2. Anatomy • A blind muscular tube with
mucosal, submucosal,
muscular and serosal layers
• Position of the base of the
appendix is constant, being
found at the confluence of
the three taeniae coli of the
caecum, which fuse to form
the outer longitudinal muscle
coat of the appendix.
WHAT IS APPENDIX?
3. Various positions of the appendix:
• Vascularisation
Appendicular
artery, a branch of
the lower division of
the ileocolic artery,
4. APPENDICITIS:-
Definition:
• An inflammation of the vermiform
appendix
Aetiology:
• Decreased dietary fibre and increased
consumption of refined carbohydrates
• Obstruction of the appendix lumen
– Fecolith (composed of inspissated
faecal material, calcium phosphates,
bacteria, epithelial debris, rarely a
foreign body)
– Tumour (carcinoma of caecum)
– Intestinal parasites (Oxyuris /
Enterobius vermicularis – pinworm)
5. Pathophysiology of Appendicitis
• 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
6. History
• Primary symptom: abdominal pain
• ½ to 2/3 of patients have the classical
presentation
• Pain beginning in epigastrium or
periumbilical area that is vague and hard
to localize
7. History
• Associated symptoms: indigestion,
discomfort, flatus, need to defecate,
anorexia, nausea, vomiting
• As the illness progresses RLQ localization
typically occurs
• RLQ pain was 81 % sensitive and 53%
specific for diagnosis
8. History
• Migration of pain from initial periumbilical
to RLQ was 64% sensitive and 82%
specific
• Anorexia is the most common of
associated symptoms
• Vomiting is more variable, occuring in
about ½ of patients
11. CLINICAL SIGNS
• Psoas sign: place patient in L lateral
decubitus and extend R leg at the hip. If
there is pain with this movement, then the
sign is positive.
• Obturator sign: passively flex the R hip
and knee and internally rotate the hip. If
there is increased pain then the sign is
positive
14. Diagnosis
• Acute appendicitis should be suspected in
anyone with epigastric, periumbilical, right
flank, or right sided abd pain who has not
had an appendectomy
15. Diagnostic Scoring
• Diagnosis is essentially clinical
• HOWEVER a decision to
operate based on clinical
suspicion only can lead to the
removal of a normal appendix.
• A number of clinical and
laboratory-based scoring
systems have been devised to
assist diagnosis.
• The most widely used
is Alvarado score.
16. The Alvarado (MANTRELS)
Score
Score
Symptoms
•Migratory RIF pain
•Anorexia
•Nausea and vomiting
1
1
1
Signs
•Tenderness (RIF)
•Rebound tenderness
•Elevated temperature
2
1
1
Laboratory
•Leucocytosis
•Shift to the left (segmented
neutrophils)
2
1
TOTAL 10
• < 5 is strongly against a diagnosis of appendicitis
• 7 or more is strongly predictive of acute appendicitis
• In patients with an equivocal score of 5 or 6, abdominal
USG or contrast-enhanced CT scan is used to further
reduce the rate of negative appendicectomy
21. Treatment
• Intravenous fluids
• to establish adequate urine output
• Appropriate antibiotics
• Reduces the incidence of
postoperative wound infection
• When peritonitis is suspected,
therapeutic intravenous antibiotics
to cover Gram-negative bacilli as
well as anaerobic cocci should be
given
• Salicylates
• Appendicectomy
22. Treatment
• Appendicectomy is the standard of care
• Patients should be NPO, given IVF, and
preoperative antibiotics
• Antibiotics are most effective when given
preoperatively and they decrease post-op
infections and abscess formation
23. Treatment
• There are multiple acceptable antibiotics to
use as long there is anaerobic flora,
enterococci and gram(-) intestinal flora
coverage
• One sample monotherapy regimen is
Zosyn (piperacillin+ tazobactam) 3.375g or
Unasyn (ampicillin and Salbactam) 3g
• Also, short acting narcotics should be used
for pain management
24. Epidemiology of
Appendicectomy
• The incidence of appendicectomy appears
to be declining due to more accurate
preoperative diagnosis
• Despite newer imaging techniques, acute
appendicitis can be very difficult to
diagnose
26. Conventional Appendicectomy
Gridiron incision :
right angles to a line
joining the ASIS to the
umbilicus. Centred on
McBurney’s point
Lanz incision : 2 cm
below the umbilicus
centred on the mid-
clavicular-mid
inguinal line
2/
31/
3
2
cm
31. Problems Encountered During
Appendicectomy
Problems Management
A normal appendix is
found
Demands careful exclusion of
other possible diagnosis
Remove the appendix to avoid
future diagnostic difficulties
The appendix cannot be
found
Caecum should be mobilised,
and the taeniae coli should be
traced to their confluence on the
caecum before the diagnosis of
‘absent appendix’ is made
An appendicular tumour
is found
Small tumours (< 2.0 cm in
diameter) can be removed by
appendicectomy
Larger tumours should be treated
by a right hemicolectomy
An appendix abscess is
found and the appendix
cannot be removed
easily
Should be treated by local
peritoneal toilet, drainage of an
abscess and intravenous
antibiotics
34. • Position the patient on the OR table
• Skin preparation
• Induction of anesthesia
• Procedures done aseptically
• Closing of the incision
• Dressing of the site
INTRAOPERATIVE NURSING
CARE
35. • Monitor vital signs for sign of infection and
shock such as fever, hypotension and
tachycardia.
• Monitor I and O for sign of imbalance,
dehydration, and shock.
• Assess abdomen for increased pain,
distention, rigidity, and rebound tenderness
because these may indicate postoperative
complications.
• Evaluate dressing and incision.
• Evaluate the passing of flatus or feces.
POST OPERATIVE MANAGEMENT
AND NURSING CARE
36. • Monitor for nausea and vomiting.
• Laboratory values are monitored and patient is
evaluated for sign and symptoms of electrolyte
imbalances.
• Wound drains, I.V, and all other catheter are
monitored and evaluated for signs of infections.
• Turning , coughing, deep breathing, and
incentive spirometry are performed every 2
hours.
• Diet is advised as ordered.
• Administration of medications as ordered
37. Patient Education and Health Maintenance
oInstruct patient to avoid heavy lifting for 4 to
6 weeks after surgery.
oInstruct patient to report symptoms of
anorexia, nausea, vomiting, fever, abdominal
pain, incision area redness and drainage
postoperatively.
Microscopic anatomy:
- average length is between 7.5 and 10 cm
- lumen is irregular, being encroached upon by multiple longitudinal folds of mucous membrane lined by columnar cell intestinal mucosa of colonic type
- Crypts are present but not numerous. In the base of the crypts lie argentaffin cells (Kulchitsky cells)
- submucosa contains numerous lymphatic aggregations or follicles.
CT findings of appendicitis fall into 3 categories
1. appendiceal changes
2. cecal apical changes
3. inflammatory changes in the right lower quadrant
