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Acute Appendicitis
- 1. APPENDIX Dr.S.SABIRA Dr.J.SAHRUDAI M.S.(General surgery) 2nd Yr postgraduate , Department of General Surgery, Kurnool Medical College ,Kurnool.
- 2. ANATOMY Length = 2-20 cms ( Average - 9 cm ) , Longer in children Diameter = 7.5 - 10 mm ( Average - 5 mm ) • Worm like diverticulum • Arising from posterior-medial wall of caecum • 2 cm below the ileocaecal junction Valve of Gerlach - Appendicular orifice Lumen of appendix - Small , narrow / obliterated after mid adult life
- 3. 1. Retrocaecal / Retrocolic - 65% - Most common 2. Pelvic - 31 % - 2 nd most common 3. Splenic - Preileal (1.0%) - Most dangerous 4. - Post ileal ( 0.4% ) 5. Paracolic/ Paracaecal - 2% 6. Mid Inguinal / sub caecal - 2 % 7. Promontoric - <1% POSITIONS OF APPENDIX
- 4. 2 cm below the junction b/w trantubercular & right lateral planes . Mc Burney’s point : • Site of maximum tenderness • Medial 2/3 rd , lateral 1/3 rd of spinoumbilical line SURFACE MARKING
- 5. Arterial supply Appendicular artery - Branch of Inferior division of ileocolic artery - branch of SMA Anastomosis with posterior caecal artery Venous supply Appendicular vein draining to Ileocolic vein - SMV - Portal vein Lymphatics Ileocolic / appendicular nodes ( 4-6) in mesoappendix BLOOD SUPPLY
- 6. NERVE SUPPLY Sympathetic - T9,T10 segments through Coeliac plexus Parasympathetic - Through Vagus Referred Pain to Umbilicus = T10 segment of spinal cord innervates Sympathetic fibers - Appendix. Somatic fibres- Umbilicus Inflammation of Parietal peritoneum = Right iliac fossa pain
- 7. Cecal bud is a diverticulum that arises from the post arterial segment of the midgut loop. The Cecum & appendix are formed by enlargement of this bud . Proximal part of the bud grows rapidly to form caecum, Distal part remains narrow and forms Appendix Appendix arises from apex of the caecum , subsequently, the lateral wall of the cecum grows rapidly than medial wall Appendix comes to medial side EMBRYOLOGY OF APPENDIX
- 8. 1. Narrow lumen 2. Mucosa - Epithelial invaginations - Crypts of Lieberkuhn , Base of the crypts - Argentaffin cells / Kulchitsky cells = CARCINOID TUMOURS . Appendix is the most frequent site for the carcinoid tumours. 3. Submucosa & laminate propria - Lymphoid follicles - Abdominal Tonsil 4. Muscularis externa HISTOLOGY
- 9. ACUTE APPENDICITIS M/C - Cause of Acute Abdomen in young adults . Age = Teenage & early 20’s , M:F - 3:2 Incidence decreased d/t - improved hygiene & use of antibiotics for gastroenteritis cases in childhood . WHY MOST COMMON ….???? 1. Presence of lymphatic follicles in submucosa . 2. Appendicular artery is an end artery. 3. Small lumen - Early obstruction by faecolith . 4. Gaps in muscularis externa - cause fast spread of infection.
- 10. OBSTRUCTION OF LUMEN , DECREASED DIETARY FIBRE INTAKE , INCREASED CONSUMPTION OF REFINED CARBOHYDRATES CAUSES 1. FAECOLITH - Composed of inspissated faecal material , Ca2+ phosphates , bacteria & epithelial debris Incidental finding. Indication for PROPHYLACTIC APPENDICECTOMY 2. STRICTURE - Indicates previous appendicitis 3. CA CAECUM - causes obstruction - Appendicitis in middle aged & elderly 4. INTESTINAL PARASITES - Pin worm (Oxyuris vermiullaris ) - Proliferate in appendix and occlude the lumen 5. FOREIGN BODY
- 11. PATHOPHYSIOLOGY Infection ( Baterial , viral ) Lymphoid hyperplasia Narrowing of lumen Luminal obstruction Continuous mucous secretion Inflammatory exudation Increased Intraluminal pressure Obstruction of lymphatics Oedema & Mucosal ulceration Seepage of Bacteria through mucosal ulceration into submucosa ( Resolution occurs spontaneously or if Antibiotics are used ) If continues causes ,Venous & Arterial obstruction Ischemia of Appendix Bacterial invasion into muscularis propria & Submucosa causing ACUTE APPENDICITIS
- 12. ACUTE APPENDICITIS Ischemia Gangrenous appendicitis with Bacterial peritonitis Greater omentum & small bowel loops Get adhered to appendix and decrease the spread into peritoneal cavity Early mass formation / Phlegmonous mass / Paracaecal abscess Rarely inflammation resolves Distended mucus filled organ MUCOCELE OF APPENDIX If has risk factors like - Extremes of age , Immunosuppression , DM , Faecolith obstruction , pelvic appendix , previous abdominal surgery Limits the ability of greater omentum to get attach to appendix PERFORATION OF APPENDIX WITH DIFFUSE PERITONITIS SYSTEMIC SEPSIS SYNDROME
- 13. Acute inflammed appendix with purulent exudate extending into mesoappendix Appendix with Pus filled lumen (L) & inflammation extending into inflammed serosa
- 14. SYMPTOMS 1. PeriUmbilical colicky pain ——— RIF pain - intense , constant , localised somatic pain ,aggrevated by coughing & sudden movements. ( MIGRATORY PAIN ) 2. Anorexia - Useful & constant clinical feature 3. Nausea , vomitings with central abdominal pain 4. Pelvic appendix ( Atypical presentation ) - Suprapubic discomfort & tenesmus , Tenderness on per rectal examination
- 15. SIGNS • Limitation of Respiratory movements in lower abdomen • Low grade pyrexia • Localised tenderness in RIF • Muscle guarding & Reboud tenderness 1. POINTING SIGN - Point with finger towards RIF 2. ROVSING’S SIGN - On press over LIF causes pain in RIF 3. PSOAS SIGN - Patient lies with hip flexed (to get relief ) due to inflamed appendix lies on Psoas muscle. 4. OBTURATOR SIGN - When Hip flexed & internally rotated cause pain in Hypogastrium ( Obturator test / Zachary cope ) 5. Cutaneous hyperaesthesia in RIF
- 16. ATYPICAL PRESENTATIONS RETROCAECAL APPENDIX • SILENT APPENDIX - Absent rigidity , No deep tenderness also • Deep tenderness in Loin • Rigidity of Quadratus lumborum • Psoas sign/ spasm PELVIC APPENDIX • Early diarrhoea , Deep tenderness above just above & right of pubic symphysis • Tenderness in Pouch of Douglous • Frequency of micturition if contact with bladder • Psoas spasm & obturator spasm • Absence of abdominal rigidity POST ILEAL APPENDIX • Diarrhoea • Marked Retching • Illdefined tenderness in Right of Umbilicus
- 18. PRE OPERATIVE INVESTIGATIONS IN APPENDICITIS ROUTINE Full Blood count Urinalysis SELECTIVE Pregnancy test Urea & serum electrolytes Supine abdominal Xray Ultrasound of Abdomen and pelvis Contrast enhanced CT of abdomen & pelvis ( Low dose in Young adults )
- 19. USG image of RIF - Demonstrating Mildly enlarged appendix , measuring 8 mm in diameter , consistent with acute appendicitis Arrow indicates - Small pocket of free fluid Sagittal section of CT scan of abdomen;Demonstrating An enlarged 10mm , enhancing Retrocaecal appendix with periappendiceal fat stranding
- 20. • More than or equal to 7 = Strongly predictive of Acute Appendicitis • 5-6 = Equivocal score — Do USG / CECT • <5 = Unlikely
- 21. TREATMENT UNCOMPLICATED APPENDICITIS ( without Appendicolith, abscess , perforation ) Conservative management • Bowel Rest • IV Antibiotics- 3rd gen cephalosporins, Metronidazole • 90% are treated , 10% pts with in 1 Yr recurrence with No complications • > 40 yrs of age with appendix mass — conservative management — should be followed up for ? Malignancy Operative management • Preoperative : IV Fluids , IV Antibiotics • Under General Anesthesia - Open / Lap appendicectomy • After Anesthesia — Palpate at RIF — If mass is felt — adopt conservative management
- 22. INCISIONS FOR APPENDICECTOMY 1. McArthur GRID IRON INCISION - Perpendicular to line joining the ASIS & Umbilicus , Medial 2/3 rd & lateral 1/3rd at McBurney’s point. If better access is required in cases of Retrocaecal/Paracaecal/ Fixed appendix 2. RUTHERFORD MORRISON’S INCISION - • Oblique muscle cutting incision • Lower end at - Burney’s point • Extending obliquely upwards & laterally • All layers are divided in line of incision
- 23. 3.LANZ INCISION (Transverse skin crease incision ) Exposure is better & extension is easier , more popular 2 cm below the umbilicus Medially , Centered on Mid clavicular & mid inguinal line 4.LOWER MIDLINE ABDOMINAL INCISION If intestinal obstruction +
- 24. • Removal of Appendix- After diving Mesoappendix and crushing , Excision of appendix , Z suture / purse string at the 1.25 cm from the base of appendix into the muscle coat of caecum with absorbable 2-0/3-0 suture material
- 25. BASE OF APPENDIX GANGRENOUS BASE Don’t crush/Ligate “ 2 “ stitches through caecal wall close the base Appendix amputated with caecal wall Stitches are tied Second layer closure with Interrupted Seromuscular sutures INFLAMMED BASE Don’t crush Do Ligation close to caecal wall Stump invaginate CAECAL WALL OEDEMA Don’t do invagination Apply Z suture
- 27. APPENDICITIS IN PREGNANCY • M/C Extrauterine acute abdominal condition in pregnancy • Incidence = 0.5-1 per 1000 pregnancies • More common in 2nd trimester • Diagnosis complicated due to delay in presentation • Establish diagnosis preoperatively - NEGATIVE APPENDICECTOMY leads to Fetal loss 4% , Preterm labour - 10% • Investigations- USG , MRI • MANAGEMENT - No evidence to support Non operative approach, Should proceed to surgery , Open / Lap approach ( Open Hasson technique ) • COMPLICATIONS - Fetal loss (3-5%) …20% in cases of perforated appendix
- 28. PROBLEMS DURING APPENDICECTOMY NORMAL APPENDIX Rule out Terminal ileitis ,Meckel’s diverticulum , Tubal or Ovarian causes in women —— if not there , Remove Macroscopically appearing normal appendix because in some microscopic evidence of inflammation + APPENDIX NOT FOUND Mobilise caecum —— Trace Taeniae Colo to their confluence APPENDICULAR TUMOUR < 2 cm - Appendicectomy, > 2 cm - Right Hemicolectomy APPENDICULAR ABSCESS + APPENDIX CAN’T REMOVED EASILY Drain Abscess + IV Antibiotics, Rare situation - Frankly necrotic appendix - Caecectomy /Partial Right Hemicolectomy
- 29. APPENDICITIS COMPLICATING CROHN’S DISEASE Crohn’s disease of ileocaecal region 1. Caecal wall Healthy — Do Appendicectomy, 2.Appendix involved with crohn’s disease - Conservative management with IV corticosteroids +Systemic Antibiotics APPENDIX ABSCESS I.V.Antibiotics— Failure of Resolution of appendix mass /Continued pyrexia — Pus in phlegmonous mass — USG/CT guided percutaneous drain / Laparotomy. PELVIC ABSCESS Occasional complication of appendicitis Spiking pyrexia after several days of appendicitis Boggy mass in pelvis USG/CT guided percutaneous drainage
- 30. Failure of mass to resolve - suspect carcinoma / Crohn’s disease APPENDICULAR MASS - MANAGEMENT OCHSNER - SHERREN REGIME Extent of mass marked , Abdomen examined regularly , Temperature,Pulse rate - 4 th hourly , CECT + IV Antibiotics, If Abscess + Drain it Clinical Improvement with in 24 hours • Interval Appendicectomy (6 weeks). • > 40 yrs of age - Appendiceal neoplasm • CT & Colonoscopy follow up • If not improved ,raising pulse rate , spreading abdominal pain, increasing mass/ Peritonitis • Stop conservative management • Early Laparatomy
- 31. POST OPERATIVE COMPLICATIONS WOUND INFECTION (M/C) 5-10% Pts , Pain & erythema of wound on 4-5 Post operative day , Drainage of abscess + Antibiotics INTRAABDOMINAL ABSCESS 5-7 Post operative day — spiking fever , malaise , anorexia — Intraperitoneal collection — USG /CT guided percutaneous drainage RESPIRATORY COMPLICATIONS - Analgesia + Chest Physiotheraphy VENOUS THROMBOEMBOLISM - Early Mobilisation PORTAL PYAEMIA (PYLEPHLEBITIS ) • Very serious complication of Gangrenous appendicitis • High fever , jaundice, Rigors — due to septicemia in portal venous system — Intrahepatic abscess — Treatment - Drainage of abscess + Antibiotics
- 32. FAECAL FISTULA Leakage from appendicular stump - due to caecal wall edema / Crohn’s disease ADHESIVE INTESTINAL OBSTRUCTION treat by Laparoscopy
- 33. CRACINOID TUMOUR / ARGENTAFFINOMA NEOPLASMS OF APPENDIX - 1% OF APPENDICECTOMY SPECIMENS Arise in Argentaffin tissue ( Kulchitsky cells of the crypts of lieberkuhn) M/C in Vermiform appendix - in Distal 1/3 rd of appendix Gross — Feels moderately hard , yellow tumour between intact mucosa & peritoneum Microscopic — Tumour cells are small , arranged in small nests & trabecular with in muscle IHC Marker - “ CHROMOGRANIN-B “ Treatment - < 1 cm - Appendicectomy alone , > 2 cms - Right Hemicolectomy
- 34. EPITHELIAL TUMOURS 1. MUCINOUS - Disseminate — Pseudomyxoma peritonei (PMP) 2. NON MUCINOUS - Intestinal type Based on degree of cytological atypia & architectural features - Infiltrative , Pushing invasion
- 35. Progressive peritoneal tumour deposits , Mucinous ascites , omental caking & ovarian involvement Due to perforation of Mucinous appendiceal tumour • Progressive & massive abdominal distension • Anorexia • Symptoms of Bowel dysfunction PSEUDOMYXOMA PERITONEI
- 36. EPITHELIAL TUMOUR WITHOUT PMP — DEPEND ON DEGREE OF CYTOLOGICAL ATYPIA TREATMENT Low grade epithelial Tumour • i.e., No e/o mucin / Tumour beyond appendix • Low risk • Follow up - Colonoscopy - Colonic epithelial lesions • Surveillance for 5 yrs - Clinical review , low dose CT abdomen • Tumour markers - CEA ,CA 19-9 , CA 125 High grade / Invasive Adenocarcinoma • Goblet cell / invasion beyond appendix • High risk of nodal involvement — Future PMP • Treat as PMP - Cytoreductive surgery with HIPEC (heated Intraperitoneal chemotherapy) • Right Hemicolectomy with prophylactic regional (Right parietal ) peritonectomy with omentectomy with Intraperitoneal chemotherapy with B/L SalpingoOopherectomy
- 37. THANK YOU