Refaratacute Appendicitis

7/28/2019 Refaratacute Appendicitis

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First Moscow State Medical University

MEDICAL FACULTY

Division of Foreign Students with Instruction Conducted in English

ACUTE APPENDICITIS

By Nurul Farahida Alias

Medical Faculty, English Medium, Group 93

Supervisor: Dr. Lebedeva M. A.

,

. . .

MOSCOW 2012


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ANATOMY

The appendix is a blind-ended tube connected to thecaecum. Average length is 7.5 10 cm long that hangs off

of the caecum. The caecum is a pouch-like structure of the

colon, and the appendix is located near the junction of the

ileum and caecum. Its Latin name is appendix veriformis.

Location of the tip may varies:-

1. Retrocaecal

2. Pelvic

3. Subcaecal

4. Preileal (behind ileum)

5. Subhepatic

During operation, to find the appendix, you may gently tract on the taenia coli (on

anterior side of colon) then lead to the base of the appendix. Studies proposed that

the appendix may harbor bacterias that beneficial in the function of the humancolon. It is verified being rich in infection-fighting lymphoid cells, suggesting its role

in the immune system.

Blood supply

- The appendix is supplied by the ileocolic artery (a. ileocolica)

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- It passes behind the terminal ileum to enter the mesoappendix

- Thromboses may result in the necrosis of the appendix (gangrenous

appendicitis)

Histology

The layers of appendix are mucosa, submucosa, and muscularis externa.

- Lumen : multiple longitudinal folds of mucous membrane, lined by columnar

cells of intestinal mucosa of colonic type

- Base of crypts : Argentaffins cells (Kulchitskys cells). May give rise to

carcinoid tumors. Carcinoid tumor may present with appendicitis when

appendiceal lumen is occluded.

Submucosa layers have numerous (diffused) lymphoid tissue or follicles. The

follicles have paler germinal centres similar to follicles of Peyers patches in the

small intestine.

Extreme proliferation of the lymphocytes (lymphoid hyperplasia) can be the

consequence of bacterial of viral stimulation that will lead to obstruction of lumen

and causes appendicitis. This may be one of many possible causes of appendicitis.

Mesoappendix is the serosal sheet of peritoneum covers the appendix, which held

the appendicular artery (from ileocolic artery). Sometimes, we may find an

accessory appendicular artery(from posterior caecal artery).

ACUTE APPENDICITIS

It is the inflammation of the appendix. Always, it is

classified as a medical emergency and many cases

required the removal of the inflamed appendix. It often

occurs in people between the ages of 10-30 years old.

Untreated, mortality is high, mainly because of rupturedappendix, peritonitis and shock.

AETIOLOGY

1. Decreased dietary fibre and increased consumption of refined

carbohaydrates.


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2. Bacterial proliferation within appendix. Mixed growth of aerobic and

anaerobis organisms.

3. Obstruction of the lumen

a. Faecolith condensed faecal material, calcium phosphates, bacteris

and apithelial debris

b. Fibrotic structure indicate previous appendicitis that resolved without

surgery

c. Tumor carcinoma of the caecum, usually in middle and elderly age.

d. Intestinal parasites oxyuris vermicularis (pinworm)

PATHOGENESIS

Obstruction of the appendix caused by faecolith, mucous plug, foreign body,

parasite or tumor. ( early signs : periumbilical pain/cramp and vomiting due to

distention of appendix). Narrowing the lumen which causes continuous mucus

secretion and inflammatory exudates. The intraluminal pressure will rise next the

causes edema and mucosa ulceration.

Rapid invasion of the wall (submucosa) by bacteria with secondary inflammation.

(Signs : gradual onset and systemic, anorexia, malaise, low grade fever,

leucocytosis in a blood test). This causing the wenous obstruction and ischemia of

the appendix wall, and the wall is invaded further to muscularis externa.

Inflammation spreads to involve the whole wall and neighboring peritoneum (Signs :

pain is constant and localized, peritoneal signs according to the location of

appendix).

These processes may develop within 48 hour duration. Untreated, it may lead to

perforation to neighboring structures.

SYMPTOMS

Classic symptoms often do not appear in young children and the elderly and the

diagnosis is particularly easy to miss in these age groups:

1. Pain:

o Early periumbilical pain moves after hours or sometimes days to the

right iliac fossa as the peritoneum becomes involved. Pain which wakes

the patient or keeps a child awake is significant.


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o Migrating pain started in the epigatric region then to the right iliac

fossa region.

o Movement and coughing aggravate pain. The patient may lie still with

shallow breathing, and coughing hurts.

2. Nausea, vomiting, anorexia. The patient is usually constipated but may

have diarrhoea. Rapidly progressive cases may have marked vomiting withoutfever and diarrhoea, which may be marked in post-ileal appendix (which is

rare).

3. Temperature and pulse are normal at first. Low-grade pyrexia then

develops. A rising pulse rate may be an indication of peritonitis.

4. Localised tenderness, guarding and rebound tenderness in the right

iliac fossa.

o A retrocaecal or pelvic appendix may be missed.

o Rectal examination: localised tenderness and this may be the only

sign of an inflamed retrocaecal or pelvic appendix.

o

Other methods to demonstrate an inflamed appendix include: thepsoas test (extend the hip and abduct the thigh with the patient on the

left side) and the obturator test (flex the right thigh and internally

rotate the hip).

5. Right iliac fossa peritonism:

o Can be demonstrated by percussion tenderness or rebound

tenderness.

o Rovsing's sign: pain in the right iliac fossa induced by palpation of

the left iliac fossa.

6. Stage of illusion: just after perforation, a child may sit up in bed apparently

better. A rising pulse rate may be the only indication of perforation, before

the obvious signs of peritonitis develop.

7. Atypical presentations include:

o An infant with watery diarrhoea and vomiting.

o A child with vague abdominal pain and anorexia.

o A shocked and confused elderly patient not in pain.

8. Pain and tenderness may be higher in pregnant women but right iliac fossa

symptoms are still the main presentation.

Special features according to position

1. Retrocaecal

a. Deep tenderness is present in the right flank.

b. Rigidity is often absent, even with deep pressure tenderness maybe

lacking (silent appendix) because the caecum which is destended by

gas, prevents the pressure exerted by the hand to reach the appendix.


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2. Pelvic

a. Suprapubic discomfort and tenderness in retrovesical pouch.

b. Early diarrhoes due to appendix contact with rectum

c. Complete absence of abdominal rigidity.

d. Psoas spasm is present

e. Spasm of the obturator internus when the hip is flexed and internally

rotated pain in the hypogastrium.

f. Increased frequency of micturition from contact with bladder

3. Preileal

a. Diarrhea because the appendic irritates the lower ileum, the patient

usually passes small loose stooles soon after eating of drinking.

b. Tenderness in right side of umbilicus.

4. Subhepatic

a. May be in pregnancy

b. Tenderness in hepatic region. Maybe mistaken with acute cholecystitis.

SIGNS

1. Tenderness in McBurneys point.

2. Blumberg sign : rebound tenderness

3. Muscle rigidity : signs of peritoneum involvement

4. If the appendix lies in the pelvis, a digital rectal examination causes

tenderness in retrovesical pouch.


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DIAGNOSIS

1. Alvarado score

o Abdominal pain that migrates to the right iliac fossa

o Anorexia (loss of appetite) orketonesin the urine

o Nausea orvomiting

o Pain on pressure in the right iliac fossa

o Rebound tenderness

o Feverof 37.3 C or more

o Leukocytosis, or more than 10000 white blood cells per microliter in the serum

o Neutrophilia, or an increase in the percentage of neutrophils in the serum whiteblood cell count.

A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8

indicates a probable appendicitis, and a score of 9 or 10 indicates a very probable acute

appendicitis

SYMPTOMS (MANTRELS) SCORE

M : Migratory right iliacfossa pain

1 point

A : Anorexia 1 point

N : Nausea and vomiting 1 point

T :Tenderness in RLQ 2 points

R : Rebound tenderness 1 point

E : Elevated temperature orFever

1 point

L : Leukocytosis 2 points

S : Shift to left(segmented neutrophils)

1 point

Total score10

points
http://en.wikipedia.org/wiki/Abdominal_painhttp://en.wikipedia.org/wiki/Right_iliac_fossahttp://en.wikipedia.org/wiki/Anorexia_(symptom)http://en.wikipedia.org/wiki/Ketoneshttp://en.wikipedia.org/wiki/Ketoneshttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Rebound_tendernesshttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Leukocytosishttp://en.wikipedia.org/wiki/White_blood_cellshttp://en.wikipedia.org/wiki/Blood_serumhttp://en.wikipedia.org/wiki/Neutrophiliahttp://en.wikipedia.org/wiki/Leukocytosishttp://en.wikipedia.org/wiki/Right_iliac_fossahttp://en.wikipedia.org/wiki/Anorexia_(symptom)http://en.wikipedia.org/wiki/Ketoneshttp://en.wikipedia.org/wiki/Urinehttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Rebound_tendernesshttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Leukocytosishttp://en.wikipedia.org/wiki/White_blood_cellshttp://en.wikipedia.org/wiki/Blood_serumhttp://en.wikipedia.org/wiki/Neutrophiliahttp://en.wikipedia.org/wiki/Leukocytosishttp://en.wikipedia.org/wiki/Abdominal_pain


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2. XRAY with barium enema

o may show an absence of filling of the appendix

3. Ultrasound

o Mostly used for pregnant patients (For male and non-pregnant patients

: CT)

o Findings : blind-ending, non peristaltic bowel loop originating from

caecum.

o More than 6mm in diameter.

Sonogram of a 10-year-old female who presented with

nausea, vomiting, and abdominal pain. The appendix

measured 10.0 mm in maximal anteroposteriordiameter in both the noncompression (A)

and compression (B) views

4. CT scan

o CT scan with oral contrast of rectal Gastrograffin enema.

o Typical findings are nonfilling appendix with distension and thickenedwalls of appendix and caecum, enlarged mesenteric nodes and

periappendiceal inflammation.

5. Lab findings

o Mild leucocytosis


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o Urine : erythrocytes maybe found if position of appendix is retrocaecal.

Diagnostic Algorithm

1. Hospitalization

2. Physical examination

3. Laboratory tests

4. Plane abdominal X-ray imaging

5. US

6. Laparoscopy

7. Consultations (urologist, gynecologist, infectionist etc.)

TREATMENT

Early operative appendectomy is the only correct treatment of acuteappendicites!

Once the decision to operate for presumed acute appendicitis has beenmade, the patient should be prepared for the operating room. Adequatehydration should be insured, electrolyte abnormalities corrected, andpreexisting cardiac, pulmonary, and renal conditions should be addressed.

Many trials have demonstrated the efficacy of preoperative antibiotics inlowering the infectious complications in appendicitis. It is common practiceby most surgeons in the US and West Europe to routinely administerantibiotics to all patients with suspected appendicitis. If simple acuteappendicitis is encountered, there is no benefit in extending antibioticcoverage beyond 24 h. If perforated or gangrenous appendicitis is found,antibiotics are continued until the patient is afebrile and has a normal whiteblood cell count.

For intraabdominal infections of gastrointestinal tract origin of mild tomoderate severity, the Surgical Infection Society (USA) has recommendedsingle-agent therapy with cefoxitin, cefotetan, or ticarcillin-clavulanic acid.For more severe infections, single-agent therapy with carbapenems orcombination therapy with a third-generation cephalosporin, monobactam, or


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aminoglycoside, plus anaerobic coverage with clindamycin andmetronidazole, is indicated.

SURGERY

Open Appendectomy

Most surgeons employ either a McBurney (oblique) or Rocky-Davis

(transverse) right lower quadrant muscle-splitting incision in

patients with suspected appendicitis.

If the diagnosis is in doubt, a lower midline incision is

recommended by some to allow a more extensive examination of

the peritoneal cavity.

Laparoscopic Appendentomy

Location of laparoscopic ports for laparoscopic.

a) appendectomy the window in mesoappendix should be done as close to the

base of appendix as possible

b) after the base of the appendix is adequately exposed, it could be divided

using astapling device

c) the mesoappendix is divided with a stapling deviceor by using electrocautery

for dissection and lips or a ligating loop to secure the appendiceal artery


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POST-OPERATIVE COMPLICATIONS

1. Wound infection

2. Wound suture fistula

3. Bleeding

4. Abdominal abscess

5. Intestinal obstruction

6. Appendiceal stump sutures failure

7. Peritonitis

8. MECKELS DIVERTICULUM

a. Incidence -2-3:100 appendectomies

b. Abdominal cavity should be routinely examined for MsD

in all cases of exploration during appendectomy

c. Modern Approach

Meckels diverticulum showing pathological changes should always be

removed. In gangrenous or perforated appendicitis, an incidentally

detected Meckels diverticulum should be left intact. In low-grade

inflammatory appendicitis, the low associated complication rate would

militate in favor of removal of the diverticulum.

COMPLICATIONS OF ACUTE APPENDICITIS

Appendicular infiltrate formation

Appendicular abscess

Peritonitis


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Sepsis

Pylephlebitis

DIFFERENTIAL DIAGNOSIS

1. According to location of appendix

o Retrocaecal position

i. Perforation of gastric ulcer or duodenal ulcer

ii. Crohns disease

iii. Cancer of caecum

iv. Urotheliasis

v. Diverculitis

o Subhepatic position

i. Acute cholecystitis

ii. Duodenal ulcer

iii. Paranephritis

iv. Kidney stone

v. Hepatitis

o Pelvic postion

i. Intestinal obstruction

ii. Sigmoid diverculitis

iii. Gastroenteritis

iv. Ectopic pregnancy

2. According to age

o In children

i. Gastroenteritis

ii. Mesenteris adenitis


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iii. Meckels diversulitis

iv. Intussusception

v. Henoch-Schonlein purpura

o In adults

i. Regional enteritis

ii. Perforated peptic ulcer

iii. Testicular torsion

iv. Pancreatitis

v. Rectus sheathe hematoma

vi. Pelvic inflammatory disease

vii. Ovarian torsion

viii. Endometriosis

o In elderly

i. Diverculitis

ii. Intestinal obstruction

iii. Colonic carcinoma

iv. Mesenteris ischemia

v. Leaking aortic aneurysm


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