AC APPENDICITIS By Col Abrar Hussain Zaidi OUTLINE

AC. APPENDICITIS By; Col. Abrar Hussain Zaidi

OUTLINE Introduction n Surgical anatomy n Epidemiology n n Pathophysiology Diagnosis n Management n Complications n Prognosis n

INTRODUCTION A wormlike intestinal diverticulum starting from the blind end of the cecum in the right lower part of the abdomen and ending in a blind extremity. n Located At OR NEAR Mc. Burney's point n Appendicitis (or epityphlitis) is condition characterized by inflammation of the appendix n

INTRODUCTION n Fitz described the natural history of appendicitis as early as 1889. n That same year, Mc. Burney gave his classic treatise on the anatomy of appendicitis n Mc. Burney's point, 1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus.

INTRODUCTION[cont] n n Appendicitis is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases. The surgeon's goals are to evaluate a relatively small population of patients referred for suspected appendicitis and to minimize the negative appendectomy rate without increasing the incidence of perforation. The emergency department clinician must evaluate the larger group of patients who present to the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner.

Anatomy

Anatomy

Anatomy n The appendix averages from 5 to 20 cm, with an average length of 9 cm. n Mc. Burney’s point is defined as the area under a single finger that lies 1. 5 to 2 inches from the ASIC along a straight line from that anatomical landmark to the umbilicus.

Epidemiology n n n The lifetime risk of developing acute appendicitis is 7% and hasn’t changed since it was first characterized. Mortality is low, less the 1%, except in the elderly andpediatric populations. Mean age at time of surgery is 25. 5 years. Sex a slight predominance of men affected vs. women, up to 67% in some studies. Negative appendectomy rates traditionally 2030% are improving slightly, Perforation rate still remains at near 20% despite advances in technology.

Pathophysiology Inciting factor Obstruction of the appendiceal lumen n Bacterial overgrowth of the distal lumen takes place. n Intraluminal pressure rises. This results in venous hypertension, which perpetuates the cycle by contributing to wall thickening. n This sequence of events occurs over 24 -36 hours. n unchecked -leads to perforation and peritonitis.

Pathophysiology[cont. ] Inflammation of appendiceal lymphoid tissue results in the majority of cases of appendicitis, about 60%. This can be caused by something as simple as gastroenteritis or may be a manifestation of more advanced colonic disease such as Crohn’s.

Pathophysiology[cont. ] n luminal obstruction – fecaliths+others [Fecaliths calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix ] [ Obstruction of the appendiceal lumen has less commonly been associated with parasites (eg, Schistosomes species, Strongyloides species), foreign material (eg, shotgun pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors and lymphoid follicle hyperplasia-many causes n n [Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis. ]

Diagnosis ACUTE APPENDICITIS IS ESSENTIALLY A CLINICAL DIAGNOSIS

Some considerations Acute abdominal pain is defined as previously undiagnosed pain of <72 hours duration n Accounts for about 2% of hospital admissions n In only 50% of patients is the preoperative diagnosis correct n n Right iliac fossa pain accounts for about half of all cases of acute abdominal pain

Clinical presentation CLASSICAL 2. VARIANT 1.

Clinical presentation[cont] · Patient’s profile · Complaints/H. O Present illness · Past history

Clinical presentation [cont] While taking history and doing physical examination; n Careful attention should be paid to the sequence of events. Pain almost always precedes nausea and vomiting n patients that state they are hungry (hamburger sign) almost invariably are not suffering from acute appendicitis. n

Clinical presentation [cont] Essential Diagnostic features n Shifting of pain to right iliac fossa n Localized tenderness n Rebound tenderness

Alternative modes of presentations. n n n n TYPICAL /CLASSICAL < 50% VARIABLITY COMMON Children Pregnancy Adolescent girls Elderly Variable positions of appendix Sub-acute and recurrent appendicitis

Special features The signs/, according to position of the appendix. Retrocaecal. Pelvic. Post ileal

Special features Pointing sign n Rovsing’s sign n The psoas sign n The obturator test n

Variable /atypical presentation n Children n Pregnancy n Adolescent n Elderly n Variable girls positions of appendix n Sub-acute and recurrent appendicitis

Alvarado’s Scoring System n n n Symptoms Score Migratory right iliac fossa pain Nausea / Vomiting Anorexia Signs Tenderness in right iliac fossa Rebound tenderness in right iliac fossa Elevated temperature Laboratory findings Leucocytosis Shift to the left of neutrophils Total 1 1 1 2 1 10

Scoring Aggregate score 7 -10 (emergency surgery group): n These patients were prepared for emergency appendicectomy. Aggregate score 5 -6 (observation group): admitted and kept under observation for 24 hours with frequent reevaluation of the n clinical data and reapplication of the score. Patients who improve shown by a decrease in score are discharged with the instructions that they should come back if symptoms persist or increase in intensity. Aggregate score 1 -4 (discharge home group): n These patients, after giving initial symptomatic treatment, are discharged and sent home with the instructions, to come back if symptoms persist or condition become worse.

Causes of right iliac fossa pain-D/D n n n n Appendicitis, Diverticulitis Urinary tract infection Non-specific abdominal pain Pelvic inflammatory disease Renal colic Ectopic pregnancy Constipation

Causes of right iliac fossa mass-D/D n n n n Appendix mass Crohn's disease Caecal carcinoma Mucocele of the gallbladder Psoas abscess Pelvic kidney Ovarian cyst

Radiology/imaging n n In most cases of appendicitis, radiographs are not necessary. Radiologic examinations are reserved in cases where ambiguity exists, or where the morbidity of the operation (including anesthesia) would be poorly tolerated by the patient.

Radiology/imaging n Plain films A fecalith is present in < 15% of cases. Free air from perforation is seen 1% of n the time. 1 Overall a very poor study. n n Ultrasound Most effective in young females of child-bearing age in the evaluation of adnexal disease which is high on the differential. n U/S is no better than history and physical alone n INDEED MORE IMPORTANT TO RULE OUT A CONDITION OR FIND AN ASSOCIATED PROBLEM n

Radiology/imaging n Computed Tomography Superior in both pediatric and adult populations in elucidating equivocal cases n It has a sensitivity ranging from 96 -100%, a specificity of 89 -97%, a PPV of 92 -97%, and a NPV of 95 -100%. CT scan of the appendix has been n

Radiology/imaging Radio-nuclide SCAN Sensitivity and specificity of >90% achieved. Added expense of about $500 and the Delay in acquisition of 5 hours rarely justify this novel radiographic approach.

Management The goal of the surgical approach n An early diagnosis with resection of an acutely inflamed appendix prior to perforation, n A minimum of negative appendectomies.

Management n Pre-operative n Operation n post treatment operative treatment n Treatment of complications

Pre-operative treatment n Pain n Antibiotics n Fluids n Preparation n Consent

Operative. Treatment Open Appendectomy A transverse Rocky-Davis or the classical Mc. Burney skin incision is made in the. RLQ over the area of maximal tenderness. n If purulent or cloudy peritoneal fluid is encountered, it should be sent for culture and sensitivity. n The appendix is identified at the confluence of the taeniea coli, and the mesoappendix is clamped and divided. n A silk purse string suture is placed at the base of the n appendix, then clamped, ligated with catgut, and divided sharply.

Operative. Treatment[cont] The appendiceal stump can be cauterizedeither chemically or electrically (dealer’s choice), and “dunked” into the cecum. n The fascia is closed, and the skin also except in cases of n perforated appendicitis.

Operative. Treatment[cont] n n If the appendix is perforated, historical management has been either delayed primary closure or primary closure with drainage. When a normal appendix is encountered, a limited exploration is warranted to rule out nearby pathology. In all cases except for IBD, the appendix should be removed to eliminate the possibility of confusion in future cases of RLQ pain. If an appendix is removed in the presence of active IBD, a fecal fistula may ensue. LOOK FOR MECKLE’S DIVERTICULUM/OTHRERS

Operative. Treatment[cont] Laparoscopic Appendectomy n One randomized study suggests that even though hospital stay was about the same, patients undergoing laparoscopic appendectomy returned to work in 7 versus 10 days. They also had fewer wound infections. However, laparoscopy was associated with a greater number of intra abdominal abscesses (5% versus 1%) and a longer operating time (60 versus 40 minutes). Finally, almost a fourth of 285 patients randomized to laparoscopy required conversion to open apendicectomy. Nonetheless, the patients who underwent laparoscopy were more pleased with their cosmetic surgery. Another study suggests that laparoscopic appendectomy at least had no obvious disadvantages. In defense of laparoscopy, it has proved its worth in certain circumstances, for example in women of childbearing age, due to its increased diagnostic value. Additionally, in obese or heavily muscles individuals where larger incisions and excessive retraction may be required, laparoscopy has turned out to be the preferred modality for many. 4

If normal appendix removed -need to look for: n Meckel's diverticulum n Acute salpingitis n Crohn's disease

Antibiotics Generally not disputed, but the length of treatment is. n For perforated appendicitis, some surgeons will use extended spectrum synthetic penicillins. n Others will use ampicillin, gentamycin, and metronidazole. n Nevertheless, monotherapy with a second generation cephalosporin is more economical n n A total of 3 days of antibiotic therapy above and beyond the point where the patient is no longer febrile or has a leukocytosis is sufficient.

COMPLICATIONS n n n Perforation Abscess and mass formation Liver abscess Gen. peritonitis Septicaemia

Appendiceal Mass and Abscess A palpable conglomeration of inflamed tissues, including the appendixand adjacent viscera. n CT scan of the abdomen and appendix can delineate a phlegmon versus an abscess, the treatment of which are distinct. n A difference of opinion revolves around the necessity of an operative approach n conservative regimen. A conservative approach with antibiotics, the so-called Ochsner method, n n

Ochsner method, Based on the following three principles: 1. 2. 3. It is more difficult to remove the appendix One can always revert to an operative approach if the patient deteriorates Conservative treatment works in > 80% however, the conservative approach requires an extended hospital stay initially, not to mention the interval appendectomy that will be performed at a later date.

Appendicular abscess may be treated with ; n Percutaneous Drainage and concomitant IV antibiotics. As it resolves, an interval appendectomy can be entertained, usually at least 3 months after the attack. It has been shown that of the patients treated nonoperatively for abscess as well as phlegmon 5% will fail this approach, and up to 40% will return within a year with recurrent acute appendicitis requiring appendectomy. 4 n Open drainage

Prognosis and Outcomes CURE RATES HAVE SIGNIFICANTLY IMPROVED OVER LAST 70 YEARS THANKS TO; Better diagnosis, antibiotics, early and better surgical treatment

Prognosis and Outcomes n n The overall mortality rate of 0. 2 -0. 8% is attributable to complications of the disease rather than to surgical intervention. Mortality rate rises above 20% in patients older than 70 years, primarily because of diagnostic and therapeutic delay. Perforation rate is higher among patients younger than 18 years and patients older than 50 years, possibly because of delays in diagnosis. Appendiceal perforation is associated with a sharp increase in morbidity and mortality rates.

Prognosis and Outcomes n Although perforation rates have not decreased over the past 70 years, mortality has decreased from 26% to less than 1% over the same period. Most of the morbidity n and mortality associated from appendicitis is suffered by the very young and the very old. n A retrospective review found a perforated appendix rate of 20%. n Overall mortalitywas only 0. 24%, but of the deaths reported, 93% occurred in the age group >50