emanates from the chest cavity, liver, gallbladder, stomach, bowel, or right kidney or ureter. Diagnoses of pain in this area are cholecystitis and hepatitis. Left upper Quadrant pain: heart or chest cavity, spleen, stomach, pancreas (especially acute pancreatitis) or left kidney or ureter. Left Lower Abdominal pain: bowel, left ureter, or pelvis and is most commonly associated with diverticulitis. Right lower Quadrant pain is associated with appendix, bowel, right ureter, or pelvis, with the most common diagnosis being appendicitis. Cholecystitis or peptic ulcer perforation also must be considered. Centralized abdominal across several quadrants: typically associated with the bowel, whereas abdominal wall pain from trauma or inflammation can occur in any quadrant.

Appendicitis-Clinical Presentation

The most reliable historical feature in the diagnosis of acute appendicitis is the sequence of symptoms. Three s/s most predictive of acute appendicitis include pain that starts in the epigastrium or periumbilical are, migration of the pain to the RLQ and abdominal rigidity. The pain can be diffuse or occur at other sites of the abdomen, including LLQ. Anorexia, N/V, constipation or rarely diarrhea accompanied by low grade fever follows the onset of pain. Pain perception may be decreased in the elderly, s/s may be vague in elderly which is why they have an increase incidence of perforation.

Appendicitis -Patho

Thought to be caused by the blockage of the appendiceal lumen, leading to distention of the appendix as a result of accumulated intramural fluid with secondary bacterial infection.

Appendicitis-Management

Treatment includes prompt appendectomy, preferably within 24 hrs of symptom onset to prevent perforation and peritonitis. Perioperative abx treatment with Metronidazole and ceftrizoxime. If appendix perforated triple abx required: Ampicillin, Gentamicin and clindamycin or monotherapy with Cefotetan

Visceral pain

usually arise from a hollow viscus result from distention or spasm of a hollow organ due to intestinal obstruction. It is commonly described as a dull and crampy and is poorly localized.

Parietal pain:

is a sharp and well localized pain arise from irritation of the parietal peritoneum, such as the pain of acute appendicitis with inflammation spread to the peritoneum.

Referred pain:

is an aching type of pain experienced away from the disease process and is perceived to be near the surface of the body.

Reasoning behind questions and answers form: Margaret Fitzgerald. NURSE PRACTITIONER CERTIFICATION EXAMINATION AND PRACTICE PREPARATION (Kindle Locations 2401-2406). Kindle Edition.

Acute appendicitis is an inflammatory disease of the vermiform appendix caused by infection or obstruction. The peak age of patients with acute appendicitis is 10 to 30 years; this condition is uncommon in infants and elderly adults. At either end of the life span, a delay in diagnosis of appendicitis commonly occurs because providers do not consider appendicitis a possibility. There is no true classic presentation of acute appendicitis. Vague epigastric or periumbilical pain often heralds its beginning, with the discomfort shifting to the right lower quadrant over the next 12 hours. Pain is often aggravated by walking or coughing. Nausea and vomiting are late symptoms that invariably occur a number of hours after the onset of pain; this late onset helps to differentiate appendicitis from gastroenteritis, in which vomiting usually precedes abdominal cramping. The presentation of appendicitis also differs significantly according to the anatomical position of the appendix, with pain being reported in the epigastrium, flank, or groin. The obturator and psoas signs indicate inflammation of the respective muscles and strongly suggest peritoneal irritation and the diagnosis of appendicitis; these signs are also known as obturator muscle and iliopsoas muscle signs. Rebound tenderness indicates the likelihood of peritoneal irritation and helps with the diagnosis of acute appendicitis. A total WBC count and differential are obtained as part of the evaluation of patients with suspected appendicitis. The most typical WBC count pattern found in this situation is the "left shift:" A "left shift" is usually seen in the presence of severe bacterial infection, such as acute appendicitis, bacterial pneumonia, and pyelonephritis. The following are typically noted in the "left shift": • Leukocytosis: An elevation in the total WBC. • Neutrophilia: An elevation in the number of neutrophils in circulation. Neutrophilia is defined as an absolute neutrophil count (ANC) ANC is calculated by multiplying the percentage of neutrophils by the total WBC in mm3. A total WBC (TWBC) of 12,000 mm3 X 70% neutrophils yields an ANC of 8300 neutrophils/mm3. Neutrophils are also known as "polys" or "segs, both referring to the polymorph shape of the segment nucleus of this WBC. • Bandemia: An elevation in the number of bands or young neutrophils in circulation. Usually less than 4% of the total WBCs in circulation are bands. When this percentage is exceeded, and the absolute band count (ABC) is greater than 500 mm3, bandemia is present. A TWBC of 12,000 mm3 with 8% bands yields an ABC of 860/mm3. The presence of bandemia indicates that the body has called up as many mature neutrophils as were available in the storage pool and is now accessing less mature forms. The presence of bandemia further reinforces the seriousness of the infection. An increase in circulating bands also occurs in pneumonia, meningitis, septicemia, pyelonephritis, and tonsillitis when caused by bacterial infection. Although additional neutrophil forms exist, these do not belong in circulation even with severe infection. Myelocytes and metamyelocytes are immature neutrophil forms that are typically found in only the granulopoiesis pool. The presence of these cells is an ominous marker of life-threatening infection, and these are occasionally found in the presence of appendiceal rupture. In addition to the WBC differential, abdominal or transvaginal ultrasound reveals the inflamed appendix, usually greater than 6 mm in diameter, with a diagnostic accuracy of greater than 85%. Ultrasound offers an option in women or children with an equivocal presentation. CT of the abdomen is more accurate, however, because of its ability to define better the anatomical abnormality associated with appendicitis. CT is the preferred diagnostic procedure when there is a suspicion of appendiceal perforation because this study reveals periappendiceal abscess formation or when an atypical presentation raises the issue of another possible diagnosis. Appendiceal perforation is usually associated with a marked leukocytosis with total WBC count often exceeding 20,000 mm3 to 30,000 mm3, fever greater than 102°F (>38°C), peritoneal inflammation findings, symptoms lasting longer than 24 hours, and an ill-defined right lower quadrant abdominal mass that is usually indicative of abscess formation. Surgical removal of an inflamed appendix via laparoscopy or laparotomy is indicated. If there is evidence of rupture with localized abscess and peritonitis, CT-directed abscess aspiration may be indicated first, with an appendectomy performed after appropriate antimicrobial therapy.