Appendicitis- a simplistic view for GPs

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a simplified overview on appendicitis for beginners and general practitioners

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Appendicitis- a simplistic view for GPs

  1. 1. A Presentation
  2. 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. 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. 4. Anatomy
  5. 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. 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. 7. Symptoms
  8. 8. Signs
  9. 9. Migration of Pain
  10. 10. Examination
  11. 11. Tenderness
  12. 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. 13. MANTRELS Score Migration of pain Anorexia Nausea / vomiting Tenderness RLQ Rebound Elevated temp. Leukocytosis Shift to left
  14. 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. 15. HIGH RISK PATIENTS & GROUPS
  16. 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. 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. 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. 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. 20. Immunocompromised • HIV, chronic steroids, sickle cell, chemotherapy, DM, dialysis • Increased risk of complications and misdiagnosis • Inflammatory response decreased
  21. 21. Differential Diagnosis • Gastroenteritis • Mesenteric lymphadenitis • PID • Mittelschmertz • Crohn's disease • Diverticulitis • Endometriosis • TOA • Ectopic pregnancy • UTI • Pyelonepritis • Other processes involving appendix
  22. 22. INVESTIGATIONS
  23. 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. 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. 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. 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. 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. 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. 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. 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. 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. 32. No single evaluation can substitute for the diagnostic accuracy of the experienced physician.
  33. 33. WHEN IN DOUBT DO NOT DISCHARGE
  34. 34. COMPLICATIONS OF ACUTE APPENDICITIS
  35. 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. 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. 37. WHEN TO STOP? • Toxic symptoms • Increase in size of mass • Abscess formation • Features of peritonitis
  38. 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. 39. MANAGEMENT • Antibiotics • Extra peritoneal drainage
  40. 40. GANGRENOUS APPENDIX
  41. 41. PERFORATED APPENDIX
  42. 42. LAP APPENDECTOMY
  43. 43. LAP APPENDECTOMY
  44. 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. 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

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