Appendicitis

AppendicitisR.Nandinii

Group K1

Anatomy• a blind muscular tube with mucosal,

submucosal, muscular and serosal layers

• At birth, appendix is short and broad at its junction with the caecum, but differential growth of the caecum typical tubular structure by about the age of 2 years

• During childhood, continued growth of the caecum commonly rotates the appendix into a retrocaecal but intraperitoneal position

• Position of the base of the appendix is constant, being found at the confluence of the three taeniae coli of the caecum, which fuse to form the outer longitudinal muscle coat of the appendix.

Source: Bailey & Loves Short Practice of Surgery 25th ed

Various positions of the appendix:

• Mesentery of the appendix or mesoappendix arises from the lower surface of the mesentery or the terminal ileum and is itself subject to great variation

• Vascularisation Appendicular artery, a branch of the lower division of the ileocolic artery, passes behind the terminal ileum to enter the mesoappendix a short distance from the base of the appendix


Definition:

• An inflammation of the vermiform appendix

Aetiology:• No unifying hypothesis

• Decreased dietary fibre and increased consumption of refined carbohydrates

• Obstruction of the appendix lumen

–Fecolith (composed of inspissated faecal material, calcium phosphates, bacteria, epithelial debris, rarely a foreign body)–Tumour (carcinoma of caecum)–Intestinal parasites (Oxyuris/Enterobius vermicularis –

pinworm)Source: Bailey & Loves Short Practice of Surgery 25th ed

PATHOPHYSIOLOGY

Risk Factors for Perforation of The Appendix


Clinical Manifestations


Special Features Based OnAppendix Locations


Differential Diagnosis


Investigation


Diagnostic Scoring

• Diagnosis is essentially clinical;

• HOWEVER a decision to operate based on clinical suspicion only can lead to the removal of a normal appendix.

• A number of clinical and laboratory-based scoring systems have been devised to assist diagnosis.

• The most widely used is Alvarado score.


The Alvarado (MANTRELS) Score

Score

Symptoms•Migratory RIF pain•Anorexia•Nausea and vomiting

111

Signs•Tenderness (RIF)•Rebound tenderness•Elevated temperature

211

Laboratory•Leucocytosis•Shift to the left (segmented neutrophils)

21

TOTAL 10

• < 5 is strongly against a diagnosis of appendicitis• 7 or more is strongly predictive of acute

appendicitis • In patients with an equivocal score of 5 or 6, abdominal

USG or contrast-enhanced CT scan is used to further reduce the rate of negative appendicectomySource: Bailey & Loves Short Practice of Surgery 25th

ed

CT Scan images of Appendicitis:

1. enlarged appendix 2. appendiceal wall thickening

Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.

CT Scan images of Appendicitis

3. appendicolith 4.periappendiceal fat stranding

Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.

Treatment

• Intravenous fluids

• to establish adequate urine output

• Appropriate antibiotics

• Reduces the incidence of postoperative wound infection

• When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram-negative bacilli as well as anaerobic cocci should be given

• Salicylates

• Appendicectomy


Appendicectomy

• Conventional Appendicectomy

• Laparoscopic Appendicectomy

• Postoperative Complications


Conventional Appendicectomy

Gridiron incision : right angles to a line joining the ASIS to the umbilicus. Centred on McBurney’s point

Lanz incision : 2 cm below the umbilicus centred on the mid-clavicular-midinguinal line

2/31/3

2 cm

Conventional Appendicectomy

• Caecum is identified

• Base of mesoappendix is clamped in artery forceps, divided, and ligated

• The freed appendix is crushed near its junction with the caecum in artery forceps, which is removed and reapplied just distal to the crushed portion

• An absorbable ligature is tied around the crushed portion close to the caecum

• The appendix is amputated between the artery forceps and the ligature

• An absorbable purse-string or ‘Z’ suture may then be inserted into the caecum about 1.25 cm from the base

• The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied, thus burying the appendix stump


Laparoscopic appendicectomy• The placement of operating ports may vary according to operator

preference and previous abdominal scars.

• The operator stands to the patient’s left and faces a video monitor placed at the patient’s right foot.

• A moderate Trendelenburg tilt of the operating table

• The appendix is identify & controlled using a laparoscopic tissue-holding forceps.

• By elevating the appendix, the mesoappendix is displayed

• A dissecting forceps is used to create a window in the mesoappendix to allow the appendicular vessels to be coagulated or ligated using a clip applicator.

• The appendix, free of its mesentery, can be ligated at its base with an absorbable loop ligature,divided, & removed through one of the operating ports.

• It is not usual to invert the stump of the appendix

• A single absorbable suture is used to close the linea alba at the umbilicus, and the small skin incisions may be closed with subcuticular sutures.

• Patients who undergo laparoscopic appendicectomy are likely to have less postoperative pain & to be discharged from hospital and return to activities of daily living sooner than those who have undergone open appendicectomy.


Problems Encountered During Appendicectomy

Problems Management

A normal appendix is found Demands careful exclusion of other possible diagnosisRemove the appendix to avoid future diagnostic difficulties

The appendix cannot be found

Caecum should be mobilised, and the taeniae coli should be traced to their confluence on the caecum before the diagnosis of ‘absent appendix’ is made

An appendicular tumour is found

Small tumours (< 2.0 cm in diameter) can be removed by appendicectomyLarger tumours should be treated by a right hemicolectomy

An appendix abscess is found and the appendix cannot be removed easily

Should be treated by local peritoneal toilet, drainage of an abscess and intravenous antibiotics


Appendix mass• If an appendix mass is present & the condition of the patient

is satisfactory, the standard treatment is the conservative

• Careful recording of the patient’s condition and the extent of the mass should be made and the abdomen regularly re-examined.

• mark the limits of the mass using a skin pencil.

• Temperature and pulse rate should be recorded 4- hourly and a fluid balance record maintained

• A contrast-enhanced CT examination of the abdomen should be performed and antibiotic therapy instigated.

• An abscess, if present, should be drained radiologically.

• Clinical deterioration or evidence of peritonitis is an indication for early laparotomy.

• Clinical improvement is usually evident within 24–48 hoursSource: Bailey & Loves Short Practice of Surgery 25th ed

Criteria for stopping conservative treatment of an appendix mass

• A rising pulse rate

• Increasing or spreading abdominal pain

• Increasing size of the mass


Postoperative Complications

• Wound infection

• Intra-abdominal abscess

• Adhesive intestinal obstruction

• Rare

• Ileus

• Respiratory – pneumonitis or collapse

• Venous thrombosis and embolism

• Portal pyaemia (pylephlebitis)

• Faecal fistula


Other causes of acute appendicitis

• Recurrent Acute Appendicitis

• Neoplasms of the Appendix

Recurrent Acute Appendicitis

• Widely known but unfavourable

• Not uncommon for patients to attribute such attacks to ‘biliousness’ or dyspepsia

• Attacks vary in intensity and may occur every few months

• Through history, patient might have had milder but similar attacks of pain showing fibrotic appendix indicative of previous inflammation

• Chronic appendicitis, per se, does not exist; however, there is evidence of altered neuroimmune function in the myenteric nerves of patients with so called recurrent appendicitis (Büchler)


Excised appendix showing the point of luminal

obstruction with distal fibrosis


Neoplasms Of The Appendix


Appendicitis

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