Appendix short note by S.

Wichien (SNG KKU)

Acute appendicitis Incidence -7% of popu--appendectomy -10:10,000 /yr -mean age 31.3 yr median age 22 yr -m:f = 1.2-1.3 : 1 -misdx/rupture rate--15.3% -neg appendec in repro female--23% obstruction of lumen -fecalith--most common -others--hypertrophy of lymphoid, Barium,tumor,vegetable,parasite Pathogenesis -[Link] lumen--close loop obstr -continue normal secretion -rapidly distension (normal lumen capacity--0.1ml) -distent--+[Link] of viscer aff fiber :dull pain in mid abdomen :reflex n/v -inflam at parietal perito--shift pain -inc P--venous/capilla occlude -infarct develop in antimesentery -perforate--beyond point of obstr Bacteriology -child--no Porphyromonas Gingivalis -polymicrobial infection -perito c/s should in immunosup pt -ATB 24-48 hr in non-perforate 7-10 d in perforate Symptoms -Anorexia--always in appendicitis -Vomiting--neural stimulate/ileus -[Link] [Link] lower epigas/umbilical pain :usually 4-6 hr [Link] pain to RLQ :some pt,pain begins in RLQ Pain by location -long appendix--LLQ -retrocecal--frank/back pain -pelvic type--suprapubic pain -retroileal--testicular pain Sequence -anorexia(1st)--[Link]--vomiting -if vomiting 1st--hould be questioned Signs -temp is rarely more than 1c -prefer to lie supine -tender at McBurney point -Rovsing sign--indirect tener -cutaneous hyperesthesia--T10,11,12 -volun/involuntary guarding -Psoas sign--retrocecal type -Obturator sign--pelvistype Lab -mild leukocytosis 10,000-18,000 ->18,000 = complicated appendicitis -UA--r/o UTI Appendiceal rupture -<5, >65 yr--highest rate suspected in -fever >39 -WBC >18,000 -illed define mass--phlegmon/abscess Imaging [Link] film -rarely helpful in dx -r/o other pathology -rare fecalith but if have--hi suggest [Link] enema -if appendix fills on barium enema, appendicitis is excluded [Link] compression sonography -blind ending tube -AP diameter -noncompress appendix >=6mm -thickening of appendiceal wall -periappendiceal fluid -sens 55-96% spec 85-98% False positive -Dilated follapian -obesity--non compress -periappendicitis False negative -retrocecal -perforate--compressible -confine appendicitis at tip -mark dilate--as smb [Link] resolution CT -dilated >=5 cm, thickened wall -dirty fat--thick mesoappendix -phlegmon -fecalith--not pathognomonic -arrowhead sign--thick cecum -should in Alvarado score 5-6

Appendix short note by [Link] (SNG KKU)

Alvarado scale Symptoms migrate pain 1 Anorexia 1 N/v 1 Signs RLQ tender 2 Rebound 1 Elevate temp 1 Lab Leukocytosis 2 Left shift 1 Scores 9-10 = almost certain dx 7-8 = hi likelihood of appendicitis 5-6 = compatible ,but not dx score 5-6 or some 7-8--CT score 7--should sx Differential dx [Link] mesenteric adenitis -confused c appendicitis in children -present c URI or subside -pain usually diffuse -tender not sharp localized -general lymphadenopathy -relative lymphocytosis -Yersinia enterocolitica/tuberculosis Samonella,campylobactor jejuni [Link] gastroenteritis -profuse watery diarrhea -n/v -hyperperistalsis abdo cramp -no localizing sign [Link] disorder PID Rupture grafian follicle--mittelschmerz Euptured ectopic preg Twisted ovarian cyst [Link] urogenitel system Torsion testis Acute epididymitis Seminal vesiculitis [Link] intes dz Meckel diverticulitis -same c/p as appendicitis -require same tx Intussuception -appendicitis not common in <=2yr -bloody mucoid stool -sausage shaped mass may in RLQ Crohn`s enteritis -acute regional enteritis -fever,RLQ pain/tender,leukocytosis -often stimulate appendicitis Colonic lesion -diverticulitis -perforate ca of caecum Epiploic appendagitis -infarction of colonic appendage -2nd to torsion -continuous abdo pain in area of colon -lasting several day -appetite unaffected -rebound [Link] UTI -acute pyelonephritis on rt side -mimic retroileal type UC -referr pain to labia,scrotum,penis -hematuria -absence of fever or leukocytosis [Link] Henoch-Schonlein Purpura -2-3wk after streptococcal infection -abdo pain,jt pain,purpura,nephritis FB perforate of bowel Closed loop intes obstruction Mesenteric vascular obstruction Pluritis RLL Acute cholecystitis Acute pancreatitis Hematoma of abdo wall

Appendix short note by [Link] (SNG KKU)

Open appendectomy Incision -McBurney (oblique) -Rocky Davis (transverse) -if abscess is suspected :laterally placed incision :to retroperitoneal drainage :avoid contaminate to perito cavity -if dx is in doubt ; lower midline Stump -simple ligation or purse string -nonabsorb suture Other -peritoneal cavity is irrigated -if perforate or gangrene :2nd closure in 4-5d :child : little subcu fat, can 1st closure -if not found appendicitis, look :cecum and mesentery :small bowel-extent at least 2 feet :a medial extension of incision (Fowler-Weir) if further evaluation of lower abdomen is indicated :if suspect upper abdo ,should closed incision then upper midline Laparoscopic appendectomy -under GA -NG tube, foley catheter -surgeon stand to left of pt -use 3 ports 1st trocar = umbilicus (10mm) 2nd trocar = suprapubic (10/12mm) 3rd trocar = LLQ,epigas,RUQ (5mm) -dissection at base of appendix -create a window between mesentery and base of appendix -benefit in obesed pt Compare c open appendectomy -higher of cost,duration of surgery -intra abdo abscess >3x -benefit :dec post op pain = 8/100 point (not sig) :less hospital stay = 1d Summary not been resolved whether LA is more effective than open appendectomy Chronic appendicitis -pain lasts longer -less intense than acute appendicitis -same location -less vomiting -leukocyte--normal -CT--nondiagnosis -laparoscopy can be effective -appendectomy is curative -symptom not cured or recur are diagnosed c crohn dz In the young -more rapid progresion to rupture -underdevelop greater omen -major c/p c appen rupture :wound infect/intra abdo abscess -Tx regimen for perforate appendix :immediate appendectomy :irrigation of peritoneal cavity -ATB 24-48hr in nonperforate ATB 7-10d in perforate In HIV -present similar of normal host -inc risk of rupture--delays in s+s -low CD4 count asso inc in rupture DDX CMV -anywhere in GI tract -vasculitis of bl vv in submuco -leading to thrombosis -mucosal ischemia -ulceration,gangrene bowel perforate Kaposi sarcoma/Lymphoma -RLQ pain c mass Tuberculosis Other cause of infectious colitis Spontaneous peritonitis -CMV,TB,cryptococcus,stronyloid Neutropenic enterocolitis -typhlitis

Appendix short note by [Link] (SNG KKU)

In pregnancy -1/766 birth -neg appendectomy--25% :anatomical change :inc abdo laxity Clinical -RUQ pain--74% classic pain--57% -physio leukocytosis 16,000 Ix Ultrasound /MRI Laparoscopy--equivocal case Tx Lap appen -inc preg related c/p -inc 2.3x fetal loss than open sx Overall fetal loss 4% Early delivery 7% Parasite Ascaris lumbricoides--most common [Link] [Link] Echinococcus [Link] Tumor -malignancy--rare -mostcarcinoid Carcinoid -firm,yellow,bulbar mass in appendix -appendix is most site of GI tract -carcinoid syndrome--in metas -located in tip -malignant potential is related to size -<1cm rarely in extension outside Tx 1.<1cm--appendectomy 2.>1 <2cm [Link]/mid appendix--appendectomy [Link]/mesoappen/metas--rt colec 3.>2cm--rt colectomy Adenocarcinoma -mucinous adenocarcinoma colonic adenocarcinoma adenocarcinoid -present c appendicitis -may c ascitis or mass Tx rt hemicolectomy Pseudomyxoma peritoni -rare -progresss slow -female 2-3x than male -appendix--site of origin -neoplas mucus secreting cell in perito -mucinous ascites -diffuse collection of gelatinous fluid c mucinous on peritoneal and omentum -rt hemidiaphragm,rt retrohepatic, lt paracolic gutter,lig of Treitz,ovary -peritoneal surface of bowel--free -present c abdo pain,mass -rare LN metas,distant metas Tx -all gross should be removed -appendectomy is routine performed -hysterctomy c bilat SO in women -recurrent--additional sx Lymphoma -extremely uncommon -non Hodgkin Lymphoma -1-3% of GI tract -CT--appendiceal diameter >2.5 cm or surrounding soft tissue thickening Tx -appendectomy -rt hemicolectomy,if extension onto caecum or mesentery Mucocele -accum mucoid material -caused by 4 process [Link] cyst [Link] hyperplasia [Link] [Link] -incidental finding in appendicitis -should not rupture :if lap finding--convese to open Tx [Link] wide resection of mesoappendix cyto exam intraperitoneal mucous [Link] hemicolectomy -if +ve margin at base -if +ve peiappen LN