ACUTE APPENDICITIS

ACUTE APPENDICITIS

Q. 1

A female who underwent laproscopic appendicectomy for acute appendicitis, on post op. day 2 bumped her nose on to a table. She developed difficulty in breathing and examination showed a swelling in the anterior part of the nasal septum. Next line of management is:

 A

Incision and drainage

 B

Oral antibiotics for 7-10 days

 C

Observation

 D

IV antibiotics

Q. 1

A female who underwent laproscopic appendicectomy for acute appendicitis, on post op. day 2 bumped her nose on to a table. She developed difficulty in breathing and examination showed a swelling in the anterior part of the nasal septum. Next line of management is:

 A

Incision and drainage

 B

Oral antibiotics for 7-10 days

 C

Observation

 D

IV antibiotics

Ans. A

Explanation:

 

Nasal septal hematoma is a rare but potentially serious complication of nasal trauma.

The trauma allows blood to pass into both mucoperichondrial planes.

Because the septal cartilage has no blood supply of itself and receives all of its nutrients and oxygen from the perichondrium, untreated septal hematoma may lead to destruction of the septum resulting in a saddle nose deformity.

Immediate drainage is necessary.


Q. 2 A febrile 12-year-old child presents with severe right lower quadrant pain that is interpreted by the attending physician as acute appendicitis. The patient has also been complaining of joint pain. At laparotomy, the surgeon notes that the appendix is normal; however, the mesenteric lymph nodes are markedly enlarged and contain focal areas of microabscess formation on cut section. This patient is most likely?

 A An asthmatic

 B

Deficient in C1 esterase inhibitor activity

 C

HLA-B27 positive

 D

Leukopenic

Ans. C

Explanation:

Yersinia enterocolitica is the pathogen producing this clinical syndrome.

Yersinia is transmitted to patients via the oral route, via contaminated blood products, or by cutaneous inoculation.

Patients developing iron overload because of multiple transfusions (i.e., thalassemia patients) are at increased risk of Yersinia infections because some strains are unable to synthesize bacterial iron chelators called siderophores.

They can, however, use host-chelated iron stores or the drug deferoxamine (a siderophore produced by Streptomyces pilosus).

Yersinia is associated with reactive arthritis following an infection by an enteropathogenic organism.

Most patients who develop arthritis express HLA-B27.

A history of asthma is not associated with Yersinia infections.
Deficiency in C1 esterase inhibitor activity produces the syndrome of angioedema.
This is an autosomal dominant trait associated with a deficiency of the serum inhibitor of the activated first complement component.
The patients have multiple episodes of edema, affecting skin and mucosal surfaces such as the larynx and the GI tract.
Leukopenia is not associated with the clinical scenario in the question. Normal-to-elevated leukocyte counts are the rule in Yersinia infection.
 
Ref: Brooks G.F. (2013). Chapter 19. Yersinia and Pasteurella. In G.F. Brooks (Ed),Jawetz, Melnick, & Adelberg’s Medical Microbiology, 26e.

Q. 3 A febrile 12 year old child presents with severe right lower quadrant pain that is interpreted by the attending physician as acute appendicitis. The patient has also been complaining of joint pain. At laparotomy, the surgeon notes that the appendix is normal; however, the mesenteric lymph nodes are markedly enlarged and contain focal areas of microabscess formation on cut section. This patient is most likely:

 A

An asthmatic

 B

Deficient in C1 esterase inhibitor activity

 C

HLA-B27 positive

 D

Leukopenic

Ans. C

Explanation:

Yersinia enterocolitica is the pathogen producing this clinical syndrome.
Yersinia is transmitted to patients via the oral route, via contaminated blood products, or by cutaneous inoculation.
Patients developing iron overload because of multiple transfusions (i.e., thalassemia patients) are at increased risk of Yersinia infections because some strains are unable to synthesize bacterial iron chelators called siderophores.

They can, however, use host-chelated iron stores or the drug deferoxamine (a siderophore produced by Streptomyces pilosus).

Yersinia is associated with reactive arthritis following an infection by an enteropathogenic organism.
Most patients who develop arthritis express HLA-B27.
A history of asthma is not associated with Yersinia infections.
 
Deficiency in C1 esterase inhibitor activity  produces the syndrome of angioedema. This is an autosomal dominant trait associated with a deficiency of the serum inhibitor of the activated first complement component.
The patients have multiple episodes of edema, affecting skin and mucosal surfaces such as the larynx and the GI tract.
 
Leukopenia is not associated with the clinical scenario in the question. Normal-to-elevated leukocyte counts are the rule in Yersinia infection.
 
Ref: Brooks G.F. (2013). Chapter 19. Yersinia and Pasteurella. In G.F. Brooks (Ed),Jawetz, Melnick, & Adelberg’s Medical Microbiology, 26e.

Q. 4

A 25 year old woman complains of abdominal pain of rapid onset in the right lower quadrant. She subsequently undergoes surgery for suspected acute appendicitis. At surgery, however, a tubal pregnancy is discovered. The most frequent predisposing factor for this condition is?

 A

Endometriosis

 B

A an intrauterine device

 C

Leiomyomas of the uterus

 D

Pelvic inflammatory disease

Ans. D

Explanation:

The great majority of ectopic pregnancies (90%) occur in the fallopian tubes. The
other sites are the ovaries, abdominal cavity, and the intrauterine segment of the fallopian tubes. Any condition that leads to anatomical abnormalities of the uterus and fallopian tubes may predispose to ectopic pregnancy. The most frequent of such conditions is pelvic inflammatory disease (PID), which is usually associated with salpingitis. PID is a common infectious condition most frequently caused by Neisseria gonorrhoeae and Chlamydia trachomatis, both sexually transmitted. Other cases are due to a polymicrobial population, including staphylococci, streptococci, coliform bacteria, and Clostridium perfringens, acquired during abortion or delivery. PID leads to acute purulent salpingitis. If this is untreated or inadequately treated, it progresses to salpingo-oophoritis, tubal abscesses, pyosalpinx, or hydrosalpinx. Even milder cases may cause adhesions within the tube or between the tube and the ovary that interfere with implantation of the ovum and result in tubal pregnancy. All the remaining conditions listed above may also predispose to ectopic pregnancy.
 
Endometriosis refers to the presence of endometrium in abnormal locations, such as the ovary, uterine ligaments, rectovaginal pouch, and pelvic peritoneum. It is an important clinical condition manifesting with pain, dysmenorrhea, and infertility. Scarring at endometriotic sites may cause peritubal adhesions and ectopic pregnancy.
 
An intrauterine device may also increase the risk of ectopic pregnancy, but the mechanism of action is not clear.
 
Leiomyomas of the uterus are the most frequent benign tumor in women. They develop from the smooth muscle as well-circumscribed nodules within the uterine wall (intramural), in a subserosal or submucosal location. Leiomyomas may cause significant distortion of the uterine wall and interfere with implantation, increasing the risk of ectopic pregnancy.
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 10. Ectopic Pregnancy. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Q. 5

A 26 year old female who underwent laparoscopic appendicectomy for acute appendicitis, on post op. day 2 bumped her nose onto a table. She developed difficulty in breathing and examination showed a swelling in the anterior part of the nasal septum. Next line of management is:

 A

Incision and drainage

 B

Oral antibiotics for 7-10 days

 C

Observation

 D

IV antibiotics

Ans. A

Explanation:

Q. 6

In a group of patients presenting to a hospital emergency with abdominal pain, 30% of patients have acute appendicitis, 70% of patients with appendicitis have a temperature greater than 37.5°C and 40% of patients without appendicitis have a temperature greater than 37.5°C and 40% of patients without appendicitis have a temperature greater than 37.5°C. Consdidering these findings, which of the following statements is correct –

 A

The sensitivity of temperature greater than 37.5°C. as a marker for appendicitis is 21/4

 B

The specificity of temperature greater than 37.5°C as a marker for appendicitis is 42/70

 C

The positive predictive value of temperature greater than 37.5°C as marker for appendicitis is 21/30

 D

The specificity of the test will depend upon the prevalence of appendicitis in the population to which it is applied

Ans. B

Explanation:

Ans. is ‘b’ i.e., The specificity of temperature greater than 37.5°C as a marker for appendicitis is 42/70

o Suppose, there are 100 persons, then

Persons with the disease (appendicitis) —> 30 Persons without the disease  —> 70

o Assume that the screening criteria for the presence of appendicitis is temperature above 37.5°C

o First,

No. of persons with the disease

We know that the no. of persons with appendicitis are                   —> 30

No of patients with appendicitis and with temp > 37.5°c                  —>70%= 70×30/100 = 21

These patients are true positive

No. of patients with appendicitis but without temperature elevation –> 30-21 =9 These patient are false negative.

o Now

Total no of persons without the disease –> 70

No. of persons without the disease but with temperature elevated —> 40×70/ 100 = 28 These patient are false positive cases.

Persons without appendicitis who also do not have temperature elevation —> 70-28 = 42 These are true negative

Screening test                                        Patient with                                           Patient without

(fever) results                                         appendicitis                                          appendicitis

Fever present                                         21(True postive)                                  28 (False positive)

Fever not present                                  9 (false negative)                                 42 (true negative)

o Specificity = True negative/True negative + False positive = 42/42+28 = 42/70

o Sensitivity = True positive/True positive + False negative = 21/21+9 = 21/30

o Positive predictive value = True positive/(true+false) postive = 21/21+28 = 21/49

o Negative predictive value = True negative/(true+false) negative = 42/42+9 = 42/51


Q. 7

Which of the following organisms produces signs and symptoms that mimic acute appendicitis‑

 A Enteropathic Escherichia coli

 B

Enterobius vermicularis

 C

Trichomonas hominis

 D

Yersinia enterocolitica

Ans. D

Explanation:

Ans. is ‘d’ i.e., Yersinia enterocolitica 


Q. 8

When acute appendicitis is suspected, it can be confirmed by –

 A

Clinical examination

 B

USG

 C

CT scan

 D

All

Ans. D

Explanation:

Ans. is a, b, c, and d ie Clinical examination, USG, CT scan and Blood counts 

As described in the above question, the diagnosis of appendicitis is primarily clinical, assisted by blood counts. Ultrasound and CT can be utilized to make the diagnosis in equivocal cases.

Lets also see the management of appendicitis:

Management of appendicitis:  [Ref Sabiston 18/e p1339; Schwartz 9/e p1084]

The treatment of appendicitis is appendectomy. (It can be done open or laparoscopically)

Prophylactic antibiotics are indicated preoperatively. Postoperative antibiotic coverage is of no use in simple (uncomplicated) acute appendicitis. If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count.

Perforated Appendicitis (Maingot’s 11/e p603)

Rupture is suspected in the presence of fever with a temperature of >39°C (102°F) and a white blood cell count of >18,000 cells/mm3.

The management of perforation depends on the nature of the perforation.

If the perforation is free causing intraperitoneal dissemination of pus and fecal material, urgent laparotomy is done for appendectomy and irrigation and drainage of the peritoneal cavity.

If the perforation is contained it would result in an appediceal mass or abscess. This is managed as described under.

Appendiceal Abscess/ Mass

Patients who present late in the course of appendicitis with a palpable or radiographically documented mass (abscess or phlegmon) are treated with‑

conservative therapy and interval appendectomy 6 to 10 weeks later.

(conservative management includes intravenous antibiotics and fluids as well as bowel rest.)

– Patients with large abscesses, greater than 4 to 6 cm in size, and especially those patients with abscess and high fever, benefit from abscess drainage.

Patients who continue to have fever, persistent pain and leukocytosis or develop complications like bowel obstruction after several days of nonoperative treatment are likely to require immediate appendectomy during the same hospitalization, whereas those who improve promptly may be considered for interval appendectomy. Bailey lists Criteria for stopping conservative treatment and going for appendectomy

A rising pulse rate

–  increasing or spreading abdominal pain

–   increasing size of the mass



Q. 9

Diffuse peritonitis in acute appendicitis is caused due to:

 A Early rupture of appendix

 B

Late rupture of appendix

 C

Fecolith

 D

Old age

Ans. A

Explanation:

Ans is ‘a’ i.e. Early rupture of appendix

Perforation of appendix in acute appendicitis commonly leads to an abscess cavity walled off by the small bowel loops and the omentum, forming a phlegmon. Rarely the appendix may perforate freely into the peritoneal cavity and cause generalized peritonitis. This usually occurs in cases of early rupture of the appendix as inflammatory process did not get time to be localized by the omentum and bowel loops.

Usually the rupture of appendix is a late sequelae of appendicitis, usually occurring 48 to 72 hours from the onset of symptoms.


Q. 10 Earliest symptoms in acute appendicitis is ‑

 A

Periumbilical pain 

 B

Fever

 C

Vomiting

 D

Rise of pulse rate

Ans. A

Explanation:

Ans. is ‘a’ i.e., Periumbilical pain 

Acute appendicitis begins as periumbilical pain, which is a visceral pain followed by anorexia and nausea; then, the pain shifts to the right lower quadrant due to peritoneal irritation.

Clinical features :

  • The classical features of acute appendicitis begin with poorly localized colicky abdominal pain.
  • This is due to midgut visceral discomfort in response to appendiceal inflammation and obstruction.
  • The pain is frequently first noticed in the periumbilical region.

Symptoms of appendicitis

  • Periumbilical colic
  • Pain shifting to the right iliac fossa
  • Anorexia
  • Nausea 

Clinical signs in appendicitis

  • Pyrexia
  • Localized tenderness in the right iliac fossa
  • Muscle guarding
  • Rebound tenderness

Q. 11 Acute appendicitis is due to –

 A

Faecoliths

 B

Worms of ileo-caecal region

 C

Streptococcal infections

 D

a and b

Ans. D

Explanation:

Ans. D

  • Appendicitis is clearly associated with bacterial proliferation within the appendix, a mixed growth of aerobic and anaerobic organisms is usual (no single organism is responsible).
  • Obstruction of the appendix lumen either by a faecolith or a stricture.
  • Obstruction of the appendiceal orifice by a tumor.
  • Intestinal parasites, particularly Oxyuns vermicularis (pinworm), can proliferate in the appendix and occlude the lumen.

Q. 12 All of the following are early complications arising after appendicectomy for acute appendicitis except‑

 A

Ileus

 B

Sterility

 C

Intestinal obstruction

 D

Pulmonary complications

Ans. B

Explanation:

Ans. is ‘b’ i.e., Sterility 

1. Wound infection

  • Wound infection is the most common postoperative complication, occurring in 5-10% of all patients. 
  • This usually presents with pain and erythema of the wound on the fourth or fifth postoperative day, often soon after hospital discharge.

2. Intraabdominal abscess

  • Approximately 87% of patients following appendectomy will develop a postoperative intra-abdominal abscess.

3. Ileus

  • Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is indicative of continuing intra-abdominal sepsis.

4. Respiratory

  • In the absence of concurrent pulmonary disease, respiratory complications are rare following appendicectomy.

5. Venous thrombosis and embolism
6. Portal pyemia

  • This is a rare but very serious complication of gangrenous appendicitis associated with high fever, rigors, and jaundice.

7. Fecal fistula

  • Leakage from the appendicular stump occurs rarely but may follow if the encircling stitch has been put in too deeply or if the caecal wall was involved by edema or inflammation.

8. Adhesive intestinal obstruction

  • This is the most common late complication of appendicectomy.

Q. 13 All are useful in acute appendicitis except – 

 A

Antibiotics

 B

Analgesics

 C

IV Fluids

 D

Purgation

Ans. D

Explanation:

Ans. is ‘d’ i.e., Purgation 

Non-operative management-

  • Treatment is bowel rest and intravenous antibiotics, often metronidazole and 3rd generation cephalosporin.
  • Analgesics are given to relieve the pain.

Surgical management-

  • The traditional treatment for acute appendicitis is appendicectomy.

Q. 14 Which of the following is not a sign seen in acute apendicitis

 A Rovsing’s

 B

Rosenstein’s sign

 C

Boa’s sign

 D

Hamburger sign

Ans. C

Explanation:

Ans. is ‘C’  

Accessory signs of appendicitis

  • Aure-Rozanova’s sign: Increased pain on palpation with finger in right Petit triangle (can be a positive Shchetkin-Bloomberg’s).
  • Bartomier-Michelson’s sign: Increased pain on palpation at the right iliac region as the person being examined lies on his or her left side compared to when he/she lies on the back.
  • Dunphy’s sign: Increased pain in the right lower quadrant with coughing.
  • Hamburger sign: The patient refuses to eat (anorexia is 80% specific for appendicitis)
  • Kocher’s (Kosher’s) sign: From the person’s medical history, the start of pain in the umbilical region with a subsequent shift to the right iliac region.
  • Massouh sign: Developed in and popular in southwest England, the examiner performs a firm swish with his or her index and middle finger across the abdomen from the xiphoid process to the left and the right iliac fossa. A positive Massouh sign is a grimace of the person being examined upon a right sided (and not left) sweep.
  • Obturator sign: The person being evaluated lies on her or his back with the hip and knee both flexed at ninety degrees. The examiner holds the person’s ankle with one hand and knee with the other hand. The examiner rotates the hip by moving the person’s ankle away from his or her body while allowing the knee to move only inward. A positive test is pain with internal rotation of the hip.
  • Psoas sign, also known as “Obraztsova’s sign”, is right lower-quadrant pain that is produced with either the passive extension of the right hip or by the active flexion of the person’s right hip while supine. The pain that is elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and causes pain.
  • Rovsing’s sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain.
  • Sitkovskiy (Rosenstein)’s sign: Increased pain in the right iliac region as the person is being examined lies on his/her left side



Q. 15 Acute appendicitis is characterized by all of the following except:

 A

Anorexia

 B

Rovsing’s sign

 C

Fever >42 degree celsius

 D

Periumbilical colic

Ans. C

Explanation:

Ans. C: Fever > 42-degree celsius

  • The classical features of acute appendicitis begin with poorly localized colicky abdominal pain.
  • Appendicitis usually starts with periumbilical and diffuse pain that eventually localizes to the right lower quadrant (sensitivity, 81%; specificity, 53%).
  • Appendicitis is also associated with gastrointestinal symptoms like nausea, vomiting and anorexia.
  • Diarrhea may occur in association with perforation, especially in children.
  • The body temperature and pulse rate may be normal or slightly elevated.
  • Patients with appendicitis usually move slowly and prefer to lie supine due to the peritoneal irritation.
  • On abdominal palpation, there is the tenderness with a maximum at or near McBurney’s point.
  • Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness (i.e., pain in the right lower quadrant when the left lower quadrant is palpated) are strong indicators of peritoneal irritation.
  • Pain with an extension of the right leg (psoas sign) indicates a focus of irritation in the proximity of the right psoas muscle.
  • Similarly, stretching of the obturator internus through internal rotation of a flexed thigh (obturator sign) suggests inflammation near the muscle.

Q. 16 Investigation of choice forF’acute appendicitis in children:

 A

CT scan

 B

Ultrasound

 C

MRI

 D

X-ray

Ans. B

Explanation:

Ans. b. Ultrasound

‘Abdominal ultrasound detects a dilated (<6 mm) tubular, aperistaltic structare which is not compressible and is
surrounded by fluid. Ultrasound has a sensitivity of 85%-90% and specificity of 95-100% diagnosing appenticitis.



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