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Appendicitis in children-.pptx
- 2. INTRODUCTION Appendicitis : Inflammation of the appendix
- 3. Historical background In 1886 DR.REGINALD FITZ coined the term appendicitis. Morton is credited with performing the first deliberate appendectomy for a perforated appendix in the United States in 1887. In 1889 McBurney reported his treatment of appendicitis with appendectomy before rupture
- 4. Incidence Most common acute surgical condition in children Major cause of childhood morbidity The lifetime risk 9% for male 7% for female Peak incidence between age 11-18 Race – whites>black Season – peak incidence in autumn and spring
- 5. Anatomy The appendix 1st becomes visible during the 8th week of gestation as a continuation of the inferior tip of the cecum. The appendix rotates to its final position on the posteromedial aspect of the cecum, about 2 cm below the ileocecal valve, during late childhood. The variability in this rotation leads to multiple possible final positions of the appendix. The exact location varies widely
- 6. BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
- 8. The appendix averages 8 cm in length but can vary from 0.3 to 33 cm. The diameter of the appendix ranges from 5 to 10 mm. The mesoappendix arises from the lower surface of the mesentery or the terminal ileum. Function is unknown. BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
- 9. Its blood supply is the appendicular artery is a branch of the ileocolic artery, which passes behind the terminal ileum. It is an end artery
- 10. Etiology EXACT CAUSE – not completely understood ASSOCIATED FACTORS: Fecoliths Decreased dietary fibre Increased consumption of refined carbohydrates Incompletely digested food particles Lymphoid hyperplasia
- 11. INTRALUMINAL SCARRING blunt trauma •TUMORS OR MALIGNANCIES carcinoid tumors •MICROORGANISMS: a. BACTERIA– Yersinia Salmonella Shigella spp b.VIRUSES – Mumps CoxsackievirusB Adenovirus Infectious mononucleosis c. OTHERS - Ascaris lumbricoides
- 12. Pathophysiology
- 15. Diagnosis: Best made with careful history and physical examination Laboratory investigations Scoring systems
- 16. Clinical presentation Children with appendicitis usually lie in bed with minimal movement. Older children may limp or flex the trunk Infants may flex ther right leg over the abdomen.
- 17. Classical features : • Periumbillical colic • Pain shifting to the right iliac fossa • Anorexia • Nausea • Indigestion or subtle changes in bowel habits • Diarrohea
- 18. Age dependent signs and symptoms
- 20. Physical examination Presence of LOCALIZED ABDOMINAL TENDERNESS the SINGLE MOST reliable finding in the diagnosis of acute appendicitis
- 21. McBurney described : “the seat of greatest pain . . . has been very exactly between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from the process to the umbilicus.” From then on, this location was known as the McBurney point
- 22. Physical sign: Pyrexia Localized tenderness in the right iliac fossa Muscle guarding Rebound tenderness Signs to elicit in appendicitis : Pointing sign Rovsing’s sign Psoas sign Obturator sign
- 23. ROVSING’S SIGN Palpating in the left lower quadrant causes pain in the right lower quadrant
- 24. Obturator sign Spasm of the obturator internus when the hip is flexed and internally rotated. If inflamed appendix is in contact with the muscle, the maneuver causes pain in the hypogastrium
- 25. Psoas sign Extending the right hip causes pain along posterolateral back and hip, suggesting retrocecal appendicitis
- 26. Digital rectal examination If other signs point to appendicitis, the rectal examination is unnecessary. Maybe helpful if pelvic appendix or abscess suspected Tenderness in the rectovesical pouch or the pouch of douglas,especially on the right sight – indicates pelvic appendix
- 27. If appendicitis is allowed to progress 1.Diffuse peritonitis and shock – more common ininfants 2.Formation of abscess – older children and teenagersare more likely to have
- 28. Differential diagnosis Appendix Cecum and colon Hepatobiliary Small intestines • Appendicular tumor • Carcinoid tumor • Appendiceal mucocele • Diverticulitis • Intestinal obstruction • Crohn's disease • Typhilitis • Cecal carcinoma • Cholecystitis • Hepatitis • cholangitis • Adenitis • Meckel’s diverticulitis • Gastroenteritis • Intestinal obstruction • Intussusception • TB • Typhoid (ulcer perforation)
- 29. Urinary tract Uterus/ovary Others • Hydronephrosis • Wilm’s tumor • Ureteral or renal calculus • Ectopic pregnancy • Salphingitis • Ruptured ovarian cyst BANGABA • Pancreatitis • Parasitic infection • Pleuritis • Pneumonia • Schonlein-Henoch purpura • Porphyria • Psoas abscess • Kawasaki disease • Burkitt lymphoma • Omental torsion • Rectus sheath hematoma • Sickle cell disease • CMV • Torsion of appendix N D H eU piS pH lE oI K icH aM U J I BMEDICAL UNIVERSITY
- 30. Investigations CBC WBC – elevated leukocyte and neutrophil count Urine analysis Indicated to help exclude genitourinary conditions May have some WBC or RBC
- 31. Other investigation: Serum electrolytes Liver function tests C-reactive protein Tumor markers Tuberculin Test Viral markers Beta HCG
- 32. Imaging Plain radiographs Most helpful in evaluating complicated cases in which small bowel obstruction or free air is suspected Findings: Fecolith Sentinel loops of bowel and localized ileus Scoliosis from psoas muscle spasm Abnormal gas shadow in the RLQ Calcified appendicolith
- 33. USG of whole abdomen Highly operator dependent Helpful in other diagnoses Findings – Wall thickness >6mm Appendicolith Luminal distension Lack of compressibility Complex mass in the RLQ
- 34. Barium enema contrast radiograph Absent or incomplete filling ofappendix Irregularities of the appendiceallumen Extrinsic mass effect on cecum or terminalileum
- 35. Computed tomography Gold standard Findings Enlarged appendix >6mm Appendiceal wall thickening >1mm Periappendiceal fatstranding Appendiceal wall enhancement
- 36. Clinical scoring system <3 – low likelihood 4-6 – needs further evaluation >7 – high likelihood The ALVARADO (MANTRELS) Score Symptoms Score Migratory RIF pain 1 Anorexia 1 Nausea and vomiting 1 Signs Tenderness(RIF) 2 Rebound tenderness 1 Elevated temperature 1 Laboratory Leukocytosis 2 Shift to left(segmented neutrophils) 1 Total 10
- 37. Paediatric appendicitis scores Features Score Fever >38oC 1 Anorexia 1 Nausea/Vomiting 1 Cough/percussion/hopping tenderness 2 Right lower quadrant tenderness 2 Migration of pain 1 Leukocytosis > 10,000/L 1 Polymorphonuclear neutrophilia>7500/L 1 Total 10 •≤2 low likelihood •3-7 needs further evaluation •≥8 high likelihood
- 38. Management Medical management : Correction of dehydration Correction of electrolytes Management of pain Antibiotic therapy The use of antibiotic for treatment of appendicitis is clearly beneficial For simple appendicitis Single preoperative dose to 24 hours of post operative antibiotic therapy Complicated appendicitis A 10-day course of intravenous ampicillin, gentamicin,and clindamycin or metronidazole is the gold standard for the treatment of complicated appendicitis
- 39. Surgical management For uncomplicated appendicitis Non-operative management : Used in an environment where surgery notavailable. Patient having spontaneous resolution. Surgery remains the gold standard. Bowel rest Intravenous antibiotics If tends to be complicated, Surgery is the choice of treatment. Criteria for stopping A rising pulse rate Increasing or spreading abdominal pain Increasing size of the mass
- 40. For complicated appendicitis the majority of pediatric surgeons will perform appendectomy within 8 hours Opinions range from nonoperative treatment to aggressive surgical resection with antibiotic irrigation, drainage of the peritoneal cavity, and delayed wound closure
- 41. Operative interventions include Interval appendectomy – Performing appendectomy following initial successful non-operative management in patients with no further symptoms Majority of pediatric surgeons perform this routinely (6-8wk interval)
- 42. Open appendectomy BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
- 44. Problems encountered during appendectomy A normal appendix isfound The appendix cannot befound An appendicular tumour is found An appendix abscessfound Pelvicabscess
- 46. Outcome The mortality rate for complicated appendicitis has dropped to nearly 0 Antibiotics have markedly decreased the incidence of infectious complications. The overall morbidity in children with complicated appendicitis is <10%
- 47. Summary Appendicitis is a common cause of abdominal pain in children. Repeated abdominal pain should not be overlooked. A careful history and physical examination can reliablymake diagnosis in majority of cases Minimally invasive appendectomy is treatment of choice. Post-operative management is determined by operative findings.