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Appendix Pp For Online

  1. 1. Acute Appendicitis
  2. 2. Introduction <ul><li>The vermiform appendix is considered by most to be a vestigial organ, its importance in surgery is only due to its tendency for inflammation resulting in the syndrome called acute appendicitis . </li></ul><ul><li>Acute appendicitis is the most common cause of an “acute abdomen” in young adults. </li></ul><ul><li>Appendectomy is the most frequently performed urgent abdominal operation </li></ul><ul><li>Despite extraordinary advances in the modern radiographic imaging & laboratory investigations, the diagnosis of appendicitis remains essentially clinical requiring a mixture of observation, surgical science & clinical sense. </li></ul>
  3. 3. Anatomy <ul><li>The vermiform appendix is present only in mammals. </li></ul><ul><li>The position of the appendix is variable: </li></ul><ul><li>- Retrocecal 74%. </li></ul><ul><li>- Pelvic 21%. </li></ul><ul><li>- Postileal 5%. </li></ul><ul><li>- Paracecal 2%. </li></ul><ul><li>- Subcecal 1.5%. </li></ul><ul><li>- Preileal 1%. </li></ul><ul><li>The position of the base of the appendix is constant, being found at the confluence of the 3 taenia coli of the cecum which fuse to form the outer longitudinal muscle coat of the appendix. </li></ul><ul><li>The mesentery of the appendix (mesoappendix) arises from the lower surface of the mesentery of the terminal ileum. </li></ul><ul><li>The appendicular artery , a branch of the lower division of the ileocolic artery lie in the free border of the mesoappendix. It is an “end-artery”, thrombosis of which results in necrosis of the appendix (gangrenous appendicitis). </li></ul>
  4. 4. Acute Appendicitis <ul><li>Acute appendicitis is relatively rare in infants, becomes increasingly common in childhood & early adult life, reaching a peak incidence in the teens & early 20s. </li></ul><ul><li>After middle age, the risk of developing acute appendicitis in the future is quite small. </li></ul><ul><li>Etiology: There is no unifying hypothesis regarding the etiology of acute appendicitis. </li></ul><ul><li>While appendicitis is associated with bacterial proliferation within the appendix, no single organism is responsible, mixed growth of aerobic & anaerobic organisms is usual. </li></ul><ul><li>Obstruction of the appendix lumen is important, some form of luminal obstruction by either a fecolith or stricture is found in the majority of cases. </li></ul><ul><li>Obstruction of orifice by tumor (carcinoma of the cecum) is a cause of acute appendicitis, in middle age & elderly. </li></ul>
  5. 5. Pathology <ul><li>Obstruction of the lumen is essential for development of appendiceal gangrene & perforation. </li></ul><ul><li>In early appendicitis, the lumen is patent despite mucosal inflammation & lymphoid hyperplesia. </li></ul><ul><li>In children & young adults, an infective agent possibly viral initiates the inflammatory process, which within the narrow lumen of the appendix leads to luminal obstruction. </li></ul><ul><li>Once obstruction occurs, continued mucus secretion & inflammatory exudation increase intraluminal pressure, obstructing lymphatic drainage. </li></ul><ul><li>Edema & mucosal ulceration develop with bacterial translocation to the submucosa. </li></ul><ul><li>Resolution could occur at this point, whether spontaneous or in response to antibiotic therapy. </li></ul><ul><li>Progression of the condition leads to further distension of the app. Causing venous obstruction & ischemia of the app. Wall. </li></ul><ul><li>With ischemia, bacterial invasion occurs through the muscularis propria & submucosa. </li></ul>
  6. 6. <ul><li>Finally, ischemic necrosis of the appendix wall produces gagrenous appendicitis , with free bacterial contamination of the peritoneal cavity. </li></ul><ul><li>Alternatively, the greater omentum & loops of small intestine become adherent to the inflamed app., walling off the spread of peritoneal contamination resulting in appendicular mass or paracecal abscess. </li></ul><ul><li>Rarely, appendiceal inflammation resolves leaving a distended mucus filled organ termed mucocele of the appendix. </li></ul><ul><li>The great threat of acute appendicitis is the potential for peritonitis , factors which promote this process: 1) extremes of age, 2) immunosupression, 3) D.M., 4) fecolith obstruction of the appendix lumen, 5) a free lying pelvic appendix, & 6) previous abdominal surgery which limits the ability of the greater omentum to wall off the spread of peritoneal contamination. </li></ul><ul><li>In these situations a rapidly deteriorating clinical course is accompanied by signs of diffuse peritonitis & systemic sepsis syndrome. </li></ul>
  7. 7. Clinical diagnosis - History <ul><li>Periumbilical colic </li></ul><ul><li>Pain shifts to right iliac fossa </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea </li></ul>Clinical features of appendicitis
  8. 8. <ul><li>The classical features of acute appendicitis begin with poorly localized colicky abdominal pain, due to midgut visceral discomfort in response to appendiceal inflammation. </li></ul><ul><li>Pain is frequently first noticed in the periumbilical region, associated with anorexia, nausea, once or 2 episodes of vomiting. Anorexia is constant feature especially in children. </li></ul><ul><li>With progressive inflammation, the parietal peritoneum in the rt. iliac fossa becomes irritated, producing intense more localized, constant somatic pain . Typically, cough or sudden movement exacerbates the rt. iliac fossa pain. </li></ul><ul><li>This typical sequence is present in 50% of cases. Atypical presentation is common: elderly (no localization), pelvic app. (no somatic pain, suprapubic discomfort & tenesmus). </li></ul><ul><li>No fever during the first 6 hours, then slight pyrexia (37.2-37.7), pulse rate (80-90). </li></ul><ul><li>Typically, 2 clinical syndromes of acute appendicitis: acute catarrhal (nonobstructive) & acute obstructive appendicitis . The latter is characterized by a much more acute course, the onset of symptoms is abrupt, with more tendency for perforation. </li></ul>
  9. 9. Clinical diagnosis - Signs <ul><li>Pyrexia </li></ul><ul><li>Localized tenderness in the rt. iliac fossa </li></ul><ul><li>Muscle guarding </li></ul><ul><li>Rebound tenderness </li></ul>Clinical signs of appendicitis <ul><li>Pointing sign </li></ul><ul><li>Rovsing’s sign </li></ul><ul><li>Psoas sign </li></ul><ul><li>Obturator sign </li></ul>Signs to elicit in appendicitis
  10. 10. <ul><li>The diagnosis of acute appendicitis depends on clinical examination rather than history or investigations. </li></ul><ul><li>The main features : unwell patient, low grade fever. </li></ul><ul><li>Patient is asked to point where the pain began & to where it moved, (pointing sign). </li></ul><ul><li>Superficial palpation starting from the left iliac fossa, anticlockwise to the right iliac fossa, will detect muscle guarding over the point of maximum tenderness, classically McBurney’s point . </li></ul><ul><li>Asking the patient to cough or gentle percussion rebound tenderness. </li></ul><ul><li>Deep palpation over the left iliac fossa pain in the right iliac fossa (Rovsing’s sign). </li></ul><ul><li>If the appendix lies over the psoas muscle the patient will lie with the right hip flexed for pain relief (Psoas sign). </li></ul><ul><li>If the appendix is in contact with the obturator internus muscle, flexion & internal rotation of the hip pain in the hypogastrium (Obturator sign). </li></ul>
  11. 11. Special features – according to position of the appendix <ul><li>Retrocecal: </li></ul><ul><li>Rigidity is often absent, even on deep pressure (silent appendix), as the cecum (distended with gas prevents the pressure exerted by the hand to reach the appendix. </li></ul><ul><li>+ve deep tenderness in the loin, with +ve psoas sign & pain on hyperextension of the hip joint. </li></ul><ul><li>Pelvic: </li></ul><ul><li>Early diarrhea (rectal irritation), -ve abdominal rigidity, P/R: shows tenderness in the rectovesical or Douglas pouch. +ve psoas & obturator signs. If appendix is in contact with urinary bladder frequency of micturition. </li></ul>
  12. 12. Special features – according to age <ul><li>Infants: </li></ul><ul><li>Rare before 3 years, patient is unable to give history, diagnosis is often delayed, high incidence of perforation & morbidity. </li></ul><ul><li>Rapid diffuse peritonitis as the greater omentum is not developed no localization of infection. </li></ul><ul><li>The elderly: </li></ul><ul><li>Gangrene & perforation occur more frequently, the clinical picture may simulate subacute intestinal obstruction. </li></ul><ul><li>Coincident medical conditions produce higher mortality. </li></ul><ul><li>The obese: </li></ul><ul><li>Obesity may obscure local signs of acute appendicitis, causing delay in diagnosis, technical operative difficulty may necessitate midline incision. </li></ul>
  13. 13. Appendicitis with pregnancy <ul><li>Appendicitis is the most common extrauterine acute abdominal condition in pregnancy. </li></ul><ul><li>Early non-specific symptoms are often attributed to the pregnancy leading to delayed diagnosis. </li></ul><ul><li>The cecum & appendix are pushed to the right upper abdominal quadrant atypical site of pain & tenderness. </li></ul><ul><li>The inflamed appendix may induce uterine irritation & contractions abortion. </li></ul><ul><li>Fetal loss occurs in 3-5% of cases, increasing to 20% if perforation is found at operation. </li></ul>
  14. 14. Differential diagnosis <ul><li>Divericulitis </li></ul><ul><li>Intestinal obstruction </li></ul><ul><li>Colonic carcinoma </li></ul><ul><li>Mesenteric infarction </li></ul><ul><li>Aortic aneurysm </li></ul><ul><li>Mittelschmerz </li></ul><ul><li>Salpingitis </li></ul><ul><li>Pylonephritis </li></ul><ul><li>Ectopic pregnancy </li></ul><ul><li>Torsion/ruptured ovarian cyst </li></ul><ul><li>Endometriosis </li></ul><ul><li>Regional enteritis </li></ul><ul><li>Ureteric colic </li></ul><ul><li>Perforated ulcer </li></ul><ul><li>Torsion testis </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Rectus sheath hematoma </li></ul><ul><li>Gastroenteritis </li></ul><ul><li>Mesenteric adenitis </li></ul><ul><li>Meckel’s diverticulitis </li></ul><ul><li>Intussusception </li></ul><ul><li>Henoch-Schonlein purpura </li></ul><ul><li>Lobar pneumonia </li></ul>Elderly Female Adult Children
  15. 15. Children <ul><li>Acute gastroenteritis : </li></ul><ul><li>Intestinal colic, diarrhea, vomiting, but no localized tenderness, history of affection of other family member. </li></ul><ul><li>Postileal appendicitis mimic this condition, thus hospital admission & careful observation are necessary. If serious doubt, laparoscopy or surgical intervention may be indicated. </li></ul><ul><li>Mesenteric lymphadenitis: </li></ul><ul><li>The pain is colicky in nature, patient is completely free in between attacks, which lasts for few minutes, cervical lymph nodes may be enlarged. </li></ul><ul><li>Shifting tenderness if the child turns to the left side is convincing evidence. </li></ul><ul><li>It represents a common diagnostic difficulty in children, if doubt exploration is advised. </li></ul>
  16. 16. <ul><li>Meckel’s diverticulitis: </li></ul><ul><li>It may be impossible to distinguish from acute appendicitis, pain may be central or left sided, previous attacks of abdominal pain or anemia. </li></ul><ul><li>Intussusception: </li></ul><ul><li>It is important to differentiate between both conditions. </li></ul><ul><li>Appendicitis is uncommon between <2 years, the median age for intussusception is 18 months. </li></ul><ul><li>A mass may be palpable in the right lower quadrant. </li></ul><ul><li>The preferred treatment for intussusception is reduction by a careful barium enema. </li></ul><ul><li>Henoch-Schonlein purpura: </li></ul><ul><li>Often preceded by sore throat or respiratory infection. Nearly always ecchymotic rash in the extensor surface of the limbs & buttocks, the face is usually spared. </li></ul><ul><li>Lobar pneumonia & pleurisy: </li></ul><ul><li>Especially at the right lung base, abdominal tenderness is minimal, pyrexia marked, chest examination reveals pleural friction rub or altered breath sounds. Chest x-ray is diagnostic. </li></ul>
  17. 17. Adults <ul><li>Terminal ileitis: </li></ul><ul><li>May be nonspecific, due to Crohn’s disease or Yersinia infection. </li></ul><ul><li>In its acute form, may be indistinguishable from acute appendicitis unless a doughy mass of inflamed ileum can be felt. </li></ul><ul><li>Previous history of abdominal cramping, weight loss & diarrhea suggests regional ileitis rather than appedicitis. </li></ul><ul><li>Ureteric colic: </li></ul><ul><li>Does not commonly cause diagnostic problem, the character & radiation of pain is different. </li></ul><ul><li>Differentiate by urine analysis, plain abdominal x-ray film. </li></ul><ul><li>Renal U/S or I.V.P. is diagnostic. </li></ul><ul><li>Right-sided acute pyelonephritis: </li></ul><ul><li>Accompanied & often preceded by increased frequency of micturition. </li></ul><ul><li>The leading features: tenderness confined to the loin, fever (39), rigors & pyuria. </li></ul>
  18. 18. <ul><li>Perforated peptic ulcer: </li></ul><ul><li>Duodenal contents pass along the paracolic gutter to the right iliac fossa. </li></ul><ul><li>History of dyspepsia & very sudden onset of pain, which starts in the epigastrium & passes down the right paracolic gutter. </li></ul><ul><li>Rigidity & tenderness in the right iliac fossa as appendicitis, but is usually greater in the right hypochondrium. </li></ul><ul><li>Plain x-ray erect shows air under diaphragm. </li></ul><ul><li>Testicular torsion: </li></ul><ul><li>In teenager or young adult, easily missed, pain can be referred to the right iliac fossa. </li></ul><ul><li>Patient may be shy to reveal, missed if the testis were not examined. </li></ul><ul><li>Acute pancreatitis: </li></ul><ul><li>Should be suspected in any adult with acute abdomen. </li></ul><ul><li>Serum & urinary amylase are diagnostic. </li></ul><ul><li>Rectus sheath hematoma: </li></ul><ul><li>Rare, acute pain & tenderness in right iliac fossa, no gastrointestinal upset. </li></ul><ul><li>Usually after vigorous exercise, or trauma to a patient on anticoag. </li></ul>
  19. 19. Adult females <ul><li>Pelvic disease in women of child-bearing period most often simulates acute appendicitis. </li></ul><ul><li>A careful gynecological history should be taken in all women with suspected acute appendicitis concentrating on menstrual cycle, vaginal discharge & possible pregnancy. </li></ul><ul><li>Salpingitis: </li></ul><ul><li>Condition that poses greatest difficulty in young women. </li></ul><ul><li>Typically the pain is lower than in appendicitis & is bilateral. </li></ul><ul><li>History of vaginal discharge & dysmenorrhea are helpful points. </li></ul><ul><li>Opinion of gynecologist may be helpful. </li></ul><ul><li>If uncertain, diagnostic laparoscopy should be undertaken. </li></ul><ul><li>Mittelschmerz: </li></ul><ul><li>Midcycle rupture of a follicular cyst with bleeding produces lower abdominal & pelvic pain, typically midcycle. </li></ul><ul><li>Systemic upset is rare, pregnancy test is –ve, symptoms usually subsides within hours. </li></ul><ul><li>Occasionally, diagnostic laparoscopy is required. </li></ul>
  20. 20. <ul><li>Torsion/hemorrhage of an ovarian cyst </li></ul><ul><li>Can be difficult diagnostic problem. </li></ul><ul><li>When suspected, pelvic U/S & gynecological opinion should be sought. </li></ul><ul><li>If encountered at operation, ovarian cystectomy should be performed, with visualization of the contralateral ovary. </li></ul><ul><li>Ectopic pregnancy: </li></ul><ul><li>A ruptured ectopic pregnancy can be easily differentiated from acute appendicitis, well defined signs of hemoperitoneum. </li></ul><ul><li>But right sided tubal abortion or right sided unruptured tubal pregnancy are difficult to differentiate. </li></ul><ul><li>Signs are similar to acute appendicitis except for: </li></ul><ul><li>1) History of missed period. </li></ul><ul><li>2) Pain starts in the right iliac fossa & stays there. </li></ul><ul><li>3) Pain is severe & continues until operation. </li></ul><ul><li>4) Severe pain is felt if the cervix is moved on vaginal examination. </li></ul><ul><li>5) Pregnancy test is +ve. </li></ul><ul><li>6) Signs of intraperitoneal bleeding with pain referred to the shoulder. Pelvic U/S should be carried out if suspected. </li></ul>
  21. 21. Elderly <ul><li>Sigmoid diverticulitis: </li></ul><ul><li>If long sigmoid loop, colon lies to the right of midline, may be impossible to differentiate between diverticulitis & appendicitis. </li></ul><ul><li>May be history of chronic constipation, colonic troubles. </li></ul><ul><li>If suspected, investigations & conservative treatment with fluids & antibiotics should be started. </li></ul><ul><li>Intestinal obstruction: </li></ul><ul><li>Signs of I.O. are clear. </li></ul><ul><li>Cons. treatment with I.V. fluids, antibiotics & nasogastric decompression is started. </li></ul><ul><li>Carcinoma of the cecum: </li></ul><ul><li>When obstructed or perforated, may mimic or cause obstructive appendicitis. </li></ul><ul><li>History of discomfort, altered bowel habit or unexplained anemia should raise suspicion. </li></ul><ul><li>A mass may be palpable, barium enema & colonoscopy are diagnostic. </li></ul>
  22. 22. Investigation <ul><li>The diagnosis of acute appendicitis is essentially clinical. </li></ul><ul><li>Routine: </li></ul><ul><li>-Full blood count. </li></ul><ul><li>-Urine analysis. </li></ul><ul><li>Selected cases: </li></ul><ul><li>-Pregnancy test (females in child bearing period). </li></ul><ul><li>-Urea & electrolytes (dehydrated & elderly patients) </li></ul><ul><li>-Plain abdominal x-ray (int. obstruction or renal colic). </li></ul><ul><li>-Pelvi/abdominal U/S. </li></ul>
  23. 23. Treatment <ul><li>The treatment of acute appendicitis is appendectomy. </li></ul><ul><li>Urgent operation is essential to prevent the increased morbidity & mortality of peritonitis. </li></ul><ul><li>There should be no unnecessary delay except for correction of unstable general condition (adequate U.O.P., pyrexia & preoperative preparation of elderly patient). </li></ul><ul><li>Single preoperative dose of antibiotics is usually sufficient to prevent wound infection. </li></ul><ul><li>If peritonitis is suspected, therapeutic I.V. antibiotics for Gram-negative & anerobic bacteria should be given. </li></ul>
  24. 24. Appendectomty <ul><li>Either conventional open operation or laparoscopic technique. </li></ul><ul><li>General anesthesia. </li></ul><ul><li>Laparoscopic: nasogastric tube & empty bladder. </li></ul><ul><li>Palpation for mass in R.I.F. </li></ul>
  25. 25. Conventional appendectomy <ul><li>Incision: grid-iron, Rutherford Morison, Lanz. </li></ul><ul><li>Technique of appendectomy. </li></ul><ul><li>Special circumstances: </li></ul><ul><li>- Edema of the cecal wall. </li></ul><ul><li>-Base of the app. severely inflamed. </li></ul><ul><li>-Gangrenous app. base. </li></ul><ul><li>-Retrograde appendectomy. </li></ul><ul><li>-Drainage of the peritoneal cavity ?? </li></ul>
  26. 26. Laparoscopic Appendectomy <ul><li>The valuable aspect of laparoscopy in the management of suspected appendicitis is as a diagnostic tool, especially in women of child-bearing age. </li></ul>
  27. 27. Problems encountered during appendectomy <ul><li>A normal appendix is found: </li></ul><ul><li>This demands careful exclusion of other possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis & tubal or ovarian causes in women. </li></ul><ul><li>It is usual to remove the appendix to avoid future diagnostic problems, even though the appendix is macroscopically normal. </li></ul><ul><li>Approximately a quarter of seemingly normal appendices show microscopic evidence of inflammation. </li></ul><ul><li>The appendix cannot be found: </li></ul><ul><li>The cecum should be mobilized & the tenia coli traced to their confluence before the diagnosis of absent appendix is made. </li></ul><ul><li>An appendicular tumor is found: </li></ul><ul><li>Tumors <2.0 cm. in diameter can be removed by appendectomy. </li></ul><ul><li>Larger tumors should be treated by right hemicolectomy. </li></ul>
  28. 28. <ul><li>An appendix abscess is found: & appendix cannot be removed easily. </li></ul><ul><li>Should be treated by local peritoneal toilet & drainage of any abscess, with I.V. antibiotics. </li></ul><ul><li>Appendicitis complicating Crohn’s disease: </li></ul><ul><li>Patient operated for appendicitis found to have concomitant Crohn’s disease of the ileocecal region. </li></ul><ul><li>Provided the cecal wall is healthy at the base of the appendix, appendectomy can be performed without increasing the risk of enterocutaneous fistula. </li></ul><ul><li>Rarely the appendix is involved with the Crohn’s disease, a conservative approach may be undertaken, with a trial of I.V. steroids & systemic antibiotics to resolve the acute inflammatory process. </li></ul><ul><li>Appendix abscess: </li></ul><ul><li>Failure of resolution of an appendix mass or continuing spiking fever indicates pus in the appendix mass. </li></ul><ul><li>U/S or abdominal CT scan identify the possibility of percutaneous drainage, if unsuccessful, laparotomy through a midline incision. </li></ul>
  29. 29. Management of an appendix mass <ul><li>If the condition of the patient is satisfactory, the standard treatment is the conservative Ochsner-Sherren regimen. </li></ul><ul><li>The inflammatory process is already localized & surgery is difficult & may be dangerous. </li></ul><ul><li>It may be impossible to find the appendix & a fecal fistula may form. </li></ul><ul><li>So, non-operative program is advised, to be prepared to operate if clinical deterioration occurs: </li></ul><ul><li>1) A rising pulse rate. </li></ul><ul><li>2) Increasing or spreading abdominal pain. </li></ul><ul><li>3) Increasing size of the mass. </li></ul><ul><li>4) Vomiting or increase gastric aspirate. </li></ul><ul><li>Careful record of the vital signs, regular abdominal examination, extent of the mass, it is helpful to mark the limits of the mass on the skin. A nasogastric tube with I.V. fluids & antibiotics therapy. </li></ul><ul><li>Clinical improvement is usually evident within 24-48 hrs. in 90% of cases. </li></ul><ul><li>Appendix should be removed after an interval of 6-8 weeks. </li></ul>
  30. 30. Postoperative complications <ul><li>Relatively uncommon & reflect the degree of peritonitis that was present at the time of operation. </li></ul><ul><li>Wound infection: </li></ul><ul><li>Most common, occurs in 5-10% of all cases. </li></ul><ul><li>Presents with pain & erythema of the wound on the fourth or fifth postop. day. </li></ul><ul><li>Treatment: by wound drainage & antibiotics, the organisms responsible are usually gm –ve & anerobic bacteria. </li></ul><ul><li>Intra-abdominal abscess: </li></ul><ul><li>Rare after the use of perioperative antibiotics. </li></ul><ul><li>Postoperative spiking fever, malaise & anorexia 5-7 days postoperatively. </li></ul><ul><li>Abdominal U/S & CT scan facilitate the diagnosis & allow percutaneous drainage. </li></ul><ul><li>Ileus: </li></ul><ul><li>A period of adynamic ileus is expected after appendectomy, may last for a number of days after gangrenous appendix. </li></ul><ul><li>Ileus persisting for >4-5 days in the presence of fever indicates intra-abdominal sepsis. </li></ul>
  31. 31. <ul><li>Portal pyaemia: </li></ul><ul><li>Rare but very serious complication of gangrenous appendicitis. </li></ul><ul><li>High fever, rigors & jaundice. </li></ul><ul><li>Due to septicemia in the portal venous system, may lead to development of intrahepatic abscesses (often multiple). </li></ul><ul><li>Treatment: systemic antibiotics & drainage of hepatic abscesses if indicated. </li></ul><ul><li>Fecal fistula: </li></ul><ul><li>Leakage from the appendicular stump is rare. </li></ul><ul><li>Occurs if the cecal wall is involved by edema or inflammation, or after appendectomy in Crohn’s disease. </li></ul><ul><li>Pulmonary complications & D.V.T: </li></ul><ul><li>Both are after appendectomy. </li></ul><ul><li>Adhesive intestinal obstruction: </li></ul><ul><li>Most common late complication after appendectomy. </li></ul><ul><li>Often a single band is responsible. </li></ul><ul><li>May cause chronic pain in the right iliac fossa. </li></ul><ul><li>Laparoscopy is of value in confirming the case & allowing adhesiolysis. </li></ul>
  32. 32. Recurrent acute appendicitis ?? <ul><li>Appendicitis can be recurrent. </li></ul><ul><li>Patients attribute such attacks to dyspepsia. </li></ul><ul><li>The attacks vary in intensity, may occur every few months, may ultimately end in severe acute attack. </li></ul><ul><li>The appendix shows fibrosis indicative of previous inflammation. </li></ul><ul><li>Patients with acute appendicitis may remember having milder but similar attacks of pain. </li></ul><ul><li>Chronic appendicitis, per se, does not exist. Patients diagnosed as thus are usually examples of the recurrent form of the disease. </li></ul>
  33. 33. Les common pathological conditions <ul><li>Mucocele of the appendix. </li></ul><ul><li>Diverticulae of the appendix. </li></ul><ul><li>Intussusception of the appendix. </li></ul><ul><li>Carcinoid tumor & Primary adenocarcinoma. </li></ul>