ACUTE APPENDICITISACUTE APPENDICITIS

ACUTE APPENDICITISACUTE APPENDICITIS

Appendicitis is defined as an inflammation Appendicitis is defined as an inflammation of the inner lining of the vermiform of the inner lining of the vermiform appendix that spreads to its other parts. appendix that spreads to its other parts. This condition is a common and urgent This condition is a common and urgent surgical illness with protean surgical illness with protean manifestations, generous overlap with manifestations, generous overlap with other clinical syndromes, and significant other clinical syndromes, and significant morbidity, which increases with diagnostic morbidity, which increases with diagnostic delay.delay.

AnatomyAnatomy

Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis

Variations in topographic position of Variations in topographic position of the appendix the appendix

From its base at the cecum, the appendix may extend (A) upward, retrocecal and retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to the left, ileocecal (may pass anterior or posterior to the ileum)

Surgical Anatomy - PositionSurgical Anatomy - Position

Blood supply to the appendix. Blood supply to the appendix.

A and B. Usual type with a single appendicular artery. C. Paired appendicular arteries.

IncidenceIncidence The lifetime rate of appendectomy is 12% for men and 25% for women, with The lifetime rate of appendectomy is 12% for men and 25% for women, with

approximately 7% of all peopleapproximately 7% of all people undergoing appendectomy for acute appendicitis undergoing appendectomy for acute appendicitis during their lifetimduring their lifetim

Despite the increased use of ultrasonography, computed tomography (CT), and Despite the increased use of ultrasonography, computed tomography (CT), and laparoscopy, the rate oflaparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%), misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture.as has the rate of appendiceal rupture.

TheThe percentage of misdiagnosed cases of appendicitis is significantly higher among percentage of misdiagnosed cases of appendicitis is significantly higher among women than among menwomen than among men

AGEAGE

EtiologyEtiology Obstruction of the lumen is the dominant etiologic factor in acuteObstruction of the lumen is the dominant etiologic factor in acute

appendicitis. appendicitis. – – Submucosal lymphoid hyperplasiaSubmucosal lymphoid hyperplasia – – Faecolith / faecal stasisFaecolith / faecal stasis – – Inspissated bariumInspissated barium – – Vegetable/fruit seedsVegetable/fruit seeds – – Worms (Entrobius vermicularisWorms (Entrobius vermicularis – – Tumours of caecum/appendixTumours of caecum/appendix

BacteriologyBacteriology

Common organisms seen in patients Common organisms seen in patients with acute appendicitiswith acute appendicitis

Classification(by V.I. Kolesnikov)

1. Appendiceal colic.2. Simple superficial appendicitis.3. Destructive appendicitis:

а) phlegmonous;б) gangrenous;в) perforated.

4. Complicated appendicitis:а) appendicular infiltrate;б) appendicular abscess;в) diffuse purulent peritonitis.

5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).

Symptoms of simple appendicitis

1. Pain localized in a right iliac area.In 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of acute appendicitis. In 2-4 hours it migrates to the area of appendix (the Kocher’s sign).2. Single nausea and vomiting.3. Fever to 37.5-380C.4. Retention of stool or single diarrhea.5. Muscular tension in a right iliac area.Rovsing's sign - pain in right lower quadrant during palpation of left lower quadrantSitkovsky’s sign - increase of pain in a right iliac area when the patient lies on the left sideBartomier’s sign - the increase of pain intensity during the palpation of right iliac area when the patient lies on the left side.Dunphy's sign-increased pain with coughing

Symptoms of phlegmonous appendicitis

1. Expressed pain in a right iliac area.2. Fever to 38-390C.3. Muscular rigidity in a right iliac area.4. Peritoneal signsBlumberg’s sign. After gradual pressing by fingers of anterior abdominal wall quick taking off the hand causes the sharp increase of pain.Voskresenky’s sign. The increase of pain during quick sliding movements by the tips of fingers from epigastric to right iliac area.Rozdolsky’s sign. Painfulness in a right iliac area during percussion.

Symptoms of gangrenous appendicitis

1. Pain in a right iliac area.2. Grave condition of the patient.3. Signs of local peritonitis.4. Signs of intoxication

Symptoms of retrocaecal appendicitis

1. Non-expressive abdominal clinic.2. Expressed pain in a right lumbar area.3. Pain and muscular rigidity in a right iliac area during palpation.Yaure-Rozanov sign - Painfullness during palpation of Petit triangleGabay’s sign - Blumberg’s sign in Petit trianglePasternatsky’s sign - tapping of lumbar region cause the painPsoas sign - pain on extension of right thigh

Symptoms of retrocaecal retroperitoneal appendicitis

1. Clinic of retroperitoneal phlegmon.2. The signs of retrocaecal appendicitis.3. Flank tenderness in right lower quadrant.

Symptoms of pelvic appendicitis

1. Clinic of irritation of pelvic organs (dysuria, pulling rectal pain, tenesmi).2. Absence of muscular tenderness.3. Painfullness of anterior rectal wall and posterior vaginal vault.

Complications

1. Appendicular infiltrate.2. Appendicular abscess.3. Diffuse peritonitis.4. Pilephlebitis

Diagnostics

1. Anamnesis.2. Objective examination.3. General blood and urine analyses.4. Vaginal examination for women.5. Rectal examination for men.

Abdominal X-rayAbdominal X-ray

Graded compression Graded compression UltrasoundUltrasound

Depends on the technique and experienceDepends on the technique and experienceNormal appendixNormal appendix

– – a blind-ended, tubular structure with a a blind-ended, tubular structure with a maximum wall thickness of 2 mm with an maximum wall thickness of 2 mm with an outer diameter of 6 mm,outer diameter of 6 mm,

– – No peristalsisNo peristalsis– – Originates from the base of the cecumOriginates from the base of the cecum

Graded compression Graded compression UltrasoundUltrasound

CTCT variable degree of distension (diameter 6–variable degree of distension (diameter 6–

40 mm)40 mm) wall thickness of 1–3 mm.wall thickness of 1–3 mm. Wall - asymmetrically thickened enhances Wall - asymmetrically thickened enhances

with intravenous contrast medium.with intravenous contrast medium. periappendiceal inflammatory massperiappendiceal inflammatory mass Thickening and enhancement with Thickening and enhancement with

intravenous contrast - adjacent wall of the intravenous contrast - adjacent wall of the cecum or ileumcecum or ileum

CTCT

Differential diagnostics

Gastrointestinal•Cholecystitis•Crohn's disease•Duodenal ulcer•Gastroenteritis•Intestinal obstruction•Meckel's diverticulitis•Mesenteric lymphadenitis•Necrotizing enterocolitis•Neoplasm (carcinoid, carcinoma, lymphoma)

Gynecologic•Ectopic pregnancy•Endometriosis•Ovarian torsion•Pelvic inflammatory disease•Ruptured ovarian cyst •Tubo-ovarian abscess

DifferentialDifferential diagnosticsdiagnostics

SystemicSystemic Diabetic Diabetic

ketoacidosisketoacidosis Henoch-Schonlein Henoch-Schonlein

purpurapurpura

PulmonaryPulmonary PleuritisPleuritis Pneumonia (basilar)Pneumonia (basilar) Pulmonary infarctionPulmonary infarction

GenitourinaryGenitourinary Kidney stoneKidney stone PyelonephritisPyelonephritis Wilms' tumorWilms' tumor

OtherOther Parasitic infectionParasitic infection Psoas abscessPsoas abscess Rectus sheath Rectus sheath

hematomahematoma

Differential diagnostics of acute Differential diagnostics of acute appendicitis with perforative peptic ulcerappendicitis with perforative peptic ulcer

Pain in the right iliac Pain in the right iliac regionregion

Muscular Muscular tenderness in the tenderness in the right iliac regionright iliac region

Single vomiting and Single vomiting and diarrheadiarrhea

Sharp acute diffuse Sharp acute diffuse painpain

Ulcerative anamnesisUlcerative anamnesis Absence of hepatic Absence of hepatic

dullnessdullness On X-ray of the On X-ray of the

abdomen air above the abdomen air above the liver (air sickle)liver (air sickle)

Rigidity of anterior Rigidity of anterior abdominal wallabdominal wall

Differential diagnostics of acute Differential diagnostics of acute appendicitis with intestinal obstructionappendicitis with intestinal obstruction

Constant pain in the Constant pain in the right iliac regionright iliac region

Muscular Muscular tenderness in the tenderness in the right iliac regionright iliac region

Single vomiting and Single vomiting and diarrheadiarrhea

Periodic acute diffuse painPeriodic acute diffuse pain Constant vomiting and Constant vomiting and

nausea without any reliefnausea without any relief Retention of stool and Retention of stool and

gasesgases Abdominal distensionAbdominal distension On X-ray of theOn X-ray of the abdomen abdomen

Kloiber's cups (air-fluid Kloiber's cups (air-fluid levels)levels)

Splashing sound, increased Splashing sound, increased

peristalsisperistalsis

ManagementManagement

Open AppendicectomyOpen Appendicectomy

• • Incission (transverse, Mc Burney’s point)Incission (transverse, Mc Burney’s point) • • Open in layers. (muscle split along its fibres)Open in layers. (muscle split along its fibres) • • Check for fluid (+/-c&S)Check for fluid (+/-c&S) • • Identify caecum and exteriorized – follow taeniae to Identify caecum and exteriorized – follow taeniae to

appendixappendix • • Mesoappendix divided + ligatedMesoappendix divided + ligated • • Clamp appendix 5mm above caecum and ligatedClamp appendix 5mm above caecum and ligated • • Cauterise residual mucosa +/- purse string (not req)Cauterise residual mucosa +/- purse string (not req) • • Return caecum, wash with warm salineReturn caecum, wash with warm saline • • Close in layersClose in layers

Open AppendicectomyOpen Appendicectomy

Open AppendicectomyOpen Appendicectomy

Open AppendicectomyOpen Appendicectomy

Open AppendicectomyOpen Appendicectomy

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

Laparoscopic AppendicectomyLaparoscopic Appendicectomy

ComplicationsComplications