APPENDICITIS Anatomy and physiology of appendix The appendix
- Slides: 55
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
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