Dr.EHAB TOTAH

Dr.EHAB TOTAH
DEFINITION
Sudden inflammation of the
appendix usually
caused by obstruction of the
lumen
Epidemiology
. Accounts for 2% of all hospital admissions
. 7-12% of population
. M>F
. 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.
. Age mainly affecting the adolescence age
group
Surgical anatomy
• Origin 2.5 cm below ileocecal valve from
postero – medial aspect of cecum
• Taenia coli coalesce
• Length usually 5-10 cm (1-25cm)
• Blood supply – appendiceal artery (end artery) ileocolic – SMA
.The appendix has an immunological function
particularly IgA secretion.
SURGYCAL ANATOMY-POSITION
Pathophysiology
.Acute appendicitis is thought to begin
with obstruction of the lumen
Obstruction can result from:
– Submucosal lymphoid hyperplasia
– Faecolith / faecal stasis
– Inspissated barium
– Vegetable/fruit seeds
– Worms (Entrobius vermicularis
– Tumors of cecum/appendix
Pathophysiology
. Mucosal secretions continue to increase
intraluminal pressure
. 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.
Pathophysiology
.Increased pressure also leads to arterial stasis
and tissue infarction
.End result is perforation and spillage of infected
appendiceal contents into the peritoneum
.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.
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
.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.
Pathophysiology
.Exceptions exist in the classic presentation due to
anatomic variability of the appendix position .
.Appendix can be retrocecal causing the pain to
localize to the right flank
.In pregnancy, the appendix can be shifted and patients
can present with RUQ pain.
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
Clinical Features - Symptoms
• Typical – periumbilical/epigastric pain
that shifts to RIF (50%).
• Afebrile/low grade fever (high in perf.)
• Anorexia
• Nausea
• Constipation/Diarrhea
• RIF tenderness Guarding
• Percussion tenderness (rebound)
• Tachycardia
Clinical Features – Special Signs
McBurney’s Point: just below the middle of a
line connecting the umbilicus and the ASIS
Rebound tenderness sign: Pain upon sudden
release of pressure over the McBurney’s Point
•Rovsing’s
LLQ
•Psoas’s
sign: pain in RLQ with palpation to
Sign :place patient in L lateral decubitus
and extend R leg at the hip. If there is pain with
sign is positive this movement, then the
•Obturator
test :passively flex the RT hip and
knee and internally rotate the hip. If there is
increased pain then the sign is positive
•Pointing sign
Differential diagnosis
• GIT
– Gastroenteritis
–Mesenteric adenitis
-Meckle’s diverticulitis
-Terminal ileitis
– Acute typhlitis
– Ca Cecum
Differential diagnosis
• Gynae
– Salpingitis
– Ectopic gestation
– Rt. Ovarian torsion
– Ruptured ovarian follicle .
• Urinary tract
– Renal colic
– Pyelonephritis
– Testicular torsion
Investigations
CBC: the WBC is of limited value.
Sensitivity of an elevated WBC is 7090%, but
specificity is very low.
UA: abnormal UA results are found
in 19-40%
Abnormalities include: pyuria,
hematuria, bacteruria
Investigation
.Imaging studies: include X-rays,
US, CT
.X-rays of abd. are abnormal in
24-95%
.Abnormal findings include:
fecalith, appendiceal gas, localized
paralytic ileus, and free air
Abdominal X-ray
Ultrasound finding
.Thickened wall >3
mm
.Diameter >6 or 7
mm
• Noncompressible
• Appendolith
• Free fluid
• Abscess
CT finding:
• variable degree of distension (diameter 640mm)
• wall thickness of 1–3 mm.
• periappendiceal inflammatory mass
• Thickening and enhancement with
intravenous contrast - adjacent wall of the
cecum or ileum
CT finding:
Scoring system:)Alvarado Score)
Feature
Score
Abdominal pain that migrates to the
RIF
Anorexia
1
Nausea/vomiting
1
Tenderness in RIF
2
Rebound tenderness
1
Temperature > 37.3
WBC >10,000/μL
1
Left shift
1
1
2
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
Diagnosis
.Acute appendicitis should be
suspected in anyone with epigastric,
periumbilical, right flank, or right
sided abd pain who has not had an
appendectomy.
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
Post op:
1.IV fluids till oral fluids are
tolerated
2. Antiemetic
3.Analgesia
4.Early ambulation
5. Home once oral diet tolerated
complications:
.Death is rare
• Perforated appendix - ~30%
complication rate
• Wound infection +/-dehiscence
• Intra-abdominal abscess
• Cecal fistulas
• Small bowel obstruction
(adhesions) (esp. after perf.)
• Ileus
• Stump appendicitis (ass with
long appendiceal stump)
Follow up:
• Most are discharged within 48hrs
• Normal activities within few weeks
(earlier for
LA)
• Routine outpatient review is not
common
practice
• 1% have appendiceal tumors carcinoid
• Tumors >1cm – consider rt
hemicolectomy
Thank you