Appendicitis
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APPENDICITISAPPENDICITIS
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Anatomy and physiology of Anatomy and physiology of appendixappendix
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The appendix is a slender, worm-shaped pouch, averaging 5—10cm in length, that protrudes from the top of the colon in the lower right abdomen
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LocationLocation
• McBurney’s point:one-third of the McBurney’s point:one-third of the way from the anterior,superior iliac way from the anterior,superior iliac spine to the umbilicus.spine to the umbilicus.
• Pelvis and right ilac fossa appendixPelvis and right ilac fossa appendix
• Anterior or posterior ileum appendixAnterior or posterior ileum appendix
• Retrocaceal appendix Retrocaceal appendix
• Right lateral caceal appendixRight lateral caceal appendix
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Retrocaceal appendixRetrocaceal appendix
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Supply & nerveSupply & nerve
• Appendix artery: a final artery ,from Appendix artery: a final artery ,from ileocolic arteryileocolic artery
• Appendix vein Appendix vein : : portal veinportal vein
• sympathetic nerve :celiac plexus and sympathetic nerve :celiac plexus and lesser splanchnic nerve lesser splanchnic nerve T10,T11T10,T11
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AAcute appendicitis cute appendicitis
Appendicitis is a Appendicitis is a common common cause of cause of abdominal abdominal painpain
life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation
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EtiologyEtiology
• Obstruction: Obstruction:
anatomy :wormed-shapedanatomy :wormed-shaped
narrownarrow
plenty of lymph glands plenty of lymph glands
mechanical reason: mechanical reason:
food residue, ascarid, food residue, ascarid,
tumor,etc. tumor,etc.
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EtiologyEtiology
• Gastrointestial diseaseGastrointestial disease
• Bacteria invasion:Bacteria invasion:
all kinds of Gall kinds of G- - bacilusbacilus
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Pathology Pathology
Four type:Four type:
• Acute simple appendicitisAcute simple appendicitis
• Acute purulent appendicitisAcute purulent appendicitis
• Perforation and gangrenousPerforation and gangrenous
• Appendiceal abscessAppendiceal abscess
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Acute simple appendicitisAcute simple appendicitis
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Acute purulent Acute purulent appendicitisappendicitis
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Perforation and gangrenousPerforation and gangrenous
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GangrenousGangrenous
Perforation
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Appendiceal abscessAppendiceal abscess
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Results Results
• Inflammation disappearInflammation disappear
• Inflammation localizationInflammation localization
• Inflammation diffusionInflammation diffusion
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Clinical manifestationClinical manifestation
symptoms : symptoms :
• abdominal pain :abdominal pain :
Periumbilical or epigastric pain that Periumbilical or epigastric pain that migrates to right lower quadrantmigrates to right lower quadrant
Pain becomes persistent and well Pain becomes persistent and well localized. It worsens with moving, localized. It worsens with moving, breathing deeply, coughing, breathing deeply, coughing, sneezing, walking, or being touchedsneezing, walking, or being touched
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Symptoms : Symptoms :
• Gastrointestinal Gastrointestinal symptoms:symptoms:
Anorexia, nausea, and vomiting Anorexia, nausea, and vomiting occur after the onset of painoccur after the onset of pain
ConstipationConstipation
DiarrheaDiarrhea
bladder and rectum stimulus bladder and rectum stimulus symptomssymptoms
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Symptoms Symptoms
• General symptoms : General symptoms :
tired ,headachtired ,headach
feverfever
Rapid pulse Rapid pulse
• SIRS (systemic inflammatory SIRS (systemic inflammatory response syndromeresponse syndrome))
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Signs Signs
• Tenderness in the right lower Tenderness in the right lower abdomen, usually about a third of abdomen, usually about a third of the distance from the navel to the the distance from the navel to the top of the hip bone top of the hip bone
peritoneal irritation sign : muscular peritoneal irritation sign : muscular rigidityrigidity
Blumberg signBlumberg sign bowel sounds disappearbowel sounds disappear
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Others Others
• Rovsing’s sign:pain in the right Rovsing’s sign:pain in the right lower quadrant upon palpation of lower quadrant upon palpation of the left lower quadrant.the left lower quadrant.
• Psoas sign :pain on active Psoas sign :pain on active elevation of the legselevation of the legs
• The obturator sign: pain on The obturator sign: pain on internal and external rotation of internal and external rotation of the hipthe hip
• Rectal exam & vaginal examRectal exam & vaginal exam
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Lab test Lab test
• Mild to moderately elevated WBC Mild to moderately elevated WBC with left shift is typical but rarely with left shift is typical but rarely may be normal, range of 11000-may be normal, range of 11000-17000/mm17000/mm33
over 20000/ mmover 20000/ mm3 3 perforationperforation
• UA may show ketonuria or a few UA may show ketonuria or a few RBCs or WBCsRBCs or WBCs
• pregnancy test (women only)pregnancy test (women only)
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Lab testLab test
• B-usB-us
• X-rayX-ray
• Diagnostic abdominal punctureDiagnostic abdominal puncture
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DiagnosisDiagnosis
•Periumbilical or epigastric pain Periumbilical or epigastric pain that migrates to right lower that migrates to right lower quadrantquadrant
•Tenderness in the right lower Tenderness in the right lower abdomen, usually about a third abdomen, usually about a third of the distance from the navel of the distance from the navel to the top of the hip boneto the top of the hip bone
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Differential diagnosis Differential diagnosis
Two type :Two type :
A: required surgeryA: required surgery
B: not required B: not required surgerysurgery
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Differential diagnosisDifferential diagnosis
Required surgeryRequired surgery::
• Perforation of gastointestinal tractPerforation of gastointestinal tract
ulcer,tumor, diverticulitisulcer,tumor, diverticulitis
• obstetrics and gynecologic disease:obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsionectopic pregancy,ovarion torsion
• Meckel diverticulitisMeckel diverticulitis
• Tumor Tumor
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Differential diagnosisDifferential diagnosis
Not required surgeryNot required surgery• Pelvic inflammationPelvic inflammation
• Mesenteric adenitis:at exploration a Mesenteric adenitis:at exploration a normal appendix and enlarged lymph normal appendix and enlarged lymph nodes in the mesenterynodes in the mesentery
• Viral & bacterial gastroenteritisViral & bacterial gastroenteritis
• Pneumonia, pleurisyPneumonia, pleurisy
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MATERIALS AND METHODS
The Alvarado score• Symptoms • Score migratory right iliac fossa pain 1 nausea/vomiting 1 anorexia 1
• Signs RIF tenderness 2 fever >37.30C 1 rebound pain in RIF 1
• Laboratory test leucocytosis (>10 X 109/L) 2 neutrophilic shift to the left >75% 1 • Total score 10
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CONCLUSION
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Treatment Treatment
• Early operation:Early operation:
surgical removal(appendectomy)surgical removal(appendectomy)
• Acute simple appendicitis: Acute simple appendicitis: appendectomy appendectomy
• Acute purulent and gangrenous Acute purulent and gangrenous appendicitis:appendicitis:
appendectomy and/or drainage appendectomy and/or drainage
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Treatment Treatment
Appendiceal abscessAppendiceal abscess::
• if local in right low quadrantif local in right low quadrant
antibiotic therapy and general treatmentantibiotic therapy and general treatment
• if infection diffusionif infection diffusion
incision and drainageincision and drainage
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Treatment Treatment
OperationOperation
• Incision :Incision :
incision over the point of maximal incision over the point of maximal tenderness,generally at McBurny pointtenderness,generally at McBurny point
true McBurney’s incisiontrue McBurney’s incision
tansvers skin incisiontansvers skin incision
3—6cm long3—6cm long
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Incision Incision
• McBurney’s McBurney’s
incisionincision
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IncisionIncision
• tansvers tansvers skin skin incisionincision
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TreatmentTreatment
OperationOperation
• Process:Process:
The taenia of The taenia of the colon are the colon are followed to followed to the base of the base of the appendixthe appendix
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TreatmentTreatment
OperationOperation
• Process:Process:
Mesoappendix Mesoappendix is divided is divided between between clamps and clamps and ligatedligated
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TreatmentTreatment
Operation Operation • Process:Process:The base of The base of
appendix is appendix is divided and divided and ligated 0.5cm ligated 0.5cm from caceum and from caceum and inverted using a inverted using a purse-stringpurse-string
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aa
b c
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Treatment Treatment
•Suspected case: not definite.Suspected case: not definite.
Admit the patient to hospital for Admit the patient to hospital for further observation 12-24hrsfurther observation 12-24hrs
Operation Operation
exploration incisionexploration incision
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Treatment Treatment
Antibiotic thearpy:Antibiotic thearpy:
• Acute simple appendicitisAcute simple appendicitis
• Contraindication of operationContraindication of operation
• Appendiceal abscessAppendiceal abscess
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TreatmentTreatment
Antibiotic thearpyAntibiotic thearpy
antibiotics: broadspectrum antibioticsantibiotics: broadspectrum antibiotics
ampicillin-sulbactamampicillin-sulbactam
gentamycin triad drugsgentamycin triad drugs
metronidazolmetronidazol
33rdrd generation cefotides generation cefotides
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Treatment Treatment
• New method :New method :
laparoscopy appendectomylaparoscopy appendectomy
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Complication Complication
Acute appendicitis:Acute appendicitis:
• Abdomen abscessAbdomen abscess
• Inter or extra fistulaInter or extra fistula
• PhylephlebitisPhylephlebitis
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ComplicationComplication
Operation :Operation :
• Incision infectionIncision infection
• Peritonitis and abdomen abscessPeritonitis and abdomen abscess
• BleedingBleeding
• Stool fistula Stool fistula
• Stump infectionStump infection
• Adhesive intestinal obstructionAdhesive intestinal obstruction
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Appendicitis in neonateAppendicitis in neonate
• SeldomSeldom
• Non-specific clinical manifestationNon-specific clinical manifestation Anorexia, nausea, and vomiting Anorexia, nausea, and vomiting
diarrheadiarrhea
dehydrationdehydration
• Difficult in early diagnosisDifficult in early diagnosis
• High rate of perforationHigh rate of perforation
• High mortalityHigh mortality
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Appendicitis in neonateAppendicitis in neonate
Diagnosis &TreatmentDiagnosis &Treatment
• Carefully physical examCarefully physical exam
• Early operationEarly operation
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Appendicitis in childAppendicitis in child
• Quick onset and severeQuick onset and severe
high fever and vomiting present earlyhigh fever and vomiting present early
• Non-typical tenderness at right low Non-typical tenderness at right low quadrantquadrant
• High rate of perforationHigh rate of perforation
• High mortalityHigh mortality
• More complicationMore complication
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Appendicitis in childAppendicitis in child
Treatment:Treatment:
• Early operationEarly operation• Transfusion and correct Transfusion and correct dehydrationdehydration
• Broadspectrum antibioticsBroadspectrum antibiotics
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Appendicitis in pregnancyAppendicitis in pregnancy
Uterus enlargementUterus enlargement
elevation of abdominal
wall
Tenderness site upper shift
appendix displaced
superiorly
Inconspicuous oftenderness
rebound tendernessmuscular rigidity
Without adherent blanket of
omentum
Peritonitis diffusion
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Appendicitis in pregnancyAppendicitis in pregnancy
Treatment :Treatment :• Operation :appendectomyOperation :appendectomy• To late pregancy :early operationTo late pregancy :early operation• Superior Incision Superior Incision • No drainageNo drainage• Broadspectrum antibioticsBroadspectrum antibiotics• Parturient with perforation :Parturient with perforation : cesarean section and appendectomycesarean section and appendectomy
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Appendictis in the elderlyAppendictis in the elderly
• Less well-defined symptoms and Less well-defined symptoms and signssigns
• Severe pathologic typeSevere pathologic type
• Error diagnosis easilyError diagnosis easily
• High rate of perforationHigh rate of perforation
• Pay attention to tumorPay attention to tumor
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Chronic appendicitisChronic appendicitis
• Etiology and pathologyEtiology and pathology
• Clinic feature and diagnosisClinic feature and diagnosis
right low quadrant painright low quadrant pain
local tendernesslocal tenderness
x-ray x-ray
• Treat Treat
appendectomyappendectomy