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FACTS
 Acute appendicitis is the most common
surgical emergency of the abdomen
 Appendectomy is one of the most
frequent...
FACTS
Mortality rate from perforated appendicitis:
 near certain death a century ago
 10-20 per cent 50 years ago
 5 pe...
FACTS
“Rates of unnecessary appendectomies and
perforation have remained relatively high
despite gaining a century of clin...
OPERATIONAL DEFINITIONS
Uncomplicated Appendicitis:
 Includes the acutely inflamed, phlegmonous,
suppurative, or mildly i...
OPERATIONAL DEFINITIONS
Complicated Appendicitis:
 Includes gangrenous appendicitis, perforated
appendicitis, localized p...
OPERATIONAL DEFINITIONS
Equivocal Appendicitis:
 A patient with right lower quadrant
abdominal pain who presents with an ...
Adult size 9 cms length ; 1-3 mm lumen
Base constant = confluence of taenia coli
Blood supply – appendicular branch of
ile...
HISTOLOGIC FEATURES
- Muscular layer not well defined
- Lymphoid aggregates in submucosa and
mucosa
- Mucosa is like colon...
PHYSIOLOGY
-Serotonin – mediates pain arising from
non inflamed appendix
- “ carcinoid tumors”
- Immune surveillance
- Sec...
DISEASES OF THE VERMIFORM
APPENDIX
I. Acute appendicitis
Etiology & Pathogenesis:
A.Role of environmental: Diet and
Hygien...
B. Role of obstruction
- anatomical
- hyperplasia of lymphoid
- neoplasm/foreign body
Sequence of events:
Increase mucus & fluids inc intraluminal
pressure – obstructed outflow of blood (venules)
& lymph inc ...
Observation:
Impacted fecalith – no local inflammation
(50%)
C. Role of colonic flora
- 60% Anaerobes – inflammed AP
- 25%...
NATURAL HISTORY
Temple et al(1995) Prospective study Ann.
Surgery
- 20% perforation < 24 hrs after onset of
symptoms
- 1 p...
CLINICAL PRESENTATIONS:
Symptoms:
Abdominal pain – crampy colicky, initial
response of muscularis of appendix to
obstructi...
CLINICAL PRESENTATIONS:
Signs:
Tenderness – local inflammatory response; tip of
appendix touching parietal peritoneum
Feve...
3 CLASSIC MANEUVERS:
• Rovsing sign – peritoneal irritation
• Psoas sign – irritation of psoas muscle
• Obturator sign – i...
Laboratory:
Leukocytes count – serial
Urinalysis – exclude ureteral stone/UTI
Liver enzymes/amylase – R/O HBT dse
BHCG – P...
Imaging studies:
• Plain film- abnormal gas pattern
-(+) fecalith/ rule out other dse.
• Graded compression USG- A-P> 6mm
...
Alvarado scale for the diagnosis of AP
Migration of pain(1),anorexia(1), N/V(1)
RLQ pain (2),rebound (1),fever (1)
Leukocy...
Acute appendicitis is essentially a clinical
diagnosis; there is no laboratory or
radiologic test yet devised that is 100%...
EVALUATION
Hx and PE – serial PE, one examiner, rectal
exam, speculum, bimanual examination,
urinalysis, pregnancy test
MA...
COMPLICATIONS
• Perforation
• Abscess formation
• Intestinal obstruction
• Bacteremia
• Sepsis
• Fistula
• Liver abscess
•...
Differential diagnosis:
Acute mesenteric adenitis, AGE, dse of male
urogenital system
Meckel’s diverticulitis, intessuscep...
Special consideration:
Lifetime risk- 12%( males )
25%( females )
Mean age – 31.3 y/o
2nd
- 4th
decade of life
Rate of mis...
Special consideration:
Advance age – 50-70% perforation
Use of imaging modalities like CT scan
Pregnancy – location of app...
II. Neoplasm
> 0-5% incidence
> AdenoCA, Cystic neoplasm, carcinoid, mets,
lymphoma, leiomyosarcoma
> Treatment: Right hem...
Appendix
Appendix
Appendix
Appendix
Appendix
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Appendix

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Transcript of "Appendix"

  1. 1. FACTS  Acute appendicitis is the most common surgical emergency of the abdomen  Appendectomy is one of the most frequently performed surgical procedures
  2. 2. FACTS Mortality rate from perforated appendicitis:  near certain death a century ago  10-20 per cent 50 years ago  5 per cent during the 1960s  1 per cent or less from the 1970s to the present
  3. 3. FACTS “Rates of unnecessary appendectomies and perforation have remained relatively high despite gaining a century of clinical experience with acute appendicitis” “The dramatic expansion of diagnostic testing options and the introduction of innovative surgical approaches during the last decade has actually caused even more debate and disagreement than resolution of issues.”
  4. 4. OPERATIONAL DEFINITIONS Uncomplicated Appendicitis:  Includes the acutely inflamed, phlegmonous, suppurative, or mildly inflamed appendix with or without peritonitis
  5. 5. OPERATIONAL DEFINITIONS Complicated Appendicitis:  Includes gangrenous appendicitis, perforated appendicitis, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess
  6. 6. OPERATIONAL DEFINITIONS Equivocal Appendicitis:  A patient with right lower quadrant abdominal pain who presents with an atypical history and physical examination and the surgeon cannot decide whether to discharge or to operate on the patient
  7. 7. Adult size 9 cms length ; 1-3 mm lumen Base constant = confluence of taenia coli Blood supply – appendicular branch of ileocolic artery Lymphatics – follows the blood supply
  8. 8. HISTOLOGIC FEATURES - Muscular layer not well defined - Lymphoid aggregates in submucosa and mucosa - Mucosa is like colon, but irregular shaped crypts
  9. 9. PHYSIOLOGY -Serotonin – mediates pain arising from non inflamed appendix - “ carcinoid tumors” - Immune surveillance - Secretes mucin, fluid & proteolytic enzymes
  10. 10. DISEASES OF THE VERMIFORM APPENDIX I. Acute appendicitis Etiology & Pathogenesis: A.Role of environmental: Diet and Hygiene Western Diet (Low fiber, High fat) Change in motility, flora, lumen – fecalith formation
  11. 11. B. Role of obstruction - anatomical - hyperplasia of lymphoid - neoplasm/foreign body
  12. 12. Sequence of events: Increase mucus & fluids inc intraluminal pressure – obstructed outflow of blood (venules) & lymph inc P appendiceal wall obstructs arterial supply mucosal ischemia, inflammation, stasis, necrosis of muscularis PERFORATION
  13. 13. Observation: Impacted fecalith – no local inflammation (50%) C. Role of colonic flora - 60% Anaerobes – inflammed AP - 25% Anaerobes – non-inflammed AP Lumen – source of microorganism (E.coli/Bacteroides) Pieper et al – inc antibody titer to Bacteriodes Gangrene & perforation
  14. 14. NATURAL HISTORY Temple et al(1995) Prospective study Ann. Surgery - 20% perforation < 24 hrs after onset of symptoms - 1 patient <10 hrs - average time to perforate 64h
  15. 15. CLINICAL PRESENTATIONS: Symptoms: Abdominal pain – crampy colicky, initial response of muscularis of appendix to obstruction Vomiting, nausea, loss of appetite
  16. 16. CLINICAL PRESENTATIONS: Signs: Tenderness – local inflammatory response; tip of appendix touching parietal peritoneum Fever rarely occurs (38.2o C)
  17. 17. 3 CLASSIC MANEUVERS: • Rovsing sign – peritoneal irritation • Psoas sign – irritation of psoas muscle • Obturator sign – irritation of obturator muscle “OVERALL CLINICAL PICTURE COUNTS”
  18. 18. Laboratory: Leukocytes count – serial Urinalysis – exclude ureteral stone/UTI Liver enzymes/amylase – R/O HBT dse BHCG – Pregnancy
  19. 19. Imaging studies: • Plain film- abnormal gas pattern -(+) fecalith/ rule out other dse. • Graded compression USG- A-P> 6mm - sensitivity (55-96%), spec (85-98%) • CT scan – dilated AP(>5cm),thickened - wall,(92% sensitive, 94% spec) BHCG – Pregnancy Imaging studies
  20. 20. Alvarado scale for the diagnosis of AP Migration of pain(1),anorexia(1), N/V(1) RLQ pain (2),rebound (1),fever (1) Leukocytosis (2), left shift (1) • 9-10 = almost certain/no labs • 7-8 = high likelihood • 5-6 =compatible with but not diagnostic
  21. 21. Acute appendicitis is essentially a clinical diagnosis; there is no laboratory or radiologic test yet devised that is 100% diagnostic of this condition
  22. 22. EVALUATION Hx and PE – serial PE, one examiner, rectal exam, speculum, bimanual examination, urinalysis, pregnancy test MANAGEMENT: a. preop – fluids/antibiotics (2nd gen) b. Operative – open/laparoscopy c. Postop - antibiotics
  23. 23. COMPLICATIONS • Perforation • Abscess formation • Intestinal obstruction • Bacteremia • Sepsis • Fistula • Liver abscess • Pyelophlebitis
  24. 24. Differential diagnosis: Acute mesenteric adenitis, AGE, dse of male urogenital system Meckel’s diverticulitis, intessusception, perforated peptic ulcer, colonic lesion, epiploic appendagitis UTI, gynecologic dse, Henoch-Schonlein purpura
  25. 25. Special consideration: Lifetime risk- 12%( males ) 25%( females ) Mean age – 31.3 y/o 2nd - 4th decade of life Rate of misdiagnosis- 15% (higher in females, 22.3 vs 9.3%) Negative appendectomy women- 23.2%
  26. 26. Special consideration: Advance age – 50-70% perforation Use of imaging modalities like CT scan Pregnancy – location of appendix base on AOG - ultrasound
  27. 27. II. Neoplasm > 0-5% incidence > AdenoCA, Cystic neoplasm, carcinoid, mets, lymphoma, leiomyosarcoma > Treatment: Right hemicolectomy > 5 yr. survival- 55%
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