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