First Aid for Surgery

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Gastrin: site of release, action (2), stimulators (4), inhibitors (2)

Site of release: antrum of stomach, duodenum, pancreas
Action: gastric acid secretion, cell growth
Stimulators: vagus, food in antrum, gastric distention, Ca
Inhibitors: antral pH <2.0, somatostatin

Cholecystokinin (CCK): site of release, action (2), stimulators (4), inhibitors (2)

Site of release: duodenum
Action: stimulates gallbladder contraction and release of bile, causes opening of the ampulla of Vater, slows gastric emptying, stimulates pancreatic acinar cell growth, inhibits gastric emptying
Stimulators: polypeptides, amino acids, fat, HCl
Inhibitors: chymotrypsin, trypsin

Secretin: site of release, action (4), stimulators (2), inhibitors (2)

Site of release: duodenum
Action: stimulates pancreatic secretion of water & bicarbonate, bile secretion of bicarbonate, pepsin secretion, inhibits gastric acid secretion
Stimulators: low duodenal pH, intraluminal duodenal fat
Inhibited: high duodenal pH

Somatostatin: site of release, action (6), stimulators (3), inhibitors (1)

Site of release: pancreas
Action: increases small bowel reabsorption of water & electrolytes; inhibits cell growth, GI motility, gallbladder contraction, gastric acid secretion, pancreatic exocrine & endocrine secretion;
Stimulators: intraluminal fat, gastric & duodenal mucosa, catecholamines
Inhibitors: ACh

Pancreatic polypeptide: site of release, action (2), stimulators (2)

Site of release: pancreas
Action: marker for other endocrine tumors of the pancreas, inhibits motilin
Stimulators: vagus, food in small bowel

Neurotensin: site of release, action (3), stimulator

Site of release: small bowel & colon
Action: pancreatic secretion, vasodilation, inhibits gastric acid secretion
Stimulator: fat

Peptide YY: site of release, action (3)

Site of release: small bowel & colon
Action: inhibits gastric acid secretion, inhibits pancreatic exocrine secretion, inhibits migrating myoelectric complexes (MMC)

Glucagon: site of release, action (7), stimulator, inhibitor

Site of release: small bowel & colon
Action: increases glycogenolysis, lipolysis, ketogenesis and gluconeogenesis; inhibits gastric acid & pancreatic exocrine secretion; inhibits GI peristalsis; increases HR & contractility
Stimulator: low serum glucose
Inhibitor: somatostatin, hyperglycemia

Motilin: action (3), stimulators (3), inhibitor

Action: inhibits migrating myoelectric complexes (MMC), increases gastric emptying, increases pepsin secretion
Stimulators: vagus, fat, intraduodenal alkaline environment
Inhibitor: pancreatic polypeptide

Crohn's disease: risk factors (8)

Jewish descent
Urban dwelling
15-40 or 50-80y/o
Family history
Smoking
Diet high in refined sugar
NSAIDs
OCPs

Crohn's: signs and symptoms (8)

Diarrhea, weight loss, fever, crampy abdominal pain, GI bleeding (usually occult), perianal disease (1/3), symptoms of perforation or fistula

Crohn's: diagnosis (4)

Physical exam: perianal skin tags, sinus tracts, abdominal mass, aphthous ulcers
Colonoscopy: skip lesions, cobblestone appearance
Esophagogastroduodenoscopy
Barium enema

Radiographic evidence of Crohn's (5)

Nodular contour of bowel
Narrowed lumen with sinuses and clefts
Linear ulcers
Asymmetrical involvement of bowel wall
String sign

Medical treatment of Crohn's (4)

Corticosteroids
Aminosalicylates (sulfasalazine, 5-ASA)
Immune modulators (azathioprine, cyclosporine, mercaptopurine)
Metronidazole

Indications of surgery in Crohn's (6)

Obstruction, abscess, fistula, perforation, perianal disease, cancer

Enteroclysis

Double-contrast study that involves passing a tube into the proximal small intestine and injecting barium and methylcellulose. Detects tumors missed on conventional imaging.

Extended enteroscopy

Similar to enteroclysis but involves advancement of enteroscope via peristalsis. Detects tumors missed in enteroclysis.

Benign neoplasms of small intestine: signs and symptoms (5)

Intermittent obstruction
Intussusception
Occult bleeding
Palpable abdominal mass
Abdominal pain

Risk factors for neoplasms of small intestine (7)

Red meat & salt-cured foods
Peutz-Jeghers syndrome (hamartomatous polyps)
Crohn's (adenocarcinoma)
Garder syndrome (adenoma)
Familial adenomatous polyposis (adenoma)
Celiac disease (lymphoma, carcinoma)
Immunodeficiency / autoimmune disease (lymphoma)

Adenocarcinoma of small intestine: risk factors, signs and symptoms, location

25-50% primary small bowel malignancies
Risk factors: Crohn's
Signs: obstruction, bleeding, mass
Location: duodenum, ileum

Carcinoid malignancy in small intestine: signs, location

40% primary small bowel malignancies
Signs: often asymptomatic, obstruction, carcinoid syndrome
Location: ileum

Lymphoma in small intestine: risk factors (3), signs (6), location (1)

Risk factors: celiac disease, immunosuppression, autoimmune disease
Signs: fatigue, weight loss, obstruction, pain, mass, bleeding
Location: ileum

Sarcoma in small intestine: signs (3), location (3)

Signs: obstruction, pain, bleeding
Location: ileum, jejunum, Meckel's diverticulum

Neuroendocrine tumor in small intestine: signs (2), location

Signs: mass, hormone-specific symptoms
Location: proximal small intestine

Metastasis to small intestine: origin (6), signs (2)

Origin: melanoma, cervical, colon, breast, lung, ovarian
Signs: obstruction, bleeding

Carcinoid tumor

Slow-growing malignant tumor of enterochromaffin cell origin in GI tract or respiratory tract

Carcinoid tumor: epidemiology

Peak incidence 50-70y/o
>90% in GI system (mostly appendix & ileum)

Carcinoid tumor: signs and symptoms (6)

Often asymptomatic
Abdominal pain, obstruction, rectal bleeding, weight loss
10% of patients have carcinoid syndrome

Carcinoid syndrome

Seen in 10% of patients with carcinoid tumor, usually after metastasis to liver. Tumor produces serotonin, bradykinin, or tryptophan, which enter the systemic circulation, causing cutaneous flushing, diarrhea, valvular lesions, and bronchoconstriction.

Carcinoid tumor: diagnosis

5-HIAA or 5-HTP in 24-hr urine
Small bowel series, enteroclysis, or extended enteroscopy
Often found incidentally during surgery for something else

Carcinoid tumor: treatment

Medical: serotonin antagonist (cyproheptadine) or somatostatin analogue (octreotide) for carcinoid syndrome
Surgical: appendectomy for appendiceal tumor <2cm, right hemicolectomy for appendiceal tumor >2cm, tumor resection for small intestinal carcinoid

GI fistula: risk factors (4)

Previous abdominal surgery (most common)
Diverticular disease
Crohn's
Colon cancer

GI fistula: signs and symptoms

Fever & leukocytosis if there is an abscess
Enterocutaneous fistula: drainage of bowel contents from skin
Entero-enteric fistula: diarrhea
Enterovesicular fistula: pneumaturia & UTI

GI fistula: treatment (4)

Somatostatin to decrease loss of volume & electrolytes
Bowel rest
IV antibiotics
Resection if no improvement after 6 weeks

Factors that keep a GI fistula tract open (FRIEND)

Foreign body
Radiation
Inflammation
Epithelialization
Neoplasm
Distal obstruction

Types of small bowel obstruction (2)

Open loop: flow is blocked but proximal decompression possible
Closed loop: inflow and outflow both blocked, e.g. incarcerated hernia, torsion, adhesions, volvulus

Mechanical causes of small bowel obstruction (11)

Intraluminal: gallstone, foreign body, intussusception
Intramural: Crohn's, lymphoma, radiation enteritis
Extrinsic: adhesion (1), hernia (2), cancer (3), abscess, congenital

Functional causes of small bowel obstruction (paralytic ileus) (7)

Hypokalemia
Peritonitis
Ischemia
Medications (opiates, anticholinergics)
Hemoperitoneum
Retroperitoneal hematoma
Post-op

Small bowel obstruction: signs and symptoms (5)

Colicky abdominal pain
Nausea
Vomiting
High-pitched bowel sounds
Abdominal distention

Small bowel obstruction: diagnosis

Supine & upright AXR
CT scan if AXR is non-diagnostic

Small bowel obstruction: treatment

Medical: IV hydration, NPO, NG decompression
Surgical: exploratory laparotomy to find & fix cause

Typical symptoms of left-sided colon cancer

Change in bowel habits (small-caliber stools)
Obstruction
Hematochezia
Weight loss & anorexia

Typical symptoms of right-sided colon cancer

Microcytic anemia
Melena
Fatigue
Weight loss & anorexia

Main functions of colon & rectum (2)

Absorption of water & electrolytes from stool
Storage of feces

Types of colonic contractions (3)

1. Retrograde: slow transit of luminal contents, increasing absorption
2. Segmental: localized simultaneous contractions of longitudinal & circular muscle
3. Mass movement: contractions of long segments lasting 30s ~3-4x per day (after waking up or eating)

Constipation

Ability to pass flatus, but inability to pass stool

Obstipation

Inability to pass flatus or stool

Irritable bowel syndrome: signs & symptoms

Altered bowel function (constipation, diarrhea) occurring intermittently over a prolonged period of time +/- abdominal pain

Irritable bowel syndrome: treatment

Reassurance & education
Medical treatment for anxiety / depression

Constipation

<3 stools/week while on a high-fiber diet
May be acute (<3m) or chronic (>3m)

Constipation: causes (6)

Diet: too little fluid or fiber
Lack of physical activity
Medications: opiates, anticholinergics
Medical illness: IBS, diabetes, hypothyroidism
Depression
Neurologic disease: Parkinson's, MS

Postvagotomy diarrhea: mechanism & treatment

Mechanism: denervation of extrahepatic biliary tree & small intestine leads to rapid transit of unconjugated bile salts into colon --> poor water absorption --> diarrhea.
Treatment: cholestyramine or surgical reversal of a segment of small intestine to prolong transit time

Diarrhea

>3 loose stools/day

Diarrhea: diagnosis (3)

Check stool for enteric pathogens or C. difficile toxin
Check stool for WBCs: IBD, infectious colitis
Check stool for RBCs: ischemia, infasive infectious diarrhea, cancer

Fecal incontinence: etiology (4)

Anal sphincter trauma: childbirth, iatrogenic, s/p fistulotomy for abscess or perianal fistula
Scleroderma
Fecal impaction
Pudendal nerve injury

Fecal incontinence: diagnosis (4)

Anal manometry: detects resting & squeeze pressures of internal & external sphincters
Endoanal U/S: more accurate, detects occult lesions
Pelvic floor EMG: differentiates between anatomic & neurogenic causes
Pudendal nerve terminal motor latency testing: predicts success of surgical repair

Pseudomembranous colitis: etiology

Overgrowth of C. difficile, usually after use of antibiotics (clindamycin, ampicillin, cephalosporins)

Pseudomembranous colitis: treatment

Stop antibiotic
PO / IV metronidazole or PO vancomycin

Actinomyces colitis: signs & symptoms (5)

Weight loss
Night sweats
Draining fistulas
Abdominal mass
Usually follows appendectomy

Actinomyces colitis: diagnosis

"Sunburst" pattern of sulfur granules on hisopathology
Culture

Actinomyces colitis: treatment

Surgical drainage
Tetracycline or penicillin

Neutropenic colitis: definition

Diffuse mucosal ulceration and invasive infection with enteric organisms

Neutropenic colitis: signs & symptoms (5)

Fever
Abdominal pain and/or partial small bowel obstruction
Diarrhea
Neutrophils <100/mL
Sepsis

Radiation-induced colitis during XRT: signs (6), diagnosis (2), etiology (3), treatment (2)

Signs & symptoms: nausea, vomiting, cramps, diarrhea, tenesmus, rectal bleeding
Diagnosis: AXR, barium enema
Etiology: mucosal edema, hyperemia, acute ulceration
Treatment: treat symptoms, decrease XRT dose

Radiation-induced colitis weeks/years later: signs (5), diagnosis (2), etiology (6), treatment (5)

Signs & symptoms: tenesmus, bleeding, abscess, rectal fistula, increased BMs
Diagnosis: barium enema, CT scan
Etiology: submucosal arteriolar vasculitis, microvascular thrombosis, wall thickening, mucosal ulceration, strictures, perforation
Treatment: stool softener, topical 5-ASA, corticosteroid enema, dilatation of stricture, proximal colostomy to repair rectovaginal fistula

Ischemic colitis: definition

Acute or chronic intestinal ischemia due to decreased intestinal perfusion or thromboembolism in IMA. Most often affects the splenic flexure.

Ischemic colitis: risk factors (7)

Old age (>60yrs)
s/p AAA repair
HTN
Coronary artery disease
Diabetes
Adhesions s/p abdominal surgery
Obstructive lesion in colon

Ischemic colitis: signs & symptoms (5)

Mild lower abdominal pain, insidious in onset
Rectal bleeding
Fever
Increased WBC
Peritoneal signs

Ischemic colitis: treatment (3)

Mild: observe
Moderate (fever, increased WBC): IV abx
Severe (peritoneal signs): exploratory laparotomy + colostomy

Ulcerative colitis: risk factors (8)

Jewish descent
White
Urban dwelling
Age 15-40 or 50-80
Family history
Diet: refined sugar
Medications: NSAIDs, OCPs
Nicotine DECREASES risk

Ulcerative colitis: 2 characteristic presentations

Insidious recurrent abdominal pain, anorexia, weight loss, mild diarrhea
Acute onset of BLOODY diarrhea, abdominal pain +/- tenesmus, vomiting, fever

Ulcerative colitis: diagnosis (2)

Endoscopy + pathologic evaluation of biopsies
Barium enema (lead pipe appearance)

Crohn's: complications (4)

Abscess
Fistulas
Obstruction
Perianal disease

Ulcerative colitis: complications (3)

Perforation
Stricture
Megacolon

Crohn's: pathology

Inflammation involves ALL bowel wall layers, which may lead to fistula & abscess formation. Rectal sparing in 50% of patients.

Ulcerative colitis: pathology

Inflammation ONLY involves mucosa, leading to exudate of pus, blood and mucus from the "crypt abscess." It ALWAYS starts in the rectum, and about 1/3 don't progress further than that.

Ulcerative colitis: treatment

Mild/moderate: 5-ASA, corticosteroids (PO or PR)
Severe: IV steroids
Proctitis: topical steroids
Refractory disease or perforation: immunosuppression, proctocolectomy, or diverting loop colostomy

Diverticular disease

Herniation of mucosa & submucosa through muscular layers of bowel wall at sites where arterioles penetrate, on mesenteric side of colon

Diverticular disease: risk factors (2)

Old age (>70yrs)
Low-fiber diet

Diverticulosis: signs & symptoms (3)

80% asymptomatic
MAY cause recurrent intermittent LLQ pain & tenderness after meals and relieved by flatus or defecation
LLQ rope-like mass palpable on exam
Massive & rapid lower GI bleeding
Orthostasis

Diverticulitis: signs & symptoms (7)

Persistent abdominal pain that is first diffuse and then becomes localized to LLQ and/or pelvis with peritoneal signs
Ileus
Fever
Anorexia
Nausea / vomiting
Change in bowel habits
Elevated WBC

Diverticulitis: diagnosis

Elevated WBC
AXR: ileus, distention, free intraperitoneal air
CT: pericolonic inflammation +/- abscess formation

Treatment of severe diverticulitis with perforation

Surgical drainage & diverting colostomy, followed by colonic reanastomosis 2-3 months later

Causes of lower GI bleed (6)

Diverticulosis
Angiodysplasia
IBD
Ischemic colitis
Cancer
Anticoagulation treatment

Angiodysplasia: signs & symptoms (3)

Slow lower GI bleeding from cecum & ascending colon
Melena and/or hematochezia
Orthostasis

Angiodysplasia

Repeated muscular contractions --> chronic intermittent obstruction of submucosal veins --> dilated venules with incompetent precapillary sphincters --> arteriovenous communication

Diverticulosis

Disruption of arteriole ad dome or antimesenteric neck of diverticulum, most commonly on mucosal side --> blood goes into bowel lumen

Lower GI bleeding: diagnosis (4)

1. NG lavage to rule out upper GI bleeding
2. Colonoscopy
3. Bleeding scan with Tc-sulfur colloid (>0.5ml/mn)
4. Angiography (>1ml/mn) to detect angiodysplasia

Lower GI bleeding: treatment (4)

1. Resuscitation
2. If site is identified: octreotide, embolization, vasoconstriction with epinephrine, vasodestruction with alcohol or Na, coagulation with heat
3. If bleeding is refractory or massive: segmental colectomy
4. If site is not identified: total abdominal colectomy + ileostomy

Large bowel obstruction: signs & symptoms (5)

Abdominal distention
Cramping abdominal pain
Nausea / vomiting
Obstipation
High-pitched bowel sounds

Large bowel obstruction: most common causes (3)

1. adenocarcinoma
2. scarring after diverticulosis
3. volvulus

Large bowel obstruction: diagnosis (3)

1. History of 8-12hrs of obstipation (flatus indicates PARTIAL obstruction)
2. Supine AND upright AXR: distended proximal colon, air-fluid levels, no distal rectal air
3. Barium enema: distinguishes between ileus & partial obstruction

Large bowel obstruction: treatment (4)

1. correct fluid & electrolyte abnormalities
2. decompress intestines with NG tube
3. broad-spectrum IV antibiotics
4. surgery to relieve obstruction

Ogilvie syndrome (pseudo-obstruction)

Massive colonic dilation without evidence of mechanical obstruction, due to imbalance between parasympathetic & sympathetic control of intestinal motility.

Ogilvie syndrome: risk factors (8)

Older age
Institutionalization
Severe acute illness / infection
Recent surgery or trauma
Neuroleptics
Opiates
Malignancy
Metabolic disturbances

Ogilvie syndrome: signs & symptoms (3)

Abdominal distention
Mild abdominal pain
Decreased / absent bowel sounds

Ogilvie syndrome: diagnosis (3)

AXR: massive colonic distention
CXR: free air under diaphragm
Enema or colonoscopy: to exclude mechanical cause for obstruction

Ogilvie syndrome: treatment (6)

1. Decompress with NG & rectal tubes
2. Correct electroly abnormalities
3. Stop narcotics, anticholinergics, etc.
4. Turn patient frequently
5. Neostigmine (AChE inhibitor) to decompress bowel
6. Exploratory laparotomy with cecostomy or loop colostomy if cecal diameter >11cm or patient has peritoneal signs

Volvulus

Rotation of intestine around its mesenteric axis, usually in sigmoid colon or cecum, leading to large bowel obstruction

Volvulus: risk factors (2)

Age >65
Hypermobile cecum after incomplete fixation in utero

Volvulus: diagnosis (2)

AXR: dilated sigmoid colon or cecum with "kidney bean" appearance
Barium enema: "bird's beak" at areas of colonic narrowing

Cecal volvulus: treatment

Right hemicolectomy (if vascular compromise) or cecopexy (suture right colon to parietal peritoneum)

Sigmoid volvulus: treatment (3)

1. Sigmoidoscopy & rectal tube insertion to decompress
2. Emergent laparotomy: if sigmoidoscopy fails, or if you suspect perforation or strangulation
3. Elective resection later, to prevent recurrence

Histologic types of colorectal polyps (5)

Inflammatory (pseudopolyp): seen in UC
Lymphoid: mucosal bumps containing intramucosal lymphoid tissue; NO malignant potential
Hyperplastic: overgrowth of normal tissue; NO malignant potential
Adenomatous: premalignant; may be tubular, tubulovillous or villous
Hamartomatous: normal tissue in abnormal configuration

Indications for colonoscopic resection of a polyp (5)

Pedunculated
Well or moderately well differentiated
No venous or lymphatic invasion
Invades only into stalk
Margins are negative

Familial polyposis coli (FAP)

Autosomal dominant mutation on chromosome 5 --> polyps develop at 20-40yrs --> colon cancer inevitable if colectomy is not performed

Gardner's syndrome

Autosomal dominant
Many colonic polyps, osteomas, epidermal cysts and fibromas
Colon cancer is inevitable without surgery

Turcot's syndrome

Autosomal recessive
Multiple adenomatous colonic polyps and CNS tumors

Cronkite-Canada syndrome

GI polyposis, alopecia, nail dystrophy, and hyperpigmentation
Very low malignant potential

Peutz-Jeghers syndrome

Autosomal dominant
Hamartomatous polyps of entire GI tract
Melanotic pigmentation of face, lips, oral mucosa, palms
Increase risk of pancreas, breast, lung, ovary, uterus cancers

HNPCC (Lynch syndrome)

Autosomal dominant
High risk of right-sided colon cancer
High risk of adenocarcinoma of uterus, ovary, cervix, breast

Diagnosis of colon cancer

Flexible sigmoidoscopy or colonoscopy
Barium enema

Diagnosis of rectal cancer

DRE
Proctoscopy or colonoscopy
Barium enema
Transrectal ultrasound, CT, or MRI to assess invasion

Dukes system for colon cancer

A: limited to wall
B: through wall of bowel, but not to lymph nodes
C: metastatic to regional lymph nodes
D: distant metastases

Operative management of CRC in cecum

Right hemicolectomy

Operative management of CRC in right colon

Right hemicolectomy

Operative management of CRC in proximal or mid-transverse colon

Extended right hemicolectomy (entire transverse colon + splenic flexure)

Operative management of CRC in splenic flexure or left colon

Left hemicolectomy

Operative management of CRC in sigmoid colon

Sigmoid colectomy

Operative management of CRC in proximal rectum

Low anterior resection
For tumors >4cm from anal verge

Operative management of CRC in distal rectum

Abdominal-perineal resection: resection of rectum, total mesorectal excision, closure of anus

Hemorrhoids

Prolapse of submucosal veins in left lateral, right anterior & right posterior quadrants of the anal canal

Risk factors for hemorrhoids (5)

Constipation
Excessive diarrhea
Pregnancy
Increased pelvic pressure (ascites, tumor)
Portal hypertension

Internal hemorrhoids

Hemorrhoids covered by columnar mucosa, above dentate line

External hemorrhoids

Hemorrhoids covered by squamous mucosa, below dentate line

Grading system for internal hemorrhoids

I: protrudes into lumen without prolapse --> bleeding --> treat via non-resectional measures
II: prolapse with straining, spontaneous return --> bleeding & feel prolapse --> non-resectional measures
III: prolapse that requires manual reduction --> bleeding, prolapse, mucus, pruritis --> non-resectional measures or excision
IV: prolapse can't be reduced --> bleeding, prolapse, mucus, pruritis, pain --> excision

Anal fissure: signs & symptoms (5)

Pain with defecation
Bright red blood on TP
Increased rectal tone
Extreme pain on DRE
Visible tear

Anal fissure: treatment (5)

Sitz baths
Fiber supplements
Increased fluid intake
Lateral internal sphincterotomy (last resort)
Forceful anal dilation (last resort)

Anorectal abscess: risk factors (7)

Constipation
Diarrhea
IBD
Immunocompromise
History of recent surgery or trauma
History of CRC
Previous anorectal abscess

Anorectal abscess: signs & symptoms (4)

Sudden onset rectal pain
Fever, chills, malaise
Leukocytosis
Perianal swelling with erythema & warmth

Anal fistula

Abnormal connection between the epithelialised surface of the anal canal and perianal skin

Risk factors for anal fistula (6)

History of ischiorectal abscess
Crohn's
Trauma
Foreign body
TB
CRC

Treatment of anal fistula

Intraoperative unroofing of entire fistula tract. Loop heavy suture through tract to keep it patent for drainage & to stimulate fibrosis.

Pilonidal disease

Cystic inflammation at or near the cranial edge of the gluteal cleft, usually seen in young men. Presents as an abscess or a draining sinus with pain at the top of the gluteal cleft.

Anal cancer: risk factors (6)

HPV
HIV
Smoking
Multiple sexual partners
Anal intercourse
Immunosuppression

Anal squamous cell carcinoma: treatment

Radiation + chemotherapy
Surgery only in case of recurrence

Treatment of anal margin tumors (except SCC)

Wide local excition +/- radiation +/- chemo
80% successful without abdominal-perineal resection if tumor is small & not deeply invasive

Anal canal tumors (epidermoid, melanoma)

Chemo (5-FU & mitomycin C) + radiation
Abdominal-perineal resection if follow-up biopsy shows residual tumor

Causes of obstruction of appendix lumen (5)

Lymphoid hyperplasia
Fecalith
Foreign objects: seeds, barium from previous x-ray
Stricture: e.g. tumor
Parasites: esp. Ascaris

Typical symptoms of appendicitis (4)

Abdominal pain followed by vomiting
Pain that is initially diffuse and epigastric or periumbilical, and then localizes to RUQ
Fever
Leukocytosis

Typical signs of appendicitis (5)

Direct rebound tenderness at McBurney's point
Rovsing's sign: pain in RLQ during palpation of LLQ
Ilipsoas sign: pelvic pain upon extension of right thigh
Obturator sign: pelvic pain upon internal rotation of right thigh
Dunphy's sign: increased pain with coughing

Location of somatic pain of appendicitis according to anatomic location

Long tip: LLQ pain
Retrocecal: flank or back pain
Pelvic: suprapubic pain
Retroileal: testiclar pain
Malrotation: perplexing pattern or pain

Appendicitis: CT findings (4)

>6mm dilation of appendix
Appendiceal thickening
Periappendiceal streaking (densities in perimesenteric fat)
Appendicolith

Appendicitis: ultrasound findings

Enlarged (>6mm) noncompressible appendix
False positives: dilated fallopian tube, inspissated stool (looks like appendicolith), obesity (fat prevents compression of appendix)
False negatives: inflammation only in tip, retrocecal appendix, large appendix (looks like small bowel), perforation (allows compression of appendix)

Mucinous appendiceal tumor

Rare
Rupture leads to pseudomyxoma peritonei, bowel obstruction, and perforation
Associated with migratory thrombophlebitis

Hepatoduodenal ligament

Contains common bile duct, portal vein, proper hepatic artery
Forms anterior boundary of epiploic foramen of Winslow
Connects greater and lesser peritoneal cavities

Pringle maneuver

Compression of the hepatoduodenal ligament
Performed to control bleeding from the liver

Sphincterotomy (papillotomy)

Cut through sphincter of Oddi to allow stones to pass from CBD to duodenum. Performed during ERCP.

Kocher incision

Incision at right costal margin during open cholecystectomy