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Acute appendicitis
Acute appendicitis is inflammation of the appendix that is commonly caused by obstruction. It occurs in about 10% of the population between ages 10-20 but can occur at any age. The obstruction leads to bacterial proliferation, invasion of the appendix wall, and damage from pressure necrosis. Initial pain is periumbilical but shifts to the right lower quadrant as the inflamed appendix touches the peritoneum. Signs include maximum tenderness, guarding, and rebound tenderness in the right iliac fossa. The Alvarado score is used to evaluate the likelihood of appendicitis. Treatment is antibiotic therapy and an appendectomy.
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Acute appendicitis
- 1. Acute Appendicitis JMJ 1 K.Kavindya M. Fernando
- 2. What is acuteappendicitis? • Acute inflammation of the appendix JMJ 2
- 3. How does thisinflammation occurs? • Occurs due an obstruction • Obstruction can occur by a • Faecolith • Foregin body • Finbrous stricture from previous inflammation • Enlarged lymphoid follicles JMJ 3
- 4. How common itis? • About 10% of the population will develop acute appendicitis (Benjamin IS, Patel AG; Managing acute appendicitis. BMJ. 2002 Sep 7;325(7363):505-6) • Most common between the ages of 10 and 20 years but can occur at any age • Appendicitis is more common in men (Humes DJ, Simpson J; Acute appendicitis. BMJ. 2006 Sep 9;333(7567):530-4.) JMJ 4
- 5. Why does acuteappendicitis is not common among extremes of age? • In infants lumen of the appendix is • Wide mouthed & well drained • In old age – lumen of appendix is • Almost obliterated JMJ 5
- 6. What happens afterthe obstruction? JMJ 6 Appendix acts as a closed loop Bacteria proliferates in the lumen Invade the appendix wall Appendix is damaged by pressure necrosis
- 7. What happens afterthe obstruction? JMJ 7 Vascular supply by end arteries They get thrombosed Gangrene formation Perforation of appendix Branches of the appendicular branch of ileocolic artery
- 8. JMJ 8 Can acuteappendicitis occur without getting it obstructed? • Yes • Direct infection of the lymphoid follicles from the appendix lumen • Hematogeneous infection • More likely to resolve than obstructed cases Ellis, H., Clane, S. R. & Watson, C., 2011. Acute Appendicitis. In: General Sugery Lecture Notes. pp. 199- 203.
- 9. Pathological course of appendicitis JMJ9 Acute appendicitis Perforation Localized Generalized Localized
- 10. History and Examination Signs andsymptoms JMJ 10
- 11. PAIN • Pain commencesas a central periumbilical colic, • Shifts after about 6 hours to the RIF • According to the anatomical variations of the position other symptoms may differ JMJ 11
- 12. Anatomical variations of appendix JMJ12 Retrocecal Pre-ileal Post-ileal Pelvic Paraceacal
- 13. Why does patientfeel pain in periumbilical region? • Referred pain • Normal visceral innervation of the appendix • comes from the 10th thoracic spinal segment • Corresponding dermatome • Encircles the abdomen • At the level of abdomen JMJ 13
- 14. Why does thepain shifted to the right iliac fossa • Initial periumbilical pain – referred pain • When the inflamed appendix touches the peritoneum, • Patient feels pain in right iliac fossa (over the point where the inflamed appendix touches the peritoneum) JMJ 14
- 15. Other symptoms • Anorexia •Nausea / Vomiting • Fever (low grade – unless perforated) • Diarrhoea can occur when ileum is irritated by the inflamed appendix JMJ 15
- 16. JMJ 16 Typical historyis almost diagnostic of acute appendicitis
- 17. What are thesigns which suggest Acute appendicitis/ • Maximum tenderness • Guarding • Rigidity in the iliac fossa • Rebound tenderness – cough can mimic it • Tenderness and guarding would be generalized if appendix has perforated JMJ 17
- 18. What is guarding? •When you try to touch the abdomen, • Surrounding abdominal muscles, will go into a spasm • This spasm may cause pain JMJ 18
- 19. What is rigidity? •Due to the inflammation of the whole abdomen, • The abdominal walls have already went into a spasm • When you touch the abdomen, feeling of • Board like rigidity JMJ 19
- 20. Rovsing’s sign • palpationof the left lower quadrant increases the pain felt in the right lower quadrant. • This pressure stretches the entire peritoneal lining, and so causes pain in any location where the peritoneum is irritating the muscle JMJ 20
- 21. Psoas test • extendthe hip and abduct the thigh with the patient on the left side JMJ 21 Obturator test • flex and internally rotate the right hip
- 22. How to detectpelvic and retroceacle appendix? • Rectal examination may reveal localised tenderness as the only sign of an inflamed retrocaecal or pelvic appendix JMJ 22
- 23. What is AlvaradoScore? JMJ 23 SYMPTOMS Points allocated • Migratory RIF pain 1 • Anorexia 1 • Nausea & Vomitting 1 SIGNS • Tenderness in RIF 2 • Rebound tenderness 1 • Elevated temperature (99.1 0F) 1 LABORATORY • Leukocytosis (WBC> 10,000) 2 • Shift to left (neutrophil preponderance) 1 TOTAL 10
- 24. Interpretation JMJ 24 • Score<4 – strongly against a diagnosis of appendicitis • Score 5-6 – possible acute appendicitis • Score >7 - probable acute appendicitis
- 25. Differential diagnosis 1/2 •Intra abdominal causes • Meckle’s diverticulitis • Acute intestinal obstruction – colicky pain, vomiting, noisy bowel sounds, X-ray abdomen • Gastroenteritis – diarhhoea, abdominal pain • Acute colonic diverticulitis – solitary ceacal diverticulum , sigmoid colon (mobile bowel) • Crohn’s disease JMJ 25
- 26. Differential diagnosis 2/2 •Gyanacological problems in females • Ectopic pregnancy • Ruptured or torted ovarian cyst – sudden severe RIF pain radiating to loin • Urogenital problems • Ureteric colic – pain radiates from loin to groin • Testicular torsion – periumbilical pain & vomiting JMJ 26
- 27. Investigations • Leucocyte count– • A mild polymorph leukocytosis • Normal level does not exclude the diagnosis • UFR – • To exclude UTI • Urine for hCG • In females to exclude the ectopic pregnancy • USS abdomen • where the diagnosis is doubtful and in the assessment of an appendix mass or abscess JMJ 27
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- 29. Management • Resuscitate thepatient • Intravenous fluid • Antibiotics • Opiate analgesia • appendicectomy – treatment of choice JMJ 29
- 30. Management • Antibiotic prophylaxis– preoperatively • Operation peritonitis – continue antibiotic therapy • Mrtranidazole • Gentamycin or cephalosporins JMJ 30
- 31. Appendicectomy Acute appendicitis Appendicectomy Acuteappendicitis + generalized peritonitis Surgery (intraperitoneal lavage with N/S +AB) Appendicectomy + drain Appendicular mass – inflammatory mass Planned appendicectomy Appendicectomy with next episode Interval appendicectomy Appendicular abscess Exploration + evacuation of pus +/- appendicectomy JMJ 31
- 32. Disadvantages of operating firsthand • Dissemination of infected material • Inflammation vasodialatation hemmorrage • Feacal fistula • Post-op complications • Wound infection • Residual abscess JMJ 32
- 33. Advices on discharge •Clean and dressing after 5day • Suture removal – 10 days • R/V at clinic with histology report • Come back if develop pain or fever JMJ 33
- 34. Prognosis • Appendicectomy isrelatively safe with a mortality rate for non-perforated appendicitis of 0.8 per 1,000 and mortality after perforation of 5.1 per 1,000 (Humes DJ, Simpson J; Acute appendicitis. BMJ. 2006 Sep 9;333(7567):530-4.) JMJ 34
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