MSC - F. Surgery Answers 2025

Symptoms:

o Persistent RLQ pain (typical of appendicitis).

o Palpable firm, tender, immobile mass in the RLQ (by day 3–4).

oLow-grade fever, nausea, possible ileus.

Key Differential Diagnoses:

oCrohn’s disease, cecal tumor, ovarian pathology (e.g., abscess), tuboovarian abscess, diverticulitis.

Three Periods of Appendix Mass

1. Formation period (≤5 days):

oProgressive inflammation with adhesions.

2.Formed appendix mass (stable phase):

oWell-demarcated inflammatory mass.

3.Resolution or abscess formation:

oResorption (gradual improvement) OR

o Abscess formation (worsening pain, fever, leukocytosis).

Diagnostics

1. Laboratory:

o↑ WBC (neutrophilia), ↑ CRP.

2.Imaging:

oUltrasound (US): Hypoechoic mass with fluid (if abscess).

oCT (gold standard): Heterogeneous mass with fat stranding; may show abscess (fluid collection with rim enhancement).

3.Digital rectal exam: Tenderness in the right rectal wall (if pelvic location).

Treatment

1.Unformed Infiltration (Early Stage)

Appendectomy if the appendix can be safely isolated without damaging adhered structures.

2.Formed Appendix Mass (Conservative Therapy)

Bed rest, liquid/soft diet.

Antibiotics: Broad-spectrum (e.g., ceftriaxone + metronidazole).

Adjuvants: Cold packs, leeches (hirudotherapy), laser therapy (to reduce inflammation).

After improvement (normalized temp/labs): Switch to warm compresses, physiotherapy, and laser therapy to promote resorption.

3.Abscess Formation

Signs: ↑ Pain, fever (hectic), ↑ leukocytosis, US/CT shows fluid collection.

Treatment:

o Percutaneous drainage (US/CT-guided) + IV antibiotics.

oDelayed appendectomy:

After 3–4 weeks (if infiltrate resolves).

After 3 months (if abscess drained).

Key Points

Avoid early surgery in a formed mass (risk of injury to adhered bowel).

Monitor for complications: Abscess, peritonitis, sepsis.

Elective appendectomy is recommended after resolution to prevent recurrence.

7.Subdiaphragmatic abscess of appendicular origin. Clinic, diagnosis and treatment.

Subdiaphragmatic Abscess of Appendicular Origin

(Clinic, Diagnosis, and Treatment)

Pathogenesis

Cause: Complication of acute appendicitis (especially with subhepatic appendix position).

Spread of Infection:

oPus ascends via the right lateral paracolic gutter → subphrenic space.

oMay also occur due to:

Generalized peritonitis.

Ruptured liver abscess (from pylephlebitis – portal vein thrombophlebitis).

Location:

oRight-sided (most common).

o Divided into anterior and posterior subdiaphragmatic abscesses.

Clinical Presentation

Symptoms:

o Pain in the lower thorax (right hypochondrium or flank).

o Referred pain to the shoulder (due to diaphragmatic irritation). o Dry cough (phrenic nerve irritation).

oSystemic intoxication:

High hectic fever (spiking temperatures).

Chills, weakness, night sweats (hyperhidrosis).

Tachycardia, tachypnea.

Physical Exam:

oTenderness on intercostal space palpation (especially 9th–11th ribs).

oDecreased breath sounds on the affected side (due to pleural effusion).

o Liver dullness may be displaced downward.

Diagnosis

1. Laboratory Findings:

o Leukocytosis (↑ WBC, left shift – toxic granulations).

o ↑ CRP, ESR.

oPossible hypoalbuminemia (chronic infection).

2.Imaging:

oX-ray (Chest/Abdomen):

Elevated/arched hemidiaphragm (right side).

Pleural effusion (reactive).

Subdiaphragmatic air-fluid level (if gas-forming organisms).

o Ultrasound (US):

 Hypoechoic fluid collection below the diaphragm.

oCT (Gold Standard):

Clearly defines abscess size/location.

May show gas bubbles (indicating abscess).

oDiagnostic Puncture (US/CT-guided):

Confirms pus (Gram stain/culture → guides antibiotics).

Treatment

1.Surgical Drainage (Primary Treatment)

Approach depends on abscess location:

2. Antibiotic Therapy

Empirical IV antibiotics (broad-spectrum):

o Ceftriaxone + Metronidazole (covers enteric bacteria + anaerobes).

oPiperacillin-Tazobactam or Carbapenems (severe cases).

Adjust based on culture/sensitivity.

3.Percutaneous Drainage (Alternative)

CT/US-guided drainage for selected cases (if accessible).

Followed by delayed appendectomy (after 6–8 weeks).

4.Appendectomy

Elective appendectomy after abscess resolution (~6–12 weeks later).

Complications

Pleural empyema (if abscess ruptures into pleura).

Sepsis, septic shock.

Hepatic abscess (via portal pyemia).

Key Points

High mortality if untreated (requires urgent intervention).

CT is diagnostic gold standard.

Surgical drainage + antibiotics is mainstay.

Delayed appendectomy prevents recurrence.

8.Pyleflebitis. Concept, etiopathogenesis, clinical picture, diagnosis and treatment.

Pylephlebitis (Septic Thrombophlebitis of the Portal Vein)

(A Severe Complication of Destructive Appendicitis)

Pathogenesis

Origin:

oBegins with thrombophlebitis of appendiceal veins (due to destructive appendicitis).

o Septic thrombi spread via:

Ileocolic vein → superior mesenteric vein (SMV) → portal vein.

oLeads to thrombophlebitis of intrahepatic veins → multiple liver abscesses.

Microbiology:

oPolymicrobial (Gram-negative rods – E. coli, Klebsiella; anaerobes –

Bacteroides).

Clinical Presentation

Timing: 2–3 days post-appendectomy (or during severe appendicitis).

Systemic Signs:

o Hectic fever (39–40°C), chills, profuse sweating (septic state).

oTachycardia, hypotension (septic shock risk).

Abdominal Signs:

oRight hypochondrium tenderness (hepatic involvement).

o Hepatomegaly (enlarged, tender liver).

oJaundice (due to hepatocellular injury + bile duct obstruction).

Portal Hypertension Complications:

oAscites, splenomegaly (late-stage).

Laboratory Findings:

o↑ WBC (marked leukocytosis with left shift).

o ↑ CRP, ↑ bilirubin, ↑ liver enzymes (AST/ALT, ALP).

o Positive blood cultures (often polymicrobial).

Diagnosis

1. Imaging:

oCT abdomen with contrast (Gold Standard):

Portal vein thrombosis (hypodense thrombus, vessel wall enhancement).

Liver abscesses (hypodense lesions with rim enhancement).

Mesenteric vein thrombosis (SMV involvement).

oUltrasound (Doppler):

Non-occlusive thrombus in portal vein, absent flow.

oMRI/MR Venography: Alternative if CT inconclusive.

2.Blood Cultures:

oEssential for targeted antibiotic therapy.

Treatment

1.Antibiotics (Empirical → Culture-Guided)

Initial Broad-Spectrum IV Therapy:

oCeftriaxone + Metronidazole (covers enteric Gram-negatives + anaerobes).

oPiperacillin-Tazobactam or Carbapenems (meropenem) for severe cases.

Duration: 4–6 weeks (or longer if liver abscesses present).

2.Anticoagulation

Low Molecular Weight Heparin (LMWH) → transition to Warfarin (target INR 2–3).

Rationale: Prevents thrombus extension, reduces septic embolism risk.

3.Portal Vein Catheterization (Rare, High-Risk Cases)

Umbilical vein cannulation for direct antibiotic/anticoagulant infusion.

4.Drainage of Liver Abscesses

Indication: Abscess >3 cm or failed medical therapy.

Methods:

oPercutaneous drainage (US/CT-guided).

oSurgical drainage (if ruptured/multiloculated).

5.Supportive Care

IV fluids, vasopressors (if septic shock).

Nutritional support (liver dysfunction may require protein restriction).

Complications

Septic shock, multi-organ failure.

Portal hypertension → variceal bleeding, ascites.

Hepatic failure (due to abscesses/thrombosis).

Prognosis

Mortality: 20–50% (depends on early diagnosis/treatment).

Survivors may develop chronic portal vein thrombosis → portal cavernoma.

Key Takeaways

1.Suspect pylephlebitis in post-appendectomy patients with persistent fever, jaundice, and hepatomegaly.

2.CT with contrast confirms diagnosis (portal vein thrombus + liver abscesses).

3.Aggressive IV antibiotics + anticoagulation are mainstays of therapy.

4.Drain abscesses >3 cm; monitor for portal hypertension complications.

9.Pelvic abscess. Clinical picture, diagnosis and treatment.

Pelvic Abscess (Abscess of the Pelvic Cavity) in Appendicitis

Epidemiology & Pathogenesis

Incidence: ~1% of acute appendicitis cases.

Causes:

oPelvic appendix position → inflammation spreads to the rectouterine

(Douglas) or rectovesical pouch.

oSecondary to peritonitis (localized purulent effusion).

Microbiology: Polymicrobial (Gram-negative bacilli, anaerobes).

Clinical Presentation

Symptoms

Pelvic pain (suprapubic or deep rectal discomfort).

Irritative urinary symptoms: Dysuria, frequency (due to bladder irritation).

Rectal/colonic irritation: