The document discusses pediatric gastroenterology, specifically acute appendicitis. It defines appendicitis and its classifications. It discusses the epidemiology, including risk factors, incidence rates, mortality rates, and populations most affected. It explores the etiology, pathophysiology, clinical manifestations, diagnostic factors, and management of acute appendicitis. Physical exam findings and scoring systems to determine likelihood are presented. Treatment typically involves surgical appendectomy, with antibiotics sometimes used for complicated cases.
In this PPT presentation I try to teach many causes of Abdominal pain in various quadrants of the abdomen. Since it is individual case based teaching i concentrate only in the essential minimum an undergraduate medical student should know and you will have immersive learning experience.
In this PPT presentation I try to teach many causes of Abdominal pain in various quadrants of the abdomen. Since it is individual case based teaching i concentrate only in the essential minimum an undergraduate medical student should know and you will have immersive learning experience.
An anorectal abscess is a collection of pus in the anal or rectal region.
It may be caused by infection of an anal fissure, sexually transmitted infections or blocked anal glands.
An anorectal abscess is a collection of pus that builds up in the rectum and anus.
With prompt treatment, client with this condition usually recover very well.
Complications tend occur when treatment is delayed.
NECROTISING FASCIITIS- the flesh eating infection
#surgicaleducator #necrotisingfasciitis #surgicaltutor #babysurgeon #usmle
· Dear Viewers
· Greetings from “Surgical Educator”
· Today in this episode I have discussed about Necrotising Fasciitis- the flesh eating infection
· It is common in immunocompromised patients even after trivial trauma.
· I have discussed about the overview,etiology,types,clinical features,complications and treatment of Necrotising Fasciitis
· I hope this video is interesting and also useful to all of you
· You can watch the video in the following links:
· surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
Thank you for watching the video
This presentation gives general overview of all aspects of bowel sounds including its pathophysiology, auscultation techniques and features of normal versus abnormal bowel sounds.
An anorectal abscess is a collection of pus in the anal or rectal region.
It may be caused by infection of an anal fissure, sexually transmitted infections or blocked anal glands.
An anorectal abscess is a collection of pus that builds up in the rectum and anus.
With prompt treatment, client with this condition usually recover very well.
Complications tend occur when treatment is delayed.
NECROTISING FASCIITIS- the flesh eating infection
#surgicaleducator #necrotisingfasciitis #surgicaltutor #babysurgeon #usmle
· Dear Viewers
· Greetings from “Surgical Educator”
· Today in this episode I have discussed about Necrotising Fasciitis- the flesh eating infection
· It is common in immunocompromised patients even after trivial trauma.
· I have discussed about the overview,etiology,types,clinical features,complications and treatment of Necrotising Fasciitis
· I hope this video is interesting and also useful to all of you
· You can watch the video in the following links:
· surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
Thank you for watching the video
This presentation gives general overview of all aspects of bowel sounds including its pathophysiology, auscultation techniques and features of normal versus abnormal bowel sounds.
Management of Typhoid Intestinal Perforation which is a common and the most dreaded surgical complication of Typhoid fever.
This menace is still on the rise in low and medium income countries where we still battle with lack of potable water and open defecation.
This presentation is especially targeted at trainee surgeons in Nigeria and Medical Students also who may find it worthwhile.
Abdominal pain is one of common problems
encountered by doctors, either in primary or
secondary health care (specialists). It may be
mild, but it may also a life-threatening sign. It
has been estimated that almost 50% adults have
experienced abdominal pain. In general, abdominal pain is categorized
based on the onset as acute or chronic pain.
Sudden onset of abdominal pain that lasts for less
than 24 hours is considered as acute abdominal
pain.
The problems of a surgeon
If 'I' operate 'and 'the' problem 'is' not 'surgical, Pt
exposed 'to' unnecessary 'risk ,'anesthetic,'etc.'
Risks 'greater' with 'concomitant 'illness,'older 'age'
If 'I' do 'not' operate 'and' problem 'is' surgical, 'patient 'at'
risk 'because' of 'wrong' therapy.'
Again 'the' older 'patient 'is' under 'greater' burden.'
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
3. DEFINITION
INFLAMMATION of the APPENDIX
First described in 1886 by DR. REGINALD FITZ1
Most common surgical condition requiring
emergency surgery in adults2
Remains the most common acute surgical
condition in children & major cause of childhood
morbidity5
4. DEFINITION
SIMPLE APPENDICITIS inflamed appendix, in
the absence of gangrene, perforation, or
abscess around the appendix2
COMPLICATED APPENDICITIS perforated or
gangrenous appendicitis or the presence of
peri-appendicular abscess2
5. EPIDEMIOLOGY
INCIDENCE RATE 1/1,000 (West)1, 2.5/1,000 (Philippines)
~100,000 children treated in children’s hospitals for AP each year5
MORTALITY RATE <1% (low)
GENDER male-to-female ratio is 1.4:1
AGE most common age group ––– 10–19 y/o1
1-2/10,000 children ––– BIRTH TO 4 y/o5
19-28/10,000 children ––– <14 y/o
RACE WHITES>BLACKS; more frequently in WESTernized societies, but
increasing in African Americans, Asians, and Native Americans
SEASON peak incidence in AUTUMN and SPRING
LIFETIME RISKS:
MALE3
8.6%
FEMALE3
6.7%
CHILDREN5
~7%
6. ETIOLOGY
EXACT CAUSE not completely understood1
ASSOCIATED FACTORS1,5:
• FECALITHS or APPENDICOLITHS common
in developed countries with refined, low-
fiber diets
• INCOMPLETELY DIGESTED FOOD RESIDUE
to include foreign body ingestion
• LYMPHOID HYPERPLASIA SUBMUCOSAL
LYMPHOID FOLLICLES few at birth but
multiply steadily during childhood
7. ETIOLOGY
ASSOCIATED FACTORS (con’t)1,5:
• INTRALUMINAL SCARRING blunt trauma
• TUMORS OR MALIGNANCIES carcinoid tumors
• MICROORGANISMS:
a. BACTERIA Yersinia, Salmonella, & Shigella spp.,
b. VIRUSES Mumps, Coxsackievirus B & Adenovirus,
Infectious mononucleosis
c. OTHERS Ascaris lumbricoides
• OTHER DISEASES:
a. IBD1 for adults)
b. CYSTIC FIBROSIS5 for children
9. PATHOPHYSIOLOGY
Vascular
Thrombosis
Ischemic
Necrosis
PERFORATION
GANGRENOUS APPENDICITIS
*50% of patients with fecaliths
*Patients with S/S for >48 hrs more likely to perforate
Leak of Contents into the Omentum
and SurroundingTissues
INHIBITION OF LYMPHATIC
AND BLOOD FLOW
Abscess
Formation Peritonitis
Supportive
Thrombosis
COMPLICATIONS
*Children with perforation rate
(82% for <5yo & 100% for infants)
*Impaired arterial perfusion, ischemia
of the wall of the appendix
*Escalating diffuse abdominal pain
with rapid development of toxicity
evidenced by dehydration and signs
of sepsis including hypotension,
oliguria, acidosis, & high-grade fever
Small Bowel
Obstruction
10. CLINICAL MANIFESTATIONS
LOCATION1:
• Right Lower Quadrant
• Right Upper Quadrant
• Left Side of the Abdomen
• Pelvis and Right flank
PRESENTATION2:
• Retrocecal/retrocolic (64%)
• Subcaecal (32%)
• Pre-ileal (1%)
• Post-ileal (2%)
• Pelvic appendix
POSITION of the appendix is a critical factor affecting presentations of signs & symptoms
11. CLINICAL MANIFESTATIONS
PAIN (depends on the location) 1:
• IF UNUSUALLY POSITIONED – challenge in
diagnosis regarding the pain
• IF BEHIND THE CECUM OR BELOW THE
PELVIC BRIM – may prompt very little
tenderness
• IF RETROCECAL/RETROCOLIC – psoas
stretch sign
FOR ELDERLY can be subtle, nausea, anorexia, and
emesis may be the predominant complaints1
FOR VERY YOUNG atypical presentation, pain
patterns –– common1
12. CLINICAL MANIFESTATIONS
EMESIS only mild and scant1
NAUSEA & VOMITING occur in more than half the patients, usually follow the
onset of abdominal pain by several hours
ANOREXIA so common that the diagnosis of appendicitis SHOULD BE
QUESTIONED IN ITS ABSENCE1
PELVIC APPENDICITIS more likely to present with dysuria, urinary frequency,
diarrhea, or tenesmus1
DIARRHEA & URINARY SYMPTOMS also common, particularly in cases of
perforated appendicitis when there is likely inflammation near the rectum and
possible abscess in the pelvis
FEVER common, typically low-grade unless perforation has occurred
13. CLINICAL MANIFESTATIONS
NONSPECIFIC COMPLAINTS occur first1
Changes in bowel habits, malaise & vague,
perhaps intermittent, crampy, abdominal
pain in the EPIGASTRIC or PERIUMBILICAL
REGION1
Pain migrates to RLQ in 12–24 hours,
(sharper & localized at MCBURNEY’S POINT)1
1 = Anterior superior iliac spine
2 = Umbilicus
x = McBurney’s point
ADULTS
14. CLINICAL MANIFESTATIONS
SAME CLASSIC PRESENTATION <50% of cases,
therefore, majority of cases of appendicitis have an
“atypical” presentation5
BEGINS INSIDIOUSLY with brief period of
generalized malaise & anorexia family is not likely
to seek consultation – assumption of “STOMACH FLU”
ESCALATES RAPIDLY with progressive abdominal pain
followed by vomiting perforation likely to occur
within 48° of the onset
PEDIA
16. MORPHOLOGY
OUTER ASPECT OF APPENDIX INVOLVED BY ACUTE
INFLAMMATION. A THICK PURULENT COATING IS SEEN TOGETHER
WITH MARKED HYPEREMIA OF THE SEROSA.
Gross Findings4
ACUTE APPENDICITIS WITH MASSIVE INFLAMMATORY INFILTRATE,
EXTENSIVE ULCERATION, AND HEMORRHAGE. AN ISLAND OF
HEAVILY INFLAMED RESIDUAL MUCOSA IS SEEN IN THE CENTER.
Histologic Findings4
18. PHYSICAL EXAMINATION
HALLMARK of diagnosing acute
appendicitis remains a careful and
thorough Hx & PE
Presence of LOCALIZED ABDOMINAL
TENDERNESS the SINGLE MOST
reliable finding in the diagnosis of
acute appendicitis
19. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
REBOUND TENDERNESS
Elicited by deep palpation of the
abdomen followed by the sudden
release of the examining hand5
20. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
ROVSING’S SIGN
Palpating in the left lower
quadrant causes pain in the
right lower quadrant1
21. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
OBTURATOR SIGN
Internal rotation of the hip
causes pain, suggesting the
possibility of an inflamed
appendix located in the pelvis1
22. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
ILIOPSOAS SIGN
Extending the right hip causes
pain along posterolateral
back and hip, suggesting
retrocecal appendicitis1
23. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
DUNPHY SIGN Coughing may elicit pain
d/t abdominal wall movement5
24. PHYSICAL EXAMINATION
OTHER SIGNS OF APPENDICITIS:
BASSLER SIGN Sharp pain created by
compressing the inflamed appendix between
abdominal wall and Iliacus
TEN HORN SIGN Pain in the RLQ or
McBurney’s Point caused by gentle traction of
right testicle or the spermatic cord for males
27. DIAGNOSTIC FACTORS
CBC (with DIFFERENTIAL COUNT)
• WBC 10,000–18,000/mm3 in 70% cases1
11,000–16,000/mm3 for pediatric patients5
>20,000/mm3 –––– indicates PERFORATED CASES
• “LEFT SHIFT” toward immature PMN leukocytes in >95% of cases
URINALYSIS
• Indicated to help EXCLUDE genitourinary conditions1
• Often with WBC and RBC d/t result of the proximity of the
inflamed appendix to the ureter or bladder, but it should be free
of bacteria5
LABORATORY TESTS
28. DIAGNOSTIC FACTORS
OTHER TESTS
• ELECTROLYTES & LIVER PANEL most helpful only in
assessing the level of illness and direct fluid
resuscitation, but RARELY aid accurate diagnosis5
• C-REACTIVE PROTEIN increases in proportion to the
degree of inflammation, but non-specific as well5
• AMYLOID A PROTEIN consistently elevated in
patients with acute appendicitis (SENSITIVITY –– 86%;
SPECIFICITY –– 83%)
29. DIAGNOSTIC FACTORS
PLAIN RADIOGRAPHS
• Most helpful in evaluating complicated cases in which
small bowel obstruction or free air is suspected5
• FINDINGS:
1. Sentinel loops of bowel & localized ileus
2. Scoliosis from psoas muscle spasm
3. Colon “CUT-OFF” Sign colonic air–fluid level above
the right iliac fossa
4. RLQ soft-tissue mass
5. Calcified appendicolith (5-10% of cases)
IMAGING TESTS
30. DIAGNOSTIC FACTORS
ULTRASOUND
• Highly operator dependent
• SENSITIVITY – 0.86
• SPECIFICITY – 0.81
• FINDINGS5:
1. Wall thickness ≥6 mm
2. Appendicolith
3. Luminal distention
4. Lack of compressibility
5. Complex mass in the RLQ
WALL-C
MAIN LIMITATION an inability to visualize the appendix in up to 20% cases
31. DIAGNOSTIC FACTORS
• GOLD STANDARD for pediatric evaluation
• BUT carries negative effects of radiation &
increased costs
• SENSITIVITY – 0.94
• SPECIFICITY – 0.95
• FINDINGS5:
1. Distended (>7 mm) thick-walled appendix
2. Inflammatory streaking of surrounding mesenteric fat
3. Pericecal phlegmon or abscess
4. Appendicoliths more readily seen (40-50%) than
plain radiographs (5-15%
COMPUTED TOMOGRAPHY Also helpful in demonstrating NON-APPENDICEAL
CAUSES of abdominal pain
33. DIAGNOSTIC FACTORS
MAGNETIC RESONANCE IMAGING
• EQUIVALENT to CT in diagnostic
accuracy for appendicitis
• LIMITED because it is less available,
more costly, often requires sedation
• DOES NOT involve ionizing radiation
• Most useful in adolescent girls when
advanced imaging is needed
34. DIAGNOSTIC FACTORS
WHITE BLOOD CELL SCAN
• RADIONUCLIDE-LABELED WBC SCANS
• Also been used in some centers in
evaluating atypical cases of possible
appendicitis in children
• SENSITIVITY – 0.97
• SPECIFICITY – 0.80
37. DIAGNOSTIC FACTORS
• Dx of ACUTE APPENDICITIS made in only 50-70% of children at the
time of initial assessment
• NEGATIVE APPENDECTOMY rates (10-20%)
• PERFORATION rates (30-40%) REMAINS HIGH!!
MEDICAL ALERT!!
38. MANAGEMENT
MEDICAL MANAGEMENT
ANTIBIOTIC THERAPY
• Lowers the incidence of POSTOPERATIVE WOUND INFECTIONS
& INTRAPERITONEAL ABSCESSES in perforated appendicitis,
but their role is less well defined in simple appendicitis5
• Antibiotic coverage is continued postoperatively for 3-5 days
• For SIMPLE NON-PERFORATED AP one pre-op dose of a single broad-spectrum
agent (CEFOXITIN) or equivalent is sufficient
• For PERFORATED OR GANGRENOUS APPENDICITIS combination regimens such as
Zosyn (piperacillin/tazobactam), ticarcillin/clavulanate, or ceftriaxone/metronidazole
39. MANAGEMENT
For UNCOMPLICATED APPENDICITIS:
NON-OPERATIVE vs OPERATIVE
• NON-OPERATIVE:
a. Used in an environment where Sx not available & antibiotics alone not effective
b. Pt’s who did not pursue medical treatment occasionally have spontaneous resolution
• OPERATIVE remains the standard of care
URGENT vs EMERGENT
• Dependent on each institution & surgeon
• URGENT best done within hours
• EMERGENT done as soon as possible because minutes can make a difference
SURGICAL MANAGEMENT
40. MANAGEMENT
For COMPLICATED APPENDICITIS:
• Refers to PERFORATED APPENDICITIS commonly associated with an ABSCESS
or PHLEGMON
NON-OPERATIVE vs OPERATIVE
• NON-OPERATIVE patients with complicated appendicits & a contained
abscess or phlegmon but limited peritonitis ––– conservative management
only (antibiotics, bowel rest, fluids, and possible percutaneous drainage) d/t
risk for POSTOPERATIVE INTRA-ABDOMINAL ABSCESS FORMATION
• OPERATIVE sepsis & generalized peritonitis would prompt immediate
management at the OR with concurrent resuscitation
41. MANAGEMENT
OPERATIVE INTERVENTIONS:
1. INTERVAL APPENDECTOMY3,5
• Performing appendectomy following initial successful non-operative management
in patients with no further symptoms
• GOAL –– To prevent future attacks or to identify other disease (e.g. malignancies)
• Role following successful management of conservative treatment of complicated
appendicitis –– UNCLEAR
• Majority of pediatric surgeons perform this routinely (4-6 wk interval) after initial
non-operative management of perforated appendicitis5
42. MANAGEMENT
IF WITHOUT CONTRAINDICATIONS –
if suggestive of medical Hx & PE with
supportive Labs should undergo
APPENDECTOMY urgently1
2. OPEN APPENDECTOMY3
• Under GA, placed in supine position
• RLQ MCBURNEY’S INCISION (oblique) or
ROCKY-DAVIS INCISION (transverse)3
43. MANAGEMENT
2. OPEN APPENDECTOMY (con’t)
• If appendix not easily identified, the CECUM
and MESENTERY should be located3
• Appendiceal stump managed by SIMPLE
LIGATION or by LIGATION AND INVERSION3
• If appendicitis not found, a methodical search
must be made for an alternative diagnosis3
• NEGATIVE APPENDECTOMY term used for
an operation performed for suspected
appendicitis, in which the appendix is found
to be normal on histological evaluation2
44. MANAGEMENT
3. LAPAROSCOPIC APPENDECTOMY3
• First reported laparoscopic appendectomy
was performed in 1983 by Semm
• Under GA, an OGT and NGT are used
• Surgeon and assistant stands on the pt’s left
FACING THE APPENDIX
• Screens should be positioned on the pt’s
right or at the foot of the bed
• Stump should be carefully examined to
ensure hemostasis, complete transection,
and ensure that no stump is left behind
45. MANAGEMENT
3. LAPAROSCOPIC APPENDECTOMY (con’t)
ADVANTAGES:
• Fewer incisional surgical site infections
• Less pain, shorter length of stay
• Quicker return to normal activity
DISADVANTAGES:
• Increased risk of intra-abdominal abscess LAPAROSCOPIC APPENDICECTOMY. ARROW
SHOWS THE INFLAMED APPENDIX.
46. MANAGEMENT
4. LAPAROSCOPIC SINGLE-INCISION APPENDECTOMY
• “GROWING INTEREST”3 –– Instead of two or three incisions, a SINGLE INCISION
made, typically periumbilical
• Almost similar with the typical laparoscopic appendectomy
• NO DIFFERENCE in the ff:
a. Return to bowel function
b. Post-operative pain
c. Return to normal activity
d. Overall cost
e. Incidence of hernia formation
• Late outcomes & patient quality-of-life outcomes REMAIN TO BE INVESTIGATED
47. MANAGEMENT
5. NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY
• New surgical procedure using FLEXIBLE ENDOSCOPES in the abdominal cavity
• Access gained by way of organs that are reached through a NATURAL, ALREADY-
EXISTING external orifice (e.g. transvaginal approach)