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APPENDICITIES

Acute appendicitis is one of the most common surgical emergencies Incidence:


60-80/100,000 Peak @ 10-30yrs Male=Female Mortality 1%(unperforated) ~5%(
perforated) Mainly clinical diagnosis.
Anatomy of appendix
Embryologically,the appendix is continuation of

caecum The vermiform appendix is only present in human being and certain anthrop
oid apes Presence of lymphoid tissue on the wall of the appendix is characterist
ic of human vermiform appendix. Blood supply- appendicular artery –end artery ap
pendicular vein Lymph drain-ileocolic lymph node.
ANATOMY OF APPENDIX
average length 10 cm . diameter between 7 and 8 mm. Location- lower right
quadrant of the abdomen, or
more specifically, the right iliac fossa. Its position abdomen corresponds to
a point on the surface known as McBurney's point. The most common explanation
is that the human appendix is a vestigial structure which does absolutely nothin
g for the body.
Structure
Serous coatcomposed of peritoneal coat
Muscle coatlongitudinal and circular muscle hiatus muscularies.
Sub mucosaabdominal tonsil (200 at the age 12-20)
Mucousresemble as large intestine.
Anatomical positions

Retrocaecal-70% Pelvic-25% Subceacal-2% Splenic-1% Paraceacal-1% Paracolic-1%.


function
Maturation of B-lymphocytes Secretory immunes- mechanism in the
gut
Congenital anomalies
Agenesis Duplication Diverticula Left side appendix-situs inversus
viscerum.
WHAT IS APPENDICITIS?
Appendicitis is a painful swelling and infection of the appendix.
Appendicitis refers to inappropriate activity of the vermiform appendix, a worm-
shaped extension of the colon.
TYPES OF APPENDICITIS
THERE ARE 4 TYPES OF APPENDICITIS:ACUTE APPENDICITIS SUBACUTE APPENDICITIS RECUR
RENT APPENDICITIS CHRONIC APPENDICITIS
AETIOLOGICAL FACTORS FOR ACUTE APPENDICITIS
RACIAL & DIETARY FACTORS:MORE COMMON IN WHITE RACES. YOUNG MALES ARE AFFECTED MO
RE OFTEN DIET RICH IN MEAT PRECIPITATES APPENDICITIS & DIET RICH IN FIBRE PROTEC
TS THE PERSON FROM APPENDICITIS.
FAMILIAL SUSEPTIBILITY:IT IS RELATED TO HAVING A LONG RETROCAECAL APPENDIX IN WH
ICH. BLOOD SUPPLY IS DIMINISHED TO THE DISTAL PORTION WHICH PRECIPITATES APPENDI
CITIS.
SOCIO-ECONOMIC STATUS:IT IS COMMON IN MIDDLE CLASS & RICH PEOPLE.
OBSTRUCTIOMN OF THE LUMEN A) IN THE LUMEN-INTESTINAL WARM e.g. ROUNMD WORM,THRED
WORM ETC VEGITABLE,FRUIT SEED,FAECES MATERIAL, BARIUM B) IN THE WALL-STRICTURE,N
EOPLASUM ETC.
PATHOLOGY
OBSTRUCTIVE-
lumen capacity 0.1 ml, secration up to 0.5 ml (mucocele of

appendix) leads to obstruction intraluminl presure if increase more than 50cm of


water stimulates to visceral nerve –dull and diffuse pain in umbelical and epig
astric region (T 10) Rapid multiplication of bacteria of the appendix also leads
to increase distention. Pressure within lumen increases so that it exceeds veno
us pressure. Venous and capillaries are occluded, arterial inflow continuous res
ulting in engorgement and vascular congestion, at this stage nausea and vomiting
starts visceral pain increases. Serosa involved, hiatus muscularies and local p
eritonitis(pain shift to Rt lower qut.) when bacterial invasion occure to deep c
oat- fever ,tachycardi and leucocytosis
NON OBSTRUCTIVE This is less dangerous condition. Inflammation occur in lym
ph follicle or mucus
membrane. The end artery if involved, lumen will trombosed and localized gangr
ene will appear. Such inflammation terminates either by suppuration, gangrene,
fibrosis or resolution.
bacteriology
Most frequently seen organisms are-
E-coli, enterococi,non-haemolytic streptococi, anarobis streptococi, and Cl.Welc
hii.
SUBACUTE APPENDICITIS
sequence described above is not
inevitabl. Some episodes of acute appendicities apparently subside spontaneously
before they reach to acute stage
RECURRENT APPENDICITIS
These type of attack are milder. The patient remain free between attack
and physical examination is normal Ba-meal X-ray shows-normal filling of the a
ppendix due to disappearance of obstruction.
CHRONIC APPENDICITIS
Patient often complaint of persistence
pain in RIF Resected appendix shows-fibrosis of appendicular wall Ulceration
and scaring and filtration by chronic inflammatory cells.
SYMPTOMS OF APPENDICITIS
PAIN:
diffuse and dull pain (RIF) takes 1 to 12 Hr.to localised. variation of pain acc
ording to site.
VOMITING:
Occurs once or twice due to reflex pylorospasm. Children and teenagers frequentl
y vomit Usually not persistence
ANOREXIA
In 95 % patient anorexia is the first symptom,follwed by abdominal pain and this
followed by nausea and vomiting
.
PHYSICAL SIGNS
FEVER:
Low grade fewer around 100 degree F indicates bacterial inflammation.
Slight Pyorrhea or haematuria.
PULSE RATE:( NOTE:- PAIN FIRST, FOLLOWED BY VOMITING AND THEN BY FEVER IS CALLED
AS MURPHY ‘S TRIAD OF SYMPTOMS OF ACUTE APPENDICITIS.)
INSPECTION-dry tongue, anxious PALPATION-Mc Burney’s paint guarding rigidity Cut
aneous hyperaesthesia
SIGNS OF APPENDICITIS
Rebound tenderness:hand pressure to a patient’s abdomen and then letting go. Pai
n felt upon the release of the pressure indicates rebound tenderness.
Rovsing’s sign:Deep palpation of the left iliac fossa may cause pain in the righ
t iliac fossa. This is the Rovsing s sign, also known as the Rovsing s symptom.
It is used in the diagnosis of acute appendicitis.
Psoas sign:-left lateral position
extend patients thigh. (this stretches the iliopsoas muscle) positive in retroca
ecal appendicities. (haematuria/pyorrhoea)
Obturator sign:-The right obturator muscle also runs near
appendix. A doctor tests for the obturator sign by asking the patient to lie dow
n with the right leg bent at the knee. Moving the bent knee left and right requi
res flexing the obturator muscle and will cause abdominal pain if the appendix i
s inflamed.(diarrhoea)
Percussion:- Light percussion on Mc Burney’s point will elicit
pain in early appendicitis.
Auscultation:-
Auscultation of abdomen will reveal merge or no bowel movement on the right ilia
c fossa.
Rectal Examination:- There is tenderness in the right
rectal wall – Differential Tenderness
VARIATIONS IN ACUTE APPENDICITIS
RETROCAECAL APPENDICITIS :- Silent (no obvious rigidity and tenderness in right
iliac fossa) PELVIC APPENDICITIS:- Causes Diarrhoea. PRE AND POST ILEAL APPENDIC
ITIS :- Continuous irritation of ileum causes nausea and vomiting. SUBHEPATIC AP
PENDICITIS :- Manifest as pain in right iliac fossa and in this case it is very
difficult to remove from grid iron incision. IN PREGNANCY :- The location of pai
n is shifted higher up and laterally.
ALVARADO SCORING SYSTEM Symptoms
Migratory right iliac fossa pain Anorexia 1 point 1 point 1 point Signs
CORE < 5: NOT SURE SCORE 5-6: COMPATIBLE SCORE 6-9: PROBABLE SCORE >9: CONFIRMED
Nausea and vomiting
Right iliac fossa tenderness Rebound tenderness Fever Laboratory
2 points 1 point 1 point
Leucocytosis Shift to left (segmented neutrophils) Total score
2 points 1 point 10 points
INVESTIGATIONS
Total WBC count is almost always increased than the normal value. Plain X-ray Ab
domen erect is taken to rule out perforation or may show dilated bowel loops in
the right Iliac fossa. Abdominal ultrasound to rule out other causes like gynaec
ological causes. Ultrasonography and Doppler sonography provide useful means to
detect appendicitis especially in children. Ba-Meal enemaCT scan is the investig
ation of choice. C- reactive protein is elevated in any inflammatory conditions
like Appendicitis.
DIFFERENTIAL DIAGNOSIS
IN CHILDREN: ENTEROCOLITIS MECKEL’S DIVERTICULUM WORM BALL ACUTE ILIAC LYMPHA
DENITIS
IN YOUNG ADULTS: RIGHT SIDED URETERIC COLIC AMOEBIC TYPHILITIS TORSION OF UNDE
SCENDED TESTIS MECKEL’S DIVERTICULUM
IN MIDDLE AGE: ACUTE PANCREATIS ACUTE CHOLECYSTITIS PERFORATED DUODENAL ULCER
IN FEMALES: RUPTURED ECTOPIC GESTATION BILATERAL SALPINGO-OOPHORITIS
COMPLICATION OF APPENDICITIS
APPENDICULAR RUPTURE :- Causes generalized peritonitis with 1020 % mortality rat
e. Emergency laparotomy, appendicectomy, peritoneal wash followed by drainage of
peritoneal cavity is done. APPENDICULAR MASS (PHLEGMON):- Following an attack o
f acute appendicitis, infection is sealed off by greater omentum, caecum, termin
al ileum etc which results in a tender, soft/ firm mass in right iliac fossa. Pr
esence of mass is a contradiction for appendicectomy because it is very difficul
t to remove appendix from such a mass & attempt to remove may result in Faecal f
istula.
APPENDICULAR ABSCESS:Progressive suppurative process in an appendicular abscess
which may follow rupture of the appendix. Commonest site of abscess is lateral p
art of the iliac fossa. Second common position is in the pelvis. SUPPURATIVE PYL
EPHLEBITIS :Ascending septic thrombophlebitis of the portal venous system (Pylet
hrombophlebitis) is a grave but rare complication of gangrenous appendicitis.
TREATMENT OF APPENDICITIS
NON-SURGICAL TREATMENT:-
SURGICAL TREATMENT:-
Typically, appendicitis is treated by removing the appendix. If appendicitis is
suspected, a doctor will often suggest surgery without conducting extensive diag
nostic testing. Prompt surgery decreases the likelihood the appendix will burst.
Surgery to remove the appendix is called appendectomy and can be done two ways.
The older method, called laparotomy, removes the appendix through a single inci
sion in the lower right area of the abdomen. The newer method, called laparoscop
ic surgery, uses several smaller incisions and special surgical tools fed throug
h the incisions to remove the appendix. Laparoscopic surgery leads to fewer comp
lications, such as hospital-related infections, and has a shorter recovery time.
Lanz’s incision McBurney’s Gird iron incision. Paramedian incision Ruthe
rford morison incision Battle’s pararectal incision.
Laproscopic appendiscectomy Needlescopic approach
Operative procedure Type of incision Position Type of anaesthesia Drug
s used for anaesthesia Steps-ISOLATION
DIVISION OF MESOAPPENDIX. REMOVEL
ISOLATION
DIVISION OF MESOAPPENDIX.
REMOVEL
Appendicities during pregnancy Appendicular phlegmon Appendicular abscess
METHOD OF APPENDECTOMY SURGERY
INCISION TO BE TAKEN FOR APPENDECTOMY
.
APPENDIX ATTACHED TO MESENTERY
USE OF SCISSORS TO DIVIDE THE MESENTERY
Appendicitis following Colonoscopy
David James, MB, BS, FRCS(C) Campbell River & District General Hospital
THE ENIGMATIC APPENDIX
Variable position Variable length Arterial supply Demographics Variabl
e pathophysiology
ACUTE APPENDICITIS
Catarrhal Obtructive - Mucocoele
- Gangrene - perforation
OBSTRUCTIVE APPENDICITIS
Faecolith Pips Kinks Adhesions Worms F.B. Gallstone Hernia End
ometriosis Barium Tumour
FIRST APPENDECTOMY
1735 Claudius Amyand (Founder and Surgeon,
St Georges Hospital, London) First to successfully remove appendix from living
subject 11 yr old boy with scrotal hernia and faecal fistula
PITFALLS
“The novice may well smile at the long list of
differential diagnoses for acute appendicitis until, as personal experience grow
s, the chagrin of slowly ticking off mistakes one by one from the list comes to
pass” Zachary Cope (St Mary’s Hospital):The Acute Abdomen
Solitary Diverticulum of caecum with diverticulitis Sigmoid colon phlegmon
Tumour
CASE REPORT
55 yr old Male Colonoscopy for rectal bleeding Haemorrhoids, no biopsy or
polypectomy Easy day care Central/RLQ abd pain within hours Temp 38 Tend
er RLQ, rebound WBC 13,000 Xray: no free air or fluid levels CT
Colonoscopy: A Prospective Report of Complications
Jerome Waye: J. Clin. Gastroenterol 1992 2097 pt No monitoring Results:
complications 39 pt (1.8%)
Diagnostic Polypectomy Perforation Bleeding Post Polypectomy Synd 0 0 0.3% 3.3%
1.2%
Complications of Colonoscopy
Dominitz et al Gastrointestinal Endoscopy
Apr 2003 Overall rate 0.35% for diagnostic perf 0.2% bleed 0.09% Overall rat
e 2.3% with polypectomy perf 0.32% bleed 1.7% post polypectomy synd 1%
Other Complications
Bowel prep, medications Splenic injury Tearing mesenteric vessels Bacter
aemia Retroperitoneal abscess Subcutaneous emphysema Snare entrapment Ap
pendicitis
APPENDICITIS FOLLOWING COLONOSCOPY
Literature:
First case: Houghton, Aston 1988 A few case reports This is 9th reported cas
e
Aetiology of postcolonoscopy appendicitis
Coincidence?
1 in 250,000 chance >500,000 colonoscopies/yr in USA Barotrauma Faecal Impac
tion Polypectomy
“The patient with an acute abdomen remains one of the last bastions of clinical
medicine”
“The appendix does not grumble – it either screams or remains silent”