Post on 10-Apr-2018
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Acute Appendicitis
Clifford CaruanaMater Dei Hospital
4th February 2009
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Definition
Sudden inflammation of the appendix usuallycaused by obstruction of the lumen resulting
in invasion of the appendix wall by the gut
flora
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Epidemiology
RIF pain is common 50% of acute abdo pain
Accounts for 2% of all hospital admissions 7-12% of population
70,000 appendicectomies per year UK
Incidence decreasing
M>F
Age
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Age
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Surgical Anatomy
Only humans, some apes and wombat
Continuation of the caecum
Origin 2.5 cm below ileocecal valve frompostero medial aspect of caecum
Taeni coli coalesce
Length usu 5-10 cm (1-25cm)
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Surgical Anatomy - Position
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Surgical Anatomy
Congenital absence rare 68 cases reported
Duplication -
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Pathology
Obstruction of the lumen
Submucosal lymphoid hyperplasia
Faecolith / faecal stasis Inspissated barium
Vegetable/fruit seeds
Worms (Entrobius vermicularis
Tumours of caecum/appendix
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Pathology
Secondary infection
Continued mucous production
Mucus PUS
Distension of appendix visceral pain pressure blocks lymph and venous drainage oedema
Irritates parietal peritoneum Localised more
severe Pain Ellipsoidal infarcts in antimesenteric border
perforation
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Clinical Features - Symptoms
Typical periumbilical/epig pain that shifts to
RIF (50%)
Afebrile/low grade fever (high in perf) Anorexia
Nausea
Constipation/Diarrhoea
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Clinical features - Signs
RIF tenderness Guarding
Percussion tenderness (rebound)
Tachycardia Brown-furred tongue
Foul Breath
Hyperaesthesia (Sherrens Triangle)
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Clinical Features Special Signs
Rovsings sign
Pointing sign
Psoass Sign (Copes) Obturator test
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GIT
Gastroenteritis
Mesenteric adenitis
Intestinal obstruction
Meckles diverticulitis
Terminal ileitis (Crohns, Yersinia enterocolytica)
Ca Caecum
Sigmoid diverticulitis Acute typhlitis
(Cholecystitis, Perf ulcer)
Differential diagnosis
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Differential diagnosis
Gynae
Salpingitis
Ectopic gestation
Rt Ovarian torsion
Ruptured ovarian follicle (Mittelschmerz)
Urinary tract
Renal colic
Pyelonephritis
Testicular torsion
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Differential diagnosis
Others
Referred pain (Pneumonia, pleurisy)
Preherpitic neuralgia Porphyria
Henoch Schonlein syndrome
Pancreatitis
Rectus sheath haematoma
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Investigations
Dx is a clinical one
WCC 70% - 90% - elevated WCC.
Neutrophilia CRP
Urinalysis pyuria/haematuria (do not
exclude appendicitis)
HIT
AXR limited value
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Abdominal X-ray
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Graded compression Ultrasound
Depends on the technique and
experience
Thin pts better
Normal appendix
a blind-ended, tubular structure
with a maximum wall thickness of
2 mm with an outer diameter of
6 mm, No peristalsis
Originates from the base of the
cecum
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Graded compression Ultrasound
Thickened wall >3 mm
Diameter >6 or 7 mm
Noncompressible
Appendolith
Circumferential color
flow
Echogenic mesentery Free fluid
Abscess
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CT
variable degree of distension (diameter 640mm)
wall thickness of 13 mm.
Wall - asymmetrically thickened enhanceswith intravenous contrast medium.
periappendiceal inflammatory mass
Thickening and enhancement withintravenous contrast - adjacent wall of thececum or ileum
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CT
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Scoring systems
Alvarado Score
Samuel Score (Paediatric)
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Alvarado ScoreFeature Score
Abdominal pain that migrates to the RIF 1
Anorexia / ketnouria 1
Nausea/vomiting 1
Tenderness in RIF 2
Rebound tenderness 1
Temperature > 37.3 1
WCC >10,000/L 2
Neutrophilia 14th Feb 09 23
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Delayed diagnosis
Pregnant females similar incidence.
gestational age ass c` dx accuracy perf
risk
Very young children lack of history + non-
specific symptoms. Underdeveloped
omentum
Elderly often overlooked assmortality
Major mental illness impaired capacity,
difficulty accessing healthcare, misdiagnosis4th Feb 09 24
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Management
Patients c` appendicitis should be preparedfor theatre
Patients c` atypical features further imaging
/ observation / Dx - Laparoscopy
Meta-analysis combination of a stronginflamm response (WCC CRP); signs ofperitoneal irritation; migratory painHIGHpredictive power
Open vs Laparoscopy
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Management
LA OA
Decreased wound infection rate Cheaper
Earlier return to normal life Shorter operating time
Shorter Hospital stay
Can assess the rest of the abdominal
cavity with ease? Associated with increased intra-
abdominal infections
More beneficial in obese, females and
employed pts
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Open Appendicectomy
Incission (transverse, Mc Burneys point)
Open in layers. (muscle split along its fibres)
Check for fluid (+/-c&S)
Identify caecum and exteriorized follow taeniae toappendix
Mesoappendix divided + ligated
Clamp appendix 5mm above caecum and ligated
Cauterise residual mucosa +/- purse string (not req) Return caecum, wash with warm saline
Close in layers
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Laparoscopic Appendicectomy
Usu 3 ports. 1 umbilical, 1 suprapubic (12mm)
and 1 rt periumb region (anatomy) (5mm)
Pneumoperitoneum (10-14mmHg) Appendix is grasped and retracted up to
expose mesoappendix dividedligated
Appendix transacted and delivered in
endobag
Peritoneal irrigation
Closure of fascia and skin4th Feb 09 28
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POSTOP
IV fluids till oral fluids are tolerated
Antiemetic
Analgesia
Early ambulation
Home once oral diet tolerated
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Antibiotics
Should be used routine in emergency
appendicectomies
Single use preop is enough after non-perfappendicectomy
No need for oral after finishing IV (even after
perf)
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Appendiceal masses
Typically present late
Palpable tender mass in RIF
Should be treated conservatively - IV fluids +antibiotics (resolves or forms abscess)
abscess (drained open or percutaneous)
Interval appendicectomy may be considered
but no longer recommended
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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)
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Follow up
Most are discharged within 48hrs
Normal activities within few weeks (earlier for
LA) Rountine outpatient review is not common
practice
1% have appendiceal tumours - carcinoid
Tumours >1cm consider rt hemicolectomy
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