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![Alvarado score [5]
• Score < 3: Low likelihood of
appendicitis
• Score : 4 - 6: consider
further imaging
• Score >=7 : High likelihood of
appendicitis
• Inconsistent in children and
women
• Sensitivity for ruling out > ruling in
Component Maximum score
Migration of pain to right
lower quadrant
Anorexia
Nausea / Vomiting
Fever > 37.3 C
Right iliac fossa tenderness
Rebound tenderness
Leucocytosis > 10 x 10
^9 Left shift of neutrophils
MAXIMUM TOTAL
1
1
1
1
2
1
2
1
10](https://image.slidesharecdn.com/appendixpresentation-250708080442-23131049/85/Appendix-power-point-presentation-pptx-24-320.jpg)
![Tzanakis score [9]
• Circa 2005
• Score > 8 = diagnostic of
acute appendicitis
• Sensitivity:95.4%
• Specificity: 97.4%
Parameter Score
Presence of right
lower abdominal 4
tenderness
Rebound tenderness 3
Laboratory findings:
WBC > 12,000
2
Ultrasound finding:
Indicative of 6
appendicitis
Total 15](https://image.slidesharecdn.com/appendixpresentation-250708080442-23131049/85/Appendix-power-point-presentation-pptx-25-320.jpg)
![Appendicitis Inflammatory
Response Score (AIRS) [11]
• 0 - 4: Low probability - OPD
follow-up
• 5 - 8: Indeterminate - Active
observation / Diagnostic
laparoscopy
• 9-12: High probability - Surgical
exploration
Findings Score
Vomiting 1
Right inferior fossa pain 1
Rebound tenderness /
muscular defence
Light : 1
Medium : 2
Strong : 3
Body temp >= 38.5 C 1
Polymorphonuclear
leucocytes
70% - 84% :1
>= 85% : 2
White Blood Cell count
10.0 - 14.9 x 10^9 : 1
>=15 x 10^9 :
2
C-reactive protein
concentration
10 - 49 : 1
>=50 : 2
MAXIMUM TOTAL 12](https://image.slidesharecdn.com/appendixpresentation-250708080442-23131049/85/Appendix-power-point-presentation-pptx-26-320.jpg)
![RIPASA Score
[12]
• Includes; age, gender, duration of symptoms
prior to presentation.
• Circa 2014
• More accurate among Asian population
• Sensitivity = 96.7%
• Specificity = 93%
• Diagnostic accuracy = 95.1 %
• Score > 7.5 - significant for appendicitis](https://image.slidesharecdn.com/appendixpresentation-250708080442-23131049/85/Appendix-power-point-presentation-pptx-27-320.jpg)
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Appendix power point - -presentation.pptx
- 1.
- 2. Learning Outcomes • Recapon anatomy and physiology of appendix • Conditions affecting the appendix - appendicitis, neoplasms • Appendicectomy - emergency vs delayed (interval) • Appendicectomy - open vs laparoscopic • Take Home Message
- 3. Anatomy recap • Averagelength 6 cm to 9 cm (1 cm to 30 cm) • Arterial supply: Appendicular artery • Venous drainage: Appendicular vein • Nerve supply: Superior mesenteric plexus (T10 - L1) • Parasympathetic via vagus nerve • Lymphatic drainage: Ileocolic nodes along ileocolic artery Images adapted from COSECSA module
- 4. Histology of appendix-recap • Three layers; • Serosa - extension of peritoneum • Muscular layer • Submucosa + mucosa Image adapted from NUS Medicine //https: medicine.nus.edu.sg//
- 5. Physiology • NOT avestigial organ • It is an IMMUNOLOGIC ORGAN • Maturation of B lymphocytes • Actively participates in secretion of immunoglobulins especially IgA • Reservoir to recolonise the colon with healthy bacteria
- 6.
- 7. • Males >females ( 8.6% ; 6.7%) • Incidence in general population - worldwide : 0.1 % - 0.2 % • Incidence in Uganda - 7.7 % (AG Marion, 2018) Appendicitis - epidemiology AG Marion, et al, 2018, The Use of Alvarado Score In Diagnosis of Acute Appendicitis at Jinja Regional Referral Hospital
- 8. Appendicitis - microbiology •More anaerobes compared to normal appendix • Cultures tend to grow; - Escherichia coli - Bacteroides species - Fusobacterium nucleatum / necrophorum (62%) Others: Peptostreptococcus, Pseudomonas species, Bacteroides sphlanchnicus, Bacteroides intermedius, Lactobacillus
- 9. 4 stages; 1. Luminalobstruction 2. Appendiceal distention 3. Ischemia and infarction 4. Bacterial invasion, translocation and perforation Appendicitis - pathophysiology Image adapted from COSECSA module
- 10. Patho- physiology of appendicitis Image adapted fromthe Calgary guide of Understanding Disease, https: calgaryguide.ucalgary.ca/ appendicitis/
- 11. • Peri-umbilical diffusepain which later localises to right lower quadrant (sens. 81%, spec, 53%) • Nausea • Vomiting • Anorexia • Obstipation prior to pain + sensation that defecation will relieve the pain • Diarrhea in children - related to perforation Appendicitis - clinical features
- 12. • General exam •Altered or normal vital signs • Slow movements - related to peritonitis • Specific exam • Point of maximum tenderness at McBurney’s point • Signs of peritonism Appendicitis - clinical picture Sensitive signs; • McBurney sign • Rovsing sign • Obturator sign • Psoas sign • Dunphy sign • Markle sign
- 13. Rovsing sign • Painin the RLQ that occurs with release of applied pressure to the left lower quadrant, results from focal peritoneal inflammation in the RLQ. Images adapted from Ubaidi, B A, et al, 2016, Missed Appendicitis in Primary Care: Lessons Learned, Journal of Cardiology & Current Research, DOI: 10.15406/jccr.2016.07.00256
- 14. Obturator sign • Painwith internal rotation of the flexed right thigh, indicates inflammation adjacent to the obturator internus muscle in the pelvis. Images adapted from Ubaidi, B A, et al, 2016, Missed Appendicitis in Primary Care: Lessons Learned, Journal of Cardiology & Current Research, DOI: 10.15406/jccr.2016.07.00256
- 15. Psoas sign • Painwith right hip flexion, can be seen with a retrocecal appendix due to inflammation adjacent to the iliopsoas muscle group. Images adapted from Ubaidi, B A, et al, 2016, Missed Appendicitis in Primary Care: Lessons Learned, Journal of Cardiology & Current Research, DOI: 10.15406/jccr.2016.07.00256
- 16. Dunphy sign • Increasedabdominal pain on coughing • This is due to jostling of inflamed peritoneum • More specific in paediatric age group
- 17. Markle sign • Abdominalpain when patient drops from tiptoes to heels • Sensitivity: 74%
- 18.
- 19. Appendicitis in young •Presentation: Diffuse abdominal pain • Clinically: Generalized lymphadenopathy + voluntary guarding + tenderness • Specific signs and rigidity are RARE • Paed specific signs: pain with percussion, pain on coughing, hopping / refusal to use right lower limb • Negative appendicectomy rates: < 5 years - 25%, 5 - 12 years - 10% • Appendiceal rupture rates: < 5 years : 46%, 5 - 12 years : 20% • Differential diagnosis: Acute mesenteric adenitis • Management: Immediate appendicectomy (if ruptured), early appendicectomy (if
- 20. Appendicitis in theelderly • Presentation: Lower abdominal pain • Clinically: Localization of right lower quadrant tenderness IS NOT common • Differential diagnoses: - Acute diverticulitis - Perforating carcinoma of caecum / sigmoid colon • Investigations - Contrasted CT scan of abdomen - Internal surveillance of colon - colonoscopy / barium enema Management : Laparoscopic appendicectomy preferred (if temp > 38C, left shift of leucocytes in anorexic male with long duration of pain prior to admission)
- 21. Appendicitis in pregnant •Incidence: 1 in 766 live births • Can occur at any time in pregnancy but is rare in 3rd trimester • Clinical features: Sudden onset right sided abdominal pain • Investigations: MRI scan of abdomen • Management: Appendicectomy • Risks of appendicectomy: Laparoscopic - 2.31 increased risk of fetal loss compared to open • Risk of fatal loss after appendicectomy: 4% • Risk of early delivery after appendicectomy: 7% - 10%
- 22. • Incidence: 0.5% •Increased risk of appendiceal rupture (43% at presentation) • Clinical features: - Peri-umbilical pain radiating to right lower quadrant (91%) -Rebound tenderness (74%) +/ - Fever • Investigations: Relative leucocytosis • Differential diagnosis: Opportunistic infections + neutropenic enterocolitis (typhilitis) Appendicitis in HIV population
- 23.
- 24. Alvarado score [5] •Score < 3: Low likelihood of appendicitis • Score : 4 - 6: consider further imaging • Score >=7 : High likelihood of appendicitis • Inconsistent in children and women • Sensitivity for ruling out > ruling in Component Maximum score Migration of pain to right lower quadrant Anorexia Nausea / Vomiting Fever > 37.3 C Right iliac fossa tenderness Rebound tenderness Leucocytosis > 10 x 10 ^9 Left shift of neutrophils MAXIMUM TOTAL 1 1 1 1 2 1 2 1 10
- 25. Tzanakis score [9] •Circa 2005 • Score > 8 = diagnostic of acute appendicitis • Sensitivity:95.4% • Specificity: 97.4% Parameter Score Presence of right lower abdominal 4 tenderness Rebound tenderness 3 Laboratory findings: WBC > 12,000 2 Ultrasound finding: Indicative of 6 appendicitis Total 15
- 26. Appendicitis Inflammatory Response Score(AIRS) [11] • 0 - 4: Low probability - OPD follow-up • 5 - 8: Indeterminate - Active observation / Diagnostic laparoscopy • 9-12: High probability - Surgical exploration Findings Score Vomiting 1 Right inferior fossa pain 1 Rebound tenderness / muscular defence Light : 1 Medium : 2 Strong : 3 Body temp >= 38.5 C 1 Polymorphonuclear leucocytes 70% - 84% :1 >= 85% : 2 White Blood Cell count 10.0 - 14.9 x 10^9 : 1 >=15 x 10^9 : 2 C-reactive protein concentration 10 - 49 : 1 >=50 : 2 MAXIMUM TOTAL 12
- 27. RIPASA Score [12] • Includes;age, gender, duration of symptoms prior to presentation. • Circa 2014 • More accurate among Asian population • Sensitivity = 96.7% • Specificity = 93% • Diagnostic accuracy = 95.1 % • Score > 7.5 - significant for appendicitis
- 28. Paediatric Appendicitis Score (PAS) •To predict appendicitis in < 18 years • Developed in 2002 • Low risk PAS (<4) - unlikely to be appendicitis • Equivocal PAS (4-6) - further imaging warranted - US / MRI • High risk PAS (>6) - surgical consult warranted + NPO + IV fluids + analgesia + /- US Parameter Score 1 1 1 1 Nausea / vomiting Anorexia Migration of pain to RLQ Fever > = 38.0 C RLQ tenderness to cough, percussion or hopping 2 2 1 Tenderness over RIF Leucocytosis WBC > 10,000/mm3 Neurophilia > 7500 1 Maximum Total 10
- 29. • Laboratory investigations •Full Blood Count • C-Reactive Protein • Tests to rule out other conditions - Urinalysis, Urine / Serum hcg • Radiology investigations • Abdominal ultrasound • Abdominal Computed Tomography (CT) scan • Abdominal Magnetic Resonance Imaging (MRI) scan - pregnant populations Appendicitis -investigations
- 30. US - Appendicitis Findings; •Distended non-compressible appendix with diameter > 6mm • Thickening of the appendiceal wall, • Increased echogenicity of the surrounding fat signifying inflammation • Loculated pericecal fluid Image adapted from Zinner, M et al, 2019, Maingot's Abdominal Operations, 13th ed
- 31. CT - appendicitis Findings; •Dilated thick-walled appendix (>6 mm) • Appendix that does not fill with enteric contrast or air • Surrounding fat stranding to suggest inflammation Image adapted from Zinner, M et al, 2019, Maingot's Abdominal Operations, 13th ed
- 32. • Resuscitation • IVantibiotics • Appendicectomy - urgent vs emergency • Open appendicectomy • Laparoscopic appendicectomy • NOTES - Natural Orifice Transluminal Endoscopic Surgery • Incidental appendicectomy Appendicitis - management
- 33. • Through varyingincisions • McBurney (Gridiron incision) • Lanz • Rocky Davis • Antegrade vs retrograde approach Open appendicectomy Image adapted from Zinner, M et al, 2019, Maingot's Abdominal Operations, 13th ed Antegrade Retrograde Image adapted from Google Images
- 34. Laparoscopic appendicectomy • Advantages: •Diagnostic as well as therapeutic • Fewer incisional site infections • Disadvantages: • Increased operative duration • Increased operating room costs • Increased risk of intra-abdominal abscesses Images adapted from Brunicardi, C , et al, 2015, Schwartz's Principles of Surgery, 10th ed
- 35. Open vs LaparoscopicAppendicectomy Open appendicectomy Laparoscopic appendicectomy Duration Post-op pain + narcotic requirements Length of hospital stay Operating room costs Surgical Site Infections Intra-abdominal abscesses Shorter Longer More Less Longer Shorter Low High Higher risk Lower risk Lower risk Higher risk
- 36. • Performed toprevent one from developing appendicitis • Indicated for some special populations; • Children about to begin chemotherapy • Disabled who cannot describe symptoms / react normally to abdominal pain • Patients with Crohn’s disease with normal caecum • Individuals going to travel to remote places where there in no access to medical or surgical care • During Ladd’s procedure for malrotations / other abdominal procedures Neither clinically nor economically appropriate Incidental appendicectomy
- 37. NOTES appendicectomy • Accessto appendix is via naturally existing external orifice • Most common routes; • Trans-vaginally • Trans-gastrically • Advantages: Reduction of post-op wound pain; no abdominal scar; shorter convalescence; avoidance of wound infection • Disadvantages: Complications associated with closure of enterotomy
- 38. What is chronicappendicitis? • Incidence : 1.5 % of all appendicitis cases • Inflammation persists > 3 weeks • Usually females; patients managed non-operatively Criteria; • No alternative diagnosis • Pathologic evidence of chronic inflammation / fibrosis • Complete relief of symptoms after appendicectomy
- 39. What is recurrentappendicitis? • Incidence: 10% Causes; • Partial luminal obstruction • Missed diagnosis • Atypical presentation • Prior treatment with antibiotics • Management: Appendicectomy
- 40.
- 41. Appendicular Neoplasms • Prevalence< 1% • Most common; • Appendicular carcinoid • Appendicular adenocarcinoma • Appendicular mucocele • Pseudomyxoma • Appendicular lymphoma
- 42. Appendicular carcinoid • Mostcommon site of carcinoid tumor (2nd - small bowel, 3rd - rectum) • Most commonly found at tip of appendix • Do not usually have carcinoid features until metastases are widespread • Macroscopic appearance: firm, yellow, bulbar mass • Average size: 2.5 cm • Management depends on size and location of carcinoid Feature of carcinoid Management tenet < 1cm 1 - 2 cm > 2cm Appendicectomy Depends on location, presence of mesenteric spread, lymphatic invasion Right hemicolectomy Image adapted from COSECSA module
- 43. Appendicular adenocarcinoma • 3types; • Mucinous type • Colonic type • Signet-ring type • Worst prognosis = signet-ring type • Symptoms - similar to acute appendicitis • Clinical features: ascites + palpable RIF mass • Management - right hemicolectomy • Survival: 55% overall but varies by stage, grade and histological type
- 44. Appendicular mucocele • Obstructivedilatation of intraluminal accumulation of mucoid material. Management options - Appendicectomy - if unruptured • Processes by which mucoceles form; - Right hemicolectomy / ileocecectomy • Retention cysts • Mucosal hyperplasia • Cystadenoma • Cystadenocarcinomas
- 45. Pseudomyxoma peritonei • Collectionsof gelatinous fluid + implants on peritoneal surfaces and omentum • Clinical picture: Abdominal pain, Abdominal distention +/- mass • Diagnosis: CT abdominal scan - mutinous ascites + tumor deposits • Management: Thorough surgical debulking + omentectomy + appendicectomy + TAHBSO • Alternative: Cytoreductive surgery + intraperitoneal hyperthermic chemotherapy
- 46. Appendicular lymphoma • Extra-nodalsite for non-Hodgkin’s lymphoma • Primary lymphoma of appendix = 1-3% of GI lymphomas • Diagnosis = CT abdominal scan - tumor >= 2.5 cm + soft tissue thickening • Management - depends on location of tumor • Tumor confined to appendix - appendicectomy • Tumor extending to caecum / mesentery - right hemicolectomy = adjuvant therapy
- 47. Take Home Message •Mainstay of management of appendicitis is APPENDICECTOMY • Remember OCHSNER SCHERREN management for patients with RIF mass • Scoring systems and further imaging aid in reducing negative appendicectomy rates
- 48. References 1. Zinner, Met al, 2019, Maingot's Abdominal Operations, 13th ed, pp. 1814 -64 2. Brunicardi, C , et al, 2015, Schwartz's Principles of Surgery, 10th ed, pp 1240 -59 3. The Appendix - COSECSA module 4. AG Marion, et al, 2018, The Use of Alvarado Score In Diagnosis of Acute Appendicitis at Jinja Regional Referral Hospital, 5. Alvarado, A, 1986, A Practical Score For Early Diagnosis of Acute Appendicitis, Annals of Emergency Medicine, 15(5), pp 557 -64
- 49. 6. Bharath, Bet al, 2020, A Comparative Study of Tzanakis Score Versus Alvarado Score in Acute Appendicitis t a Rural Hospital, Journal of Evidence Based Medicine and Health, pISSN -2349-2562, eISSN 2349 - 2570,vol 7, (35) DOI: 10.8410/jebmh/2020/384 7. Mattei, P et al, 1994, Chronic and Recurrent Appendicitis are Uncommon Entities Often Misdiagnosed, Journal of American College of Surgeons, 178 (4); pp 385-9 8. Samuel, M, 2002, Pediatric Appendicitis Score, Journal of Paediatric Surgery, Vol 37, No 6, pp 887 - 881 9. Tzanakis, NE et al, 2005, A New Approach to Accurate Diagnosis of Acute Appendicitis, World Journal of Surgery; 29(9), pp 1151 - 1156 10.Ubaidi, B A, et al, 2016, Missed Appendicitis in Primary Care: Lessons Learned, Journal of Cardiology & Current Research, DOI: 10.15406/jccr.2016.07.00256 11. Von-Muhlen, B, et al, 2015, AIR Score Assessment for Acute Appendicitis, Arq Bras Cir Dig, 28(3); pp 171-3, doi: 10.1590/s0102-67202015000300006 12.Nanjundaiah, N et al, 2014, A Comparative Study of RIPASA Score and Alvarado score in Diagnosis of Acute Appendicitis, Jounral of Clinical and diagnostic Research, 8 (11), doi: 10.7860/JCDR/2014/9055.5170 References - cont.