MSC - F. Surgery Answers 2025
.pdf
MSC – F. Surgery Answers
Acute appendicitis
1. Etiology, pathogenesis and classification of acute appendicitis.
Definition
Acute appendicitis is an inflammation of the vermiform appendix and is the most common surgical abdominal emergency, affecting approximately 35% of patients with acute surgical pathology. The mortality rate is 0.1–0.2%.
Historical Background
The term "acute appendicitis" was introduced by American surgeon Fitz in 1886.
The first successful appendectomy was performed by Cronley in 1884.
Etiology and Pathogenesis
Several theories explain the development of acute appendicitis:
1. Mechanico-Infectious Theory (Aschoff, 1908)
oObstruction of the appendiceal lumen (due to fecaliths, lymphoid hyperplasia, foreign bodies, or adhesions) leads to bacterial overgrowth.
oIncreased intraluminal pressure → impaired blood flow → bacterial invasion → inflammation ("primary affect") → progression to transmural inflammation.
2.Neurovascular Theory
oReflex vasospasm (due to stress, infections, or other factors) causes ischemia of the appendix wall.
oMucosal barrier breakdown → bacterial invasion → inflammation.
3.Allergic Theory
oSome cases may result from a hyperergic (exaggerated immune) reaction, leading to rapid inflammation.
4.Primary Gangrenous Appendicitis (in Elderly Patients)
oCaused by acute thrombosis of the appendiceal artery without prior obstruction.
Classification of Acute Appendicitis
1. Catarrhal (Simple) Appendicitis
o Early stage, mucosal inflammation, reversible.
oNo pus or necrosis.
2.Destructive Appendicitis
oPhlegmonous – Purulent inflammation, wall thickening.
o Gangrenous – Necrosis due to vascular thrombosis.
oPerforated – Rupture leading to peritonitis.
3.Complicated Appendicitis
oAppendix mass (inflammatory phlegmon).
o Abscess formation (localized or diffuse).
o Generalized peritonitis (due to perforation).
o Pylephlebitis (septic thrombophlebitis of the portal vein).
Variants of Appendix Position
The appendix can be located in different anatomical positions, influencing clinical presentation:
1.Common (60–70%) – Right iliac fossa.
2.Pelvic (15%) – Low position due to long mesentery or mobile cecum.
3.Retrocecal (20%) – Behind the cecum (may mimic retroperitoneal pathology).
4.Medial – Behind the terminal ileum.
5.Lateral – Along the ascending colon.
6.Subhepatic – High position near the liver.
7.Left-sided – Due to situs inversus or mobile cecum.
2.Diagnosis of acute appendicitis.
Diagnostic Algorithm
1.Clinical assessment (history + physical exam).
2.Laboratory tests (WBC, CRP, urinalysis).
3.Imaging:
o Ultrasound (first-line in children & pregnant women). o CT scan (gold standard, 95% accuracy).
oMRI (pregnancy).
4.Diagnostic laparoscopy (if uncertainty persists).
3.Clinical picture, diagnosis and treatment of acute appendicitis with its typical location.
Acute appendicitis presents with variable clinical features depending on:
Morphological changes in the appendix (catarrhal, phlegmonous, gangrenous).
Anatomic position of the appendix (common, retrocecal, pelvic, etc.).
Patient’s age (elderly, children, pregnant women).
Reactivity state (immunocompromised patients may have atypical presentations).
1.Clinical Presentation Based on Appendix Position
A. Common (Typical) Appendix Position (60-70%)
Symptoms:
Pain:
oStarts as dull, persistent pain in the epigastrium or periumbilical region (visceral pain due to distension).
oShifts to the right iliac fossa (RIF) within 4-6 hours (somatic pain due to parietal peritoneal irritation).
Nausea (80-90% of cases).
Reflex vomiting (1-2 times).
Anorexia (loss of appetite is a key feature).
Signs on Examination:
General condition: Usually stable (unless complicated).
Tongue: Coated (furred) with white deposit (indicates inflammation).
Localized tenderness & guarding in RIF.
Rebound tenderness (Blumberg’s sign) – Pain worsens upon sudden release of pressure.
Special Tests (Appendicitis Signs):
1. Rovsing’s Sign
o Method: Palpate the left iliac fossa (LIF) → push toward RIF.
o Positive: Pain in RIF due to retrograde colonic gas pressure.
oSensitivity: 60-70%.
2.Psoas Sign
oMethod: Extend the right hip or ask the patient to lift the right leg against resistance.
oPositive: Pain due to irritation of the psoas muscle (retrocecal appendix).
3.Obturator Sign
oMethod: Flex and internally rotate the right hip.
oPositive: Pain in the pelvis (pelvic appendix).
4.Dunphy’s Sign
oMethod: Ask the patient to cough.
oPositive: Sharp pain in RIF (peritoneal irritation).
5.Temperature Differential
oRectal temperature > Axillary by 1.5°C suggests pelvic inflammation.
Laboratory Findings:
Leukocytosis (10,000–18,000/mm³) with neutrophilia (>75%).
CRP (C-reactive protein) elevated (>10 mg/L).
Urinalysis: Usually normal (may show mild pyuria if appendix is near ureter).
B.Retrocecal Appendix (20%)
Pain localizes in the right flank/lumbar region (mimicking pyelonephritis).
Diarrhea (due to cecal irritation).
Dysuria (if appendix irritates the ureter).
Absence of classic RIF tenderness (peritoneal signs appear late).
Psoas sign positive (due to muscle irritation).
Higher fever & leukocytosis (compared to typical appendicitis).
C.Pelvic Appendix (15%)
Suprapubic pain (mimicking cystitis or gynecological pathology).
Diarrhea & tenesmus (rectal irritation).
Dysuria (bladder irritation).
No abdominal rigidity (peritoneal signs absent).
Digital rectal exam (DRE): Tenderness on anterior rectal wall.
Temperature differential (rectal > axillary by 1-1.5°C).
3.Differential Diagnosis
Acute appendicitis must be distinguished from:
1.Acute cholecystitis (RUQ pain, Murphy’s sign +).
2.Acute pancreatitis (epigastric pain, elevated amylase/lipase).
3.Perforated peptic ulcer (sudden severe pain, rigid abdomen).
4.Diverticulitis (left-sided in elderly, but right-sided cecal diverticulitis mimics appendicitis).
5.Renal colic (flank pain, hematuria).
6.Gynecological causes (ectopic pregnancy, ovarian torsion, PID).
4.Diagnostic Algorithm
1.Clinical assessment (history + physical exam).
2.Laboratory tests (WBC, CRP, urinalysis).
3.Imaging:
o Ultrasound (first-line in children & pregnant women).
o CT scan (gold standard, 95% accuracy).
oMRI (pregnancy).
4.Diagnostic laparoscopy (if uncertainty persists).
5.Treatment
Emergency appendectomy (open or laparoscopic).
Antibiotics (if perforation or abscess present).
Laparoscopic approach preferred (shorter recovery, less pain).
Delayed surgery (6-12 weeks) for appendiceal abscess (drainage + IV antibiotics first).
Conclusion
Classic appendicitis: RIF pain, nausea, anorexia, guarding.
Atypical cases (retrocecal/pelvic): Flank pain, diarrhea, dysuria.
High-risk groups (elderly, pregnant): Subtle signs → High perforation risk.
Imaging (US/CT/MRI) confirms diagnosis.
Surgery (appendectomy) is definitive treatment.
4.Retrocecal and pelvic appendicitis. Features of the clinical picture, diagnosis and treatment.
1. Retrocecal Appendicitis
Definition:
Inflammation of the appendix located behind the cecum, either freely communicating with the peritoneal cavity or walled off by adhesions.
Clinical Features:
Pain:
oStarts as dull pain in the right flank/lumbar region (mimicking kidney disease).
oMay radiate to the groin, thigh, or pelvis.
GI Symptoms:
oNausea/vomiting (less pronounced than in typical appendicitis).
oDiarrhea (due to cecal irritation).
Urinary Symptoms:
oDysuria (if appendix irritates the ureter).
o Hematuria/proteinuria (mimicking pyelonephritis).
Physical Exam Findings:
Minimal abdominal tenderness (due to retroperitoneal location).
Negative Blumberg’s sign (peritoneal irritation absent early).
Special Signs:
o Rozanov’s sign: Tenderness in Petit’s triangle (right lumbar region).
oPsoas sign: Pain on right hip extension (due to psoas muscle irritation).
o Varlamov’s sign: Pain on percussion of right costal margin.
o Punin’s sign: Tenderness over right L1-L2 transverse process.
Diagnosis:
Lab Tests:
o Leukocytosis (often higher than in typical appendicitis).
oUrinalysis: May show RBCs/WBCs (mimicking UTI).
Imaging:
oUltrasound (limited utility due to retrocecal position).
o CT scan (gold standard) – Shows thickened appendix behind cecum.
Treatment:
Emergency appendectomy (open or laparoscopic).
Antibiotics if abscess or perforation suspected.
Difficult dissection (due to adhesions) → may require retrograde appendectomy.
2.Pelvic Appendicitis
Definition:
Appendix located in the pelvis (more common in women, 30% vs. 16% in men).
Clinical Features:
Pain:
oStarts periumbilical → localizes to suprapubic/right inguinal region.
GI/GU Symptoms:
oDiarrhea/tenesmus (rectal irritation).
oDysuria/urgency (bladder irritation).
Absence of classic peritoneal signs (due to pelvic location).
Physical Exam Findings:
Minimal abdominal rigidity (no direct parietal peritoneum irritation).
Special Signs:
oCope’s sign (Obturator sign):
Flex right hip + internal rotation → Pelvic pain.
oDigital Rectal Exam (DRE):
Tenderness on anterior rectal wall (Douglas pouch).
o Vaginal Exam (in women):
Cervical motion tenderness (must rule out PID).
Diagnosis:
Lab Tests:
o Mild leukocytosis (less pronounced due to early walling-off).
oUrinalysis: May show sterile pyuria.
Imaging:
oTransvaginal/rectal ultrasound (if CT unavailable).
o CT scan (best) – Visualizes pelvic appendix.
Treatment:
Laparoscopic appendectomy (preferred due to better pelvic visualization).
Antibiotics if perforation/abscess present.