Appendicities by Vaibhav wavhal
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Appendicities by Vaibhav wavhal

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appendicitis is one of the commonest surgical disorder. the main etiology of appendictis is .......................

appendicitis is one of the commonest surgical disorder. the main etiology of appendictis is .......................

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Appendicities by Vaibhav wavhal Appendicities by Vaibhav wavhal Presentation Transcript

  • Appendicitis
    By Dr.VaibhavWavhal,
    JRII, ShalyaTantra
  • contents
    Introduction
    History
    Basics of Appendix
    Incidence
    Pathophysiology
    Aetiology
    Symptoms & signs
    Differential diagnosis
    Investigations
  • introduction
    Appendicitis remains one of the most
    common acute surgical diseases.
    The incidence of acute appendicitis
    roughly parallels that of lymphoid
    development, with the peak incidence
    in early adulthood.
    Appendicitis occurs more frequently in males
    especially at the time of puberty. With an overall
    ratio of 1.3:1 in the year 2001.
    View slide
  • Appendicitis
    The term appendicitis consist of 2 terms-
    Appendix+ itis :- impliesinflammationof appendix
    Appendage:- something attached to something large
    View slide
  • history
    In 1500, Alchemist-
    used the term Perityphilitis for inflammation arroundcaecum
    In 1736, Claudius-
    1stappendicectomy in 11 yr boy with scrotal hernia, within scrotum he found appendix perforated by pin.
    In 1886, Reginald Fitz
    coined the term appendicitis and recommended early surgical treatment of the disease.
  • History…………
    In 1889, Chester McBurney
    described characteristic migratory pain as well as localization of the pain at McBurny`s point. And also described it`s surgical management.
    The mortality rate from appendicitis decreased with the widespread use of broad-spectrum antibiotics in the 1940s.
    Laparoscopic appendectomy was first reported by the gynaecologist Kurt Semm in 1982 but has only gained widespread acceptance in recent years.
  • EMBRYOLOGY
    The appendix, ileum, and ascending colon are all derived from the midgut.
    The appendix first appears at the 8th week of IUL.
  • ANATOMY
    Site- Rtilliacfossa
    Posteromedial to caecum
    2.5 cm below ileocaecal valve
    Base of appendix- surface anatomy @ Mcburney`s point.
    length-2 to 20 cm and the average length is 9 cm in adults.
  • ANATOMY…………
    The base of the appendix is located at the convergence of the taeniae along the inferior aspect of the caecum, and this anatomic relationship facilitates identification of the appendix at operation.
    The three taenia coli converge at the junction of the caecum with the appendix.
  • ANATOMY…………
    The tip of the appendix may lie in a variety of locations.
    The most common location is retrocaecal but within the peritoneal cavity.
    It is pelvic in 30% cases.
    Other positions are subcaecal,
    preileal, postileal and paracaecal.
  • ANATOMY…………
    Arterial Supply:
    The appendiceal artery,
    a branch of the ileocolic artery,
    supplies the appendix. It is
    an end artery.
    Acc. Appendicular A.-
    supplies base of appendix
  • appendix
    Histology
    Appendix containsthat goblet cells, which produce mucus, are scattered throughout the mucosa.
    Layers- Serosa, muscle coat, submucosa
    Muscular layer shows pecularity of gap in between them, hence immediate spread of infection into peritonium
    The submucosa contains lymphoid follicles(abdominal tonsils), few @ birth. Increases to peak of 200 & more at the age of 14-20 years. And then reduces with age.
  • Functions:
    For many years, the appendix was erroneously viewed as a vestigial organ with no known function.
    It is now well recognized that the appendix is an immunologic organ which actively participates in the secretion of immunoglobulins, particularly IgA. Though the appendix is an integral component of the gut-associated lymphoid tissue (GALT) system.
  • incidence
    Age-75% in younger population
    Sex- frequency 0.3% more in males
    Geographic- more in western countries
    Social status- more in rich people
    Diet- more in meat eating peoples
  • Appendicitis- pathophysiology
    Mainly 2 causes:- obstructive(75%)
    catarrhal
    catarrhal-
    source- flora bacteria, most commonly
    aerobic E.Coli(94%)
    mucosal & submucosal inflammation
    intraluminalswelling & altered serosa
    diffuse peritonitis
    Fate- suppuration, gangrene, fibrosis, resolution
  • Obstructive-
    Causes- fecalith, gall stones, worms(tapeworms), food debris
    Pathological changes depends upon the matter in obstructed lumen- For eg. If obstructed lumen is without any matter, then continous mucus secretion leads to mucocele which further leads into proliferation & deeper invasion of bacteria into layers of appendix. This results in thrombosis of vessels & finally gangrene A. perforation
    Appendicitis- pathophysiology
  • Pathophysiology…..
    Rarest cause- strangulation of appendix within the hernial sac, 1st observed in patient with Rt. Femoral hernia.
    Earlier type is more dangerous, since it results in end artery thrombosis which leads to gangrene.
    Catarrhal type shows gradual onset with dull, aching pain. Whereas obstructive type, shows sudden onset with colicky pain at the onset.
  • Symptoms(murphy`s triad)
    Pain:-
    The initial pain is due to the early obstruction, dilation, and infection of the appendix, it stretches wall. Onset of periumbilical colicky pain, as this visceral pain is mediated through visceral pain fibres, it is poorly localized.
    Mucocele of appendix-cramping pain
  • Symptoms….
    When the infection in the appendix becomes established and transmural, the serosa of the appendix and the parietal peritoneum are involved, causing a localized pain from somatic pain fibres in the abdominal wall at McBurney's point
  • Symptoms……
    Vomitting:-
    Shortly after the initial pain, anorexia, nausea, and occasionally vomiting develop. Anorexia is the most constant symptom of appendicitis.
    Reasons-distension of appendix produces neural stimulation and occasionally ileus.
  • Symptoms…..
    Fever
    Usually there is mild temerature rise by 1`C(1.8`F). It is a late physical finding in appendicitis. Before perforation, the body temperature is usually no more than 39 to 39.5°C, but with perforation may rise to 40 to 41°C. If fever has been present since the onset of the illness, consider other causes.
    With appearance of vomiting & fever there is
    shifting of paintowards Rtilliacfossa.
  • Other symptoms
    Bowels-Usually H/o constipation, in children diarhoea is more common feature.
    Loss of appetite
    Sequence of symptoms
    i. anorexia ii. Pain
    iii. Nausea iv. Vomiting
    v.temperature
  • signs
    Tachycardia, dry tongue
    Tenderness over
    McBurney'spoint
    Shake test
    Muscle guarding
    Rebound tenderness(release test/blumberg sign)
  • Signs….
    Rovsingsign
    Psoas sign- in retrocaecalappendictis
    Passive Extension of thigh in left recumbent position
    Obturatorsign- in pelvic appendicitis
    Passive int. rotaion of flexed thigh
    Baldwing test-in retrocaecal appendicitis
    hand placed over flank of patient, raising patient leg in knee extended position
  • Signs…..
    Bowel sounds- silent in right iliac fossa
    P/R or P/V examination- in cases of pelvic appendicitis
    Hyperesthesia at sherren`s triangle.
    When sudden absence of hyperesthesia during illness, it`s S/o Gangrenous appendix
  • Alvarado score
  • Lab. investigations
    Polymorphic leukocyosis
    Upto 17000/mm3
    In perforated appendicitis- upto20000/mm3
    • Urine examination-
    hematuria, Mild pyuria- in pelvic appendicitis
    • CRP- C Reactive Protein
    • By latex fixation test- when CRP> 6mg/l is S/O acute appendicitis
  • others
    • X-RAY
    • Fluid level localized to caecum
    • Fecalith at Rt. Iliac fossa
    • USG
    • CT- unenhanced CT
    • Peritoneal aspiration-
    it shows acute inflammatory cells and mesothelial hyperplasia
  • laproscopy
    • Diagnostic laproscopy
    • for women of childbearing age in whom preoperative pelvic ultrasound or CT scan fails to provide a diagnosis.
  • Differential diagnosis
    Intra abdominal causes
    Perforated peptic ulcer
    Meckel's diverticulitis
    Intussusception
    Acute gastroenteritis
    Acute mesentric adenitis
  • dd……..
    Intra abdominal UT related
    Rt. Ureteric colic
    Acute pyelonephritis
    Gynaecology related
    Ruptured ectopic pregnancy
    Twisted ovarian cyst
  • dd…..
    CNS related
    H. zoster- two to three days before development of rash
    RS related
    Important in cases of children-pleurisy, basal pnemonia
  • dd……..
    In infants-USG helpful
    In preschool-aged children, DD
    Intussusception-distinguished by the colicky nature of the pain, with intervening pain-free periods, and the absence of peritonitis.
    Meckel's diverticulitis
    Gastroenteritis
    In school-aged children- USG shows enlarged lymph nodes in ilealmesentry.
    H/o constipation
  • dd…..
    In adults- DD with
    Colitis
    Pyelonephritis- high grade fever, pyuria with leukocytosis
    Diverticulitis
    Elderly patients
    Appendicitis in pregnancy
    Site of pain changes with trimester
  • Thank you