Diseases of the Appendix

דמה אברהם יונתן

ד" בס

Appendicitis

> Disease of the young> Incidence> Rare in very young children and elderly> Overall mortality 0.25%> Higher mortality in age extremes

Plan

1. Introduction

2. Diagnosis

3. Treatment preop, op and post op

4. Special consideration

5. Complication

6. Neoplasm

Introduction

> Embryology> Normal anatomy> Pathophysiology> Bacteriology

Embryology

Embryology

Anatomy

Anatomy

Pathophysiology

Diagnosis

> Clinical

> History

> Physical examination

> Laboratory > Imaging

> Plain abdominal film

> US

> CT

History

> 1889: Chester McBurney> History 24-36 hours> Abdominal pain: (diffuse and periumbilical, localizing to the RLQ)> Anorexia (almost always).> Vomiting (75%).> Low grade fever.> If >38 suspect perforation

> Only 55% have classical features.

Physical exam

Peritoneal inflamation sign

> Dunphy's sign> Rovsing's sign> Guarding> Rebound sign> Obturator sign> Psoas sign

Dunphy

Rovsing

Guarding

Rebound

Obturator

Psoas

Diffuse Peritonitis

מתקדם כשהמצב

Laboratory settings

> WBC> Urinalysis

היא בתוספתן דלקת של אבחנהקלינית כל קודם

Scoring

בטוחים לא אנחנו עם ....אבל

Diagnosis - US

> Noninvasive> Available> Operator dependant> Sensitivity 80%> Specificity 90%> Positive Findings

• Noncompressible tubular structure

• >7 mm

• Fluid

• appendicolith

CT

> Requires contrast - oral and IV> Radiation> Sensitivity 90-95%> Specificity 90%> Findings

> Nonfilling tubular structure (target)> >7 mm> Pericecal inflammation and Fluid> appendicolith

Target

מ" 7< מ

Fecalith

DD

> Go by organ systems or by category> Consider symptoms, Age and Sex> Concomitant conditions

Differential diagnosis

Diagnostic laparoscopy

If you are not sure…

Treatment

> Medical > Periappendicular abscess> Surgical

Surgical Treatment

> Appendectomy : Laparoscopic versus open Sex Habitus Diagnostic uncertain NOTES, SILS, Lap assisted

Lap versus open appendectomy

After the surgery

Complication

In op:>Lap converted to open>Bowel resection

Post op:>Wound infection>Deep space infection/abcess>Small bowel obstruction>Infertility>Enterocutaneous Fistula

Special issues

> Normal appearing appendix> Meckels diverticulum> Interval appendectomy> Chronic or recurrent appendicitis> Children> Pregnancy> Crohns dis> FMF

Neoplasms

> Rare

> Mucocele

> benign, malignant, pseudomyxoma

> Treatment (Rt colectomy vs appendectomy)

> Survival rate 55% vs 20%> Adenocarcinoma> Carcinoid

> Treatment: size, location

> Survival

Laparoscopic Appendectomy

תודה