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APPENDIXHOUSSAM OSMAN
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ANATOMY AND FUNCTION
Develops as protuberance of the terminal portion of thececum.
the growth rate of the cecum exceeds that of the
appendix, displacing the appendix medially toward theileocecal valve. Appendix / cecum relationship:
the relation of the base of the appendix to the cecum isconstant, while the tip can be found:
1- retrocecal 2-pelvic 3-subcecal4- peri-ileal 5- right pericolic position Length range 1-30 cm with average 6-9. Immunological organ that actively participate in
secretion of Ig (IgA) and component of GALT, but its
functional is not esential.
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ACUTE APPENDICITIS
Incidence 0.1-0.2%
Appendectomy for appendicitis is the most
common performed emergency operation in theworld.
Disease of young with 40 % of cases beingbetween 10-24 Yr
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A.A:EITIOLOGY AND PATHOGENESIS
Obstruction of the lumen is the dominant causal factor.The obstructing object can be:
*fecalith ; the most common
*lymphoid tissue hypertrophy
*inspisated barium from previous study
*tumors
*seeds
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The proximal obstruction of the appendiceal lumen producesa closed-loop obstruction, and continuing normal secretion bythe appendiceal mucosa rapidly produces distention.
with the progressive distention, the venous return andsubsequently the arteriolar inflow compromise and ellipsoidal
infarcts develop in the antimesenteric border. As distention,bacterial invasion, compromise of vascular supply, andinfarction progress, perforation occurs, usually through one ofthe infarcted areas on the antimesenteric border. Perforationgenerally occurs just beyond the point of obstruction ratherthan at the tip because of the effect of diameter onintraluminal tension.
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A.A:BACTERIOLOGY
Bacteria cultured in cases of appendicitis are similar tothose seen in other colonic infection.
The principal organisms seen are E. coli and Bacteroidfragilis.
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A.A:CLINICAL MANIFESTATIONS
Symptoms Pain: begins as visceral diffuse steady moderately severe
periumblical pain, sometimes accompanied by intermittent
crampy pain. Then, shifting of to localized pain in RLQmanifest the somatic component. Somatic pain depends onthe location of the tip of the appendix.
LLQ LLQ painretrocecal flank or back painpelvic suprapubic painretroileal testicular pain
Anorexia: nearly always Vomiting: once or twice Obstibation: prior to the onset of the pain. Some might c/o
diarrhea.
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A.A:CLINICAL MANIFESTATIONS
Signs: VS : minimally changed by uncomplicated appendix. If not
think of either complicated appendicitis or other diagnosis.
Pt prefers to stay in R thigh flexion position. McBurneys point tenderness and rebound tenderness.
Rovsings sign
Cutaneous hyperesthesia T10,11,12.
Psoas sign and obturator sign. Guarding and rigidity appear with more severe inflammatory
process.
Retrocecal : tenderness more in the flank.
Pelvic: painful rectal exam.
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A.A:LABS
Mild leukocytosis 10-18
WBC > 18 increase the possibility of perforation
UA to r/o UTI
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A.A:IMAGING STUDY
Plain X ray: not helpful*non specific abnormal gas pattern.*fecalith if present id highly suggestive of the diagnosis.
CXR: r/o referred pain from lower lobe pneumonia. Barium enema and radioactive labeled leukocyte scan : filing
of the appendix excludes the diagnosis, otherwiseinsignificant.
U/S:
*enlarged diameter, presence of fecalith, wall thickening andperiappendicular fluid.*normal: exclude the diagnosis.*not visualized: inconclusive study.
CT: dilatation, wall thickening, thick mesoappendix, arrowhead sign.
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ALVARADO SCALE
9-10: almost certain appendicitis and should go to OR.
7-8: high likelihood of appendicitis, imaging study. 5-6: compatible but not diagnostic, CT scan is
appropriate.
0-4: extremely unlikely.
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A.A:APPENDICEAL RUPTURE
Overall rate is 25.8%
Higher rates in children < 5 (45%) and pt > 65 (51%).
Suspect if:*fever > 102
*WBC > 18
In majority of cases ,rupture is contained and pt display
localized tenderness. Generalized peritonitis occurswhen the walling-off process is ineffective.
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PHLEGMON AND ABSCESS
Ill defined mass on physical exam
Phlegmon : matted loops of bowel adherent to adjacentinflamed appendix.
CT
Phlegmon and small abscess: conservative management andIV Abx.
Well localized abscess: percutaneous drainage. Complex abscess: extraperitoneal surgical drainage .
Interval appendectomy done at least 6 weeks following the
acute event.
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A.A:DIFFERENTIAL DIAGNOSIS
Acute mesenteric adenitis:
More common in children.
Current or recent Hx of URTI.
Generalized lymphadenopathy may be noted.Tenderness is not sharply localized
Relative lymphocytosis may be present
Self-limited disease.
Acute gastroenteritis:
Childhood disease.
Profuse watery diarrhea, N/V.
Hyperperistaltic abdominal cramp.
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Male urogenital system:Testicular torsion.Acute epididymitis.Seminal vesiculitis.
Meckels diverticulitis:Surgically treated.
Intussusceptions:Children younger than 2 Yr, well nourished suddenly doubled up
by apparent colicky pain. Infant looks well between attacksBloody mucoid stool.Sausage shaped mass in RLQEmpty RLQBarium enema if no signs of peritonitis
Crohns enteritis:Difficult to differentiate clinically.
Diagnosis may be made intraoperatively.
Perforated PU:
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Perforated PU:
Occur when the spilled contents gravitate down the right gutterwith spontaneous sealing of perforation.
colonic lesion:
Diverticulitis or perforating cecal cancer.
Elderly.
CT.
Epiploic appendagitis:
Infarction of the colonic appendage secondary to torsion.
UTI:Right acute pyelonephritis: associated with chills, R CVA
tenderness, pyuria, and bacteruria.Ureteral stone: referred pain down to the genatilia and
hematuria.
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Primary peritonitis:Hx of liver or renal disease.Diagnosed by peritoneal aspiration G+veFlora, G-ve rods suspect secondary peritonitis
Henoch schonlein purpura:2-3 weeks after strep infection.Joint pain, purpura, and nephritis.
Yesiniosis:
Fecal oralMesenteric adenitis, ileitis, colitis, and acute appendicitisMajority are mild and self-limited.
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PID:
Esp if confined to R tube.
Purulent vaginal discharge.
Cervical motion tenderness.
Ruptured Graafian follicle:
Ovulation.
Brief mild, diffuse lower abdominal pain and tenderness.Midpoint of menstrual cycle ( Mittelschmerz)
Ruptured ectopic pregnancy:
Missing menses.Vaginal bleeding.
Pelvic mass + high HCG + low Hct
Cervical motion and adnexal tenderness
Emergency surgery.
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Twisted ovarian cyst:
Vaginal exam may reveal pelvic mass.Transvaginal U/S and CT
Torsion needs emergent operative intervention while rupture canbe managed conservatively.
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A.A:APPENDICITIS IN PREGNANCY
1:2000 Pregnancies.
More frequent during 1st and 2nd trimesters.
Appendix displaced laterally and superiorly.
Less frequent rebound and guarding. WBC > normal pregnancy level ( 15-20 ).
U/S: if equivocal, laparoscopy can be done esp early in pregnancy.
Any operation has 10-15% premature labor risk.
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A.A:APPENDICITIS IN AIDS
Incidence 0.5%
No absolute leukocytosis.
High risk of rupture (which can be related to delay in presentation).
Low CD4 correlate with increased risk of rupture. Consider opportunistic infection in D.D ( CMV,kaposi,TB,lymphoma).
If the pt presents with classic symptoms and signs: appendectomy.
When diarrhea is the prominent symptom: c-scope may beconsidered.
Equivocal presentation: CT
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A.A:TREATMENT
Prepare pt for operation:
Hydration.
Correct electrolytes disturbances.
Address pre-existing cardiac,renal and pulmonary issues. Abx coverage for 24 hrs in simple appendectomy. In case of
perforation continue abx till pt afebrile and normal WBC.
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Open appendectomy:
Incision:
*McBurney incision or Rocky Davis incision.
*if abscess suspected: laterally displaced incision to allowretroperitoneal drainage.
*if diagnosis in doubt: lower midline incision
Taeniae coli converge at the base of the appendix.
Divide mesoappendix and mobilize the appendix with ligation of theappendiceal artery.
Stump can be simply ligated or ligated with inversion.
Laparoscopy
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Prognosis
Mortality rate is 0.06% in unruptured appendix.
3% in case of rupture.
15% in case of rupture in elderly
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CHRONIC APPENDICITIS
Long lasting pain and less intense than that of acute appendicitis.
Normal WBC count
CT generally nondiagnostic.
Appendectomy is curative in 82-93% of pt. many of those whosesymptoms are not cured or recur are ultimately diagnosed withCrohns.
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Appendiceal parasites: Ascaris lumbricoides is the most common.
Enterobius vermicularis, Strongyloides stercoralis, Echinococcus
granulosis. Anti helminth showed follow recovery from appendectomy.
Incidental appendectomy: Generally neither clinically nor economically appropriate.
It should performed under special circumstances:*children about to undergo chemotherapy.
*disables who can not describe or react normally to abdominal pain.
*Crohns pt in whom the cecum is free of macroscopic disease.
*travelers to remote places with no access to medical or surgical
care.
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TUMORSCarcinoid:
Appendix is the most common GIT site.
Rarely associated with carcinoid syndrome ( 2.9 % of cases ).
Intraoperative finding of firm, yellow, bulbar mass in the appendix.
Less than 1 cm: simple appendectomy is sufficient.
With extension into mesoappendix or tumor larger than 1.5 cm:RHC
Adenocarcinoma:
3 histological type: mucinous, colonic, and adnenocarcinoma.
Most mode of presentation is acute appendicitis, but may alsopresent with ascites or palpable mass, or may be discoveredincidentally.
RHC is the recommended treatment.
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Mucocele: Lead to progressive enlargement of the appendix.
4 histological types: retention cysts, mucosal hyperplasia,
cystadenoma, cystadenocarcinoma. Benign etiology: simple appendectomy.
Pseudomyxoma peritonei:
*diffuse collections of gelatinous fluid are associated with mucinousimplants on peritoneal surfaces and omentum.
*caused by neoplastic mucous-secreting cells within the peritoneumwith the appendix being the site of origin for most cases.
*CT is the preferred imaging modality.
*surgical debulking is the mainstay of treatment and appendectomyroutinely performed. Hysterectomy and bilateral salpingio-oopheorectomy is performed in women.
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Lymphoma: Extremely uncommon.
Non-Hodgkins, Burkitts, and leukemia.
Usually present as acute appendicitis. Appendiceal diameter 2.5cm or surrounding soft tissue thickening are suspicious.
If confined to appendix: appendectomy.
Extension to cecum or mesentery: RHC.
A postoperative staging workup is indicated prior to adjuvanttherapy.