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 anthropoid apes Presence of lymphoid tissue on the wall of

the appendix is characteristic of human vermiform appendix.

Blood supply- appendicular artery –end artery

appendicular 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 nothing for the body.

Structure

Serous coat- composed of peritoneal coat

Muscle coat- longitudinal and circular muscle

hiatus muscularies. Sub mucosa-

abdominal tonsil (200 at the age 12-20) Mucous-

resemble 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 RECURRENT APPENDICITIS CHRONIC APPENDICITIS

AETIOLOGICAL FACTORS FOR ACUTE APPENDICITIS

RACIAL & DIETARY FACTORS:- MORE COMMON IN WHITE RACES. YOUNG MALES ARE AFFECTED MORE OFTEN

DIET RICH IN MEAT PRECIPITATES APPENDICITIS & DIET RICH IN FIBRE PROTECTS THE PERSON FROM APPENDICITIS.

FAMILIAL SUSEPTIBILITY:- IT IS RELATED TO HAVING A LONG RETROCAECAL APPENDIX IN WHICH. BLOOD SUPPLY IS DIMINISHED TO THE DISTAL PORTION WHICH PRECIPITATES APPENDICITIS.

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,THREDWORM ETC VEGITABLE,FRUIT SEED,FAECES MATERIAL, BARIUM B) IN THE WALL-STRICTURE,NEOPLASUM 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 epigastric region (T 10)

Rapid multiplication of bacteria of the appendix also leads to increase distention.

Pressure within lumen increases so that it exceeds venous pressure.

Venous and capillaries are occluded, arterial inflow continuous resulting in engorgement and vascular congestion, at this stage nausea and vomiting starts visceral pain increases.

Serosa involved, hiatus muscularies and local peritonitis(pain shift to Rt lower qut.)

when bacterial invasion occure to deep coat- fever ,tachycardia and leucocytosis

NON OBSTRUCTIVE- This is less dangerous condition. Inflammation occur in lymph follicle or mucus

membrane. The end artery if involved, lumen will

trombosed and localized gangrene 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.Welchii.

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 appendix 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 APPENDICITISPAIN:- diffuse and dull pain (RIF) takes 1 to 12 Hr.to localised. variation of pain according to site.

VOMITING:- Occurs once or twice due to reflex pylorospasm. Children and teenagers frequently 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 SIGNSFEVER:- 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, anxiousPALPATION-Mc Burney’s paint guarding rigidity Cutaneous hyperaesthesia

SIGNS OF APPENDICITIS

Rebound tenderness:- hand pressure to a patient’s abdomen and then letting go. Pain 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 right 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 retrocaecal 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 down with the right leg bent at the knee. Moving the bent knee left and right requires flexing the obturator muscle and will cause abdominal pain if the appendix is 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 iliac 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 APPENDICITIS :- Continuous irritation of ileum causes nausea and vomiting.

SUBHEPATIC APPENDICITIS :- 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 pain is shifted higher up and laterally.

ALVARADO SCORING SYSTEM

CORE < 5:

NOT SURE

SCORE 5-6: COMPATIBLE

SCORE 6-9:

PROBABLE

SCORE >9: CONFIRMED

Symptoms

Migratory right iliac fossa pain 1 point

Anorexia 1 point

Nausea and vomiting 1 point

Signs

Right iliac fossa tenderness 2 points

Rebound tenderness 1 point

Fever 1 point

Laboratory

Leucocytosis 2 points

Shift to left (segmented neutrophils) 1 point

Total score 10 points

INVESTIGATIONSTotal WBC count is almost always increased than the normal value.Plain X-ray Abdomen 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 gynaecological causes. Ultrasonography and Doppler sonography provide useful means to detect appendicitis especially in children. Ba-Meal enema-CT scan is the investigation of choice.C- reactive protein is elevated in any inflammatory conditions like Appendicitis.

DIFFERENTIAL DIAGNOSISIN CHILDREN:-ENTEROCOLITIS WORM BALL MECKEL’S DIVERTICULUM ACUTE ILIAC LYMPHADENITIS

IN YOUNG ADULTS:-RIGHT SIDED URETERIC COLIC TORSION OF UNDESCENDED

TESTISAMOEBIC TYPHILITIS MECKEL’S DIVERTICULUM

IN MIDDLE AGE:-ACUTE PANCREATIS PERFORATED DUODENAL ULCERACUTE CHOLECYSTITIS

IN FEMALES:-RUPTURED ECTOPIC GESTATION BILATERAL SALPINGO-

OOPHORITIS

COMPLICATION OF APPENDICITIS APPENDICULAR RUPTURE :- Causes generalized

peritonitis with 10-20 % mortality rate. Emergency laparotomy, appendicectomy, peritoneal wash followed by drainage of peritoneal cavity is done.

APPENDICULAR MASS (PHLEGMON):- Following an

attack of acute appendicitis, infection is sealed off by greater omentum, caecum, terminal ileum etc which results in a tender, soft/ firm mass in right iliac fossa.

Presence of mass is a contradiction for appendicectomy because it is very difficult to remove appendix from such a

mass & attempt to remove may result in Faecal fistula.

APPENDICULAR ABSCESS:- Progressive suppurative process in an

appendicular abscess which may follow rupture of the appendix. Commonest site of abscess is lateral part of the iliac fossa. Second common position is in the pelvis.

SUPPURATIVE PYLEPHLEBITIS :- Ascending septic thrombophlebitis of the

portal venous system (Pylethrombophlebitis) 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 diagnostic 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 incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.

Lanz’s incision McBurney’s Gird iron incision. Paramedian incision Rutherford morison incision Battle’s pararectal incision.

Laproscopic appendiscectomy

Needlescopic approach

Operative procedure Type of incision Position Type of anaesthesia Drugs used for anaesthesia Steps-ISOLATION DIVISION OF MESOAPPENDIX. REMOVEL

ISOLATIONISOLATION

DIVISION OF MESOAPPENDIX.DIVISION OF MESOAPPENDIX.

REMOVELREMOVEL

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 Variable pathophysiology

ACUTE APPENDICITIS

Catarrhal

Obtructive - Mucocoele

- Gangrene - perforation

OBSTRUCTIVE APPENDICITIS Faecolith Pips Kinks Adhesions Worms F.B. Gallstone Hernia Endometriosis 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 grows, 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 Tender 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 0 0.3% Bleeding 0 3.3% Post Polypectomy - 1.2% Synd

Complications of Colonoscopy

Dominitz et al Gastrointestinal Endoscopy Apr 2003

Overall rate 0.35% for diagnostic perf 0.2% bleed 0.09% Overall rate 2.3% with polypectomy perf 0.32% bleed 1.7% post polypectomy synd 1%

Other Complications

Bowel prep, medications Splenic injury Tearing mesenteric vessels Bacteraemia Retroperitoneal abscess Subcutaneous emphysema Snare entrapment Appendicitis

APPENDICITIS FOLLOWING COLONOSCOPY

Literature:

First case: Houghton, Aston 1988 A few case reports This is 9th reported case

Aetiology of post-colonoscopy appendicitis

Coincidence?

1 in 250,000 chance

>500,000 colonoscopies/yr in USA Barotrauma Faecal Impaction 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”