Appendicitis
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  • Microscopic anatomy: - average length is between 7.5 and 10 cm - lumen is irregular, being encroached upon by multiple longitudinal folds of mucous membrane lined by columnar cell intestinal mucosa of colonic type - Crypts are present but not numerous. In the base of the crypts lie argentaffin cells (Kulchitsky cells) - submucosa contains numerous lymphatic aggregations or follicles.
  • Mittelschermz: ovulation pain
  • CT findings of appendicitis fall into 3 categories 1. appendiceal changes 2. cecal apical changes 3. inflammatory changes in the right lower quadrant
  • Possible findings in acute appendicitis 1. enlarged appendix 2. appendiceal wall thickening 3. appendiceal wall enlargement 4. periappendiceal fat stranding 5. focal cecal apical thickening

Transcript

  • 1. AppendicitisR.NandiniiGroup K1
  • 2. Anatomy• a blind muscular tube with mucosal, submucosal,muscular and serosal layers• At birth, appendix is short and broad at its junctionwith the caecum, but differential growth of thecaecum  typical tubular structure by about the ageof 2 years• During childhood, continued growth of the caecumcommonly rotates the appendix into a retrocaecal butintraperitoneal position• Position of the base of the appendix is constant, beingfound at the confluence of the three taeniae coli of thecaecum, which fuse to form the outer longitudinalmuscle coat of the appendix.Source: Bailey & Loves Short Practice of Surgery 25thed
  • 3. Various positions of the appendix:• Mesentery of the appendix or mesoappendixarises from the lower surface of the mesenteryor the terminal ileum and is itself subject togreat variation• Vascularisation Appendicular artery, abranch of the lower division of the ileocolicartery, passes behind the terminal ileum toenter the mesoappendix a short distance fromthe base of the appendixSource: Bailey & Loves Short Practice of Surgery 25thed
  • 4. Definition:• An inflammation of the vermiform appendixAetiology:• No unifying hypothesis• Decreased dietary fibre and increased consumption of refinedcarbohydrates• Obstruction of the appendix lumen–Fecolith (composed of inspissated faecal material, calciumphosphates, bacteria, epithelial debris, rarely a foreign body)–Tumour (carcinoma of caecum)–Intestinal parasites (Oxyuris/Enterobius vermicularis – pinworm)Source: Bailey & Loves Short Practice of Surgery 25thed
  • 5. PATHOPHYSIOLOGY
  • 6. Risk Factors for Perforation ofThe AppendixSource: Bailey & Loves Short Practice of Surgery 25thed
  • 7. Clinical ManifestationsSource: Bailey & Loves Short Practice of Surgery 25thed
  • 8. Special Features Based OnAppendix LocationsSource: Bailey & Loves Short Practice of Surgery 25thed
  • 9. Differential DiagnosisSource: Bailey & Loves Short Practice of Surgery 25thed
  • 10. InvestigationSource: Bailey & Loves Short Practice of Surgery 25thed
  • 11. Diagnostic Scoring• Diagnosis is essentially clinical;• HOWEVER a decision to operate based on clinical suspiciononly can lead to the removal of a normal appendix.• A number of clinical and laboratory-based scoring systemshave been devised to assist diagnosis.• The most widely used is Alvarado score.Source: Bailey & Loves Short Practice of Surgery 25thed
  • 12. The Alvarado (MANTRELS) ScoreScoreSymptoms•Migratory RIF pain•Anorexia•Nausea and vomiting111Signs•Tenderness (RIF)•Rebound tenderness•Elevated temperature211Laboratory•Leucocytosis•Shift to the left (segmented neutrophils)21TOTAL 10• < 5 is strongly against a diagnosis of appendicitis• 7 or more is strongly predictive of acute appendicitis• In patients with an equivocal score of 5 or 6, abdominal USG orcontrast-enhanced CT scan is used to further reduce the rate ofnegative appendicectomySource: Bailey & Loves Short Practice of Surgery 25thed
  • 13. CT Scan images of Appendicitis:1. enlarged appendix 2. appendiceal wall thickeningSource:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acuteappendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.
  • 14. CT Scan images of Appendicitis3. appendicolith 4.periappendiceal fat strandingSource:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acuteappendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.
  • 15. Treatment• Intravenous fluids• to establish adequate urine output• Appropriate antibiotics• Reduces the incidence of postoperative wound infection• When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram-negative bacilli as well as anaerobic cocci should be given• Salicylates• AppendicectomySource: Bailey & Loves Short Practice of Surgery 25thed
  • 16. Appendicectomy• Conventional Appendicectomy• Laparoscopic Appendicectomy• Postoperative ComplicationsSource: Bailey & Loves Short Practice of Surgery 25thed
  • 17. Conventional AppendicectomyGridiron incision : right anglesto a line joining the ASIS to theumbilicus. Centred onMcBurney’s pointLanz incision : 2 cm below theumbilicus centred on the mid-clavicular-midinguinal line2/31/32 cm
  • 18. Conventional Appendicectomy• Caecum is identified• Base of mesoappendix is clamped in artery forceps, divided, and ligated• The freed appendix is crushed near its junction with the caecum in artery forceps,which is removed and reapplied just distal to the crushed portion• An absorbable ligature is tied around the crushed portion close to the caecum• The appendix is amputated between the artery forceps and the ligature• An absorbable purse-string or ‘Z’ suture may then be inserted into the caecumabout 1.25 cm from the base• The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied,thus burying the appendix stumpSource: Bailey & Loves Short Practice of Surgery 25thed
  • 19. Source: Bailey & Loves Short Practice of Surgery 25thed
  • 20. Laparoscopic appendicectomy• The placement of operating ports may vary according to operator preference andprevious abdominal scars.• The operator stands to the patient’s left and faces a video monitor placed at thepatient’s right foot.• A moderateTrendelenburg tilt of the operating table• The appendix is identify & controlled using a laparoscopic tissue-holding forceps.• By elevating the appendix, the mesoappendix is displayed• A dissecting forceps is used to create a window in the mesoappendix to allow theappendicular vessels to be coagulated or ligated using a clip applicator.• The appendix, free of its mesentery, can be ligated at its base with an absorbableloop ligature,divided, & removed through one of the operating ports.• It is not usual to invert the stump of the appendix• A single absorbable suture is used to close the linea alba at the umbilicus, and thesmall skin incisions may be closed with subcuticular sutures.• Patients who undergo laparoscopic appendicectomy are likely to have lesspostoperative pain & to be discharged from hospital and return to activities of dailyliving sooner than those who have undergone open appendicectomy.Source: Bailey & Loves Short Practice of Surgery 25thed
  • 21. Source: Bailey & Loves Short Practice of Surgery 25thed
  • 22. Problems Encountered DuringAppendicectomyProblems ManagementA normal appendix is found Demands careful exclusion of other possiblediagnosisRemove the appendix to avoid future diagnosticdifficultiesThe appendix cannot be found Caecum should be mobilised, and the taeniaecoli should be traced to their confluence on thecaecum before the diagnosis of ‘absentappendix’ is madeAn appendicular tumour is found Small tumours (< 2.0 cm in diameter) can beremoved by appendicectomyLarger tumours should be treated by a righthemicolectomyAn appendix abscess is found andthe appendix cannot be removedeasilyShould be treated by local peritoneal toilet,drainage of an abscess and intravenousantibioticsSource: Bailey & Loves Short Practice of Surgery 25thed
  • 23. Appendix mass• If an appendix mass is present & the condition of the patient issatisfactory, the standard treatment is the conservative• Careful recording of the patient’s condition and the extent of the massshould be made and the abdomen regularly re-examined.• mark the limits of the mass using a skin pencil.• Temperature and pulse rate should be recorded 4- hourly and a fluidbalance record maintained• A contrast-enhanced CT examination of the abdomen should beperformed and antibiotic therapy instigated.• An abscess, if present, should be drained radiologically.• Clinical deterioration or evidence of peritonitis is an indication for earlylaparotomy.• Clinical improvement is usually evident within 24–48 hoursSource: Bailey & Loves Short Practice of Surgery 25thed
  • 24. Criteria for stopping conservative treatment ofan appendix mass• A rising pulse rate• Increasing or spreading abdominal pain• Increasing size of the massSource: Bailey & Loves Short Practice of Surgery 25thed
  • 25. Postoperative Complications• Wound infection• Intra-abdominal abscess• Adhesive intestinal obstruction• Rare• Ileus• Respiratory – pneumonitis or collapse• Venous thrombosis and embolism• Portal pyaemia (pylephlebitis)• Faecal fistulaSource: Bailey & Loves Short Practice of Surgery 25thed
  • 26. Other causes of acuteappendicitis• Recurrent Acute Appendicitis• Neoplasms of the Appendix
  • 27. Recurrent Acute Appendicitis• Widely known but unfavourable• Not uncommon for patients to attribute such attacksto ‘biliousness’ or dyspepsia• Attacks vary in intensity and may occur every fewmonths• Through history, patient might have had milder butsimilar attacks of pain showing fibrotic appendixindicative of previous inflammation• Chronic appendicitis, per se, does not exist; however,there is evidence of altered neuroimmune function inthe myenteric nerves of patients with so calledrecurrent appendicitis (Büchler)Source: Bailey & Loves Short Practice of Surgery 25thed
  • 28. Excised appendix showing the point of luminalobstruction with distal fibrosisSource: Bailey & Loves Short Practice of Surgery 25thed
  • 29. Neoplasms OfThe AppendixSource: Bailey & Loves Short Practice of Surgery 25thed