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Appendix

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Appendix Appendix Presentation Transcript

  •  
  • FACTS
    • Acute appendicitis is the most common surgical emergency of the abdomen
    • Appendectomy is one of the most frequently performed surgical procedures
  • 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
  • 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.”
  • OPERATIONAL DEFINITIONS
    • Uncomplicated Appendicitis:
    • Includes the acutely inflamed, phlegmonous, suppurative, or mildly inflamed appendix with or without peritonitis
  • OPERATIONAL DEFINITIONS
    • Complicated Appendicitis:
    • Includes gangrenous appendicitis, perforated appendicitis, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess
  • 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
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  • 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
    • HISTOLOGIC FEATURES
    • Muscular layer not well defined
    • Lymphoid aggregates in submucosa and mucosa
    • Mucosa is like colon, but irregular shaped crypts
    • PHYSIOLOGY
    • -Serotonin – mediates pain arising from non inflamed appendix
    • - “ carcinoid tumors”
    • Immune surveillance
    • Secretes mucin, fluid & proteolytic enzymes
    • DISEASES OF THE VERMIFORM APPENDIX
    • Acute appendicitis
    • Etiology & Pathogenesis:
    • Role of environmental: Diet and Hygiene
    • Western Diet (Low fiber, High fat) Change in motility, flora, lumen – fecalith formation
  • 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 P appendiceal wall obstructs arterial supply mucosal ischemia, inflammation, stasis, necrosis of muscularis PERFORATION
  • 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
  • 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
  • CLINICAL PRESENTATIONS: Symptoms: Abdominal pain – crampy colicky, initial response of muscularis of appendix to obstruction Vomiting, nausea, loss of appetite
  • CLINICAL PRESENTATIONS : Signs: Tenderness – local inflammatory response; tip of appendix touching parietal peritoneum Fever rarely occurs (38.2 o C)
    • 3 CLASSIC MANEUVERS:
    • Rovsing sign – peritoneal irritation
    • Psoas sign – irritation of psoas muscle
    • Obturator sign – irritation of obturator muscle
    • “ OVERALL CLINICAL PICTURE COUNTS ”
  • Laboratory: Leukocytes count – serial Urinalysis – exclude ureteral stone/UTI Liver enzymes/amylase – R/O HBT dse BHCG – Pregnancy
    • 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
    • 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
  • Acute appendicitis is essentially a clinical diagnosis ; there is no laboratory or radiologic test yet devised that is 100% diagnostic of this condition
  • EVALUATION Hx and PE – serial PE, one examiner, rectal exam, speculum, bimanual examination, urinalysis, pregnancy test MANAGEMENT: a. preop – fluids/antibiotics (2 nd gen) b. Operative – open/laparoscopy c. Postop - antibiotics
    • COMPLICATIONS
    • Perforation
    • Abscess formation
    • Intestinal obstruction
    • Bacteremia
    • Sepsis
    • Fistula
    • Liver abscess
    • Pyelophlebitis
  • 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
  • Special consideration: Lifetime risk- 12%( males ) 25%( females ) Mean age – 31.3 y/o 2 nd - 4 th decade of life Rate of misdiagnosis- 15% (higher in females, 22.3 vs 9.3%) Negative appendectomy women- 23.2%
  • Special consideration: Advance age – 50-70% perforation Use of imaging modalities like CT scan Pregnancy – location of appendix base on AOG - ultrasound
  • II. Neoplasm > 0-5% incidence > AdenoCA, Cystic neoplasm, carcinoid, mets, lymphoma, leiomyosarcoma > Treatment: Right hemicolectomy > 5 yr. survival- 55%