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Acute appendicitis
The document discusses acute appendicitis, summarizing the anatomy and physiology of the appendix, signs and symptoms of appendicitis, diagnostic tests used, and treatment options. The appendix is a thin tubular organ located at the base of the cecum that helps with immune function. Acute appendicitis is caused by obstruction leading to bacterial overgrowth and inflammation. Clinical manifestations include abdominal pain and tenderness. Imaging tests like ultrasound and CT scans are used for diagnosis. Treatment involves open or laparoscopic appendectomy to remove the inflamed appendix. Antibiotics are also used before and after surgery depending on the severity of the appendicitis.
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Acute appendicitis
- 1. POKHREL, BHARAT M.D. ACUTEAPPENDICITIS
- 2. The Appendix • Athin, wormlike, tubular organ • located at the inferior part of the cecum • Length: <1 cm to >30 cm; most appendices are 6 to 9 cm long
- 3. ANATOMY • Arterial supply:Appendicular branch of Iliocolic artery • Innervation derived from sympathetic elements contributed by superior mesenteric plexus (T10-L1) • Afferents from parasympathetic elements via Vagus nerves
- 4.
- 5. Physiology • An immunologicorgan • Secretion of immunoglobulins (IgA) • Inverse association between appendectomy and development of ulcerative colitis.
- 6. Incidence • One ofthe most common surgical emergencies • Yearly incidence rate 100 per 100,000. • Lifetime risk for males 8.7%, females 6.7% • Highest incidence in second decade of life
- 7. Pathophysiology Obstruction Increase luminal pressure Secretions of fluid and mucus Stagnation Bacterial Multiplication PusFormation Impaired Blood Supply Ischemia Bacterial Invasion Gangrene Rupture
- 9. Clinical Manifestations Signs • Anorexia •Abdominal pain • Nausea, Vomiting Symptoms • Abdominal tenderness • Cutaneous hyperesthesia • Rovsing’s sign • Psoas sign • Obturator sign
- 10. Laboratory Findings • Mildleukocytosis • Increased CRP is a strong indicator of appendicitis.
- 11.
- 13. Imaging studies • Ultrasonographyand CT scan are the most commonly used tests.
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- 15. Open Appendectomy • Musclesplitting incisions at the RLQ – McBurney’s (Oblique) – Rocky-Davis (Transverse) • Incision is centered over either the point of maximal tenderness or palpable mass
- 17. Open Appendectomy • Typicallyunder GA, patient in supine position • Abdomen prepped and draped • Incision at McBurney’s point • If appendix is not easily identified, cecum should be located. • Tracing the taenia libera, the most visible of 3 taeniae coli, distally, the base of the appendix can be identified.
- 18. Laparoscopic Appendectomy • UnderGA, patient in supine position • Uses 3 ports. • 10-12mm port at umbilicus, 5mm port at suprapubic and in LLQ • Appendix should be identified by tracking taeniae libera/coli • Appendix is removed through infraumbilical trocar in a retrieval bag.
- 19. ANTIBIOTICS • Simple AcuteAppendicitis • 24 hours antibiotic coverage • Perforated or Gangrenous • Continued until patient is afebrile • Normal WBC
- 20. References • Schwartz’s Principlesof Surgery, Tenth edition
- 21.
Editor's Notes
- #8 Secretions of fluids and mucus – distention which cause dull, diffuse pain Bacteria – Marked distention – reflex nausea/vomiting Impaired blood supply: venous outflow obstruction and decrease in arterial inflow - ischemia Occluded capillary and veins – RLQ Pain
- #10 Inflammatory process in the appendeix presents as PAIN, initially diffuse visceral progressing to localized. GI symptoms that develop before the onset of pain suggest different etiology such as AGE Many have OBSTIPATION, feels that defecation will relief the pain Diarrhea may occur in association with perforation.
- #12 Patients with scores of 9 or 10 are almost certain to have appendicitis; there is little advantage in further work-up, and they should go to the operating room. Patients with scores of 7 or 8 have a high likelihood of appendicitis, whereas scores of 5 or 6 are compatible with, but not diagnostic of, appendicitis. CT scanning is certainly appropriate for patients with Alvarado scores of 5 and 6, and a case can be built for imaging for those with scores of 7 and 8. On the other hand, it is difficult to justify the expense, radiation exposure, and possible complications of CT scanning in patients whose scores of 0 to 4 make it extremely unlikely (but not impossible) that they have appendicitis.
- #15 Equivocal Appendicitis – (+) RLQ Pain with atyipical history and PE. Uncomplicated Appendicitis – acutely inflamed, phlegmonous, suppurative, mildly inflamed appendix with or without peritonitis Complicated Appendicitis – gangrenous appendicitis, perforated appe, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess Sonography: inexpensive/no contrast medium; (+) if non compressible appendix/ >6mm AP diameter; highly suggestive = thickening of appendiceal wall/periappendiceal fluid CT Scans: Focus – only RLQ; Non focused – whole abdomen Enhanced – rectally administered contrast Non enhanced – dye allergy CONS: expensive, radiation exposure Alvarado score of 5-6 Alvarado – scoring system 9-10 = almost certain; 7-8 high likelihood; 5-6 compatible with’ 0-4 extremely unlikely SYMPTOMS: migration of pain (2), Anorexia (1), Vom/Nas (1); Signs: RLQ Tenderness (2), Rebound (1), Fever (1) Labs: Leukocytosis (2), Left Shift (1)
- #16 McBurney’s – 2- 5 cm above ASIS and continues to a point one-third of the way to the umbilicus (McBurney’s Point); incision is parallel to the external oblique muscle which allows the muscle to be split in the direction of fibers, decreasing healing times and scar formation Rocky-Davis – straight transverse at the skin; GRIDIRON
- #17 Layers of Muscles and Tissue are cut and large intestine or colon is visualized (LAYERS: Skin, Fats Campers/Scarpas, Muscles (EO, IO, Rectus Abdominis, Transverse Abdominal Muscle, Pyramidalis Muscle) Fascia, Peritoneum Appendix is located: convergence of the taenia can be followed to the base of the appendix; a sweeping lateral to medial motion can aid in delivering the appediceal tip; mobilized by dividing the mesoappendix; ligate the appendiceal artery Tied and removed: stump can be managed by simple ligation and inversion with either a purse string-or z stitch Muscle and tissue are stitched; peritoneal cavity is irrigated and the wound is closed by layers