APPENDICITIS

An inflammation of the vermiform appendix, which is the small, finger-shaped pouch attached to the beginning of the large intestine on the lower-right side of the abdomen, caused by the obstruction of the tubular space inside the appendix. The initial problem is inflammation caused by obstruction of the blood vessels supplying it, and infection. If the disease is not treated, eventually the appendix will rupture and can lead to severe conditions such as Peritonitis ,Sepsis and even death.

Vermiform (Latin )=> Worm like , Appendix =>> Vermiform AppendixInitially appendix was the site for digestion of cellulose but nowadays, it is n vestigial organ in human beings and absent in many animals.Beside this, it is considered in playing important role in immune system which helps in the maturation of B lymphocytes which will help in production of antibodies A (IgA).

DEMOGRAPHICSINCIDENCE:

Appendicitis is the most common abdominal emergency found in children and young adults. In Europe and America, the incidence of appendicitis is about 100 per 100,000 patients per year.

AGE:In the United States, the highest incidence of appendicitis is found in the age group of 10-19. The incidence is highest among males aged 10 to 14, and among females aged 15 to 19. It is rare in infants and children under the age of 2.

GENDER:Males have a 1.4 times increased presentation of appendicitis compared to women across all age groups.

RACE:Appendicitis rates were 1.5 times higher in white people.

PATHOPHYSIOLOGY• acute appendicitis seems to be the end result of a primary obstruction of

the appendiceal lumen.• Once this obstruction occurs, the appendix becomes filled with mucus and

distends, causing increased intraluminal and intramural pressures.• The increase in pressure leads to thrombosis and occlusion of the small

vessels.• As bacteria begin to leak out through the dying walls, pus formation occurs

within and around the appendix causing appendiceal rupture leading to peritonitis, septicemia and eventually death.

CAUSES

• Obstruction of the lumen is the dominant causal factor. The obstructing object can be:*fecalith ; the most common*lymphoid tissue hypertrophy*inspisated barium from previous study*tumors*seeds

ANATOMY OF APPENDIX

1. Part of gastrointestinal or digestive system 2. 8 to 10 cm hallow tube that is closed at one end and is attached at other

end to cecum Appendix is located near the junction of small intestine and large

intestine in right lower quadrant of the abdomen near the right hip done Appendix position within the abdomen corresponds to a point on the surface

known as Mc Burney’s point. Mc Burney’s point- 1/3 of the distance from anterior superior iliac spine to

umbilics The relationship of base of appendix to cecum remains constant, whereas

the tip can be found in rectrocecal, plevic, subcecal, perileal or right precolic position

Found at a point where taniae coli converges on posteromedial wall of cecum

Mesoappendix peritoneal fold enclosing appendicular vesselsIt is prolongation of the mesentry of terminal ileum

BLOOD SUPPLY TO THE APPENDIX Arterial supply to appendix is by means of the appendicular artery,

inferior branch of ileocolic artery of superior mesentirc trunk Appendicular vein, branch of ileocolic vein drains appendiceacl venous

network into superior mesentric vein and eventually into portal circulation

LYMPH SUPPLY Lymph vessel drains into one or two nodes lying in the mesoappendix, from there lymph passes to no of mesentric nodes to reach superior mesentric node

NERVE SUPPLYThe nerve of appendix are derived from sympathetic and parasympathetic (vagus) nerve from superior mesenteric plexus

Cause of Inflammation:

Appendicitis is caused by the obstruction of the appendix lumen. This initial

problem is compounded into a cascade of events that lead to the inflammation of the appendix, the obstruction of the blood vessels supplying it, and infection.Once this obstruction occurs, the appendix subsequently becomes filled with mucus and distends, causing increased intraluminal and intramural pressures.The increase in pressure leads to thrombosis and occlusion of the small vessels, and stasis of lymphatic flow.As these clots and blockages progress, the appendix becomes ischemic and then necrotic.Rarely, spontaneous recovery can occur at this point. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration).The end result of this cascade is appendiceal rupture causing peritonitis, which may lead to septicemia and eventually death.

FUNCTION

Appendix was viewed as vestigial organ with no known function Now well recognized that appendix is immunologic organ that

actively participates in secretion of immunoglobulin particulary immunoglobulin A.

Lymphoid tissue first appears in the appendix approximately 2 week after birth

Also known as housekeeper of good bacteria

Treatment

Appendicitis can be treated surgically and also non-surgically. Usually surgery is mainly focused in removal of appendix as it can rupture easily. Surgical removal of appendix is based on two types of surgery:

Open appendectomy: Open appendectomy is the traditional method and the standard treatment for appendicitis. The surgeon makes an incision upto 2-4 inches long in the lower right abdomen, cuts through fat and muscles, pulls the appendix through the incision, ties it off at its base, and removes it. Care is taken to avoid spilling purulent material (pus) from the appendix while it is being removed. The incision is then sutured.

Generally McBurney incision or Rocky Davis incision is taken into consideration. In McBurney incision the cut is 2-5 cm from the right ilium's anterior superior spine, through the external oblique to the internal oblique and transversalis muscles. Whereas in Rocky Davis incision the incision is placed transversely (as opposed to obliquely, like the McBurney’s incision) between the junction of the lower and middle third of a line from the superior anterior iliac spine to the umbilicus and the lateral border of the rectus abdominis muscle.

In case of presence of abscess the incision is laterally displaced to allow retroperitoneal drainage. Taeniae coli is converged at the base of the appendix. Mesoappendix is divided and the appendix is mobilized with ligation of the appendiceal artery.

Laparoscopic Appendectomy: The laparoscopic (minimally invasive) surgical technique involves making several tiny cuts in the abdomen and inserting a miniature camera and surgical instruments. Three incisions are made in the abdomen where ag po

port or nozzle is inserted with carbon dioxide in order to inflate appendix then through second port laparoscope is inserted, camera projects a magnified image of the area onto a television monitor which helps guide the surgeons as they remove the appendix then in third port surgical instrument is inserted and appendix is removed.

Port Placement:

10-mm trocar placed through umbilicus (this port holds camera)

5-mm trocar placed at suprapubic region

5-mm trocar placed at lower left quadrant.

Instrument used in Laparoscopy:

Atraumatic grasper

Laparoscopic scissors

Dissector

Endo GIA (or stapler, or endoloop ligature applicator)

Suction/irrigation device

Extraction tube

Extraction bag

Zero-degree scope

3 Trocars (two 5mm and one 10mm)

Alternately, electrocautery tools may also be used.

Appendix can also be treated non surgically usually in the early signs and symptoms of appendicitis before its rupture. The antibiotics used according as prescribed during this early phase within 4-6 weeks can treat the appendix. These are numerous types of antibiotics that can be used for the treatment of appendix:

imipenem-cilastatin

metronidazole

ciprofloxacin

ampicillin

clindamycin

levofloxacin

cefoxitin

cefazolin

cefotetan

ampicillin-sulbactam

ertapenem

ticarcillin-clavulanata

Preventions

There is no sure way to prevent appendicitis because it comes on suddenly and the cause is usually unknown. However, eating a diet that includes fresh vegetables and fruit with high fibers may lower your risk of getting appendicitis that makes stool softer and prevents the chances of wastes to be sticked in the appendix.

To decrease the rate of rupture, get medical care right away for severe abdominal pain.