APPENDICITISAPPENDICITIS

Anatomy and physiology of Anatomy and physiology of appendixappendix

The appendix is a slender, worm-shaped pouch, averaging 5—10cm in length, that protrudes from the top of the colon in the lower right abdomen

LocationLocation

• McBurney’s point:one-third of the McBurney’s point:one-third of the way from the anterior,superior iliac way from the anterior,superior iliac spine to the umbilicus.spine to the umbilicus.

• Pelvis and right ilac fossa appendixPelvis and right ilac fossa appendix

• Anterior or posterior ileum appendixAnterior or posterior ileum appendix

• Retrocaceal appendix Retrocaceal appendix

• Right lateral caceal appendixRight lateral caceal appendix

Retrocaceal appendixRetrocaceal appendix

Supply & nerveSupply & nerve

• Appendix artery: a final artery ,from Appendix artery: a final artery ,from ileocolic arteryileocolic artery

• Appendix vein Appendix vein : : portal veinportal vein

• sympathetic nerve :celiac plexus and sympathetic nerve :celiac plexus and lesser splanchnic nerve lesser splanchnic nerve T10,T11T10,T11

  AAcute appendicitis cute appendicitis

Appendicitis is a Appendicitis is a common common cause of cause of abdominal abdominal painpain

life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation

EtiologyEtiology

• Obstruction: Obstruction:

anatomy :wormed-shapedanatomy :wormed-shaped

narrownarrow

plenty of lymph glands plenty of lymph glands

mechanical reason: mechanical reason:

food residue, ascarid, food residue, ascarid,

tumor,etc. tumor,etc.

EtiologyEtiology

• Gastrointestial diseaseGastrointestial disease

• Bacteria invasion:Bacteria invasion:

all kinds of Gall kinds of G- - bacilusbacilus

Pathology Pathology

Four type:Four type:

• Acute simple appendicitisAcute simple appendicitis

• Acute purulent appendicitisAcute purulent appendicitis

• Perforation and gangrenousPerforation and gangrenous

• Appendiceal abscessAppendiceal abscess

Acute simple appendicitisAcute simple appendicitis

Acute purulent Acute purulent appendicitisappendicitis

Perforation and gangrenousPerforation and gangrenous

GangrenousGangrenous

Perforation

Appendiceal abscessAppendiceal abscess

Results Results

• Inflammation disappearInflammation disappear

• Inflammation localizationInflammation localization

• Inflammation diffusionInflammation diffusion

Clinical manifestationClinical manifestation

symptoms : symptoms :

• abdominal pain :abdominal pain :

Periumbilical or epigastric pain that Periumbilical or epigastric pain that migrates to right lower quadrantmigrates to right lower quadrant

Pain becomes persistent and well Pain becomes persistent and well localized. It worsens with moving, localized. It worsens with moving, breathing deeply, coughing, breathing deeply, coughing, sneezing, walking, or being touchedsneezing, walking, or being touched

Symptoms : Symptoms :

• Gastrointestinal Gastrointestinal symptoms:symptoms:

Anorexia, nausea, and vomiting Anorexia, nausea, and vomiting occur after the onset of painoccur after the onset of pain

ConstipationConstipation

DiarrheaDiarrhea

bladder and rectum stimulus bladder and rectum stimulus symptomssymptoms

Symptoms Symptoms

• General symptoms : General symptoms :

tired ,headachtired ,headach

feverfever

Rapid pulse Rapid pulse

• SIRS (systemic inflammatory SIRS (systemic inflammatory response syndromeresponse syndrome))

Signs Signs

• Tenderness in the right lower Tenderness in the right lower abdomen, usually about a third of abdomen, usually about a third of the distance from the navel to the the distance from the navel to the top of the hip bone top of the hip bone

peritoneal irritation sign : muscular peritoneal irritation sign : muscular rigidityrigidity

Blumberg signBlumberg sign bowel sounds disappearbowel sounds disappear

Others Others

• Rovsing’s sign:pain in the right Rovsing’s sign:pain in the right lower quadrant upon palpation of lower quadrant upon palpation of the left lower quadrant.the left lower quadrant.

• Psoas sign :pain on active Psoas sign :pain on active elevation of the legselevation of the legs

• The obturator sign: pain on The obturator sign: pain on internal and external rotation of internal and external rotation of the hipthe hip

• Rectal exam & vaginal examRectal exam & vaginal exam

Lab test Lab test

• Mild to moderately elevated WBC Mild to moderately elevated WBC with left shift is typical but rarely with left shift is typical but rarely may be normal, range of 11000-may be normal, range of 11000-17000/mm17000/mm33

over 20000/ mmover 20000/ mm3 3 perforationperforation

• UA may show ketonuria or a few UA may show ketonuria or a few RBCs or WBCsRBCs or WBCs

• pregnancy test (women only)pregnancy test (women only)

Lab testLab test

• B-usB-us

• X-rayX-ray

• Diagnostic abdominal punctureDiagnostic abdominal puncture

DiagnosisDiagnosis

•Periumbilical or epigastric pain Periumbilical or epigastric pain that migrates to right lower that migrates to right lower quadrantquadrant

•Tenderness in the right lower Tenderness in the right lower abdomen, usually about a third abdomen, usually about a third of the distance from the navel of the distance from the navel to the top of the hip boneto the top of the hip bone

Differential diagnosis Differential diagnosis

Two type :Two type :

A: required surgeryA: required surgery

B: not required B: not required surgerysurgery

Differential diagnosisDifferential diagnosis

Required surgeryRequired surgery::

• Perforation of gastointestinal tractPerforation of gastointestinal tract

ulcer,tumor, diverticulitisulcer,tumor, diverticulitis

• obstetrics and gynecologic disease:obstetrics and gynecologic disease:

ectopic pregancy,ovarion torsionectopic pregancy,ovarion torsion

• Meckel diverticulitisMeckel diverticulitis

• Tumor Tumor

Differential diagnosisDifferential diagnosis

Not required surgeryNot required surgery• Pelvic inflammationPelvic inflammation

• Mesenteric adenitis:at exploration a Mesenteric adenitis:at exploration a normal appendix and enlarged lymph normal appendix and enlarged lymph nodes in the mesenterynodes in the mesentery

• Viral & bacterial gastroenteritisViral & bacterial gastroenteritis

• Pneumonia, pleurisyPneumonia, pleurisy

MATERIALS AND METHODS

The Alvarado score• Symptoms • Score migratory right iliac fossa pain 1 nausea/vomiting 1 anorexia 1

• Signs RIF tenderness 2 fever >37.30C 1 rebound pain in RIF 1

• Laboratory test leucocytosis (>10 X 109/L) 2 neutrophilic shift to the left >75% 1 • Total score 10

CONCLUSION

Treatment Treatment

• Early operation:Early operation:

surgical removal(appendectomy)surgical removal(appendectomy)

• Acute simple appendicitis: Acute simple appendicitis: appendectomy appendectomy

• Acute purulent and gangrenous Acute purulent and gangrenous appendicitis:appendicitis:

appendectomy and/or drainage appendectomy and/or drainage

Treatment Treatment

Appendiceal abscessAppendiceal abscess::

• if local in right low quadrantif local in right low quadrant

antibiotic therapy and general treatmentantibiotic therapy and general treatment

• if infection diffusionif infection diffusion

incision and drainageincision and drainage

Treatment Treatment

OperationOperation

• Incision :Incision :

incision over the point of maximal incision over the point of maximal tenderness,generally at McBurny pointtenderness,generally at McBurny point

true McBurney’s incisiontrue McBurney’s incision

tansvers skin incisiontansvers skin incision

3—6cm long3—6cm long

Incision Incision

• McBurney’s McBurney’s

incisionincision

IncisionIncision

• tansvers tansvers skin skin incisionincision

TreatmentTreatment

OperationOperation

• Process:Process:

The taenia of The taenia of the colon are the colon are followed to followed to the base of the base of the appendixthe appendix

TreatmentTreatment

OperationOperation

• Process:Process:

Mesoappendix Mesoappendix is divided is divided between between clamps and clamps and ligatedligated

TreatmentTreatment

Operation Operation • Process:Process:The base of The base of

appendix is appendix is divided and divided and ligated 0.5cm ligated 0.5cm from caceum and from caceum and inverted using a inverted using a purse-stringpurse-string

aa

b c

Treatment Treatment

•Suspected case: not definite.Suspected case: not definite.

Admit the patient to hospital for Admit the patient to hospital for further observation 12-24hrsfurther observation 12-24hrs

Operation Operation

exploration incisionexploration incision

Treatment Treatment

Antibiotic thearpy:Antibiotic thearpy:

• Acute simple appendicitisAcute simple appendicitis

• Contraindication of operationContraindication of operation

• Appendiceal abscessAppendiceal abscess

TreatmentTreatment

Antibiotic thearpyAntibiotic thearpy

antibiotics: broadspectrum antibioticsantibiotics: broadspectrum antibiotics

ampicillin-sulbactamampicillin-sulbactam

gentamycin triad drugsgentamycin triad drugs

metronidazolmetronidazol

33rdrd generation cefotides generation cefotides

Treatment Treatment

• New method :New method :

laparoscopy appendectomylaparoscopy appendectomy

Complication Complication

Acute appendicitis:Acute appendicitis:

• Abdomen abscessAbdomen abscess

• Inter or extra fistulaInter or extra fistula

• PhylephlebitisPhylephlebitis

ComplicationComplication

Operation :Operation :

• Incision infectionIncision infection

• Peritonitis and abdomen abscessPeritonitis and abdomen abscess

• BleedingBleeding

• Stool fistula Stool fistula

• Stump infectionStump infection

• Adhesive intestinal obstructionAdhesive intestinal obstruction

Appendicitis in neonateAppendicitis in neonate

• SeldomSeldom

• Non-specific clinical manifestationNon-specific clinical manifestation Anorexia, nausea, and vomiting Anorexia, nausea, and vomiting

diarrheadiarrhea

dehydrationdehydration

• Difficult in early diagnosisDifficult in early diagnosis

• High rate of perforationHigh rate of perforation

• High mortalityHigh mortality

Appendicitis in neonateAppendicitis in neonate

Diagnosis &TreatmentDiagnosis &Treatment

• Carefully physical examCarefully physical exam

• Early operationEarly operation

Appendicitis in childAppendicitis in child

• Quick onset and severeQuick onset and severe

high fever and vomiting present earlyhigh fever and vomiting present early

• Non-typical tenderness at right low Non-typical tenderness at right low quadrantquadrant

• High rate of perforationHigh rate of perforation

• High mortalityHigh mortality

• More complicationMore complication

Appendicitis in childAppendicitis in child

Treatment:Treatment:

• Early operationEarly operation• Transfusion and correct Transfusion and correct dehydrationdehydration

• Broadspectrum antibioticsBroadspectrum antibiotics

Appendicitis in pregnancyAppendicitis in pregnancy

Uterus enlargementUterus enlargement

elevation of abdominal

wall

Tenderness site upper shift

appendix displaced

superiorly

Inconspicuous oftenderness

rebound tendernessmuscular rigidity

Without adherent blanket of

omentum

Peritonitis diffusion

Appendicitis in pregnancyAppendicitis in pregnancy

Treatment :Treatment :• Operation :appendectomyOperation :appendectomy• To late pregancy :early operationTo late pregancy :early operation• Superior Incision Superior Incision • No drainageNo drainage• Broadspectrum antibioticsBroadspectrum antibiotics• Parturient with perforation :Parturient with perforation : cesarean section and appendectomycesarean section and appendectomy

Appendictis in the elderlyAppendictis in the elderly

• Less well-defined symptoms and Less well-defined symptoms and signssigns

• Severe pathologic typeSevere pathologic type

• Error diagnosis easilyError diagnosis easily

• High rate of perforationHigh rate of perforation

• Pay attention to tumorPay attention to tumor

Chronic appendicitisChronic appendicitis

• Etiology and pathologyEtiology and pathology

• Clinic feature and diagnosisClinic feature and diagnosis

right low quadrant painright low quadrant pain

local tendernesslocal tenderness

x-ray x-ray

• Treat Treat

appendectomyappendectomy