appendicitis is the most common cause of acute abdomen in young adult
appendicectomy is the most performed operation , first major procedure performed by a surgeon in training
anatomy : average length of appendix is 7.5-10cm , it is supplied by appendicular artery
positions of appendix : retrocaecal 74% , pelvic 21% , paracecael 2% , subcaecal 1.5%, preileal 1% , postileal 0.5%
causes of appendicitis ?
common in young and white race , less fiber diet , family history 30% , obstruction : faecoliths-stricture-foreign body-round worm or thread worm
how age affect the outcome of appendicitis ?
rare in infants and common in childhood and early adult life , peak in teens and early 20s , male to female ratio 3:2
types of appendicitis ?
1-acute non obstructive (catarrhal):
the appendix appear red, edematous , hemorrhagic and the fate of this type is one of those : resolution ,fibrosis , suppuration , recurrent appendicitis
2-acute obstructive appendicitis :
the appendix will appear blackish , gangrenous , edematous , fate is perforation which can be found at the tip or base of appendix
3-recurrent appendicitis :
appendix will appear fibrosed and thickened
what is the pathogenesis of appendicitis ?
luminal obstruction by faecolith lead to mucus and inflammatory fluid collect inside the lumen , that will increase intraluminal pressure , lead to blockage of lymphatic and venous drainage , cause mucosal ulceration and ischemia , bacterial spread through submucosa and muscularis propria lead to acute obstructive appendicitis
what are the risk factor for perforation of appendicitis ?
extremes of age , immunosuppression , diabetes mellitus , fecolith ,pelvic appendix , previous abdominal surgery
what are the clinical feature of appendicitis or what are the sign and symptoms ?
periumbilical colic , pain shifting from umbilical area to right iliac fossa
anorexia
nausea
vomiting
pyrexia
localized tenderness , muscle guarding , rebound tenderness
what are signs to be elicit help to diagnose the appendicitis
1-poining sign(ask patient to mention where the maximums pain feeling ,+ if the point on mcburney's point)
2-rovsing sign (palpation of left iliac fossa with slight push to right , will lead to elicit pain in right iliac fossa )
3-psoas sign (retrocecal appendix , put hand slightly above knee , ask pt to left his right leg against resistance this will elicit pain due to friction of psoas muscle with inflammed appendix)
4-obturator sign (pelvic appendix )
special feature of appendicitis according to appendix position :
retrocecal : rigidity often absent , deep tenderness present , hip joint flexed position , hyperextention of hip cause pain (psoas test positive)
pelvic : early diarrhea , frequency of micturition , absence of rigidity and tenderness , rectal examination reveals tenderness , obturator sign positive
infants : perforation and postoperative morbidity high , but appendicitis rare in infants
children : usually complete aversion to food
elderly : gangrene and perforation occur frequently , localization poor , peritonitis occur early
pregnancy : appendicitis is most common extra-uterine acute abdomen , incidence in prengancy 1:1500-2000 , diagnosis is delayed , pain in right lower quadrant of the abdomen , fetal loss occur in 3-5%
can i lost my baby if i have appendicitis ?
fetal loss ratio is 3-5% in pregnant women with appendicitis
what is differential diagnosis of appendicitis in children ?
gastroenteritis , meckel's diverticulitis , mesenteric lymphadenitis , intussusception , henoch-schonlein purpura ,lobar pneumonia
what is differential diagnosis of appendicitis in adult ?
regional enteritis , ureteric colic , perforated peptic ulcer , torsion of testis , pancreatitis , mesenteric infarction
what is differential diagnosis of appendicitis in female adult ?
+above , mittelschmerz pain , pelvic inflammatory disease , ectopic pregnancy , torsion/rupture ovarian cyst , endometriosis
what is differential diagnosis of appendicitis in elderly ?
diverticulitis , intestinal obstruction , colonic carcinoma , mesenteric infarction , leaking aortic aneurysm
what are investigation needed in appendicitis ?
routine : complete blood count , general urine exam
selective : pregnancy test , urea and electrolyte , supine abdominal radiograph , ultrasound of abdomen/pelvis (90% accuracy ), contrast enhanced abdomen and pelvic computed tomography (95%)
what are the sonographic criteria for appendicitis
non compressible appendix of size >6mm Anterior-Posterior diameter
thickened appendix wall >2mm -target sign
appendicolith
interruption of submucosal continuity
peri-appendicular fluid
indication for appendectomy :
acute appendicitis , recurrent appendicitis , mucocele of appendix , carcinoma
ALVARADO SCORE (mantrels)
symptoms :
migratory pain (from umbilical to right iliac fossa) =1 point
anorexia =1 point
nausea/vomiting = 1 point
signs :
pyrexia =1 point
RIF tenderness = 2points
RIF rebound tenderness = 1 points
laboratory values :
leukocytosis =2 points
left shift (increase premature cell of wbc)or >75% neutrophils= 1 point
score of 7 or more strongly predictive of acute appendicitis (admission / surgery 93% appendicitis)
5-7 - monitoring / admission 66% appendicitis
<4 discharge , 30% appendicitis
what are the surgical approaches for appendicectomy ?
gridiron , rutherford morison's , lanz crease , right lower paramedian , lower midline , laparoscopic
what are the postoperative complications of appendicectomy ?
wound infection 5-10% in 4th -5th day post operation , bacteroides species and anaerobic streptococci are most common organism , treatment : wound drainage , antibiotics
intraabdominal abcess : 8% , 5-7 days after operation , treatment : percutaneous drainage , laparotomy
paralytic ileus , pneumonia , venous thrombosis and embolism (rare)
portal pyemia : pylephlebitis , rare but serious complication of gangrenous appendicitis
symptoms : high grade fever with rigor , jaundice
treatment : antibiotics , percutaneous drainage
fecal fistula (leakage from appendicular stump )
adhesive intestinal obstruction : late complication , single band adhesion often found
appendicular mass(peri-appendicular phlegmon):
occured 3-5days after attack of acute appendicitis
composed of :
inflammed appendix
greater omentum
edematous cecum
iluem
on exam : tender , smooth , firm , well localized
management of appendicular mass :
conservative oschsner -sherren regime:
npo , iv fluid , broad spectrum antibiotics , daily measurement of mass , temperature and pulse rate recorded 4 hourly
criteria for stopping conservative management :
increase or spreading of abdominal pain
increase size of mass
rise in pulse rate
contraindication for oschsner sherren :
when diagnosis in doubt
acute appendicitis in children and elderly
burst, gangrenous appendicitis
diffuse peritonitis
appendicular abscess : occur in
retrocecal appendix
subcecal , preileal , postileal appendix
not in pelvic
clinical feature of appendicular abscess :
high fever , features of toxicity , tender , smooth , soft swelling in right iliac fossa
treatment of appendicular abscess :
incision in lower lateral aspect of swelling , skin-external oblique muscle , abscess cavity is opened , pus is drained extra-peritoneally , wound closed
recurrent acute appendicitis :
recurrent episode of lower abdominal pain , incomplete obstruction , intensity vary , occur every few months , appendix thickened and fibrosed