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Acute Appendicitis

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Despite newer imaging techniques, acute appendicitis can be very difficult to diagnose. ... should be hospitalized under the care of a surgeon or gastroenterologist ... – PowerPoint PPT presentation

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Title: Acute Appendicitis


1
Acute Appendicitis
2
Epidemiology
  • The incidence of appendectomy appears to be
    declining due to more accurate preoperative
    diagnosis.
  • Despite newer imaging techniques, acute
    appendicitis can be very difficult to diagnose.

3
Pathophysiology
  • Acute appendicitis is thought to begin with
    obstruction of the lumen
  • Obstruction can result from food matter,
    adhesions, or lymphoid hyperplasia
  • Mucosal secretions continue to increase
    intraluminal pressure

4
Pathophysiology
  • Eventually the pressure exceeds capillary
    perfusion pressure and venous and lymphatic
    drainage are obstructed.
  • With vascular compromise, epithelial mucosa
    breaks down and bacterial invasion by bowel flora
    occurs.

5
Pathophysiology
  • Increased pressure also leads to arterial stasis
    and tissue infarction
  • End result is perforation and spillage of
    infected appendiceal contents into the peritoneum

6
Pathophysiology
  • Initial luminal distention triggers visceral
    afferent pain fibers, which enter at the 10th
    thoracic vertebral level.
  • This pain is generally vague and poorly
    localized.
  • Pain is typically felt in the periumbilical or
    epigastric area.

7
Pathophysiology
  • As inflammation continues, the serosa and
    adjacent structures become inflamed
  • This triggers somatic pain fibers, innervating
    the peritoneal structures.
  • Typically causing pain in the RLQ

8
Pathophysiology
  • The change in stimulation form visceral to
    somatic pain fibers explains the classic
    migration of pain in the periumbilical area to
    the RLQ seen with acute appendicitis.

9
Pathophysiology
  • Exceptions exist in the classic presentation due
    to anatomic variability of the appendix
  • Appendix can be retrocecal causing the pain to
    localize to the right flank
  • In pregnancy, the appendix ca be shifted and
    patients can present with RUQ pain

10
Pathophysiology
  • In some males, retroileal appendicitis can
    irritate the ureter and cause testicular pain.
  • Pelvic appendix may irritate the bladder or
    rectum causing suprapubic pain, pain with
    urination, or feeling the need to defecate
  • Multiple anatomic variations explain the
    difficulty in diagnosing appendicitis

11
History
  • Primary symptom abdominal pain
  • ½ to 2/3 of patients have the classical
    presentation
  • Pain beginning in epigastrium or periumbilical
    area that is vague and hard to localize

12
History
  • Associated symptoms indigestion, discomfort,
    flatus, need to defecate, anorexia, nausea,
    vomiting
  • As the illness progresses RLQ localization
    typically occurs
  • RLQ pain was 81 sensitive and 53 specific for
    diagnosis

13
History
  • Migration of pain from initial periumbilical to
    RLQ was 64 sensitive and 82 specific
  • Anorexia is the most common of associated
    symptoms
  • Vomiting is more variable, occuring in about ½ of
    patients

14
Physical Exam
  • Findings depend on duration of illness prior to
    exam.
  • Early on patients may not have localized
    tenderness
  • With progression there is tenderness to deep
    palpation over McBurneys point

15
Physical Exam
  • McBurneys Point just below the middle of a line
    connecting the umbilicus and the ASIS
  • Rovsings pain in RLQ with palpation to LLQ
  • Rectal exam pain can be most pronounced if the
    patient has pelvic appendix

16
Physical Exam
  • Additional components that may be helpful in
    diagnosis rebound tenderness, voluntary
    guarding, muscular rigidity, tenderness on rectal

17
Physical Exam
  • Psoas sign place patient in L lateral decubitus
    and extend R leg at the hip. If there is pain
    with this movement, then the sign is positive.
  • Obturator sign passively flex the R hip and knee
    and internally rotate the hip. If there is
    increased pain then the sign is positive

18
Physical Exam
  • Fever another late finding.
  • At the onset of pain fever is usually not found.
  • Temperatures gt39 C are uncommon in first 24 h,
    but not uncommon after rupture

19
Diagnosis
  • Acute appendicitis should be suspected in anyone
    with epigastric, periumbilical, right flank, or
    right sided abd pain who has not had an
    appendectomy

20
Diagnosis
  • Women of child bearing age need a pelvic exam and
    a pregnancy test.
  • Additional studies CBC, UA, imaging studies

21
Diagnosis
  • CBC the WBC is of limited value.
  • Sensitivity of an elevated WBC is 70-90, but
    specificity is very low.
  • But, predictive value of high WBC is 92 and
    predictive value is 50
  • CRP and ESR have been studied with mixed results

22
Diagnosis
  • UA abnormal UA results are found in 19-40
  • Abnormalities include pyuria, hematuria,
    bacteruria
  • Presence of gt20 wbc per field should increase
    consideration of Urinary tract pathology

23
Diagnosis
  • Imaging studies include X-rays, US, CT
  • Xrays of abd are abnormal in 24-95
  • Abnormal findings include fecalith, appendiceal
    gas, localized paralytic ileus, blurred right
    psoas, and free air
  • Abdominal xrays have limited use b/c the findings
    are seen in multiple other processes

24
Diagnosis
  • Graded Compression US reported sensitivity 94.7
    and specificity 88.9
  • Basis of this technique is that normal bowel and
    appendix can be compressed whereas an inflamed
    appendix can not be compressed
  • DX noncompressible gt6mm appendix, appendicolith,
    periappendiceal abscess

25
Diagnosis
  • Limitations of US retrocecal appendix may not be
    visualized, perforations may be missed due to
    return to normal diameter

26
Diagnosis
  • CT best choice based on availability and
    alternative diagnoses.
  • In one study, CT had greater sensitivity,
    accuracy, -predictive value
  • Even if appendix is not visualized, diagnose can
    be made with localized fat stranding in RLQ.

27
Diagnosis
  • CT appears to change management decisions and
    decreases unnecessary appendectomies in women,
    but it is not as useful for changing management
    in men.

28
Special Populations
  • Very young, very old, pregnant, and HIV patients
    present atypically and often have delayed
    diagnosis
  • High index of suspicion is needed in the these
    groups to get an accurate diagnosis

29
Treatment
  • Appendectomy is the standard of care
  • Patients should be NPO, given IVF, and
    preoperative antibiotics
  • Antibiotics are most effective when given
    preoperatively and they decrease post-op
    infections and abscess formation

30
Treatment
  • There are multiple acceptable antibiotics to use
    as long there is anaerobic flora, enterococci and
    gram(-) intestinal flora coverage
  • One sample monotherapy regimen is Zosyn 3.375g or
    Unasyn 3g
  • Also, short acting narcotics should be used for
    pain management

31
Disposition
  • Abdominal pain patients can be put in 4 groups
  • Group 1 classic presentation for Acute
    appendicitis- prompt surgical intervention
  • Group 2 suspicious, but not diagnosed
    appendicitis- benefit from imaging and 4-6h
    observation with surgical consult if serial exam
    changes or imaging studies confirm

32
Disposition
  • Group 3 remote possibility of appendicitis-
    observe in ED for serial exams if no change and
    course remains benign patient can D/C with dx of
    nonspecific abd pain
  • Patients are given instructions to return if
    worsening of symptoms, and they should be seen by
    PCP in 12-24 h
  • Also advised to avoid strong analgesia

33
Disposition
  • Group 4 high risk population(including elderly,
    pediatric, pregnant and immunocomprimised)-
    require high index of suspicion and low threshold
    for imaging and surgical consultation

34
Ileitis, Colitis, and Diverticulitis
35
Crohn Disease
  • Chronic granulomatous inflammatory disease of the
    GI tract.
  • Can involve any part of GI tract from mouth to
    anus
  • Ileum is involved in majority of cases
  • Confined to colon in 20
  • Termsregional enteritis, terminal ileitis,
    granulomatous ileocolitis

36
Crohn Disease
  • Etiology and pathogenesis are unknown.
  • Infectious, genetic, environmental factors have
    been implicated.
  • Autoimmune destruction of mucosal cells as a
    result of cross-reactivity to antigens from
    enteric bacteria.

37
Crohn Disease
  • Cytokines,including IL and TNF have been
    implicated in perpetuating the inflammatory
    response.
  • Anti-TNF(remicade) drugs have shown efficacy in
    treating Crohn disease

38
Crohn Disease
  • Epidemiology peak incidence is 15-22 years old
    with a second peak 55-66years
  • 20-30 increase in women
  • More common in European
  • 4 times more common in Jews than non-Jews
  • More common in whites vs blacks
  • 10-15 have family hx

39
Crohn Disease
  • Pathology most important is the involvement of
    all layers of the bowel and extension into
    mesenteric lymph nodes
  • Disease has skip areas between involved areas
  • Longitudinal deep ulcers and cobblestoning of
    mucosa are characteristic
  • These result in fissures, fistulas, and abscesses

40
Crohn Disease
  • Clinical features variable and unpredictable
  • Abd pain, anorexia, diarrhea, and weight loss are
    present in most cases
  • 1/3 of patients develop perianal fissures or
    fistulas, abscesses, or rectal prolapse

41
Crohn Disease
  • Patients may present with lat complications
    including
  • Obstruction, crampy abd pain, obstipation,
    intraabdominal abscess with fever
  • 10-20 have extraabdominal features such as
    arthritis, uveitis, or liver disease
  • Crohns should also be considered when evaluating
    FUO

42
Crohn Disease
  • Clinical course and manifestation depends of
    anatomic distribution.
  • 30 involves only small bowel, 30 only colon,
    and 50 involves both

43
Crohn Disease
  • Recurrence rate is as high as 50 for those
    responding to medical management
  • Rate is even higher for those requiring surgery
  • Incidence of hematochezia and perianal disease is
    higher when the colon is involved

44
Crohn Disease
  • Dermatologic complications erythema nodosum and
    pyoderma gangrenosum
  • Ocular episcleritis and uveitis
  • Hepatobiliary pericholangitis, chronic
    hepatitis, primary sclerosing cholangitis,
    cholangiocarcinoma, pancreatitis, gallstones

45
Crohn Disease
  • Vascular thromboembolic disease, vasculitis,
    arteritis
  • Other anemia, malnutrition, hyperoxaluria
    leading to nephrolithiasis, myeloplastic disease,
    osteomyelitis, osteonecrosis

46
Crohn Disease
  • Complications gt75 of patients will require
    surgery within the first 20 years
  • Abscesses present with pain and tenderness, but
    may also have palpable masses or fever spikes
  • Most common fistula sites are between ileum and
    sigmoid colon, cecum, another ileal segment, or
    the skin

47
Crohn Disease
  • Fistulas should be suspected when there is a
    change in bowel movement frequency, amount of
    pain or weight loss
  • GI bleed is common, but only 1 develop life
    threatening hemorrhage.
  • Toxic megacolon occurs in 6 of patients and
    results massive GI bleed 50 of the time

48
Crohn Disease
  • Complications can also arise from the treatment
    of the disease
  • Sulfasalazine, steroids, immunosuppressive
    agents, and antibiotics can cause leukopenia,
    thrombocytopenia, fever, infection, diarrhea,
    pancreatitis, renal insufficiency, liver failure.

49
Crohn Disease
  • Incidence of malignancy is 3 times higher in
    Crohn disease than in general population

50
Crohn Disease
  • Diagnosis history, Upper GI, air-contrast barium
    enema and colonoscopy
  • Characteristic radiologic findings in small
    intestine include segmental narrowing,
    destruction of normal mucosal pattern, and
    fistulas.

51
Crohn Disease
  • Colonoscopy is most sensitive for patients with
    colitis
  • Useful for detecting mucosal lesions, defining
    extent of involvement, occurrence of colon ca.
  • Abd CT is most useful for acute presentation

52
Crohn Disease
  • Findings of bowel wall thickening, mesenteric
    edema, local abscess formation suggest Crohn
    disease.

53
Crohn Disease
  • Differential Dx lymphoma, ileocecal amebiasis,
    sarcoidosis, deep chronic mycotic infections
    involving GI tract, GI TB, Kaposis sarcoma,
    campylobacter, Yersinia, ulcerative colitis,
    C.diff, ischemic colitis.

54
Crohn Disease
  • Tx relief of symptoms, induction of remission,
    maintenance of remission, prevention of
    complications, optimizing timing of surgery, and
    maintenance of nutrition
  • Since the disease is virtually incurable,
    emphasis should be placed of relief of symptoms
    and preventing complications

55
Crohn Disease
  • Initial ED management focus on severity of
    attack, identifying possible complications such
    as obstruction, hemorrhage, abscess, toxic
    megacolon.
  • CBC, electrolytes, BUN/creatinine, and type and
    cross if appropriate
  • Plain films may be useful for obstruction,
    perforation or toxic megacolon

56
Crohn Disease
  • Initial Tx NPO, IVF resuscitation and correction
    of electrolytes
  • NG decompression if indicated, broad spectrum
    atbx(ampicillin or a cephalosporin,
    aminoglycoside, and flagyl) should be used for
    suspected fulminant colitis or peritonitis

57
Crohn Disease
  • IV steroids hydrocortisone 300mg qd,
    methylprednisone 48mg qd, or prednisolone 60mg qd
    should be used for severe disease
  • Sulfasalazine 3-4g qd can be effective for
    mild-moderate cases, although it has many toxic
    side effects

58
Crohn Disease
  • Oral steroids are reserved for severe
    disease-prednisone 40-60mg qd
  • Immunosuppressive drugs
  • 6-MP or azathioprine are useful for steroid
    alternatives, healing fistulas, or in patients
    with contraindications to surgery
  • Response to immunosuppressant agents takes 3-6
    months

59
Crohn Disease
  • Flagyl and Cipro have been shown some improvement
    in perianal complications and fistulous disease.
  • Medically resistant or moderate cases may benefit
    from anti-TNF(Remicade) 5 mg/kg IV
  • Cellcept, etanercept, thalidomide, IL therapy may
    also be beneficial

60
Crohn Disease
  • Diarrhea can be controlled using imodium,
    lomotil, or questran

61
Crohn Disease
  • Disposition patients with signs of fulminant
    colitis, peritonitis, obstruction, significant
    hemorrhage, dehydration, electrolyte/fluid
    imbalance should be hospitalized under the care
    of a surgeon or gastroenterologist

62
Crohn Disease
  • Patients with chronic disease can be discharged
    home as long as there are no serious
    complications.
  • Alterations in maintenance therapy should be
    discussed with GI
  • Close follow up should be secured.

63
Ulcerative Colitis
  • Chronic inflammatory disease of the colon.
  • Inflammation is more severe from proximal to
    distal colon
  • Rectum is involved in nearly 100
  • Characteristic symptom is bloody diarrhea
  • Etiology remains unknown

64
Ulcerative Colitis
  • Epidemiology similar to Crohn disease
  • More prevalent in US and northern Europe.
  • First degree relatives have 15 fold increase for
    UC and 3.5 fold increase for Crohn disease

65
Ulcerative Colitis
  • Pathology involves mucosa and submucosa
  • Mucosal inflammation and formation of crypt
    abscesses, epithelial necrosis, and mucosal
    ulceration
  • Early stages mucosa membrane appears finely
    granular and friable
  • Severe cases show large oozing ulcerations and
    pseudopolyps

66
Ulcerative Colitis
  • Clinical features
  • Mild lt4 bm per day, no systemic symptoms, and
    few extraintestinal manifestations. (account for
    60 of all UC patients)
  • Severe frequent bms, anemia, fever, wt loss,
    tachycardia, low albumin, frequent
    extraintestinal manifestations. (accounts for 15
    of all patients and 90 of mortality)

67
Ulcerative Colitis
  • Moderate manifesations are less severe and
    respond well to treatment. Typically have left
    sided colitis, but can have pancolitis.

68
Ulcerative Colitis
  • Characterized by intermittent attacks of acute
    disease with remission between attacks
  • Unfavorable prognosis and increased mortality is
    seen with higher severity and extent of disease,
    short interval between attacks, and onset of
    disease after 60

69
Ulcerative Colitis
  • Extraintestinal complications arthritis,
    ankylosing spondylitis, episcleritis, uveitis,
    pyoderma gangrenosum, erythema nodosum, liver
    disease(similar to that found in Crohn disease)

70
Ulcerative Colitis
  • Complications hemorrhage, toxic megacolon,
    perirectal abscesses and fistulas, colon ca,
    perforation

71
Ulcerative Colitis
  • Dx lab findings are nonspecific.
  • Diagnosis is made by Hx of abd cramps and
    diarrhea, mucoid stools, stool negative for
    ova/parasites, negative stool cultures
  • confirmation of disease by colonoscopy showing
    granular, friable, ulceration of the mucosa, and
    sometimes pseudopolyps

72
Ulcerative Colitis
  • Differential Dx similar to that of Crohn
    disease.
  • Also be aware of STDs when confined to the rectum

73
Ulcerative Colitis
  • Treatment
  • Severe UC IV steroids, fluid replacement,
    electrolyte correction, broad spectrum atbx(amp
    and clindamycin or flagyl)
  • Cyclosporine has been advocated for steroid
    refractory cases
  • NG for toxic megacolon just as in crohn disease

74
Ulcerative Colitis
  • Mild to moderate majority of cases can be
    treated as outpatient with daily prednisone
    40-60mg
  • Active proctitis, proctosigmoiditis, and left
    side colitis can be treated with 5-aminosalicylic
    acid enemas or topical steroid preparations

75
Ulcerative Colitis
  • Treatment is very similar to Crohn disease
  • Other supportive measures include metamucil or
    other bulking agents
  • Anti-diarrheals should be used with caution in
    case of toxic megacolon

76
Ulcerative Colitis
  • DispositionFulminant attacks should be
    hospitalized for aggressive IVF and elctrolyte
    correction.
  • Complications should be managed with appropriate
    surgical or GI consult
  • Mild-moderate may be discharged with close
    follow up secured. Instructions on when to
    return should be given

77
Pseudomembranous Colitis
  • Inflammatory bowel disorder with membrane-like
    yellowish plaques of exudate overlie and replace
    necrotic intestinal mucosa

78
Pseudomembranous Colitis
  • Epidemiology
  • Clostridium Difficile- spore forming obligate
    anaerobic bacillus
  • 3 types neonatal, post-operative and antibiotic
    associated
  • Risk factors recent atbx, GI surgery, severe
    medical illness, advancing age
  • Transmission direct contact and objects

79
Pseudomembranous Colitis
  • Pathophysiology 10-25 of hospital patients are
    colonized
  • Diarrhea in recently hospitalized person should
    suggest C.difficile
  • Broad spectrum atbx such as clindamycin,
    cephalosporins, amp/amox- alter gut flora and
    allow C.difficile to flourish
  • However any atbx can lead to C.difficile

80
Pseudomembranous Colitis
  • C. difficile produces
  • toxin A enterotoxin
  • toxin B cytotoxin
  • Toxins interact and produce the colitis and
    associated symptoms

81
Pseudomembranous Colitis
  • Clinical features from frequent mucoid, watery
    stools to profuse toxic diarrhea(gt20-30
    stools/day), abdominal pain, fever, leukocytosis,
    dehydration, hypovolemia
  • Stool exam may reveal fecal leukocytes

82
Pseudomembranous Colitis
  • Complications severe electrolyte imbalance,
    hypotension, anasarca from low albumin, toxic
    megacolon, bowel perforation
  • Onset is typically 7-10 days after starting atbx
    therapy

83
Pseudomembranous Colitis
  • Extraintestinal complications are rare, but
    include arthritis, visceral abscesses,
    cellulitis, necrotizing fasciitis, osteomyelitis,
    prostheitc device infection

84
Pseudomembranous Colitis
  • Diagnosis hx of diarrhea that develops during or
    within 2 weeks of atbx treatment.
  • Confirmed by stool for C.difficile toxin and
    colonoscopy
  • Most labs use ELISA to detect C.difficile toxins
    even though there are many other modes
  • 5-20 of patients require more than one stool to
    diagnose

85
Pseudomembranous Colitis
  • Treatment d/c atbx, supportive IVF, electrolyte
    correction, flagyl 250 mg qid, or vancomycin
    125-250mg po qid(alternative regimen)
  • 25 of patients will respond to supportive
    measures only
  • Severely ill patients should hospitalized

86
Pseudomembranous Colitis
  • Relapses occur in 10-20 of patients
  • Use of anti-diarrheals should be avoided
  • Surgery or steroids are rarely needed

87
Pseudomembranous Colitis
  • Disposition
  • Severe diarrhea, symptoms that persist despite
    outpatient management, or those with systemic
    response(fever, leukocytosis, severe abdominal
    pain) should be hospitalized
  • Suspected perforation, toxic megacolon or failure
    to respond to medical treatment need a surgical
    consult

88
Pseudomembranous Colitis
  • For patients who are discharged whom good oral
    intake must be encouraged. Flagyl or vancomycin
    are equally effective for treatment.

89
Diverticulitis
  • Acute inflammation of the wall of a diverticulum
    and surrounding tissue
  • Caused by either a micro- or macroperforation

90
Diverticulitis
  • Epidemiology
  • Acquire disease of the colon has become common in
    industrialized nations
  • Approximately 1/3 of population will acquire
    diverticuli by age 50 and 2/3 by age 85
  • Rare lt20 years

91
Diverticulitis
  • Diverticulitis is estimated in 10-25 of people
    with known diverticulosis
  • Incidence increases with age
  • Only 2-4 are lt 40
  • Diverticulitis in younger age is associated with
    more complications requiring surgical intervention

92
Diverticulitis
  • Frequency is slightly higher in men, the
    incidence is on the rise in women

93
Diverticulitis
  • Pathophysiology
  • Cause is not known
  • Low residue diets have been implicated
  • Acute complications Inflammation(and associated
    complications) and Bleeding

94
Diverticulitis
  • Inflammation is the most common complication of
    diverticulosis
  • Mechanism was thought to occur when fecal
    material was inspissated in the neck of a
    diverticulum, resulting in bacterial
    proliferation, mucous secretion, and distention

95
Diverticulitis
  • More commonly, it results from high pressure in
    the colon, erosion of diverticulum wall,
    microperforation, and inflammation.
  • Free perforation can occur with generalized
    peritonitis, but is uncommon

96
Diverticulitis
  • Other complications obstruction and fistula
    formation between the bladder and diverticulum

97
Diverticulitis
  • Clinical Features most common symptom is pain.
  • Described as steady, deep discomfort in the LLQ
  • Other complaints change in bowel habit,
    tenesmus, dysuria, frequency, UTI, distention,
    nausea, vomiting,

98
Diverticulitis
  • Presentation may be indistinguishable for acute
    appendicitis
  • Diverticulitis should always be considered in
    patient gt50 with abdominal pain
  • Perforation is characterized by sudden lower
    abdominal pain progressing general abdominal pain

99
Diverticulitis
  • Physical exam frequently fever of 38 C,
    localized abdominal tenderness, voluntary
    guarding, rebound, rectal tenderness on left
    side, possibly occult blood ,
  • As always, Pelvic should be done with female
  • Watch for signs of peritonitis or perforation

100
Diverticulitis
  • Diagnosis typically suspected by Hx and physical
  • Abdominal plain films can show partial SBO, free
    air, extraluminal air
  • CT is procedure of choice. Demonstrates
    inflammation of pericolic fat, diverticula,
    thickening of bowel wall, peridiverticular abscess

101
Diverticulitis
  • Barium enema can be done, but are insensitive and
    may cause perforation due to the introduction of
    barium at high pressures
  • Routine labs include CBC, electrolytes,
    BUN/creatinine, UA
  • Sigmoidoscopy and colonoscopy are performed only
    after inflammation has decreased

102
Diverticulitis
  • Differential Dx
  • Similar to that of appendicititis, Crohn disease,
    UC, and C.difficile colitis

103
Diverticulitis
  • Treatment
  • NPO, IVF, electrolyte correction, NG for
    obstruction, Broad spectrum atbx, observation for
    complications
  • Outpatient management includes liquids only for
    48 hours and oral antibiotics(Cipro, flagyl,
    bactrim, ampicillin)

104
Diverticulitis
  • Disposition
  • Patients without signs of peritonitis or systemic
    infection maybe treated as outpatients with
    careful follow up arranged. Should be instructed
    to return for fever, increasing pain, unable to
    tolerate po.

105
Diverticulitis
  • If patient shows signs of systemic infection,
    perforation or peritonitis then they should be
    hospitalized with a surgical consult

106
Questions
  • 1. With a retrocecal appendix, the pain of acute
    appendicitis may localize to the right flank.
    (True or false)
  • 2. Outpatient antibiotics is the standard
    treatment of acute appendicitis. (True or False)

107
Questions
  • 3. Special populations of people that may have
    delayed diagnosis of acute appendicitis due to
    atypical presentation include
  • A.) very young patients
  • B.) elderly patients
  • C.) AIDS patients
  • D.) Pregnant patients
  • E.) all of the above

108
Questions
  • 4. Crohn disease can involve
  • A.) any part of the GI tract(from mouth to anus
  • B.) colon only
  • C.) esophagus only
  • D.) small intestine only

109
Questions
  • 5. Ulcerative colitis and Crohn disease are both
    considered types of inflammatory bowel disease.
    (True or False)
  • Answers 1T, 2F, 3E, 4A, 5T
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