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Appendicitis- a simplistic view for GPs
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Appendicitis- a simplistic view for GPs

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a simplified overview on appendicitis for beginners and general practitioners

a simplified overview on appendicitis for beginners and general practitioners

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  • 1. A Presentation
  • 2. Epidemiology • Acute appendicitis is the most common cause of ‘acute surgical abdomen’ • 6% of the population will suffer from acute appendicitis during their lifetime. • Nothing can be so easy or as difficult as the diagnosis of acute appendicitis
  • 3. Anatomy • Blind pouch off of cecum • Contains lymphoid tissue which peaks in adolescence, atrophies with age • Function still unclear • Appendix can be anywhere within peritoneal cavity • One study showed 65 % retrocecal, 31 % pelvic • Review of 70,000 cases showed 4 % in RUQ, 0.06 % LUQ, 0.04 % LLQ
  • 4. Anatomy
  • 5. Pathophysiology • Lymphoid hyperplasia leads to luminal obstruction • Often follows viral illness • Epithelial cells secrete mucus • Appendix distends, bacteria multiply • Visceral pain begins an average of 17 hours after obstruction • Increased pressure compromises blood supply • Somatic pain develops • Average time to perforation = 34 hrs.
  • 6. Clinical presentation • Classical presentation seen in 60 % Anorexia Peri umbilical pain, nausea, vomiting • RLQ pain developing over 24 hrs. • Anorexia and pain are most frequent • Usually nausea, sometimes vomiting • Diarrhoea, esp. with pelvic location • Usually tender to palpation • Rebound is a later finding
  • 7. Symptoms
  • 8. Signs
  • 9. Migration of Pain
  • 10. Examination
  • 11. Tenderness
  • 12. SPECIAL FEATURES, ACCORDING TO POSITION OF THE APPENDIX . RETROCAECAL -Rigidity in often absent - Psoas spasm due to inflamed appendix in contact with the muscle may cause flexion of hip PELVIC -Early diarrhoea due to contact with rectum -When inflamed appendix is in contact with Bladder, may cause frequency of micturition.
  • 13. MANTRELS Score Migration of pain Anorexia Nausea / vomiting Tenderness RLQ Rebound Elevated temp. Leukocytosis Shift to left
  • 14. MANTRELS Score • RLQ tenderness and leukocytosis = 2 points each ; all others 1 point • Score of 5 to 6 = possible appendicitis • Score of 7 to 8 = probable appendicitis • Score of 9 to 10 = very probable appendicitis
  • 15. HIGH RISK PATIENTS & GROUPS
  • 16. Ovulating women • PID, TOA, ovarian cyst rupture can mimic appendicitis • Look for cervical motion tenderness, adnexal tenderness, history of STD’s • Can have CMT with pelvic appendix
  • 17. Pregnancy • Most common surgical emergency in pregnancy • Mortality rate if missed = 2 % for mother, up to 35 % for fetus • WBC elevated in pregnancy • Appendix changes location
  • 18. Pediatric Population • Most common surgical disorder in kids • Accounts for 5 % of abd. pain visits • Up to 50 % initially misdiagnosed • < 2 yrs. : perforation rate approaches 100 % • 3 to 5 yrs. = 71 % • 6 to 10 yrs. = 40 % • Most common misdiagnosis is AGE • Sequence of pain and vomiting may be helpful • Localized tenderness not a feature of AGE
  • 19. Elderly • Vital signs and exam may not reflect severity • > age 60 : only 5 to 10 % diagnosed without delay • Perforation rate = 46 to 83 % • RLQ tenderness absent in 23 % • N/V, anorexia less common • Leukocytosis less pronounced • Only 20 % classic presentation
  • 20. Immunocompromised • HIV, chronic steroids, sickle cell, chemotherapy, DM, dialysis • Increased risk of complications and misdiagnosis • Inflammatory response decreased
  • 21. Differential Diagnosis • Gastroenteritis • Mesenteric lymphadenitis • PID • Mittelschmertz • Crohn's disease • Diverticulitis • Endometriosis • TOA • Ectopic pregnancy • UTI • Pyelonepritis • Other processes involving appendix
  • 22. INVESTIGATIONS
  • 23. CBC • 75 to 85 % have elevated WBC, but it is nonspecific • WBC normal in 80 % in the first 24 hrs. • Can see elevated ANC in up to 89 % • WBC usually 12 to 18,000 in appendicitis • Chemistry panel may help with diagnosis of dehydration
  • 24. OTHERS • Urinalysis Specific gravity, ketones Can see WBC’s, RBC’s, bacteria if inflamed appendix close to ureter > 30 WBC’s = probable UTI • HCG Essential in women of child-bearing age • CRP Acute phase reactant
  • 25. PLAIN FILMS • Low sensitivity and specificity • Appendicolith specific, but seen in only 2 % • May see local air-fluid levels, psoas obliteration, soft tissue mass, gas in appendix • All nonspecific
  • 26. ULTRASONOGRAM • 75 to 90 % sensitive, 86 to 100 % specific • Non invasive, low cost, but operator-dependent • Good for diagnosing GYN disorders 3 criteria for diagnosis Tender, non compressible appendix No peristalsis of appendix Overall diameter > 6 mm
  • 27. COMPUTED TOMOGRAM • Early studies showed low yield, but helical CT much more accurate • Sensitivity 97 to 100 %, specificity 95 % (similar no matter what type or whether contrast is used) • Often shows alternative diagnosis • More expensive, radiation exposure
  • 28. DO WE NEED IMAGING? • Literature conflicting • Imaging most useful in clinically equivocal cases • Costs of imaging minor compared to cost of unnecessary surgery or delayed diagnosis • US and CT both specific enough to rule in appendicitis, but only CT sensitive enough to rule it out
  • 29. NEJM CONSENSUS • Patients with classic presentation should go to O.R. Diagnostic accuracy approaches 95 % • If equivocal/suspect perforation : CT • US reserved for pregnant women or high suspicion of GYN disease • If study indeterminate, observe with repeated exams or laparoscopy
  • 30. ANALGESIA? Prospective studies (both EM and Surgery literature) now show appropriate use of IV narcotics does not decrease diagnostic accuracy, and may improve exam
  • 31. 7 FEATURES OF MISSED DIAGNOSIS • No nausea / vomiting • Lack of distress • No rebound • No guarding • No rectal exam (controversial) • Narcotic pain meds given • Diagnosis of acute gastroenteritis
  • 32. No single evaluation can substitute for the diagnostic accuracy of the experienced physician.
  • 33. WHEN IN DOUBT DO NOT DISCHARGE
  • 34. COMPLICATIONS OF ACUTE APPENDICITIS
  • 35. APPENDICULAR MASS • Localization of infection 3-5 days after attack of acute appendicitis • Inflamed appendix • Omentum • Caecum • Dilated ileum • Tender • Smooth • Firm • Not mobile
  • 36. Treatment (Ochsner sherren ) • Temp, BP, Pulse q 4h • Marking the mass – (progression or regression) • Antibiotics • Metronidazole • Ampicillin • Gentamycin • IV fluids • IV antibiotics • Nasogastric aspiration q 4h
  • 37. WHEN TO STOP? • Toxic symptoms • Increase in size of mass • Abscess formation • Features of peritonitis
  • 38. APPENDICULAR ABSCESS Suppuration in acute appendicitis Sites: Retrocaecal Pelvic Subphrenic lumbar C/F: High fever Features of peritonitis ( guarding / rigidity) Raised TC (>18,000)
  • 39. MANAGEMENT • Antibiotics • Extra peritoneal drainage
  • 40. GANGRENOUS APPENDIX
  • 41. PERFORATED APPENDIX
  • 42. LAP APPENDECTOMY
  • 43. LAP APPENDECTOMY
  • 44. COMPLICATIONS OF APPENDECTOMY Early complications: 1. Paralytic ileus 2. Sepsis – local wound abscess, pelvic abscess. 3. Rupture of the stump or caecal wall. 4. Haemorrhage: At any time during the first 72 hours after surgery means either leakage from the stump or a slipped arterial ligature. Late complications 1. Intestinal obstruction due to local adhesive bands. 2. Incisional hernia
  • 45. KEY POINTS Diagnosis of appendicitis is by clinical evaluation Definitive treatment is surgery Lap has distinct advantages over open surgery If Left untreated complications are dreaded