Appendix
ANATOMY
The appendix is a 5–8cm diverticulum arising from the cecum at the
convergence of the teniae coli
The appendix most commonly lies in the ileocecal location but may
also be retrocecal (16%),retroileal,or pelvic
supplied by the ileocolic branch of the superior mesenteric artery
innervated by T-10
PHYSIOLOGY
The function of the appendix in the adult human is unknown
But is likely to be related to the role of the lymphoid tissue in
immunologic processes
Early studies suggested an increased incidence of colon cancer
following appendectomy
PATHOPHYSIOLOGY
ACUTE APPENDICITIS
Luminal obstruction, caused by fecalith,foreign body,tumor of the
appendix or cecum, parasites, or fibrous bands
Acute obstructive appendicitis can progress within 12 to 24h to
gangrene of the wall of the appendix and perforation
Acute appendicitis may lead to hematogenous spread of bacteria
and infection of the portal vein (pylephlebitis) or liver abscesses
CARCINOID TUMOR OF THE APPENDIX
The most common tumor of the appendix is carcinoid
Usually, these tumors are benign
A small proportion of carcinoid tumors of the appendix are
malignant and may metastasize
CLINICAL MANAGEMENT
ACUTE APPENDICITIS
Classic Presentation
vague periumbilical pain,nausea,and vomiting
The pain moves to the right lower quadrant (RLQ)
tenderness develops at McBurney’s point
rebound tenderness is present in the RLQ
In uncomplicated appendicitis, tachycardia and fever are low
grade
Retrocecal Appendicitis
Abdominal pain, which starts in the periumbilical region
Diarrhea and urinary symptoms may develop
Pelvic Appendicitis
Nausea and vomiting are significant
Diarrhea develops from irritation of the pelvic colon
Two clinical tests that may sometimes be helpful are the Rovsing
and psoas signs
Appendicitis during Pregnancy
Midabdominal pain
Nausea
vomiting
Mild leukocytosis
The most important finding is tenderness and rebound in the right
abdomen, above McBurney’s point.
Investigation
Diagnosis of acute appendicitis is made largely on clinical grounds
Laboratory tests and radiologic examination are also useful,
particularly when the diagnosis is uncertain
Laboratory Tests
Mild leukocytosis with some shift to the left
urinary tract infection may be present
In retrocecal appendicitis, the urine may contain red cells and
leukocytes
Radiological Studies
Plain abdominal x-rays are useful in ruling out perforation of another
viscus
CT examination is indicated in the evaluation of RLQ mass when this
is present
Ultrasound examination is indicated when the diagnosis is uncertain
Laparoscopy
Laparoscopy provides the opportunity not only to establish the
diagnosis but also to perform appendectomy
Differential Diagnosis
Surgical Treatment
Once diagnosis is established,an operation should be performed as
early as possible , before perforation occur
Appendectomy can be done either laparoscopically or with an
open technique
SURGICAL TECHNIQUE
The abdomen is opened through an oblique or transverse incision
centered on McBurney’s point
The appendix is grasped and retracted, and the appendiceal
artery is divided between ligatures
The appendix is dissected to its base
where it is ligated, divided distal to the ligature, and removed
The appendiceal stump is inverted into the cecum using a
pursestring suture
Complicated Appendicitis
PERFORATION
Most patients with perforated appendicitis can be treated with
routine appendectomy
APPENDICEAL ABSCESS
A patient may present with a medical history of several days’
duration of a welldeveloped mass in the RLQ
Ultrasound and/or CT scan confirms the diagnosis
If the patient has generalized abdominal signs, immediate surgery is
indicated to drain the abscess and perform appendectomy
The patient is placed under broad-spectrum antibiotics and
carefully followed clinically
Such a patient may be discharged from hospital and readmitted for
interval appendectomy 6 to 8 weeks later.
CARCINOID TUMOR OF THE APPENDIX
Carcinoid tumors of the appendix are discovered either incidentally
or because they have caused obstructive appendicitis
Appendectomy is performed
Right hemicolectomy is indicated when the tumor is:
1. Too close to the base at the cecum
2. Two centimeters in diameter or larger
3. Malignant as evidenced by metastasis to lymph nodes or liver;
isolated liver metastasis may be locally resected.
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