I-7b
Appendix
Dr. Bibera
INTRODUCTION One of the most common causes of abdominal emergencies Accounts 1% of all surgical operation Rare in infants and elderly Maximum incidence in 10 30 years old Declining incidence thereafter
Continued mucus secretion causes intraluminal pressure increases and distention stimulating afferent fibers T8 T10 to explain the visceral pain
Bacteriology Same as the colonic flora except Porphyromonas gingivalis Routine cultures questionable Common Organisms Seen in Patients with Acute Appendicitis Aerobic and Facultative Anaerobic Gram Negative Bacilli Gram Negative Bacilli E. coli Bacteroides fragilis Pseudomonas aeruginosa Bacteroides species Klebsiella species Fusobacterium species Gram Positive Cocci Gram Positive Cocci Streptococcus anginosus Peptostreptococcus species Streptococcus species Gram Positive Bacilli Enterococcus species Clostridium species Symptoms 1. Pain Epigastric and localizes to the RLQ after 6 8 hours 45% fail to follow the visceral to somatic pattern Common in elderly Abdominal pain location depends on location of the tip of the appendix 2. Anorexia Present in almost all patients 3. Nausea and vomiting Vomiting fewer than 50% occurring after onset of pain 4. Constipation and diarrhea 5. Fever Physical Examination Signs of peritoneal irritation McBurneys sign localized and maximum tenderness over the RLQ or McBurneys point Dumphys sign cough elicits pain in 85% Rovsing sign contralateral tenderness (pain in the right lower quadrant with palpation in the left quadrant) Psoas (Obrastova) - slowly extending the patients right thigh when lying on the left side, demonstrates nearby inflammation when stretching the iliopsoas muscle Obturator sign - passive internal rotation of the flexed right thigh with patient supine, indicates irritation near the obturatorinternus Muscle guarding Abdominal mass Abscess Omentum
Anatomy and Function appendix 1st become visible in the 8th week of development as a protuberance of the cecum during development, the growth rate of cecum exceeds that of appendix, displacing the appendix medially toward the ileocecal valve the base arises from the posteromedial aspect of the cecum, where three taeniae coli meet the relationship of the base of the appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal or right pericolic position lymphoid tissue appears in the appendix 2 weeks after birth secretory immunoglobulins (IgA) are produced as part of gut-associated lymphoid tissues to protect the milieu interior the appendix is useful but not indispensable congenital defects are rare and clinically insignificant appendectomy does not predispose to bowel cancer or alter the immune system APPENDICITIS Lifetime rate of appendectomy is 12% in men and 25% in women 7% undergoing surgery had acute appendicitis Seen commonly in patients in their 2nd and 4th decades of life Misdiagnosis is constant 15.3% Higher in women and higher in 80 years old
Etiology Pathophysiology Results from obstruction of lumen followed by infection: 1. Fecalith 40% 2. Hyperplasia of the lymphoid tissue 3. Strictures 4. Tumor 5. Inspissated barium 6. Seeds, parasites Not proven Starts with appendiceal lumen obstruction
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Loops of intestine Rectal exam (helpful in some cases)
Diagnosis Making Algorithm
Laboratory CBC CRP determination Urinalysis Radiology 1. Plain abdomen To rule out other causes of abdominal pain like cholecystitis, perforated PUD, perforated viscus or pyelonephritis Sentinel loop in the RLQ 2. Barium enema Helpful in female if diagnosis is questionable Non-filling or filling defects in the appendix Extrinsic procedure defect in the cecum (inverted 3 sign) 3. UTZ 90% accurate Finding of non-compressible appendix with over 6mm diameter, presence of appendolith Complex mass To differentiate perforation and abscess formation 4. CT scan 90% accurate Finding of edema, fluid, appendolith and diameter of over 6mm Cases of suspected appendicitis Diagnosis is not certain Alvarado Scale value (MANTRELS) Symptoms Migration of pain to RLQ --- 1 Anorexia --- 1 Nausea and vomiting --- 1 Signs Tenderness, RLQ pain --- 2 Rebound --- 1 Elevated temperature --- 1 Labs Leukocytosis --- 2 Shift to the left --- 1 (MAS Modified Alvarado Scoring deletes shift to the left) Score: 9 10 = (+) 7 8 = Likelihood 5 6 = Compatible 1 4 = Observe the patient
Stages/Types of Appendicitis A. Acute Appedicitis Increase pressure within the lumen Increase mucus secretions Edema and diapedesis of bacteria Production of purulent material Infection localized to the appendix Clinically felt as visceral pain B. Acute suppurative appendicitis Increase pressure causes venous obstruction andischemia Bacteria invades the wall of the appendix Somatic pain due to irritation of the parietal peritoneum C. Gangrenous appendicitis venous and arterial thrombosis wall infarct occurs bacterial escape and peritoneal cavity contamination D. Perforated appendicitis abscess formation peritonitis APPENDICITIS IN INFANTS AND CHILDREN More difficult than in adult because of o inability of young children to give an accurate history, o diagnostic delays by both parents and physicians, o and the frequency of gastrointestinal upset in children The more rapid the progression to rupture and the inability of the underdeveloped grater omentum to conatain a rupture lead to significant morbidity rates in children Children younger than 5 years old have a negative appendectomy rate of 25% and an appendicieal perforation rate of 45% The incidence of major complication after appendectomy in children is correlated with appendicieal rupture
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The incidence of intra-abdominal abscess is also higher after the treatment of perforated appendicitis as compared to nonperforated cases (6% vs 3%) The treatment regimen for perforated appendicitis generally includes immediate appendectomy and irrigation of the peritoneal cavity Laparoscopic appendectomy has been shown to be safe and effective for treatment of appendicitis in children APPENDICITIS DURING PREGNANCY
APPENDICEAL RUPTURE Treatment Treatment is always operative because the obstructed lumen will not resolve with antibiotics alone Acute appendicitis without rupture is treated with immediate appendectomy after the medical evaluation is complete Ruptured appendicitis with local peritonitis or phlegmon is operated on early after resuscitation for fluid and electrolyte losses Ruptured appendicitis with spreading peritonitis requires more extensive fluid resuscitation, but the patient should undergo operation normally within 4 h to prevent continued peritoneal contamination Ruptured appendicitis with periappendiceal abscess formation may be treated acutely with operation, but this is associatedwith increased morbidity If vital signs, leukocytosis, and abdominal signs progress,drainage of abscess may be indicated, followed by conservative therapy. Intervala appendectomy in 6 weeks to 3 months is advised, although the overall rate of recurrence without interval appendectomy ranges from 037 percent. Preoperative antibiotics lower infectious complications, but the regimen is controversial o if simple acute appendicitis, there is no benefit to more than 24 h of antibiotics o If perforated or gangrenous, antibiotics are given until the patient is afebrile and the white blood cell count is normal Pathogens in acute appendicitis are mixed colonic flora, both aerobic and anaerobic; o Bacteroidesfragilis needs coverage o Clindamycin plus an aminoglycoside or a second-generation cephalosporin regimen is popular TUMOR Appendiceal malignancies are extremely rare. Primary appendiceal cancer is diagnosed in 0.9 to 1.4% Mucinous adenocarcinoma as the most frequent histologic diagnosis with 37% of total reported cases. Carcinoid was the second most frequent histologic diagnosis, comprising 33% of total cases. There is no accurate way of determining when and if anappendix will rupture prior to resolution of the inflammatory process Appendiceal rupture should be suspected in the presence of fever greater than 39.C (102.F) and a white blood cell countgreater than 18,000/mm3 In the majority of cases, rupture is contained and patients display localized rebound tenderness Generalized peritonitis will be present if the walling-off processis ineffective in containing the rupture
Frequently encountered extra-uterine disease requiring surgical treatment during pregnancy (1 in 2000 pregnancies) More frequent during the first two trimesters As fetal gestation process, the diagnosis of appendicitis becomes more difficult as the appendix is displaced laterally and superiorly Performance of any operation during pregnancy carries a risk of premature labor of 10-15%, and the risk is similar for both negative laparotomy and appendectomy for simple appendicitis Significant factor associated with both fetal and maternal death is appendicular perforation Fetal mortality increases from 3-5% in early appendicitis to 20% with perforation
APPENDICITIS IN ELDERLY Incidence of appendicitis in the elderly is lower than in young patients The morbidity and mortality are significantly increased in this patient population Delays in diagnosis, a ore raid progression to perforation, and comorbid disease are all contributing factors The diagnosis of appendicitis may be subtler and ales typical than in younger individuals, and a high index of suspension should be maintained In patients older than age 80 years, perforation rate of 49% and mortality rates of 21% have been reported
Ill older patient Diverticulitis Perforated PU Cholecystitis Pancreatitis Ruptured aortic aneurysm
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CARCINOID Firm, yellow, bulbar mass in the appendix Appendix is the most common site of gastrointestinal carcinoid, followed by the small bowel and then rectum.
INCEDENTAL APPENDECTOMY Appendectomy that are done incidentally upon laparotomy
MISCELLANEOUS INTERVAL APPENDECTOMY Provides much lower morbidity and mortality rates than immediate appendectomy 50% of patients treated conservatively never develop manifestations of appendicitis, and those who do, can generally be treated nonoperatively. INTRA-ABDOMINAL ABSCESSES Secondary to peritoneal contamination from gangrenous or perforated appendicitis decreased markedly since the introduction of potent antibiotics Sites of predilection for abscesses are the appendiceal fossa, pouch of Douglas, subhepatic space, and between loops of intestine Transrectal drainage is preferred for an abscess that bulges into the rectum. CHRONIC APPENDICITIS The pain lasts longer and is less intense than that of acute appendicitis, but is in the same location Lower incidence of vomiting, but anorexia and occasionally nausea, pain with motion, and malaise are characteristic. Leukocyte counts are predictably normal and CT scans are generally nondiagnostic. Laparoscopy can be effectively used in the management of this clinical entity. Appendectomy is curative. APPENDICEAL PARASITES Ascarislumbricoides is the most common, a wide spectrum of helminths have been implicated, including Enterobiusvermicularis, Strongyloidesstercoralis, and Echinococcusgranulosis. Live parasites occlude the appendiceal lumen, causing obstruction. Once appendectomy has been performed and the patient recovered, therapy with helminthicide is necessary to clear the remainder of the gastrointestinal tract. Amebiasis can also cause appendicitis. Invasion of the mucosa by trophozoites of Entamoebahistolytica incites a marked inflammatory process. Appendectomy must be followed by appropriate antibiotic therapy (metronidazole).
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