Dr A.

Badrek-Amoudi

FRCS

ABA-The Appendix- 4th year Lectures

A 15 year old girl presents with a right lower abdominal pain. A 6 year old boy with a history of sore throat presents with lower abdominal pain A 45 year old man presents with a sudden onset of epigastric pain localised to RIF

1. 2.
3. 4. 5. 6.

How do you diagnose appendicitis. What are the classical and atypical features of appendicitis Are investigations always needed and what is their role How do you prepare your patient prior to surgery What are the surgical approaches How do you care for your patient after surgery
ABA-The Appendix- 4th year Lectures

The Appendix

Introduction
1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.

ABA-The Appendix- 4th year Lectures

The Appendix

Surgical Anatomy
Surface anatomy Development: diverticulum of ceacum appearing in the 8th week of life Positions: constant base, tip varies (retroceacal, pelvic, subcaecal, preileal, pericolic) Blood supply Location during surgery Surrounding anatomical structures Part of the gut lymphoid tissue.
ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix

Acute Appendicitis
Epidemiology
Most common surgical emergency. Slightly more common in men. Incidence are falling from 100 to 50 in 100 000 (1975-1991). 1 in 6 of the population will have an appendectomy. In Saudi Arabia incidence are comparable to western figures ? More common in European societies (Diet). ? Relation to class status. Age > 2 yrs, (associated with lymphoid development). Up to 16% of appendicectomies are normal 75% are in women

ABA-The Appendix- 4th year Lectures

The Appendix

Acute Appendicitis
Pathology I
Luminal obstruction.
Lymphoid hyperplasia 60% Faecolith 35%. Inspissated barium. Fruit seeds. }<4% Worms. < 1% Extra-luminal obstruction eg Ca Cecum

Raised intra-luminal pressure

Mucus accumulation Multiplication of bacteria.
( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)

Venous and lymphoid congestion and.

ABA-The Appendix- 4th year Lectures

The Appendix

Acute Appendicitis
Pathology II
Impaired arterial flow, thrombosis and gangrene. Perforation may occur through devitalized tissue.

Histological terms used:

Catarrhal appendicitis Suppurative ;;; Necrotic ;;; Gangrenous ;;; Perforated ;;; Appendicular mass The risk of perforation is not inevitable.
ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

Clinical Features I
Full History Duration, severity, onset, System review. and examination: General, throat, chest..etc

Only 55% have classical features. Atypical 45% History 24-36 hours Abdominal pain: (diffuse and periumbilical, localizing to the RIF) Anorexia (almost always). Vomiting (75%). Low grade fever. If >38 suspect perforation Tenderness, guarding and rebound: Be gentle Rovsings, psoas, obturator signs: unreliable and late
ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

Clinical Features II
Tender Appendicular mass Atypical:
(loin, high RUQ, deep pelvic) Diarrhea ( not always gastroenteritis) Urinary frequency

The Extremes of Age: Children < 5 rapid progression Pain in the elderly is less intense
ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

Investigations
White cell count: high sensitivity 96%, low specificity Urine analysis Plain Xray, nonspecific Ultrasound highly sensitive (80-90%), excludes other pathologies. Computer Tomography: More superior to USS in diagnostic accuracy. Barium enema: Good accuracy, but technically difficult and false positives are common. Laparoscopy Active observation Computer aided diagnosis. Peritoneal lavage
ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

The Very Young

Diagnosis may be more difficult to establish, WBC is likely to be normal (12% are normal).
Children are more likely to progress to perforated appendix
(? Under-developed Greater Omentum).

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

The Very Old

Greater morbidity and mortality Less typical presentation Cancer may be a possibility as an underlying cause. Perforation of 50% and mortality of 20% has been reported

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

The Pregnant
Implications: Clinical Findings, Lab Ix, Surgery 1: 2000 pregnancies. More common in the first two trimesters The appendix is pushed superiorly and laterally WBC > 15 Premature Labor 10-15% with surgery Perforated appendix leads to fetal death in 20% Rapid diagnosis and treatment is advised.

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

In AIDS Patients
Be aware of CMV or Kaposi sarcoma as the underlying cause
WBC may not rise

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

The Management
Preop:
IVI, analgesia, IV antibiotics

Conventional appendicectomy Types of incisions Laparoscopic appendicectomy:

(questions regarding pain, hospital stay, operation time, to daily activity, wound infection)
ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

Post-Operative
1. Check the vitals 2. Check the abdominal signs and bowel movement 3. Check the wound 4. Advise on mobilization 5. In OPD:
1. Check wound 2. Check the Histology
ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

Prognosis
Mortality: from 0.2% to 1% Complications increase with perforation Morbidity:
Wound abscess, Wound infection (less with MacBurneys incision), Wound dehiscence Intra-abdominal abscess, Faecal fistula, Intestinal obstruction, Adhesive band, inguinal hernia. Fertility
ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis

Problems

Mass palpable pre-operatively

Appendix is normal at operation Tumor is found in appendix Prophylactic appendicectomy
ABA-The Appendix- 4th year Lectures

The Appendix Chronic Appendicular Conditions

Chronic Appendicitis

A loose term referring to a multitude of conditions associated with RIF pain and in which pathology of the appendix has been found.

ABA-The Appendix- 4th year Lectures

The Appendix Chronic Appendicular Conditions

Appendicular Mass
Results from either:
1. Localized by edematous, adherent omentum and loops of small bowel 2. Appendicular abscess

Incidence is 10% Higher in children Management controversy:

Interval vs Immediate appendicectomy

ABA-The Appendix- 4th year Lectures

The Appendix Chronic Appendicular Conditions

Tumors of The Appendix

Carcinoid:
Arise from Kluchitsky cells Mean age 20-40 Yellow bulbar mass In F>M In third decade of life Usually lies near the tip In the absence of LN spread with <2 cm in diameter appendicectomy is sufficient. Otherwise a R hemicolectomy is necessary.
ABA-The Appendix- 4th year Lectures

Adenocarcinoma and Lymphoma.

Differential diagnosis: Intraperitoneal Gastroenteritis Mesenteric adenitis Extraperitoneal Lobar Pneumonia

Ileocaecal Pathology: Regional ilitis Crohns Meckels diverticulitis Intussusceptions Carcinoma FB perforation Constipation Appendices epiplocae torsion Female pelvis: Ovarian: ruptured follicle Torsion of cyst Haemorrhagic cyst Acute salpingitis (PID) Ruptured ectopic pregnancy Uterine fibroid Endometriosis

Osteomyelitis

Haematoma of the rectus sheath

Genitourinary disorders: Pyelonephritis Ureteric calculi Cystitis

Neuralgic pains

Others Perforated DU Pancreatitis Acute cholecystitis Diverticulitis

Ruptured aortic/iliac aneurysm

ABA-The Appendix- 4th year Lectures