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Acute Appendicitibbbbbbbbbbbbbbbbs I.pdf
1. ACUTE APPENDICITIS
Dr. Samer Al-Hakkak
PhD General surgery
Head Department of Surgery, Jabir Medical Faculty
FRCS(Ireland);FACS(USA),MRCS(Ire),MRCPS(Glasg),MRCS(Eng),MRCS(Ed) 2020
2. THE VERMIFORM APPENDIX
*inflammation, which results in the clinical syndrome known as ‘acute appendicitis’.
*acute appendicitis is the most common cause of an ‘acute abdomen’ in young adults
*the most frequently performed urgent abdominal operation and
*is often the first major procedure performed by a surgeon in training.
The diagnosis of appendicitis remains essentially clinical
3. function:-
the appendix is the little one-ended tube that is attached to
the cecum of through the large intestine
-Sometimes its called the vermiform appendix, where vermiform means
“worm shaped”
-little worm like structure function is actually unknown
Thought some theories suggest it might be
Safe house
lymphatic and immune system
Vestigial
4. ANATOMY
Blind
Base
taeniae coli
appendicular artery -----’end-artery’
7.5 and 10 cm
mucous membrane lined by columnar cell intestinal
mucosa of colonic type Crypts are present, but are
not numerous. In the base of the crypts lie
argentaffin cells (Kulchitsky cells), which may give
rise to carcinoid tumours.
7. ACUTE APPENDICITIS
*Relatively rare in infants, reaching a peak incidence in the
teens and early 20s.
*In teenagers and young adults, the male–female ratio
increases to 3:2
*As much as 10% of population develops
It’s the most common surgical emergency of the abdomen
8. AETIOLOGY
No unifying hypothesis
Decreased dietary fiber and increased consumption of refined carbohydrates
may be important
Improved hygiene and a change in the pattern of childhood gastrointestinal
infection related to the increased use of antibiotics may be responsible
A mixed growth of aerobic and anaerobic organisms is usual cause
acute catarrhal (non-obstructive) appendicitis and acute obstructive
appendicitis
9. Pathophysiology:
*The intestinal lumen, including the appendix, is always secretory mucosa to keep
pathogens from entering the blood stream and also to
.
keep tissue moist
Even when its plugged the appendix keep secretory as usual
When this happens fluid and mucus build-up which increases the pressure in the
appendix and just like when you fill up a water balloon
It get bigger physically push on the afferent nerve fibers nerve fibers nearby
causing abdominal pain
10. Symptoms of appendicitis
*Peri-umbilical colic
*Pain shift to the right iliac fossa
*Anorexia
*Nausea
Clinical signs in appendicitis
* Pyrexia
*Localised tenderness in the right iliac fossa
*Muscle guarding
*Rebound tenderness
12. ALVARADO SCORING
symptoms score
Migratory RIF pain 1
Anorexia 1
Nausea & vomiting 1
signs Tenderness RIF 2
Rebound tenderness 1
Elevated temp 1
laboratory leukocytosis 2
Shift to left 1
total 10
Sign to elicit in appendicitis More than 7
*Pointing sign 5-7 suspected
*Rovsing s sign less than 5 unlikely
*Psoas sign
*Obturator sign
13. SPECIAL FEATURES, ACCORDING TO POSITION OF THE
APPENDIX
Retrocaecal
Rigidity is often absent
silent appendix
Psoas spasm
flexion of the hip
14. PELVIC
ü Early diarrhea
ü Complete absence of abdominal rigidity
ü Rectal examination reveals tenderness
ü Spasm of the psoas and obturator internus
muscles
ü Contact with the bladder may cause frequency
of micturition
15. POSTILEAL
ü Inflamed appendix lies behind the
terminal ileum
ü Greatest difficulty in diagnosis
ü Pain may not shift
ü Diarrhoea is a feature and marked
retching may occur
ü Tenderness, if any, is ill defined
ü Right of the umbilicus
18. RARE DIFFERENTIAL DIAGNOSES
Preherpetic pain of the right 10th and 11th dorsal nerves is localised over the
same area as that of appendicitis.
Tabetic crises are now rare. Severe abdominal pain and vomiting usher in the
crisis. Other signs of tabes confirm the diagnosis.
Spinal conditions are sometimes associated with acute abdominal pain
especially in children and the elderly. These may include tuberculosis of the
spine, metastatic carcinoma,
osteoporotic vertebral collapse and multiple myeloma.
19. The abdominal crises of porphyria and diabetes mellitus need to be
remembered.
Typhlitis or leukaemic ileocaecal syndrome is a rare but potentially fatal
enterocolitis occurring in immunosuppressed patients. Gram-negative or
clostridial septicaemia (especially Clostridium septicum) can be rapidly
progressive.
21. The diagnosis of acute appendicitis is essentially clinical; however, a decision to
operate based on clinical suspicion alone can lead to the removal of a normal
appendix in 15–30 per cent of cases.
The premise that it is better to remove a normal appendix
than to delay diagnosis does not stand up to close
scrutiny, particularly in the elderly.
22. A number of clinical and
laboratory-based scoring systems have been devised to assist
diagnosis. the most widely used is the alvarado score
A score of 7 or more is strongly predictive of acute
appendicitis.
23.
24. IN PATIENTS WITH AN EQUIVOCAL SCORE (5–6),
„Abdominal ultrasound or contrast-enhanced CT examination further
reduces
the rate of negative appendicectomy.
Abdominal ultrasound
examination is more useful in children and thin adults, particularly if
gynaecological pathology is suspected, with a
diagnostic accuracy in excess of 90 per cent
25. Contrast-enhanced ct scan is most useful in patients in whom there is
diagnostic uncertainty, particularly
older patients, in whom acute diverticulitis, intestinal obstruction
and neoplasm are likely differential diagnoses.
„Selective
use of CT scanning may be cost-effective by reducing both the
negative appendicectomy rate and the length of hospital stay
26.
27.
28. A trial of conservative management in those thought not to have obstructive
appendicitis.
treatment is bowel rest and intravenous antibiotics,
usually metronidazole and third-generation cephalosporin. the
available data indicate successful outcomes in 80–90 per cent of
patients, however there is an approximately 15 % recurrence
rate within one year.
29. ü This approach should be considered in patients with high operative risk
(multiple comorbidities).
ü As with conservative treatment of an appendix mass, patients
ü over the age of 40 should be followed up to ensure there is no underlying
malignancy
30. Surgical
The treatment for acute appendicitis is appendicectomy.there is
perception that urgent operation to prevent the increase morbidity
and mortality of peritonitis.
Short period of preparation with intravenous fluid and antibiotic
and antipyretic ,
Operation should not differed longer that it takes to optimize patent
condition.
31. ü while there
should be no unnecessary delay, all patients, particularly those most at risk
of serious morbidity, benefit by a short period of intensive preoperative
preparation.
*intravenous fluids, sufficient
to establish adequate urine output (catheterisation is needed
*only in the very ill), and appropriate antibiotics should be given.
32. with appropriate
use of intravenous fluids and parenteral antibiotics, a policy of deferring
appendicectomy after midnight to the first case on the following morning does
not increase morbidity.
however, when
acute obstructive appendicitis is recognised, operation should not be
deferred longer than it takes to optimize the patient’s condition.
33. APPENDICECTOMY
should be performed under general anaesthetic with the patient supine on the
operating table. when a laparoscopic technique is to be used, the bladder must
be empty (ensure that the patient has voided before leaving the ward).
Open method
Antibiotic
Antiseptic solution
Palpated
Gridiron incision
Rutherford Morison
Lanz lower midline
paramedian
36. PROBLEMS ENCOUNTERED DURING APPENDICECTOMY
ü A normal appendix is found
ü The appendix cannot be found
ü An appendicular tumour is found
ü An appendix abscess is found and the appendix cannot be removed easily
40. Perforation
FATE OF ACUTE APPENDICITIS
Un treated acute appendicitis What Happen??
Resolve
Mass
Abscess
41.
42. APPENDICULAR MASS
MANAGEMENT OF AN APPENDIX
MASS
?? SURGERY
the standard treatment is the conservative
Ochsner–Sherren regimen.
43. Appendicular Abscess
Failure of resolution of an appendix mass or continued spiking pyrexia usually
indicates that there is pus within the phlegmonous appendix mass. Ultrasound
or abdominal CT scan may identify an area suitable for the insertion of a
percutaneous drain. Rarely, this is unsuccessful and laparotomy through a
midline incision is indicated.
45. RECURRENT ACUTE APPENDICITIS
Appendicitis is notoriously recurrent. It is not uncommon for patients to
attribute such attacks to ‘biliousness’ or dyspepsia. The attacks vary in
intensity and may occur every few months, and the majority of cases
ultimately culminate in severe acute appendicitis. The appendix in
these cases shows fibrosis indicative of previous inflammation
46. „ Neoplasms of the appendix
Carcinoid tumours (argentaffinoma)
Argentaffin tissue (Kulchitsky cells of the crypts of Lieberkühn) and are most
common in the vermiform appendix
Occur 300–400 , rarely gives rise to metastases, Appendicectomy, hemicolectomy, ten times
more common
„ Goblet cell carcinoid tumour
Unusual combine, endocrine and glandular differentiation
„ Mucinous cystadenoma
A mucin-secreting adenoma of the appendix may rupture into the peritoneal cavity seeding it with mucus
secreting cells. Presentation is often delayed until the patient has gross abdominal distension as a result of
pseudomyxoma peritoneii, which may mimic ascites .
