appendicular neoplasm

1. Complications of appendicitis
and appendicular neoplasm
Presented by Abdurhman Maashi

2. Acute appendicitis
• Inflammation of the appendix is a significant public health problem
With a lifetime incidence of 8.6% in men , 6.7% in women .
• The highest incidence in the second and third decade of life
• Etiology is perhaps due to luminal obstruction that is due to lymphoid
hyperplasia in pediatric populations ; in adults due to fecalith , foreign
body , fibrosis , neoplasia
• E.coli and bacteroids fragilis most common isolated aerobic and
anaerobic in perforated appendicitis

3. Clinical diagnosis
• Migratory pain ( irritation of visceral peritoneum progresses to parietal
peritoneum)
• Anorexia , nausea , vomiting and fever
• Ileus , diarrhea , small bowel obstruction and hematouria
• Pregnancy history ( including menstrual ) should be obtained to rule out
other causes of abdominal pain
• Rovsing’s Sign ,Psoas Sign ,Obturator Sign
• Dunphy’s Sign: Any movement ( Coughing) causes Pain.
• Mc Burney’s Point -Tenderness

4. Imaging
• The use of imaging studies are appropriate for patients with high risk
operative intervention and general anesthesia : such as pregnant and
patients with comorbidities
• CT features suggestive for appendicitis : enlarged lumen , double wall
thickness greater than 6 mm , wall thickening greater than 2 mm ,
periappendiceal fat , appendicolith
• US signs to rule out appendicitis ; easily compressible appendix less
than 5 mm in diameter , appendicitis signs ; diameter greater than 6
mm , pain with compression , appendicolith , increased echogenicity
of fat , periappendiceal fat

5. • MRI used to avoid high risk of radiation like in pregnant ladies and
pediatric
• Differential diagnosis of appendicitis
1- Meckel’s diverticulitis
2- Acute ileitis
3- Crohn’s disease
4- PID
5- torsion of Ovarian cyst
6- Graafian follicle
7- acute mesenteric adenitis or acute gastroenteritis

7. Complications of appendicitis
• Gangrenous Appendicitis:
• Thrombosis of the appendiceal artery and veins
• Perforation:
• complication rates 58 %
• perforation rate increased at both ends of the age spectrum
• Peri-appendiceal abscess:
• most frequent complication
• peri-appendiceal fibrinous adhesions

8. • Peritonitis:
• Bacterial peritonitis in absence of fibrinous adhesions.
• Escherichia coli
• Bowel Obstruction
• Septic seeding of mesenteric vessels
• infection along the mesenteric–portal venous system
• pylephlebitis, pylethrombosis, or hepatic abscess

9. Management of appendicitis
• Absolute bed rest & NPO
• IV Fluids Supplements
• Analgesics
• Antibiotics
• Appendectomy ( within 24 hours ASAP)

10. Management of complicated appendicitis
• Patients with perforated appendicitis usually present after 24 hr of
onset , which present acutely ill and dehydrated so they require good
resuscitation
• Perforated appendicitis can be managed operatively and
nonoperatively .
• Immediate surgery for septic but usually associated with higher
complications including abscesses , enterocutaneous fistulae , due to
dense adhesions and inflammation
• So better treated with percutaneous image guided drainage ,
successful in 79% of patients better in low grade abscesses and trans
gluteal drainage

11. • Operative intervention is preferred in failure of conservative
management and in patients with free peritoneal perforation

12. Appendicular neoplasms
• The incidence of appendicular neoplasms is estimated at around 1%
of all appendectomy specimen .
• Most common neoplasms happen in appendix are :
gastroenteropancreatic neuroendocrine tumors ( GEP-NEPs)
previously called carcinoids , mucinous neoplasms or
adenocarcinoma.
• One third of appendicitis present as neoplasms while others
discovered incidentally after regional spread of the disease .

13. Carcinoid tumor
• They are submucosal rubbery masses discovered incidentally .
• They are indolent but can develop nodal or hepatic metastases ,
infrequently can be associated with carcinoid syndrome if there are
hepatic metastases 2.9%.
• For lesion less than 1 cm (95% ) , negative margin appendectomy is
adequate . For tumors 2 cm or more right hemicolectomy , 1-2 cm
there is no consensus for on a completion colectomy .
• Right colectomy is performed for mesenteric invasion , enlarged
nodes. Positive or unclear margin .
• Measurement of serum chromogranin A is recommended

14. Goblet Cell carcinomas
• Mistakenly called goblet cell carcinoids , Rather indolent biology are
adenocarcinoid with both adenocarcinoma and neuroendocrine
features .
• Carry worse prognosis than carcinoids and better than
adenocarcinoma with higher risk for peritoneal recurrence .
• In the absence of metastatic disease a right hemicolectomy is
appropriate although some advocate for right colectomy only for
tumors 2 cm or larger .

15. Lymphomas
• Are rare , 1-3% of lymphomas usually non-Hodgkin’s .
• Difficult to diagnose preoperatively ( appendiceal diameter can be 2.5
cm or larger )
• Management includes appendectomy in most cases

16. Adenocarcinoma
• IS rare originated from gastrointestinal tract with three histologic
subtypes : mucinous adenocarcinoma , colonic adenocarcinoma and
adenocarcinoid .
• Most common presentation acute appendicitis , may present with
ascites or palpable mass , or discovered incidentally during operation
• Treatment formal right hemicolectomy
• They have propensity for early perforation , clearly not associated
with worsened prognosis
• 55% overall 5 year survival with significant risk for synchronous and
metachronous neoplasms

17. Appendiceal mucocele
• Are mucus filled appendix that could be to neoplastic or non-
neoplastic pathologies ( mucosal hyperplasia , simple or retention cyst
, mucinous cystadenomas , mucinous cystadenocarcinoma )
• Most common presentation is incidental , one third of cases present
as appendicitis
• On CT imaging ; low attenuation , round , well encapsulated cystic
mass in the right , features such as wall irregularity and soft tissue
thickening suggest neoplastic process .
• Is important to assess for ascites , peritoneal disease and scaloping of
the liver surface on imaging .

18. • Is recommend that surgical excision without capsular disruption is
undertaken to avoid subsequent development of pseudomyxoma
peritonei are nearly certain in cases of adenocarcinoma
• In the absence of mesenteric or peritoneal involvement an
appendectomy with concurrent appendiceal lymphadenctomy is
sufficient .
• If peritoneal involvement is evident is important to obtain biopsies
• Colorectal , ovarian , endometrial cancers can coexist in the setting of
appendiceal mucoceles and carful examination of intra- abdominal
structures is important .

19. Pseudomyxoma peritonei syndrome
• Patients with appendiceal mucinous neoplasms develop peritoneal
dissemination leading to this syndrome
• Can occur in gastric , ovarian , pancreatic and colorectal primary
tumors
• Prognosis ranging from curative to palliative .
• HIPEC are considered the standard care for treatment of PMP
syndrome from appendiceal primaries
• Peritonectomies and intraperitoneal administration of heated
chemotherapy in the abdomen .

20. Thank you