APPENDICITIS Anatomy and physiology of appendix The appendix

APPENDICITIS

Anatomy and physiology of appendix

The appendix is a slender, worm-shaped pouch, averaging 5— 10 cm in length, that protrudes from the top of the colon in the lower right abdomen

Location • Mc. Burney’s point: one-third of the way from the anterior, superior iliac spine to the umbilicus. • Pelvis and right ilac fossa appendix • Anterior or posterior ileum appendix • Retrocaceal appendix • Right lateral caceal appendix

Retrocaceal appendix

Supply & nerve • Appendix artery: a final artery , from ileocolic artery • Appendix vein : portal vein • sympathetic nerve : celiac plexus and lesser splanchnic nerve T 10, T 11

Acute appendicitis Appendicitis is a common cause of abdominal pain life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation

Etiology • Obstruction: anatomy : wormed-shaped narrow plenty of lymph glands mechanical reason: food residue, ascarid, tumor, etc.

Etiology • Gastrointestial disease • Bacteria invasion: all kinds of G- bacilus

Pathology Four type: • Acute simple appendicitis • Acute purulent appendicitis • Perforation and gangrenous • Appendiceal abscess

Acute simple appendicitis

Acute purulent appendicitis

Perforation and gangrenous

Gangrenous Perforation

Appendiceal abscess

Results • Inflammation disappear • Inflammation localization • Inflammation diffusion

Clinical manifestation symptoms : • abdominal pain : Periumbilical or epigastric pain that migrates to right lower quadrant Pain becomes persistent and well localized. It worsens with moving, breathing deeply, coughing, sneezing, walking, or being touched

Symptoms : • Gastrointestinal symptoms: Anorexia, nausea, and vomiting occur after the onset of pain Constipation Diarrhea bladder and rectum stimulus symptoms

Symptoms • General symptoms : tired , headach fever Rapid pulse • SIRS (systemic inflammatory response syndrome)

Signs • Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone peritoneal irritation sign : muscular rigidity Blumberg sign bowel sounds disappear

Others • Rovsing’s sign: pain in the right lower • • • quadrant upon palpation of the left lower quadrant. Psoas sign : pain on active elevation of the legs The obturator sign: pain on internal and external rotation of the hip Rectal exam & vaginal exam

Lab test • Mild to moderately elevated WBC with • • left shift is typical but rarely may be normal, range of 11000 -17000/mm 3 over 20000/ mm 3 perforation UA may show ketonuria or a few RBCs or WBCs pregnancy test (women only)

Lab test • B-us • X-ray • Diagnostic abdominal puncture

Diagnosis • Periumbilical or epigastric pain that migrates to right lower quadrant • Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone

Differential diagnosis Two type : A: B: required surgery not required surgery

Differential diagnosis Required surgery: • Perforation of gastointestinal tract ulcer, tumor, diverticulitis • obstetrics and gynecologic disease: ectopic pregancy, ovarion torsion • Meckel diverticulitis • Tumor

Differential diagnosis Not required surgery • Pelvic inflammation • Mesenteric adenitis: at exploration a normal appendix and enlarged lymph nodes in the mesentery • Viral & bacterial gastroenteritis • Pneumonia, pleurisy

MATERIALS AND METHODS The Alvarado score • Symptoms • Score migratory right iliac fossa pain 1 nausea/vomiting 1 1 anorexia • Signs RIF tenderness 2 1 1 fever >37. 30 C rebound pain in RIF • Laboratory test leucocytosis (>10 X 109/L) neutrophilic shift to the left >75% • Total score 2 1 10

CONCLUSION

Treatment • Early operation: surgical removal(appendectomy) • Acute simple appendicitis: appendectomy • Acute purulent and gangrenous appendicitis: appendectomy and/or drainage

Treatment Appendiceal abscess: • if local in right low quadrant antibiotic therapy and general treatment • if infection diffusion incision and drainage

Treatment Operation • Incision : incision over the point of maximal tenderness, generally at Mc. Burny point true Mc. Burney’s incision tansvers skin incision 3— 6 cm long

Incision • Mc. Burney’s incision

Incision • tansvers skin incision

Treatment Operation • Process: The taenia of the colon are followed to the base of the appendix

Treatment Operation • Process: Mesoappendix is divided between clamps and ligated

Treatment Operation • Process: The base of appendix is divided and ligated 0. 5 cm from caceum and inverted using a purse-string

a b c

Treatment • Suspected case: not definite. Admit the patient to hospital for further observation 12 -24 hrs Operation exploration incision

Treatment Antibiotic thearpy: • Acute simple appendicitis • Contraindication of operation • Appendiceal abscess

Treatment Antibiotic thearpy antibiotics: broadspectrum antibiotics ampicillin-sulbactam gentamycin triad drugs metronidazol 3 rd generation cefotides

Treatment • New method : laparoscopy appendectomy

Complication Acute appendicitis: • Abdomen abscess • Inter or extra fistula • Phylephlebitis

Complication Operation : • Incision infection • Peritonitis and abdomen abscess • Bleeding • Stool fistula • Stump infection • Adhesive intestinal obstruction

Appendicitis in neonate • Seldom • Non-specific clinical manifestation Anorexia, nausea, and vomiting diarrhea dehydration • Difficult in early diagnosis • High rate of perforation • High mortality

Appendicitis in neonate Diagnosis &Treatment • Carefully physical exam • Early operation

Appendicitis in child • Quick onset and severe high fever and vomiting present early • Non-typical tenderness at right low quadrant • High rate of perforation • High mortality • More complication

Appendicitis in child Treatment: • Early operation • Transfusion and correct dehydration • Broadspectrum antibiotics

Appendicitis in pregnancy Uterus enlargement appendix displaced superiorly Tenderness site upper shift elevation of abdominal wall Without adherent blanket of Inconspicuous of tenderness rebound tenderness muscular rigidity Peritonitis diffusion omentum

Appendicitis in pregnancy Treatment : • Operation : appendectomy • To late pregancy : early operation • Superior Incision • No drainage • Broadspectrum antibiotics • Parturient with perforation : cesarean section and appendectomy

Appendictis in the elderly • Less well-defined symptoms and signs • Severe pathologic type • Error diagnosis easily • High rate of perforation • Pay attention to tumor

Chronic appendicitis • Etiology and pathology • Clinic feature and diagnosis right low quadrant pain local tenderness x-ray • Treat appendectomy