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  • 1. Acute Appendicitis
  • 2. Introduction
    • The vermiform appendix is considered by most to be a vestigial organ, its importance in surgery is only due to its tendency for inflammation resulting in the syndrome called acute appendicitis .
    • Acute appendicitis is the most common cause of an “acute abdomen” in young adults.
    • Appendectomy is the most frequently performed urgent abdominal operation
    • Despite extraordinary advances in the modern radiographic imaging & laboratory investigations, the diagnosis of appendicitis remains essentially clinical requiring a mixture of observation, surgical science & clinical sense.
  • 3. Anatomy
    • The vermiform appendix is present only in mammals.
    • The position of the appendix is variable:
    • - Retrocecal 74%.
    • - Pelvic 21%.
    • - Postileal 5%.
    • - Paracecal 2%.
    • - Subcecal 1.5%.
    • - Preileal 1%.
    • The position of the base of the appendix is constant, being found at the confluence of the 3 taenia coli of the cecum which fuse to form the outer longitudinal muscle coat of the appendix.
    • The mesentery of the appendix (mesoappendix) arises from the lower surface of the mesentery of the terminal ileum.
    • The appendicular artery , a branch of the lower division of the ileocolic artery lie in the free border of the mesoappendix. It is an “end-artery”, thrombosis of which results in necrosis of the appendix (gangrenous appendicitis).
  • 4. Acute Appendicitis
    • Acute appendicitis is relatively rare in infants, becomes increasingly common in childhood & early adult life, reaching a peak incidence in the teens & early 20s.
    • After middle age, the risk of developing acute appendicitis in the future is quite small.
    • Etiology: There is no unifying hypothesis regarding the etiology of acute appendicitis.
    • While appendicitis is associated with bacterial proliferation within the appendix, no single organism is responsible, mixed growth of aerobic & anaerobic organisms is usual.
    • Obstruction of the appendix lumen is important, some form of luminal obstruction by either a fecolith or stricture is found in the majority of cases.
    • Obstruction of orifice by tumor (carcinoma of the cecum) is a cause of acute appendicitis, in middle age & elderly.
  • 5. Pathology
    • Obstruction of the lumen is essential for development of appendiceal gangrene & perforation.
    • In early appendicitis, the lumen is patent despite mucosal inflammation & lymphoid hyperplesia.
    • In children & young adults, an infective agent possibly viral initiates the inflammatory process, which within the narrow lumen of the appendix leads to luminal obstruction.
    • Once obstruction occurs, continued mucus secretion & inflammatory exudation increase intraluminal pressure, obstructing lymphatic drainage.
    • Edema & mucosal ulceration develop with bacterial translocation to the submucosa.
    • Resolution could occur at this point, whether spontaneous or in response to antibiotic therapy.
    • Progression of the condition leads to further distension of the app. Causing venous obstruction & ischemia of the app. Wall.
    • With ischemia, bacterial invasion occurs through the muscularis propria & submucosa.
  • 6.
    • Finally, ischemic necrosis of the appendix wall produces gagrenous appendicitis , with free bacterial contamination of the peritoneal cavity.
    • Alternatively, the greater omentum & loops of small intestine become adherent to the inflamed app., walling off the spread of peritoneal contamination resulting in appendicular mass or paracecal abscess.
    • Rarely, appendiceal inflammation resolves leaving a distended mucus filled organ termed mucocele of the appendix.
    • The great threat of acute appendicitis is the potential for peritonitis , factors which promote this process: 1) extremes of age, 2) immunosupression, 3) D.M., 4) fecolith obstruction of the appendix lumen, 5) a free lying pelvic appendix, & 6) previous abdominal surgery which limits the ability of the greater omentum to wall off the spread of peritoneal contamination.
    • In these situations a rapidly deteriorating clinical course is accompanied by signs of diffuse peritonitis & systemic sepsis syndrome.
  • 7. Clinical diagnosis - History
    • Periumbilical colic
    • Pain shifts to right iliac fossa
    • Anorexia
    • Nausea
    Clinical features of appendicitis
  • 8.
    • The classical features of acute appendicitis begin with poorly localized colicky abdominal pain, due to midgut visceral discomfort in response to appendiceal inflammation.
    • Pain is frequently first noticed in the periumbilical region, associated with anorexia, nausea, once or 2 episodes of vomiting. Anorexia is constant feature especially in children.
    • With progressive inflammation, the parietal peritoneum in the rt. iliac fossa becomes irritated, producing intense more localized, constant somatic pain . Typically, cough or sudden movement exacerbates the rt. iliac fossa pain.
    • This typical sequence is present in 50% of cases. Atypical presentation is common: elderly (no localization), pelvic app. (no somatic pain, suprapubic discomfort & tenesmus).
    • No fever during the first 6 hours, then slight pyrexia (37.2-37.7), pulse rate (80-90).
    • Typically, 2 clinical syndromes of acute appendicitis: acute catarrhal (nonobstructive) & acute obstructive appendicitis . The latter is characterized by a much more acute course, the onset of symptoms is abrupt, with more tendency for perforation.
  • 9. Clinical diagnosis - Signs
    • Pyrexia
    • Localized tenderness in the rt. iliac fossa
    • Muscle guarding
    • Rebound tenderness
    Clinical signs of appendicitis
    • Pointing sign
    • Rovsing’s sign
    • Psoas sign
    • Obturator sign
    Signs to elicit in appendicitis
  • 10.
    • The diagnosis of acute appendicitis depends on clinical examination rather than history or investigations.
    • The main features : unwell patient, low grade fever.
    • Patient is asked to point where the pain began & to where it moved, (pointing sign).
    • Superficial palpation starting from the left iliac fossa, anticlockwise to the right iliac fossa, will detect muscle guarding over the point of maximum tenderness, classically McBurney’s point .
    • Asking the patient to cough or gentle percussion rebound tenderness.
    • Deep palpation over the left iliac fossa pain in the right iliac fossa (Rovsing’s sign).
    • If the appendix lies over the psoas muscle the patient will lie with the right hip flexed for pain relief (Psoas sign).
    • If the appendix is in contact with the obturator internus muscle, flexion & internal rotation of the hip pain in the hypogastrium (Obturator sign).
  • 11. Special features – according to position of the appendix
    • Retrocecal:
    • Rigidity is often absent, even on deep pressure (silent appendix), as the cecum (distended with gas prevents the pressure exerted by the hand to reach the appendix.
    • +ve deep tenderness in the loin, with +ve psoas sign & pain on hyperextension of the hip joint.
    • Pelvic:
    • Early diarrhea (rectal irritation), -ve abdominal rigidity, P/R: shows tenderness in the rectovesical or Douglas pouch. +ve psoas & obturator signs. If appendix is in contact with urinary bladder frequency of micturition.
  • 12. Special features – according to age
    • Infants:
    • Rare before 3 years, patient is unable to give history, diagnosis is often delayed, high incidence of perforation & morbidity.
    • Rapid diffuse peritonitis as the greater omentum is not developed no localization of infection.
    • The elderly:
    • Gangrene & perforation occur more frequently, the clinical picture may simulate subacute intestinal obstruction.
    • Coincident medical conditions produce higher mortality.
    • The obese:
    • Obesity may obscure local signs of acute appendicitis, causing delay in diagnosis, technical operative difficulty may necessitate midline incision.
  • 13. Appendicitis with pregnancy
    • Appendicitis is the most common extrauterine acute abdominal condition in pregnancy.
    • Early non-specific symptoms are often attributed to the pregnancy leading to delayed diagnosis.
    • The cecum & appendix are pushed to the right upper abdominal quadrant atypical site of pain & tenderness.
    • The inflamed appendix may induce uterine irritation & contractions abortion.
    • Fetal loss occurs in 3-5% of cases, increasing to 20% if perforation is found at operation.
  • 14. Differential diagnosis
    • Divericulitis
    • Intestinal obstruction
    • Colonic carcinoma
    • Mesenteric infarction
    • Aortic aneurysm
    • Mittelschmerz
    • Salpingitis
    • Pylonephritis
    • Ectopic pregnancy
    • Torsion/ruptured ovarian cyst
    • Endometriosis
    • Regional enteritis
    • Ureteric colic
    • Perforated ulcer
    • Torsion testis
    • Pancreatitis
    • Rectus sheath hematoma
    • Gastroenteritis
    • Mesenteric adenitis
    • Meckel’s diverticulitis
    • Intussusception
    • Henoch-Schonlein purpura
    • Lobar pneumonia
    Elderly Female Adult Children
  • 15. Children
    • Acute gastroenteritis :
    • Intestinal colic, diarrhea, vomiting, but no localized tenderness, history of affection of other family member.
    • Postileal appendicitis mimic this condition, thus hospital admission & careful observation are necessary. If serious doubt, laparoscopy or surgical intervention may be indicated.
    • Mesenteric lymphadenitis:
    • The pain is colicky in nature, patient is completely free in between attacks, which lasts for few minutes, cervical lymph nodes may be enlarged.
    • Shifting tenderness if the child turns to the left side is convincing evidence.
    • It represents a common diagnostic difficulty in children, if doubt exploration is advised.
  • 16.
    • Meckel’s diverticulitis:
    • It may be impossible to distinguish from acute appendicitis, pain may be central or left sided, previous attacks of abdominal pain or anemia.
    • Intussusception:
    • It is important to differentiate between both conditions.
    • Appendicitis is uncommon between <2 years, the median age for intussusception is 18 months.
    • A mass may be palpable in the right lower quadrant.
    • The preferred treatment for intussusception is reduction by a careful barium enema.
    • Henoch-Schonlein purpura:
    • Often preceded by sore throat or respiratory infection. Nearly always ecchymotic rash in the extensor surface of the limbs & buttocks, the face is usually spared.
    • Lobar pneumonia & pleurisy:
    • Especially at the right lung base, abdominal tenderness is minimal, pyrexia marked, chest examination reveals pleural friction rub or altered breath sounds. Chest x-ray is diagnostic.
  • 17. Adults
    • Terminal ileitis:
    • May be nonspecific, due to Crohn’s disease or Yersinia infection.
    • In its acute form, may be indistinguishable from acute appendicitis unless a doughy mass of inflamed ileum can be felt.
    • Previous history of abdominal cramping, weight loss & diarrhea suggests regional ileitis rather than appedicitis.
    • Ureteric colic:
    • Does not commonly cause diagnostic problem, the character & radiation of pain is different.
    • Differentiate by urine analysis, plain abdominal x-ray film.
    • Renal U/S or I.V.P. is diagnostic.
    • Right-sided acute pyelonephritis:
    • Accompanied & often preceded by increased frequency of micturition.
    • The leading features: tenderness confined to the loin, fever (39), rigors & pyuria.
  • 18.
    • Perforated peptic ulcer:
    • Duodenal contents pass along the paracolic gutter to the right iliac fossa.
    • History of dyspepsia & very sudden onset of pain, which starts in the epigastrium & passes down the right paracolic gutter.
    • Rigidity & tenderness in the right iliac fossa as appendicitis, but is usually greater in the right hypochondrium.
    • Plain x-ray erect shows air under diaphragm.
    • Testicular torsion:
    • In teenager or young adult, easily missed, pain can be referred to the right iliac fossa.
    • Patient may be shy to reveal, missed if the testis were not examined.
    • Acute pancreatitis:
    • Should be suspected in any adult with acute abdomen.
    • Serum & urinary amylase are diagnostic.
    • Rectus sheath hematoma:
    • Rare, acute pain & tenderness in right iliac fossa, no gastrointestinal upset.
    • Usually after vigorous exercise, or trauma to a patient on anticoag.
  • 19. Adult females
    • Pelvic disease in women of child-bearing period most often simulates acute appendicitis.
    • A careful gynecological history should be taken in all women with suspected acute appendicitis concentrating on menstrual cycle, vaginal discharge & possible pregnancy.
    • Salpingitis:
    • Condition that poses greatest difficulty in young women.
    • Typically the pain is lower than in appendicitis & is bilateral.
    • History of vaginal discharge & dysmenorrhea are helpful points.
    • Opinion of gynecologist may be helpful.
    • If uncertain, diagnostic laparoscopy should be undertaken.
    • Mittelschmerz:
    • Midcycle rupture of a follicular cyst with bleeding produces lower abdominal & pelvic pain, typically midcycle.
    • Systemic upset is rare, pregnancy test is –ve, symptoms usually subsides within hours.
    • Occasionally, diagnostic laparoscopy is required.
  • 20.
    • Torsion/hemorrhage of an ovarian cyst
    • Can be difficult diagnostic problem.
    • When suspected, pelvic U/S & gynecological opinion should be sought.
    • If encountered at operation, ovarian cystectomy should be performed, with visualization of the contralateral ovary.
    • Ectopic pregnancy:
    • A ruptured ectopic pregnancy can be easily differentiated from acute appendicitis, well defined signs of hemoperitoneum.
    • But right sided tubal abortion or right sided unruptured tubal pregnancy are difficult to differentiate.
    • Signs are similar to acute appendicitis except for:
    • 1) History of missed period.
    • 2) Pain starts in the right iliac fossa & stays there.
    • 3) Pain is severe & continues until operation.
    • 4) Severe pain is felt if the cervix is moved on vaginal examination.
    • 5) Pregnancy test is +ve.
    • 6) Signs of intraperitoneal bleeding with pain referred to the shoulder. Pelvic U/S should be carried out if suspected.
  • 21. Elderly
    • Sigmoid diverticulitis:
    • If long sigmoid loop, colon lies to the right of midline, may be impossible to differentiate between diverticulitis & appendicitis.
    • May be history of chronic constipation, colonic troubles.
    • If suspected, investigations & conservative treatment with fluids & antibiotics should be started.
    • Intestinal obstruction:
    • Signs of I.O. are clear.
    • Cons. treatment with I.V. fluids, antibiotics & nasogastric decompression is started.
    • Carcinoma of the cecum:
    • When obstructed or perforated, may mimic or cause obstructive appendicitis.
    • History of discomfort, altered bowel habit or unexplained anemia should raise suspicion.
    • A mass may be palpable, barium enema & colonoscopy are diagnostic.
  • 22. Investigation
    • The diagnosis of acute appendicitis is essentially clinical.
    • Routine:
    • -Full blood count.
    • -Urine analysis.
    • Selected cases:
    • -Pregnancy test (females in child bearing period).
    • -Urea & electrolytes (dehydrated & elderly patients)
    • -Plain abdominal x-ray (int. obstruction or renal colic).
    • -Pelvi/abdominal U/S.
  • 23. Treatment
    • The treatment of acute appendicitis is appendectomy.
    • Urgent operation is essential to prevent the increased morbidity & mortality of peritonitis.
    • There should be no unnecessary delay except for correction of unstable general condition (adequate U.O.P., pyrexia & preoperative preparation of elderly patient).
    • Single preoperative dose of antibiotics is usually sufficient to prevent wound infection.
    • If peritonitis is suspected, therapeutic I.V. antibiotics for Gram-negative & anerobic bacteria should be given.
  • 24. Appendectomty
    • Either conventional open operation or laparoscopic technique.
    • General anesthesia.
    • Laparoscopic: nasogastric tube & empty bladder.
    • Palpation for mass in R.I.F.
  • 25. Conventional appendectomy
    • Incision: grid-iron, Rutherford Morison, Lanz.
    • Technique of appendectomy.
    • Special circumstances:
    • - Edema of the cecal wall.
    • -Base of the app. severely inflamed.
    • -Gangrenous app. base.
    • -Retrograde appendectomy.
    • -Drainage of the peritoneal cavity ??
  • 26. Laparoscopic Appendectomy
    • The valuable aspect of laparoscopy in the management of suspected appendicitis is as a diagnostic tool, especially in women of child-bearing age.
  • 27. Problems encountered during appendectomy
    • A normal appendix is found:
    • This demands careful exclusion of other possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis & tubal or ovarian causes in women.
    • It is usual to remove the appendix to avoid future diagnostic problems, even though the appendix is macroscopically normal.
    • Approximately a quarter of seemingly normal appendices show microscopic evidence of inflammation.
    • The appendix cannot be found:
    • The cecum should be mobilized & the tenia coli traced to their confluence before the diagnosis of absent appendix is made.
    • An appendicular tumor is found:
    • Tumors <2.0 cm. in diameter can be removed by appendectomy.
    • Larger tumors should be treated by right hemicolectomy.
  • 28.
    • An appendix abscess is found: & appendix cannot be removed easily.
    • Should be treated by local peritoneal toilet & drainage of any abscess, with I.V. antibiotics.
    • Appendicitis complicating Crohn’s disease:
    • Patient operated for appendicitis found to have concomitant Crohn’s disease of the ileocecal region.
    • Provided the cecal wall is healthy at the base of the appendix, appendectomy can be performed without increasing the risk of enterocutaneous fistula.
    • Rarely the appendix is involved with the Crohn’s disease, a conservative approach may be undertaken, with a trial of I.V. steroids & systemic antibiotics to resolve the acute inflammatory process.
    • Appendix abscess:
    • Failure of resolution of an appendix mass or continuing spiking fever indicates pus in the appendix mass.
    • U/S or abdominal CT scan identify the possibility of percutaneous drainage, if unsuccessful, laparotomy through a midline incision.
  • 29. Management of an appendix mass
    • If the condition of the patient is satisfactory, the standard treatment is the conservative Ochsner-Sherren regimen.
    • The inflammatory process is already localized & surgery is difficult & may be dangerous.
    • It may be impossible to find the appendix & a fecal fistula may form.
    • So, non-operative program is advised, to be prepared to operate if clinical deterioration occurs:
    • 1) A rising pulse rate.
    • 2) Increasing or spreading abdominal pain.
    • 3) Increasing size of the mass.
    • 4) Vomiting or increase gastric aspirate.
    • Careful record of the vital signs, regular abdominal examination, extent of the mass, it is helpful to mark the limits of the mass on the skin. A nasogastric tube with I.V. fluids & antibiotics therapy.
    • Clinical improvement is usually evident within 24-48 hrs. in 90% of cases.
    • Appendix should be removed after an interval of 6-8 weeks.
  • 30. Postoperative complications
    • Relatively uncommon & reflect the degree of peritonitis that was present at the time of operation.
    • Wound infection:
    • Most common, occurs in 5-10% of all cases.
    • Presents with pain & erythema of the wound on the fourth or fifth postop. day.
    • Treatment: by wound drainage & antibiotics, the organisms responsible are usually gm –ve & anerobic bacteria.
    • Intra-abdominal abscess:
    • Rare after the use of perioperative antibiotics.
    • Postoperative spiking fever, malaise & anorexia 5-7 days postoperatively.
    • Abdominal U/S & CT scan facilitate the diagnosis & allow percutaneous drainage.
    • Ileus:
    • A period of adynamic ileus is expected after appendectomy, may last for a number of days after gangrenous appendix.
    • Ileus persisting for >4-5 days in the presence of fever indicates intra-abdominal sepsis.
  • 31.
    • Portal pyaemia:
    • Rare but very serious complication of gangrenous appendicitis.
    • High fever, rigors & jaundice.
    • Due to septicemia in the portal venous system, may lead to development of intrahepatic abscesses (often multiple).
    • Treatment: systemic antibiotics & drainage of hepatic abscesses if indicated.
    • Fecal fistula:
    • Leakage from the appendicular stump is rare.
    • Occurs if the cecal wall is involved by edema or inflammation, or after appendectomy in Crohn’s disease.
    • Pulmonary complications & D.V.T:
    • Both are after appendectomy.
    • Adhesive intestinal obstruction:
    • Most common late complication after appendectomy.
    • Often a single band is responsible.
    • May cause chronic pain in the right iliac fossa.
    • Laparoscopy is of value in confirming the case & allowing adhesiolysis.
  • 32. Recurrent acute appendicitis ??
    • Appendicitis can be recurrent.
    • Patients attribute such attacks to dyspepsia.
    • The attacks vary in intensity, may occur every few months, may ultimately end in severe acute attack.
    • The appendix shows fibrosis indicative of previous inflammation.
    • Patients with acute appendicitis may remember having milder but similar attacks of pain.
    • Chronic appendicitis, per se, does not exist. Patients diagnosed as thus are usually examples of the recurrent form of the disease.
  • 33. Les common pathological conditions
    • Mucocele of the appendix.
    • Diverticulae of the appendix.
    • Intussusception of the appendix.
    • Carcinoid tumor & Primary adenocarcinoma.