Appendicitis- Dr. Sigit

APPENDICITIS

Dr.sigid djuniawan, spB

Anatomy and physiology of appendix

The appendix is a slender, worm-shaped pouch, averaging 510cm in length, that protrudes from the top of the colon in the lower right abdomen

Location
McBurneys point:one-third of the way from the anterior,superior iliac spine to the umbilicus.Pelvis and right ilac fossa appendixAnterior or posterior ileum appendixRetrocaceal appendix Right lateral caceal appendix

Retrocaceal appendix

Supply & nerve
Appendix artery: a final artery ,from ileocolic arteryAppendix vein : portal veinsympathetic nerve :celiac plexus and lesser splanchnic nerve T10,T11

Acute appendicitis

Appendicitis is a common cause of abdominal pain

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

Etiology
Obstruction:
anatomy :wormed-shaped

narrow

plenty of lymph glands

mechanical reason:

food residue, ascarid,

tumor,etc.

Etiology
Gastrointestial diseaseBacteria invasion:
all kinds of G- bacilus

Pathology

Four type:
Acute simple appendicitisAcute purulent appendicitisPerforation and gangrenousAppendiceal abscess

Acute simple appendicitis

Acute purulent appendicitis

Perforation and gangrenous

Gangrenous

Perforation

Appendiceal abscess

Results
Inflammation disappearInflammation localizationInflammation diffusion

Clinical manifestation

symptoms :
abdominal pain :
Periumbilical or epigastric pain that migrates to right lower quadrant

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

Symptoms :
Gastrointestinal symptoms:
Anorexia, nausea, and vomiting occur after the onset of pain

Constipation

Diarrhea

bladder and rectum stimulus symptoms

Symptoms
General symptoms :
tired ,headach

fever

Rapid pulse
SIRS (systemic inflammatory response syndrome)

Signs
Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone
peritoneal irritation sign : muscular rigidity

Blumberg sign

bowel sounds disappear

Others
Rovsings sign:pain in the right lower quadrant upon palpation of the left lower quadrant.Psoas sign :pain on active elevation of the legsThe obturator sign: pain on internal and external rotation of the hipRectal exam & vaginal exam

Lab test
Mild to moderately elevated WBC with left shift is typical but rarely may be normal, range of 11000-17000/mm3
over 20000/ mm3 perforation
UA may show ketonuria or a few RBCs or WBCspregnancy test (women only)

Lab test
B-usX-rayDiagnostic abdominal puncture

Diagnosis
Periumbilical or epigastric pain that migrates to right lower quadrantTenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone

Differential diagnosis

Two type :

A: required surgery

B: not required surgery


Required surgery:
Perforation of gastointestinal tract
ulcer,tumor, diverticulitis
obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsion
Meckel diverticulitisTumor


Not required surgery
Pelvic inflammationMesenteric adenitis:at exploration a normal appendix and enlarged lymph nodes in the mesenteryViral & bacterial gastroenteritisPneumonia, pleurisy

Treatment
Early operation:
surgical removal(appendectomy)
Acute simple appendicitis: appendectomy Acute purulent and gangrenous appendicitis:
appendectomy and/or drainage

Treatment

Appendiceal abscess:
if local in right low quadrant
antibiotic therapy and general treatment
if infection diffusion
incision and drainage

Treatment

Operation
Incision :
incision over the point of maximal tenderness,generally at McBurny point

true McBurneys incision

tansvers skin incision

36cm long

Incision
McBurneys
incision

Incision
tansvers skin incision

Treatment

Operation
Process:
The taenia of the colon are followed to the base of the appendix

Treatment

Operation
Process:
Mesoappendix is divided between clamps and ligated

Treatment

Operation
Process:
The base of appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string

a

b

c

Treatment
Suspected case: not definite.
Admit the patient to hospital for further observation 12-24hrs

Operation

exploration incision

Treatment

Antibiotic thearpy:
Acute simple appendicitisContraindication of operationAppendiceal abscess

Treatment

Antibiotic thearpy

antibiotics: broadspectrum antibiotics

ampicillin-sulbactam

gentamycin triad drugs

metronidazol

3rd generation cefotides

Treatment
New method :
laparoscopy appendectomy

Complication

Acute appendicitis:
Abdomen abscessInter or extra fistulaPhylephlebitis

Complication

Operation :
Incision infectionPeritonitis and abdomen abscessBleedingStool fistula Stump infectionAdhesive intestinal obstruction

Appendicitis in neonate
SeldomNon-specific clinical manifestation
Anorexia, nausea, and vomiting diarrhea

dehydration
Difficult in early diagnosisHigh rate of perforationHigh mortality

Appendicitis in neonate

Diagnosis &Treatment
Carefully physical examEarly operation

Appendicitis in child
Quick onset and severe
high fever and vomiting present early
Non-typical tenderness at right low quadrantHigh rate of perforationHigh mortalityMore complication

Appendicitis in child

Treatment:
Early operationTransfusion and correct dehydrationBroadspectrum antibiotics

Appendicitis in pregnancy

Uterus enlargement

elevation of abdominal wall

Tenderness site upper shift

appendix displaced

superiorly

Inconspicuous of

tenderness

rebound tenderness

muscular rigidity

Without adherent blanket of omentum

Peritonitis diffusion

Appendicitis in pregnancy

Treatment :
Operation :appendectomyTo late pregancy :early operationSuperior Incision No drainageBroadspectrum antibioticsParturient with perforation :
cesarean section and appendectomy

Appendictis in the elderly
Less well-defined symptoms and signsSevere pathologic typeError diagnosis easilyHigh rate of perforationPay attention to tumor

Chronic appendicitis
Etiology and pathologyClinic feature and diagnosis
right low quadrant pain

local tenderness

x-ray
Treat
appendectomy

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Appendicitis- Dr. Sigit