APPENDICITIS

BYPROF/ GOUDA ELLABBAN

definition• Two clinical syndromes of acute appendicitis1. Acute catarrhal “nonobstructive”2. Acute obstructive• Eventually oedema & mucosal ulceration occur

with bacterial translocation to submucosa• Then as distention progress venous obstruction

leads ischemia of the appendix wall with bacterial translocation muscularis propria producing acute appendicitis

• So, its a transmural inflammation of the appendix

Etiology • Obstruction of the appendix lumen by 1. fecaliths 2. Lymphoid hyperplasia “ probably d.t viral infection”3. Foreign body “seeds”4. Stricture “ indicate previous appendicitis” 5. Tumor “ carcinoma of the colon or carcinoids tumor”6. Parasitic infestation particularly by oxyuris vermicularis

“pinworm” 7. IBD• Bacterial proliferation of mixed aerobic & anaerobic

organism is usual.

Clinical presentationsymptom

• Typical presentation

start as periumbilical colicky pain associated with anorexia, nausea & one or two vomiting at the onset

Then the pain shifted to right iliac fossa Atypical presentation

predominantly visceral or somatic poorly localized abdominal pain, its commonly occurs in elderly.

• usually, after 6 hours there is slight pyrexia “37.2-37.7” & tachycardia “80-90”

Clinical presentation sign• Inspection, limitation of respiratory movement at lower

abdomen• Palpation

muscle guarding, tenderness & rebound tenderness at RLQ particularly at McBurney’s point

Rovsing's sign suggests the possibility of appendicitis

The Psoas sign & obturator test “Zachary Cope”

Special feature, according to position of the appendix

• Retrocaecal 74%• Pelvic 21%• Postileal 5%

retrocaecal

tenderness may be lacking even on deep palpation in the usual site. However is often present at loin with guarding at quadratus lumborum.

Psoas spasm may be sufficient to cause hip flexion

pelvic

• It may never produce somatic pain in anterior abdominal wall

• It may cause suprapubic discomfort & tenesmus or diarrhea if irritate the rectum or urinary symptoms if irritates the ureter or bladder

• Tenderness may only be elicited by rectal examination at pouch of Douglas especially RT side

• Can cause spasm of Psoas & abturator internus

postileal

• Accounts for some cases of “missed appendicitis”

• Pain may not shifted, with tenderness if present it ill-defined or immediately to the RT of the umblicus

• Diarrhea & marked retching may occur

• At pregnancy the cecum & appendix are pushed to the RUQ at the 2nd & 3rd trimesters, result in flank or back pain & may confused with pyelonephritis

• In case of failure of the cecam to migrate to its normal position, it will be near at gallbladder

• In case of situs inversus viscerum its at left side

complication• Perforation acute toxemia septicemia & portal pyemia generalizes peritonitis or appendicular abscess• Appendix mass its occur when the greater omentum & loop of small bowl become adherent to

the inflamed appendix• Appendicular fistula in which the inflamed appendix attach to abdomenal wall making a fistula• Mucocele of the appendix if its rupture it gives pseudomyxoma peritonei in which case the RT

hemicoletomy is the correct treatment

Differential diagnosis

children Adult male Adult female elderly

Gastroenterits Mesenteric adenitisMeckel`s

diverticulitisIntussusceptionHenoch-schonlein

purpura

Lobar pneumonia

Regional enteritisUreteric colicPerforated ulcerTorsion testisPancreatitisRectus sheath hematmoa

MittelschmerzSalpingitisPyelonephritisEctopic pregnancyTorsion/rupture of ovarian cystendometriosis

Sigmoid diverticulitisIntestinal obstructionColonic carcinomaTorsion appendix epiploicaMesenteric infarction

Aortic aneurysm

Diagnosis & investigation

Diagnosis is based on history and physical examination backed by blood tests and other diagnostic procedures.

The classical physical finding in Appendicitis is diffuse pain in the umbilical region which can become localised at McBurney's point if the inflammed appendix comes into contact with the parietal peritoneum. This point is located on the right-hand side one-third of the distance between the anterior superior iliac spine and the navel, or approximately one hand's width.

Other methods include a digital rectal exam, where a finger is inserted into the rectum - if There is right sided tenderness (where the appendix normally lies), it makes it more likely that the patient has appendicitis.

Other Signs used in the diagnosis of Appendicitis are the psoas sign (common in retrocecal appendicitis), the obturator (internus) sign, Blomberg's sign and Rovsing's sign.

Laboratory evaluation:

complete blood cell count a leukocyte of greater than 10,000 cell/mL with polymorph nuclear cell predominance (70%) is common in the child young adult with appendicitis

urinalysis is abnormal in 25% to 40% of patient with appendicitis pyuria,albuminuria and hematurria are common

serum electrolytes, blood urea nitrgen and serum creatinine are obtained to idetify and correct electrolyte abnormalities cause by dehydration secondry to vomiting or poor oral intake .

Radiological evaluation

Abdominal X-ray are not helpful in diagnosing appendicitis Ultrasonography and Doppler sonography provide

useful means to detect appendicitis, but in a not neglectable minority of cases (15% approximately), especially those in an early stadium without fluid build-up, an ultrasonography of the iliac fossa region do not reveal abnormalities despite of present appendicitis

sonographic imaging can often distinguish between Appendicitis and another disease with very similar symptoms, namely the inflammation of the lymph nodes near the appendix.

CT scan is easily and readily available, it is the preferred test of choice. A properly performed CT scan has a detection rate (sensitivity) of over 95%. What is looked for on CT scan is the lack of contrast(oral dye) in the appendix as well as Signs of appendiceal enlargement, usually >6mm on cross section; There may also be evidence of inflammation in the so called "fat stranding".

Treatment

Appendicitis can be treated by removal of the appendix through a surgical procedure called an appendicectomy (also known as an appendectomy).

Antibiotics are often given intravenously to help kill remaining bacteria and thus reduce the inflammation

Preoperative preparation

Intravenous isotonic fluid replacement should be initiated to achieve a brisk urinary output to correct electrolyte abnormalities

Nasogasric suction is hopeful , especially in patient with peritonitis

Temperature elevations are treat with acetaminophen and cooling blanket

Anesthesia should not be induce in patient with temperature higher than 39 c

Antibiotic therapy broad spectrum antibiotic coverage is initiated preoperative

AppendectomyTypes of incision

Gridiron incision paramedian incision

When the diagnosis is certain

Is a vertical incision lying parallel to the mid line just 1.25-2.5cm from the line

Make a right angle to the line joining Ant.Sup.Illiac Spine to the umbilicus (McBuney’s point)

commonly 2.5cm below the umbilicus and end . just above the pupis

the bladder may getten injured

high incidence of infection and incisional hernia

give limited access to the retrocecal appendix

superficial circumflex art. Usually need legation

done when there is doubt in diagnosis

less post operative complication

paramedian incisionGridiron incision

Laparoscopic appendectomy

Has evolved from a purely diagnostic to a therapeutic modality. the surgical literature to date shows little or no patient benefit over the traditional open procedure. Laparoscopic appendectomy is more costly and offers no decrease in the length of stay or complication, with slight decrease in wound infection but a slight increase intra-abdominal infection

Postoperative complication

Postoperative wound infection can be decreased by appropriate intravenous antibiotics

administered before skin incisionPostoperative intra-abdominal and pelvic abscesses are best

treated by percutaneous CT or US guided aspirationPyelophlebitis is septic portal vein thrombosis, present with

high fever , jaundice and eventually hepatic abscesses. CT scan can demonstrate thrombus and gas in the portal vein .

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