Appendicitis DONE BY DR KURAKIN VICTOR. The appendix is a wormlike extension of the cecum and, for...

AppendicitisDONEBY

DR KURAKIN VICTOR

AppendicitisDONEBY

DR KURAKIN VICTOR

•The appendix is a wormlike extension of the cecum and, for this reason, has

been called the vermiform appendix. Its average length is 8-10 cm (ranging from

2-20 cm

Appendicitis is inflammation of the inner lining of the vermiform appendix that spreads to its other

parts. This illness is one of the more common surgical emergencies, and it is one of the most

common causes of abdominal pain .

•American C. McBurney published a series of reports that constituted the

basis of the subsequent diagnostic and therapeutic management of acute

appendicitis. Currently, appendectomy, either open or laparoscopic, remains the

treatment for noncomplicated appendicitis.

Frequency: The incidence of acute appendicitis is around 7% of the population in the United

States and in European countries.

•Etiology: Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the obstruction include

lymphoid hyperplasia secondary to irritable bowel disease (IBD) or

infections (more common during childhood and in young adults), fecal

stasis and fecaliths (more common in elderly patients), parasites (especially in

Eastern countries), or, more rarely, foreign bodies and neoplasms

•Pathophysiology: Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of

causes

If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the

appendiceal veins, leading to venous outflow obstruction.

•Within a few hours, this localized condition may worsen because of

thrombosis of the appendicular artery and veins, leading to perforation and

gangrene of the appendix.

•Clinical: The most common symptom of appendicitis is abdominal pain. Typically,

symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant

(RLQ) of the abdomen. Later, a worsening progressive pain along with vomiting, nausea,

and anorexia are described by the patient. Usually, a fever is not present at this stage .

The differential diagnosis •The differential diagnosis include cholecystitis

gastroenteritis, enterocolitis, diverticulitis, pancreatitis, perforated duodenal ulcer, renal

colic, and urinary tract infection (UTI). In pediatric patients, consider mesenteric

lymphadenitis and intussusception. In women include ovarian cyst torsion, mittelschmerz, ectopic pregnancy, and pelvic inflammatory

disease (PID). Small bowel obstruction, Crohn disease, Meckel diverticulitis, tumors,

rare conditions that mimic appendicitis .

•Tenderness in the RLQ over the McBurney point is the most important sign in these patients. Signs such

as increasing pain with cough (ie, Dunphy sign), rebound tenderness (ie, Blumberg sign), and guarding

may or may not be present . ROVSING’S SIGN

PSOAS SIGN OBTURATOR SIGN

Patients with appendicitis may not have the reported classic clinical picture 37-

45% of the time, especially when the appendix located in an unusual place

If diagnosis of appendicitis is clear- appendectomy need consider .

If picture is not clear- waiting and follow up – 4-6 hours and doing CT-scan of abdomen

•Relevant Anatomy: The appendix is a wormlike extension of the cecum, and its average length is 8-10 cm (ranging

from 2-20 cm) .

•its wall has an inner mucosal layer, 2 muscular layers, and a serosa. Several

lymphoid follicles are scattered in its mucosa .

•Many individuals may have an appendix located in the retroperitoneal space; in

the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver.

•Appendicular artery, is derived from the ileocolic artery. Sometimes, an

accessory appendicular artery (deriving from the posterior cecal artery) may be

found .

Lab Studies :

•Complete blood cell count

•Urinalysis

•Liver and pancreatic function tests (eg, transaminases, bilirubin, alkaline

phosphatase, serum lipase, amylase) may be helpful to determine the

diagnosis in patients with an unclear presentation.

Imaging Studies:

•Abdomen plain film: Occasionally, a plain film of the abdomen may demonstrate fecalith within the

appendix, but this study is rarely indicated.

•Barium enema

•Although barium enema is currently performed only rarely, in the past this examination was used to diagnose appendicitis.

•Ultrasound

•Vaginal ultrasound

•The main limitation of US scan is that its reliability is completely user-dependent.

•Computed tomography scan

•Recently, helical CT scan has demonstrated high sensitivity and

specificity in differentiating appendicitis from other conditions, and it may be

cost efficient with regards to limiting the number of unnecessary operations.

•Because of its cost, CT scans are generally reserved for patients with

uncertain diagnosis or severe obesity.

•Diagnostic laparoscopy may be useful in selected cases (eg, infants, elderly

patients, female patients) to confirm the diagnosis. If findings are positive, such

procedures should be followed by definitive surgical treatment at the time

of laparoscopy.

Staging:

•Appendicitis usually has 3 stages.

•Edematous stage

•Purulent (phlegmonous) stage

•Gangrenous stage

Medical therapy

•Appendectomy remains the only curative treatment for appendicitis

•Antibiotic prophylaxis should be administered before every appendectomy and must offer full aerobic and anaerobic coverage

Surgical therapy

•Operation of choice-appendectomy-open or laparoscopic. Since 1987, many

surgeons have begun to treat appendicitis laparoscopically. This

procedure has now been improved and standardized .

•The reported results of both laparoscopic and open-procedure

appendectomies seem to be overlapping. In fact, the average rate of

abdominal abscesses, negative appendectomies, and hospital stays are

very similar according to a recent overview of 17 retrospective studies .

•Laparoscopy has some advantages, including decreased postoperative pain, better aesthetic result, a shorter time to

return to usual activities, and lower incidence of wound infections or

dehiscence. This procedure is cost effective but may require more

operative time compared with open appendectomy.

Open appendectomy

•McBurney point

Laparoscopic appendectomy

• Some variations are possible, 3 cannulae are placed during the procedure. Two of them have a fixed

position (ie, umbilical , suprapubic or lt lower quadrant). The third is placed in

the right or left lower region, and its position may vary greatly depending on

the patient’s anatomy .

•short umbilical incision is made to allow the placement of a Hasson cannula or

Veress needle that is secured with 2 absorbable sutures .

•Pneumoperitoneum (10-14 mm Hg) is established and maintained by

insufflating carbon dioxide .

Postoperative details

•Administer intravenous antibiotics postoperatively. The length of

administration is based on the operative findings and the recovery of the patient. In complicated appendicitis, antibiotics

may be required for many days or weeks .

 complications  

•Complications may occur in patents with appendicitis, accounting for an average

morbidity near 10%. Death is rare but can occur in patients who have profound peritonitis and sepsis.

•The outcome of appendicitis, whether it is complicated or simple, is good.

Patients may return to their activities soon after the operation, and, once the

patient has recovered, no changes in lifestyle (eg, diet, exercise) are required

after appendectomy .