Done byDone by::

Fatima A. Al-HashimFatima A. Al-Hashim

Iman Al-MukhtarIman Al-Mukhtar

Supervised bySupervised by::

Dr. A. Al-MulhimDr. A. Al-Mulhim

Dr. H. WadaniDr. H. Wadani

King Faisal University

College of Medicine

Surgery I

4th year

24.may.2006

IntroductionIntroduction

AnatomyAnatomy

EtiologyEtiology

pathogenesipathogenesiss

Signs & Signs & SymptomsSymptoms

Differential Differential DiagnosisDiagnosis

History takingHistory taking

Physical Physical examinationexamination

Preoperative Preoperative complicationcomplication

InvestigatioInvestigationn

AppendectomyAppendectomy

Postoperative Postoperative complicationcomplication

IntroductionIntroduction

appendicitis is the most common cause appendicitis is the most common cause

of the intra-abdominal infection in of the intra-abdominal infection in

developed countries.developed countries.& & it is the most common emergency it is the most common emergency

surgical operation surgical operation appendicitis can occur at any age but is appendicitis can occur at any age but is

most common below 40 yrs , especially most common below 40 yrs , especially

between the ages of 8 & 14 yr &it is very between the ages of 8 & 14 yr &it is very

rare below the age of 2.rare below the age of 2.

What is appendicitisWhat is appendicitis????

Appendicitis is the inflammation of appendixAppendicitis is the inflammation of appendix..

AnatomyAnatomy

SiteSite

Rt iliac fossa , attached to the posteromedial aspect of caecum 2cm below the iliocaecal valve.

SizeSize2-20 cm long (average

10cm) & about 1\2 cm wide

Peritoneal covering of the appendixPeritoneal covering of the appendixIt is completely covered with peritoneum & is suspended to the back of the mesentery of terminal ileum by a triangular fold of peritoneum called mesoappendix

Arterial supplyArterial supply::Appendicular artery

Branch of ilio-colic artery It runs in the free border of the mesoappendix towards the tips.

Venous Venous drainagedrainageappendicular vein ileocolic vein superior mesenteric vein portal vein

Nerve supplyNerve supplyT10 supplies the peritoneal covering of the appendixreferred pain of the appendix is felt at the umbilicus which has the same nerve supply.

PositionPositionThe base of the appendix is fixed , its tip points to one of the following positions

11-- Retrocecal ( 74% ): behined the caecum ( in the retrocaecal recess)

22--pelvic (21%): the appendix hangs over the pelvic brim where it is related to external iliac vessels , ovary & uterine tube.

33--subcaecal (3.5%): the appendix lies below the caecum.

44--pre-ilial (1%): infront of the terminal part of the ileum

55--post-ileal (1\2 %): the appendix lies behined the terminal part of ileum, in contact with the ileocolic V. it is the most dangerous position because spread of the infection to the vien may lead to portal pyaemia.

MicroscopicallyMicroscopicallythe submucosa of the appendix is rich in lymphoid the submucosa of the appendix is rich in lymphoid tissuetissue

Idintification of appendix at operationIdintification of appendix at operationinside the abdomen the base of the appendix is easly inside the abdomen the base of the appendix is easly found by identifying the tenia coli of the cecum & found by identifying the tenia coli of the cecum & following them to the base of the appendix where following them to the base of the appendix where they coverage to form complete longitudinal they coverage to form complete longitudinal muscular coatmuscular coat

conginital abnormalitiesconginital abnormalities))--11--absence of appendix (agenesisabsence of appendix (agenesis

--22--double appendixdouble appendix--33--appendix lying in the Lt iliac fossaappendix lying in the Lt iliac fossa

Surface anatomy of the base of Surface anatomy of the base of

appendix ( McBurney's point )appendix ( McBurney's point )

It is a point at the junction of the lateral It is a point at the junction of the lateral

1\3 & medial 2\3 of a line extending 1\3 & medial 2\3 of a line extending

from the anterior superior iliac spine to from the anterior superior iliac spine to

the umbilicus (spino-umbilical linethe umbilicus (spino-umbilical line)

EtiologEtiologyy

Infection of appendix by 2 routsInfection of appendix by 2 routs

hematogenoushematogenous

rarerare

endogenouendogenouss common common

obstructedobstructed nonnon--obstructed obstructed appendixappendixByBy::

11--faecolithfaecolith commonest commonest22--foreign bodyforeign body

33--lymphoid hyperplasia lymphoid hyperplasia due to viral infectiondue to viral infection

44--stricturestricture55--carcinoid tumorcarcinoid tumor66--chron's diseasechron's disease

77--parasetic infection parasetic infection particularly by oxyuris particularly by oxyuris vermicularis (pin warm)vermicularis (pin warm)

due todue todirect infection of direct infection of

lymphoid follicle lymphoid follicle from appendicular from appendicular

lumenlumen

pathogenesipathogenesiss

bacterial flora located within the lumen of appendix bacterial flora located within the lumen of appendix include both aerobic & anaerobic organism typical of include both aerobic & anaerobic organism typical of those found in the large intestinethose found in the large intestine

obstructed appendixobstructed appendix

stasisstasis

prolofiration of the gas forming bacteriaprolofiration of the gas forming bacteria

increase intralumenal increase intralumenal pressurepressure

acute inflamation of mucosaacute inflamation of mucosa

acute appendicitis with edema , acute appendicitis with edema , lymphoid obstruction, & lymphoid obstruction, &

necrotizing ulceration of the necrotizing ulceration of the mucosamucosa

If the diagnosis of If the diagnosis of

appendicitis is not made appendicitis is not made

early the process will early the process will

continuecontinue

extension of inflammation across extension of inflammation across appendicael wallappendicael wall

involvment of serosa by involvment of serosa by inflammationinflammation

visceral peritonitisvisceral peritonitis

obstruction of venous & lymphatic obstruction of venous & lymphatic drainage & arterial thrombosisdrainage & arterial thrombosis

Gangrene of appendix wallGangrene of appendix wall

perforationperforation

the outcome of perforation depend on the the outcome of perforation depend on the

ability of the omentum to contain the ability of the omentum to contain the

infectioninfection

adequate adequate

omemtumomemtum

apendicular mass or apendicular mass or

abcess will resultabcess will result

InadequateInadequate

generalized generalized

peritonitisperitonitis

SymptomsSymptoms

11--Abdominal painAbdominal pain

Periumblical pain Periumblical pain migrate to migrate to

Rt lower quadrentRt lower quadrent

22--AnorexiaAnorexia

33--NauseaNausea

44--VomitingVomiting

55--lowlow--grade fevergrade fever

Common symptomsCommon symptoms::

SignsSigns

11--Right lower quadrant pain on palpationRight lower quadrant pain on palpation

))the single most important signthe single most important sign ) )

2-2- Low Low--grade fever grade fever ((38°C 38°C [[or 100.4°For 100.4°F])])

----absence of fever or high fever can occur absence of fever or high fever can occur

3-3-Localized tenderness to percussion Localized tenderness to percussion

4-4-Guarding Guarding

5-5-Other confirmatory peritoneal signsOther confirmatory peritoneal signs

))absence of these signs does not exclude appendicitisabsence of these signs does not exclude appendicitis ) )

• •Psoas signPsoas sign

• Obturator sign• Obturator sign

• Rovsing's sign• Rovsing's sign

• Dunphy's sign• Dunphy's sign----increased pain with coughing increased pain with coughing

• Flank tenderness in right lower quadrant• Flank tenderness in right lower quadrant

Differential Differential DiagnosisDiagnosis

ChildrenChildren

ElderlyElderly

--GastroenteritsGastroenterits

--Mesenteric adenitisMesenteric adenitis

--Meckel`s Meckel`s

diverticulitisdiverticulitis

--IntussusceptionIntussusception

--Lobar pneumoniaLobar pneumonia --Sigmoid diverticulitisSigmoid diverticulitis

--Intestinal obstructionIntestinal obstruction

--Colonic carcinomaColonic carcinoma

--Mesenteric infarctionMesenteric infarction

--Aortic aneurysmAortic aneurysm

Adult maleAdult male

Adult femaleAdult female

--Regional enteritisRegional enteritis

--Ureteric colicUreteric colic

--Perforated ulcerPerforated ulcer

--Torsion testisTorsion testis

--PancreatitisPancreatitis

--Rectus sheath hematmoaRectus sheath hematmoa--SalpingitisSalpingitis

--PyelonephritisPyelonephritis

--Ectopic pregnancyEctopic pregnancy

--Torsion/rupture ofTorsion/rupture of

ovarian cysteovarian cyste

--EndometriosisEndometriosis

History TakingHistory Taking

An introductionAn introductionPresenting complaintPresenting complaintHistory of presenting complaintHistory of presenting complaintPast history ( medical & surgical )Past history ( medical & surgical )Drugs/allergiesDrugs/allergiesFamily history Family history Social historySocial historyOccupational historyOccupational historySystems enquirySystems enquiry

The components of the surgical history The components of the surgical history are that of any other history, includingare that of any other history, including;;

Age & Sex :Age & Sex :

Appendicitis does occur at any age but most Appendicitis does occur at any age but most often affectsoften affects young adults or teenagers of either sex.young adults or teenagers of either sex. Ask aboutAsk about

The site of the painThe site of the painOnsetOnsetSeveritySeverityPatternPatternIs it localized in a particular Is it localized in a particular area or notarea or notRadiationRadiationDurationDurationProgressionProgressionAggregating FactorsAggregating Factors Relieving FactorsRelieving FactorsAssociated SymptomsAssociated Symptoms

Physical Physical examinationexamination

General Appearance :General Appearance :

Patient looks unwell with flushed Patient looks unwell with flushed cheekscheeks

Tongue “ white & furred with foetor oris Tongue “ white & furred with foetor oris ““

Pale ( especially in children )Pale ( especially in children )

TachycardiaTachycardia

Low grade feverLow grade fever

Head & Neck :Head & Neck :

Observe the tonsils & Palpate the lymph Observe the tonsils & Palpate the lymph nodesnodes

Chest :Chest :

Examine the LungsExamine the Lungs

Abdomen :Abdomen :

• InspectionInspection

Usually normal shape , the abdomen is slowly Usually normal shape , the abdomen is slowly moves with respiration due to painmoves with respiration due to pain

• PalpationPalpation

The Rt iliac fossa is tender with or without The Rt iliac fossa is tender with or without guarding guarding

Rebound Tenderness:Rebound Tenderness: +ve in Mcburneys point +ve in Mcburneys point

Signs :Signs :

I-I- Rovsing`s sign :Rovsing`s sign :

Pain in the Rt iliac fossa on palpation or Pain in the Rt iliac fossa on palpation or

percussion on Lt iliac fossa.percussion on Lt iliac fossa.

II-II- Psoa`s sign : Psoa`s sign :

Pain when extending the Rt hip Pain when extending the Rt hip

joint due to spasm of the psoa`a joint due to spasm of the psoa`a

musclemuscle . .

The psoas signThe psoas sign.. Pain on passive extension of Pain on passive extension of

the right thighthe right thigh.. Patient lies on left sidePatient lies on left side . .

Examiner extends patient's Examiner extends patient's right thigh while applying right thigh while applying counter resistance to the counter resistance to the right hip asteriskright hip asterisk

Anatomic basis for the Anatomic basis for the psoaspsoas signsign:: inflamed inflamed appendix is in a retroperitoneal appendix is in a retroperitoneal location in contact with the location in contact with the psoas muscle, which is psoas muscle, which is stretched by this maneuverstretched by this maneuver

III-III-Obturator`s sign :Obturator`s sign :

Pain with passive internal rotation of the Pain with passive internal rotation of the flexed flexed

Rt thigh Rt thigh it indicated inflammation it indicated inflammation overlying that muscleoverlying that muscle .

IV-IV-Blumberg`s sign :Blumberg`s sign :

Crossed Rebound tenderness in the Rt Crossed Rebound tenderness in the Rt

iliac fossa after pressing and sudden iliac fossa after pressing and sudden

release on Lt iliac fossa .release on Lt iliac fossa .

V-V-Straight leg arising sign :Straight leg arising sign :

++ve in retrocecal appendixve in retrocecal appendix

Rectal ExaminationRectal Examination : :

Tenderness in pelvic appendix Tenderness in pelvic appendix

or if there is inflammation or or if there is inflammation or

pus in Douglas pouchpus in Douglas pouch

Preoperative Preoperative complicationcomplication

Acute toxemia Acute toxemia

Septicemia Septicemia

Portal pyemiaPortal pyemia

Systemic ComplicationsSystemic Complications: :

Appeddicular Abscess

Appedidicular fistula

Rupture supportive peritonitis

Turns to chronic appendicitis

Local ComplicationsLocal Complications: :

InvestigationInvestigation

Complete Blood Count ( CBC ) :Complete Blood Count ( CBC ) :

Leukocytes Count especially neutrophiles

Urine AnalysisUrine Analysis

Albuminuria , Hematuria

(25-40% of patient).

Plain X-rayPlain X-ray

Ultra SoundUltra Sound

CT scanCT scan

AppendectomAppendectomyy

Conventional Open OperationConventional Open Operation

Grid-iron incision

Lower midline abdominal incision

Laparoscopic TechniqueLaparoscopic Technique

A normal appendix is found

The Appendix can not be found

An Appendicular Tumor is found

An Appendix Abscess is found

Postoperative Postoperative complicationcomplication

Wound Infections

Intra-abdominal Abscesses

Venous Thrombus & Embolism

Portal Pyemia ( Pylephlebitis )

Faceal Fistula

Adhesive intestinal obstruction

Right inguinal hernia

Postoperative complicationPostoperative complication

Antibiotic prophylaxis

If perforation has occurred,

IV antibiotics should be

continued for 5-10

days.