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Appendix, APPENDICITIS

ACUTE APPENDICITIS
►LEARNING OBJECTIVES

• Acute appendicitis

• What is it?

• What are the symptoms of it?

• How is it diagnosed?

• Why can it be difficult to diagnose


appendicitis?

• What other conditions mimic appendicitis?

• How is appendicitis treated?


APPENDICITIS, ACUTE

►INTRODUCTION
BACKGROUND
Appendicitis is a common and urgent surgical
illness with protean manifestations.
Appendicitis, Acute
►INTRODUCTION
BACKGROUND

No single sign, symptom, or diagnostic test


accurately confirms the diagnosis of
appendiceal inflammation in all cases.
APENDICITIS, ACUTE
►INTRODUCTION
BACKGROUND
INCIDENCE (FREQUENCY)

► Incidence of appendicitis is lower in cultures with a


higher intake of dietary fiber.
• AGE
Incidence of appendicitis gradually rises from birth,
peaks in the late teen years, and gradually declines
in the geriatric years.
APENDICITIS, ACUTE
►INTRODUCTION
BACKGROUND
INCIDENCE (FREQUENCY)

SEX
The incidence of appendicitis is
approximately 1.4 times greater in men than
in women.
Anatomy recall: lateral anterior wall of
abdomen, and vermiform appendix
RIGHT LOWER QUADRANT

• CECUM
• APPENDIX
• RIGHT OVARY AND TUBE
• RIGHT URETER
WHAT’S APPENDIX
• Located in the RLQ . Out pouching • Narrow tube • Rises from the
cecum. 2.5 cm below the ileocecal junction • worm shaped • Generally
6-10 cm long, 1.5 cm wide • The taeniae coli converge at the base
of the appendix • Wall contained lymphatic follicles
APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY
• Appendicitis:
• What is it?
• Appendicitis means inflammation of the
appendix

• What is inflammation?
A basic way in which the body reacts to infection,
irritation or other injury, the key feature being redness,
warmth, swelling and pain.
How is appendicitis happened?
• Obstruction of the appendiceal lumen is the primary
cause of appendicitis.
• *Obstruction of the lumen leads to distension of the
appendix due to accumulated intraluminal fluid.
• * Ineffective lymphatic and venous drainage allows
bacterial invasion of the appendiceal wall. perforation
and spillage of pus into the peritoneal cavity.
APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY

• ► Causes:
• The blockage (obstruction) may be due:
1) to thick mucus within the vermiform appendix.

2) to stool (hard, fecalith) that enters the appendix from the


cecum.

3) the lymphatic tissue in the appendix may swell and block


the appendix.
APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY
• ► Causes:
• ► Parasites: e.g. :Schistosomes species,
Strongyloides species
• ► Diseases: Tuberculosis, and Tumors
APPENDICITIS, ACUTE
► CLINICAL DIAGNOSIS

• HISTORY: Common symptoms of appendicitis

Typically history, begins with anorexia and


periumbilical pain followed by:

• Low-grade fever 38ºC or more , nausea, right lower


quadrant (RLQ) pain, and vomiting occurs in only
50% of cases.

► Migration of pain from the periumbilical area to the


RLQ is the most discriminating feature of the
patient's history.
APPENDICITIS, ACUTE
► CLINICAL DIAGNOSIS

• HISTORY:
• When vomiting occurs, it nearly always follows the onset pain.

• Vomiting that precedes pain is suggestive of intestinal obstruction,


and the diagnosis of appendicitis should be reconsidered.

• Absence of fever or high fever can occur.


APPENDICITIS, ACUTE

• ► CLINICAL DIAGNOSIS

• HISTORY:

• Nausea is present in 61-92% of patients; anorexia


is present in 74-78% of patients.

• Diarrhea or constipation is noted in as many as


18% of patients and should not be used to discard
the possibility of appendicitis
APPENDICITIS, ACUTE

• ► CLINICAL DIAGNOSIS
• HISTORY:

• Duration of symptoms is less than 48 hours in


approximately 80% of adults but tends to be longer
in elderly persons.

• Approximately 2% of patients report duration of pain


in excess of 2 weeks.

• A history of similar pain is reported in as many as


23% of cases.
APPENDICITIS, ACUTE

• ► CLINICAL DIAGNOSIS

• PHYSICAL EXAMINATION

• ► General Appearance;
► Patient’s well built or not

► well or poorly nourished

► Mental state: Normal

► Facial expression: feel uncomfortable

► Skin and mucous membranes: pallor, Cyanosis, Eruptions,


Pigmentation
.
APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Abdomen:

• INSPECTION

• Symmetric or not, postoperative scars (or not)


• Respiratory movements
• Visible peristalsis or not
• Dilatation of superficial veins (or not)
• Inguinal regions on both sides
• PHYSICAL EXAMINATION
• ► Palpation:
• gentle palpation (beginning at a site distant from the pain)

• RLQ tenderness is present in 96% of patients, but this is a nonspecific


finding (McBurney' Point).

• Rarely, left lower quadrant (LLQ) tenderness has been the major
manifestation in patients with situs inversus or in patients with a lengthy
appendix that extends into the LLQ.
APPENDICITIS, ACUTE

• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Palpation
• The most specific physical findings are:
► Rebound tenderness
► Pain on percussion
► Guarding (tensing of the abdominal wall muscles)
APPENDICITIS, ACUTE

• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Other confirmatory peritoneal signs
• The Rovsing sign
• ► RLQ pain with palpation of the LLQ
Other confirmatory peritoneal signs

• The psoas sign: Pain on passive extension of the right


thigh (► retroperitoneal retrocecal appendix)
• Patient lies on left side.
• Examiner extends patient's right thigh while applying
counter resistance to the right hip (asterisk)
Other confirmatory peritoneal signs

The obturator sign Pain on passive internal rotation of the


flexed thigh (►pelvic appendix)
Examiner moves lower leg laterally
while applying resistance to the lateral side of the knee
(asterisk) resulting in internal rotation of the femur.
APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION

• ► Confirmatory peritoneal signs

• Dunphy’s sign: increased pain with coughing

• Flank tenderness: in lower quadrant (retroperitoneal


retrocecal appendix)
APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION

• ► Percussion:
• Point tenderness (RUQ)

• ► Auscultation
• Not helpful in making diagnosis

► Rectal examination
Is helpful in making clinical diagnosis of localized and
generalized peritonitis.
APPENDICITIS, ACUTE

• ► Differential Diagnosis
• The differential diagnosis of appendicitis is broad
• Gastrointestinal, Gynecologic, Pulmonary,
Genitourinary, Systemic and other diseases can
mimic appendicitis.

► Gastrointestinal: e.g. (Abdominal pain: cause


unknown, Cholecystitis, Crohn's disease, Diverticulitis,
Duodenal ulcer, Gastroenteritis, Intestinal obstruction
Intussusception, Meckel's diverticulitis and etc… )
APPENDICITIS, ACUTE
• ► Differential Diagnosis

• ► Gynecologic: e.g.
• Entopic pregnancy, Endometriosis, Ovarian torsion,
Pelvic inflammatory disease, Ruptured ovarian cyst and
etc…

► Systemic e.g.:
Diabetic, ketoacidosis, Porphyria ,Sickle cell disease
etc..

• ► Pulmonary e.g.: Pleuritis, Pulmonary infarction


APPENDICITIS, ACUTE

• ► Differential Diagnosis
• ► Genitourinary e.g.: Kidney stone , Prostatitis
Pyelonephritis, Testicular torsion, Urinary tract infection
etc..
• ► Other e.g.: Parasitic infection, Psoas abscess
Rectus sheath hematoma
APPENDICITIS, ACUTE

► Laboratory Tests (studies) (white blood cell )


• The white blood cell (WBC) count is elevated
(greater than 10,000 per mm3) in 80% of cases
with Appendicitis.

• Unfortunately, the WBC is elevated in up to


70% of patients with other ► causes of right
lower quadrant pain

• Thus, an elevated WBC has a low predictive


value
APPENDICITIS, ACUTE
• ► Laboratory Tests (Blood C-reactive protein
level)

• An elevated C-reactive protein level (greater


than 0.8 mg per dL) is common in appendicitis.
• Not sensitive and specific.
• ► Elevated C-reactive protein level in
combination with an elevated WBC are highly
sensitive (97 to 100 percent)

• If all these findings are absent, the chance of


appendicitis is low
APPENDICITIS, ACUTE

• Laboratory Studies (Tests) (Urinalysis)


• ► The test may demonstrate changes such as:
• Mild pyuria.
• Proteinuria
• Hematuria
• This test serves more to exclude urinary tract causes
of abdominal pain than to diagnose appendicitis
APPENDICITIS, ACUTE
• ► Imaging Studies (Radiologic Evaluation)
• The options for radiologic evaluation of patients with
appendicitis have expanded in recent years.

► A) In evaluating right lower quadrant, pelvic pain in


pediatric and female patients.

► B) In patients in which the diagnosis of appendicitis is


equivocal by history and physical examination.
APPENDICITIS, ACUTE

• ► Radiologic Evaluation (Ultrasonogram showing)


APPENDICITIS, ACUTE

• ► Radiologic Evaluation (Computer tomography


scan showing)
APPENDICITIS, ACUTE
• Special Considerations
• young children
• While appendicitis is uncommon in young children, it
poses special difficulties in this age group.

• Young children are unable to relate a history, often


have abdominal pain from other causes and may have
more nonspecific signs and symptoms.

• These factors contribute to a perforation rate.


APPENDICITIS, ACUTE
• Special Considerations
Pregnancy
In pregnancy, the location of the appendix begins to shift
significantly by the fourth to fifth months of gestation.

Common symptoms of pregnancy may mimic appendicitis,


and the leukocytosis of pregnancy renders the WBC
count less useful.

As in nonpregnant patients, appendectomy is the standard


for treatment.
• Special Considerations
• Elderly
Elderly patients have the highest mortality rates.
The usual signs and symptoms of appendicitis may be
diminished, atypical or absent in the elderly, which
leads to a higher rate of perforation.

More frequent perforation combined with a higher incidence


of other medical problems and less reserve to fight
infection contribute to a mortality rate.
APPENDICITIS, ACUTE
• Treatment
• The standard for management of nonperforated
appendicitis remains appendectomy.

• Because prompt treatment of appendicitis is important in


preventing further morbidity and mortality.
• Appendectomy may be performed by laparotomy
(usually through a limited right lower quadrant incision)
or laparoscopy.
APPENDICITIS, ACUTE
• Complications
• Appendiceal rupture
• Accounts for a majority of the complications of
appendicitis.

• Factors that increase the rate of perforation are:


• Delayed presentation to medical care.
• Age extremes (young and old)
• Hidden location of appendix.
• A brief period of in-hospital observation (less than six
hours) in equivocal cases does not increase the
perforation rate and may improve diagnostic accuracy.
APPENDICITIS, ACUTE
• Complications
• A periappendiceal abscess
• It may be treated immediately by surgery or by
nonoperative management.
• Nonoperative management consists of parenteral
antibiotics with observation or CT-guided drainage,
followed by interval appendectomy six weeks to three
months later.
APPENDICITIS, ACUTE
• Complications
• Diagnosis
• Diagnosis of a perforated appendix is usually easier
(although immediately after rupture, the patient's
symptoms may temporarily subside).

• The physical examination findings are more obvious if


peritonitis generalizes, with a more generalized right
lower quadrant tenderness progressing to complete
abdominal tenderness.
APPENDICITIS, ACUTE

• Complications
• Diagnosis
• An ill-defined mass may be felt in the right lower
quadrant.

• Fever is more common with rupture, and the WBC count


may elevate to 20,000 to 30,000 per mm3 (200 to 300
3 109 per L).
APPENDICITIS, ACUTE

► BIBLIOGRAPHY
• Garcia Pena BM, Mandl KD, Kraus SJ, et al. Ultrasonography and
limited computed tomography in the diagnosis and management of
appendicitis in children. JAMA. Sep 15 1999;282(11):1041-
6. Medline
• Malone AJ. Diagnosis of acute appendicitis: Value of un-enhanced
CT. Am J Roentgenol. 1993;160:763-766.
• Mullins ME, Kircher MF, Ryan DP, et al. Evaluation of suspected
appendicitis in children using limited helical CT and colonic contrast
material. AJR Am J Roentgenol. Jan 2001;176(1):37-41. [Medline].
• Mun S, Ernst RD, Chen K, et al. Rapid CT diagnosis of acute
appendicitis with IV contrast material. Emerg
Radiol. Mar 2006;12(3):99-102. [Medline].
APPENDICITIS, ACUTE

• ► BIBLIOGRAPHY
• Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of
delaying appendectomy for acute appendicitis for 12 to
24 hours. Arch Surg. May 2006;141(5):504-6;
discussioin 506-7. [Medline].
• Albu E, Miller BM, Choi Y, et al. Diagnostic value of C-
reactive protein in acute appendicitis. Dis Colon
Rectum. Jan 1994;37(1):49-51. [Medline].
Peptic ulcer

• Learning objective
• What is it ?
• What cause peptic ulcer?
• What are the symptoms of peptic ulcer?
• What is it diagnosed?
• How is it treated?
Peptic ulcer

• Background
• Peptic ulcer disease is the cause for dyspepsia in about
10% of patients

• 95% of duodenal and 70% of gastric ulcers are


associated with Helicobacter pylori.

• Eradication of H pylori reduces the relapse rate of ulcers.


Dyspepsia can be defined as painful, difficult, or disturbed digestion,
which may be accompanied by symptoms such as
nausea and vomiting, heartburn, bloating, and stomach discomfort.
Peptic ulcer

• Background
• Frequency
• Ulcers of the small intestine are known as duodenal
ulcers.
• Duodenal ulcers affect about one in 10 people at some
point in their lives

• Stomach ulcers are less common, and usually affect


people aged over 65.
Peptic ulcer

• Background
• Sex
• The prevalence is probably equal in men and women.

• Age
• Stomach and duodenal ulcers increases with age.

• This is probably related to the increased prevalence of H


pylori infection in older age groups
• Anatomy recall
• Stomach
• Is the most dilated portion of alimentary canal
• Situated between the end of esophagus and the beginning of the small intestine.
• It lies in the epigastrium, umbilical and left hypochondriac regions.
• Capacity:
• Birth: 30ml
• Puberty: 800ml
• Adult: 150ml
• Parts:
• A cardiac
• A body
• A fundus
• A pyloric part (antrum and canal)
• Two covertures (greater and lesser)
• Two surfaces (anterior and posterior)
• Anatomy recall
Stomach
Layers of Stomach Wall
• Serosa
• Muscularis
• Submucosa
• Mucosa
• Stomach
• Function
• It is involves in the second phase of the digestion.

• The stomach has three tasks


• It stores swallowed food
• It mixes the food with stomach acids
• Then it sends the mixture on to the small intestine
• Stomach cell types
• Three main cells:
1) Parietal cells (or oxyntic cells)
in fundus + body
• Produced hydrochloric acid (HCl): a strong acid
that helps to break down food.

2) Chief cells
in fundus + body
Produced pepsinogen: that on contact with the
acid of the gastric juice, convert to proteolytic
enzyme - pepsin
• Stomach cell types

3) G-cells
in antrum
Produce mucus
coats and lubricates the gastric surface, and serves an
important role in protecting the epithelium from acid and
other chemical insults.
• Anatomy recall
• Duodenum
The first part of the small intestine
It is shortest and Widest
Most fixed part of the small intestine.
About 20-25cm long.
It begin at the level pylorus and ends at the junction Duodeno-jejunal flexure.
• Anatomy recall
• Duodenum
• It is divide into four parts
• Superior Part (first part): 3 cm long, and most movable of
the four parts.
• Descending Part (second part); 8-10 cm long.
• Horizontal Part (third part): 10 cm long
• Ascending Part (fourth part), 2-5 cm
Peptic ulcer

• Anatomy recall
• Duodenum
• Duodenal wall has four layers:
• Serosa
• Muscularis
• Submucosa
• Mucosal
• Anatomy recall
• Duodenum
• Type cells
• S cells: secretin
• D cells: somatostatin
• Enterochromatin cells: GIP
• N cells: Neurotensin
Peptic ulcer
• Physiopathology
• A peptic ulcer occurs when an alteration occurs in the
aggressive and/or protective factors such that the
balance is in favor of gastric acid and pepsin
• Any process
• that increases gastric acidity (e.g.., stress, fast)

• That decreases prostaglandin production (e.g.. Non


steroidal anti-inflammatory drugs: NSAIDS
• Or interferes with the mucous layer (e.g.. H. pylori)
Peptic Ulcer

• What is it?
• A peptic ulcer is a sore in the lining of the stomach or
duodenum, the first part of your small intestine.
• Peptic ulcer
• Clinical
• History

• Patients may present with a wide variety of


symptoms, or they may remain completely
asymptomatic.

• Gastric and duodenal ulcers usually cannot be


differentiated based on history alone.
Peptic Ulcer

• Clinical
• History
• Classic gastric ulcer pain is described as pain occurring
shortly after meals, for which antacids provide minimal relief.

• Duodenal ulcer pain often occurs hours after meals and at


night. Pain is characteristically relieved with food or antacids.
Peptic Ulcer

• Clinical
• History
• Pain can be sharp, dull, burning, or penetrating.

• Many patients experience a feeling of hunger.

• The pain may radiate into the back


Peptic ulcer

• Clinical
• History

• The pain from gastric/duodenal ulcers is typically located


in the epigastrium; however, it can also be perceived in
the right upper quadrant and elsewhere

• Pain with radiation to the back is suggestive of a


posterior penetrating gastric ulcer complicated by
pancreatitis.
Peptic ulcer

• Clinical
• History
• Patients with bleeding gastric/duodenal ulcers may give a
history of hematemesis, melena (coffee-ground), or
episodes of presyncope.

• Melena can be intermittent over several days or


multiple episodes in a single day

• Rarely, a briskly bleeding ulcer can present as gross


hematochezia.
Peptic ulcer

• Clinical
• History

• About 20-40% of patients describe bloating, belching,


or symptoms suggestive of gastroesophageal reflux.
Peptic ulcer

• Physical
• Physical examination usually is not helpful.

• Right upper quadrant tenderness may suggest a biliary


etiology or, less frequently, peptic ulcer disease.

• In the presence of gastric outlet obstruction, abdominal


distension and succussion splash may be found.
Peptic ulcer
• Physical
• A palpable mass should raise the suggestion of a gastric
malignancy.

• Involuntary guarding is indicative of peritonitis secondary


to gastric perforation

• Patients should be checked for melena, which is


indicative of bleeding from a gastroduodenal ulcer.

• Digital rectal examination can be easily performed in the


office to check for melena
Peptic ulcer
• Causes

• H pylori bacteria
• NSAID consumption
• Lifestyle factors
• Smoking
• Alcohol use
• Caffeine intake
• Genetics (family history)
Peptic ulcer

• Other causes
• Gastrinoma
• Systemic mastocytosis
• Basophilia
• Other factors
• Infection
• Chemotherapy
• Radiation
• Crack cocaine