Successfully reported this slideshow.

Appendicitis intussusception

2,653 views

Published on

  • Be the first to comment

Appendicitis intussusception

  1. 1. Appendicitis
  2. 2. <ul><li>60,000 appendectomies/yr </li></ul><ul><li>20,000 ruptured </li></ul><ul><li>100 deaths/year </li></ul>
  3. 3. History
  4. 4. <ul><li>Paseo Iliaca </li></ul>
  5. 5. <ul><li>Reginald Fitz - 1886 </li></ul><ul><ul><li>“ Perforating Inflammation of the Vermiform Appendix: with special reference to its early diagnosis and treatment” Am J Med Sci 1:321-46, 1886. </li></ul></ul>
  6. 7. Reginald Heber Fitz <ul><li>B. 5/5/1843 D. 9/30/1913 </li></ul><ul><li>MD Harvard 1868 - Prof. Pathology </li></ul><ul><li>25 appendectomies </li></ul>
  7. 8. Charles McBurney
  8. 9. <ul><li>B. 2/17/1845, D. 11/7/1913 </li></ul><ul><li>BA Harvard 1866 </li></ul><ul><li>MD 1870 College of Physicians and Surgeons </li></ul>Charles McBurney
  9. 10. McBurney had a point
  10. 11. <ul><li>T.G. Morton - 1887 </li></ul>
  11. 12. Pathophysiology
  12. 13. <ul><li>Obstruction </li></ul><ul><li>Increased intraluminal pressure </li></ul>
  13. 14. Stages
  14. 15. <ul><li>Simple </li></ul>
  15. 16. <ul><li>Suppurative </li></ul>
  16. 17. <ul><li>Gangrenous </li></ul>
  17. 18. <ul><li>Ruptured </li></ul>
  18. 19. <ul><li>Abscessed </li></ul>
  19. 20. Microbiology
  20. 21. <ul><li>Intraoperative cultures are useless ! </li></ul>
  21. 22. <ul><li>Bacteroides Fragilis: #1 </li></ul>
  22. 23. Diagnosis
  23. 24. <ul><li>> 90% accuracy </li></ul>
  24. 25. <ul><li>Pain </li></ul><ul><li>Shift </li></ul><ul><li>ANV </li></ul>
  25. 26. Physical Exam
  26. 27. <ul><li>Gestalt </li></ul><ul><li>Posture </li></ul><ul><li>Point tenderness </li></ul>
  27. 28. <ul><li>Laboratory Results </li></ul>
  28. 29. Signs of Perforation
  29. 30. <ul><li>AXR </li></ul><ul><li>BE </li></ul>
  30. 31. <ul><li>US </li></ul><ul><li>CT </li></ul>
  31. 33. <ul><li>MGH AJR 2005 Jun;184(6):1802-8. </li></ul><ul><li>40% scanned had appendicitis </li></ul><ul><li>Sens 99%, Specif 95% </li></ul>
  32. 34. <ul><li>88% suspected appy </li></ul><ul><li>n = 753: had CT </li></ul><ul><li>False neg rate dropped: 20% to 3% </li></ul>
  33. 36. Differential diagnosis
  34. 37. Gastroenteritis Constipation GU GYN Mesenteric Adenitis Pneumonia
  35. 38. <ul><li>Antibiotics </li></ul>
  36. 39. Treatment
  37. 40. <ul><li>Operation </li></ul>
  38. 41. <ul><li>Irrigation </li></ul><ul><li>Drainage (rarely) </li></ul><ul><li>Wound closure </li></ul>
  39. 42. Medical management
  40. 43. <ul><li>Interval appendectomy </li></ul>
  41. 44. Complications
  42. 45. Appendiceal stump blow-out Abscess Phlegmon Dehiscence Infertility SBO Wound problems
  43. 46. <ul><li>Abscess </li></ul>
  44. 47. <ul><li>Wound infection </li></ul>
  45. 48. <ul><li>Obstruction </li></ul>
  46. 49. <ul><li>Mortality </li></ul>
  47. 58. CMH Research Appendicitis - recent <ul><li>St Peter SD, Sharp SW, Ostlie DJ. Influence of histamine receptor antagonists on the outcome of perforated appendicitis: analysis from a prospective trial. Arch Surg. 2010 Feb;145(2):143-6. </li></ul><ul><li>St Peter SD, Aguayo P, Fraser JD, Keckler SJ, Sharp SW, Leys CM, Murphy JP, Snyder CL, Sharp RJ, Andrews WS, Holcomb GW 3rd, Ostlie DJ. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg. 2010 Jan;45(1):236-40. </li></ul><ul><li>Fraser JD, Aguayo P, Sharp SW, Snyder CL, Rivard DC, Cully BE, Sharp RJ, Ostlie DJ, St Peter SD. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg. 2010 Jan;45(1):231-4; discussion 234-4. </li></ul><ul><li>Fraser JD, Aguayo P, Sharp SW, Snyder CL, Holcomb GW 3rd, Ostlie DJ, St Peter SD. Physiologic predictors of postoperative abscess in children with perforated appendicitis: Subset analysis from a prospective randomized trial. Surgery. [Epub ahead of print] </li></ul><ul><li>St Peter SD, Sharp SW, Holcomb GW 3rd, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg. 2008 Dec;43(12):2242-5. </li></ul><ul><li>St Peter SD, Tsao K, Spilde TL, Holcomb GW 3rd, Sharp SW, Murphy JP, Snyder CL, Sharp RJ, Andrews WS, Ostlie DJ. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun;43(6):981-5. </li></ul>
  48. 60. 1913: Ladd Bismuth enema
  49. 61. 1927 Barium
  50. 62. 1948: Ravitch & McCune 32% Op Mortality
  51. 63. 1953: Gross opposed Nonoperative reduction
  52. 64. 1959 - air enema China
  53. 65. intuss = &quot;within&quot; (Lat.) suscipere = &quot;to receive&quot; (Lat.)
  54. 66. 1 in 2,000 2:1 m:f 3 mo < 50% < 9 mo
  55. 67. May - July ? Viral 1 in 5 + prior illness
  56. 69. Pathogenesis
  57. 70. *ceptum goes into the *cipiens =&quot;recipient&quot; *ceptum swells, bleeds (currant jelly)
  58. 72. ASx /incidental Intussusception: Watch
  59. 73. [PP are on antimesenteric border*] *Except @ Ti
  60. 74. 95% of Intussusception: Ileocolic area No PLP
  61. 75. 20% + PLP > 2 yr old
  62. 77. Ileoileocolic: 4% all cases Hard to reduce (25% success) 40% PLP
  63. 78. Pathologic Leadpoints <ul><li>Meckel’s diverticulum # 1 </li></ul><ul><li>Intestinal polyps & duplications # 2 </li></ul><ul><li>Appendix </li></ul><ul><li>Ectopic gastric or pancreatic mucosa </li></ul><ul><li>Henoch-Schonlein purpura </li></ul><ul><li>Suture line </li></ul><ul><li>Neoplasms: leukemia, lymphoma </li></ul><ul><li>Hemangioma </li></ul><ul><li>Neurofibromas </li></ul><ul><li>Foreign body / Ascaris </li></ul><ul><li>Cystic fibrosis </li></ul><ul><li>Abdominal trauma </li></ul>
  64. 79. > 5yr old = > 50% chance of PLP
  65. 80. 4% PLP 1st recurrence 14% PLP if > 1 recurrence
  66. 81. 1200 Canadian Kids: 11 Lymphomas / intussusception
  67. 82. Postoperative Intussusception: 1% all Int. 5 - 10% of all ped SBO
  68. 83. Intrauterine Intussusception
  69. 84. Clinical Presentation Classic Symptoms: Intermittent colicky abdominal pain (85%) Vomiting (50%) Classic Signs: Abdominal Mass (25 - 50%) Rectal bleeding (25 - 50%)* * late sign, currant jelly
  70. 85. Plain films 50% accuracy
  71. 89. Ultrasound >98% accuracy
  72. 92. US: ? irreducibility Thick outer rim Free peritoneal fluid Trapped fluid in *septum Big mesenteric LN No flow in in*septum (Doppler) # 1
  73. 93. Medical Mgmt - HSP Steroids?
  74. 94. Radiologic reduction (90% success) CI’s...
  75. 96. Pneumatic reduction with US or Fluoroscopic guidance Start with 50 mm Hg - > up to 110 - 120 mm Hg
  76. 97. Pneumatic Reduction ? sedation? glucagon ? abdominal manipulation ? delayed repeat enema
  77. 99. ? home after successful reduction
  78. 100. Perforation < 1% Success of air enema > 90%
  79. 101. Gou 1986 6,396 air reductions 0.14% perf rate Gu 1993 9,000 pts 0.16% perf rate
  80. 102. Increased perf risk < 6 mo old Sx > 36 hrs
  81. 103. Operation Open or Lap
  82. 108. Recurrence - 5% overall p BE 5 - 10% (AE ?) p Op reduct 3 - 5% p Op resect 1% Mean t (recur) = 8 months
  83. 109. CMH Research Intussusception <ul><li>Fraser JD, Aguayo P, Ho B, Sharp SW, Ostlie DJ, Holcomb GW 3rd, St Peter SD. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. 2009 Aug;19(4):563-5. </li></ul>

×