LEARNING OBJECTIVES Describe the appendix and appendicitis along with its pathophysiology Identify the clinical manifestations of appendicitis Discuss assessment and diagnostic findings of appendicitis ID: 932975
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Slide1
NITMED TUTORIALS
Slide2ACUTE APPENDICITIS
LEARNING OBJECTIVES
Describe the appendix and appendicitis along with its pathophysiology.
Identify the clinical manifestations of appendicitis.
Discuss assessment and diagnostic findings of appendicitis.
Describe the medical and surgical care of a patient with appendicitis.
Discuss the possible complications of appendicitis
Slide4OUTLINE
INTRODUCTION
ANATOMY
PHYSIOLOGY
DEFINITION
EPIDEMIOLOGY
AETIOLOGY
PATHOPHYSIOLOGY
CLINICAL PRESENTATIONSSYMPTOMS PHYSICAL EXAMINATIONMANAGEMENTMEDICAL SURGICAL COMPLICATIONS
Slide5INTRODUCTION
Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay.
ANATOMY
The appendix is a small, finger-like tube about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (
ie
, appendicitis).
NB: The appendix can vary in length from <1 cm to >30 cm;
Slide7ANATOMY
From its base at the cecum, the appendix may extend
(A)
upward, retrocecal and retrocolic;
(B)
downward, pelvic;
(C)
downward to the right, subcecal; or
(D) upward to the left, ileocecal (may pass anterior or posterior to the ileum) Variations in topographic position of the appendix
Slide8PHYSIOLOGY
Generally believed to have no function
GALT-gut associated lymphoid tissue
Although, function is not essential
Slide9EPEDIOMIOLOGY
Most common cause of acute surgical abdomen in children and adolescents
7-10% of the population develop acute
appedencitis
Peak incidence at early adolescence/ adulthood.
Increased rate of perforation in children
Commoner in male ( M:F 2: 1)
Slide10ETIOPATHOGENESIS
Obstruction of the Lumen ( 2/3)
Fecalith
(hardened faeces)Hypertrophy of lymphoid tissue
Vegetable and fruit seeds
Intestinal worms (
enteriobious
vermicularis)Insipissated barium Tumor ( primary/ metastatic/ carcinoid)No obstruction of the Lumen (1/3)
Slide11AETIOPATHOGENESIS
Proximal obstruction>>distal distension>>compromised blood supply>>progression to gangrene>>
peforation
>>peritonitis ( generalized or localized (abscess)
obstruction
Distention
Distention causing
Ischemia
Gangrene
Appendiceal obstruction/early appendicitis – visceral peritoneal irritation
Appendiceal distension
Irritation of parietal peritoneum (localised)
Perforation, localised/generalised peritonitis, mass
Slide12CLINICAL PRESENTATION
SYMPTOMS
Abdominal pain
is the prime symptom of acute appendicitis. Classically, pain is initially diffusely centered in the lower epigastrium or umbilical area, is moderately severe, and is steady, sometimes with intermittent cramping superimposed.
After a period varying from 1 to 12 hours, but usually within 4 to 6 hours, the pain localizes to the right lower quadrant
Anorexia
nearly always accompanies appendicitis. It is so constant that the diagnosis should be questioned if the patient is not anorectic.
Vomiting
occurs in nearly 75% of patientsNB: The sequence of symptom appearance has great significance for the differential diagnosis. In >95% of patients with acute appendicitis, anorexia is the first symptom, followed by abdominal pain, which is followed, in turn, by vomiting (if vomiting occurs). If vomiting precedes the onset of pain, the diagnosis of appendicitis should be questioned.
Slide13CLINICAL PRESENTATION
SIGNS
Temperature elevation is rarely >1°C ( Fever
)
Pulse rate
is normal or slightly elevated
Marked tenderness
often is maximal at or near the McBurney pointDirect/Indirect rebound tendernessDehydrationReduced abdominal movt Rovsing sign—Palpate LIF patient feels pain in the RIFObturator sign- RIF pain when the flexed and internally rotated Psoas sign- patient assumes a position of a flexed hip and feels pain when the hip is extended.Pointing sign- patient locates the are of maximal pain at the McBurney’s Point
Slide14LAB INVESTIGATIONS
“
No single evaluation can substitute for the diagnostic accuracy of the experienced physician.”
Slide15Investigations
FBC
Raised WBC ( neutrophils)
PCV may be normal Urinalysis
Pregnancy test
Abdominopelvic
uss
E/U/CrChest x-ray R/O bowel perforation Others Plain abdominal x-ray R/O intestinal obstructionALVARADO SCORE-MANTRELS
Slide16ALVARADO SCORE (MANTRELS)
Manifestations
Value
Symptoms
Migration of pain
1
Anorexia
1
Nausea and/or vomiting
1
Signs
Right lower quadrant
tenderness
2
Rebound
1
Elevated temperature
1
Laboratory values
Leukocytosis
2
Left shift in leukocyte count
1
Slide17MANTRELS SCORE contd.
APPLICATION
0-4 = Not likely Appendicitis
5-6 = Equivocal ( Observe patient, further investigations)7-10 = Appendicitis most likely ( Intervene)
Slide18DIFFERENTIALS Dx
Peforated
PUD
Acute intestinal obstructionPerforated thyphiod enteritis
Merkel
derviticulitis
Regional ileitis
e.g Crohn’s dxAcute pyelonephritis Renal/ureteric ColicAcute pancreatitis Messenteric adenitis Ruptured ectopic pregnancyAccidented ovarian cystsAccidented FibriodAcute PIDAbd crisis in HBSSGastroenteritis Right basal pneumonia
Slide19MANAGEMENT- clinical approach
Slide20TREATMENT
Once the decision to operate for presumed acute appendicitis has been made, the patient should be prepared for the operating room. Ensure the following
Adequate hydration
Electrolyte abnormalities should be corrected
pre-existing cardiac, pulmonary, and renal conditions should be addressed.
Administer
antibiotics
to all patients with suspected appendicitis
Slide21APPENDECTOMY
OPEN
For open appendectomy most surgeons use either a
McBurney (oblique) or Rocky-Davis
(transverse) right lower quadrant muscle-splitting incision in patients with suspected appendicitis. The incision should be centered over either the point of maximal tenderness or a palpable mass
LAPAROSCOPIC
Laparoscopic appendectomy usually requires the use of three ports. Four ports may occasionally be necessary to mobilize a
retrocecal
appendix. The surgeon usually stands to the patient's left.One assistant is required to operate the camera. One trocar is placed in the umbilicus (10 mm), and a second trocar is placed in the suprapubic position. Some surgeons place this second port in the left lower quadrant. The suprapubic trocar is either 10 or 12 mm, depending on whether or not a linear stapler will be used.The placement of the third trocar (5 mm) is variable and usually is either in the left lower quadrant, epigastrium, or right upper quadrant.
Slide22APPENDECTOMY contd.
Location of
McBurney's
point (1), located two thirds the distance from the umbilicus (2) to the anterior superior iliac spine (3).
Slide23COMPLICATIONS OF APPENDICITIS
Gangrene
Appendix mass
Appendix abscessPerforation Peritonitis
Intrabdominal
abscess
Pelvic
Retroceacal
Subhepatic Subphrenic Reccurent appendicitis Chronic appendicitis
Slide24APPENDIX MASS
When inflamed appendix, terminal ileum and caecum is wrapped up in
omentum
Mgt is conservative ( OCHNERS-SHERRENS REGIMEN)
A = Aspiration with NG TUBE if patient
B= BD ( twice daily) assessment of the patient
C= Charts
i.e
4hourly temp, pulse, resp rate, diameter of mass marked and measured BDD= Drugs i.e antibiotics and analgesics E= Electrolytes correctionF= Fluid rehydration ( NPO to allow inflammation subsides)Then Interval Appendectomy @6-8weeks
Slide25APPENDIX ABSCESS
MGT is via
Incision and Drainage of abscess
If appendix seen excise otherwise interval appendectomy at 6-8weeks
Slide26RUPTURED APPENDIX
Exploratory Lap or Mini lap
Peritoneal toileting/ lavage with saline
If appendix stump is seen excise it.
Slide27CONCLUSION
Appendicitis is a common surgical emergency with a varied clinical presentation
Several patient groups are at high risk of misdiagnosis
Lab and imaging studies are helpful, but no single study is a substitute for good clinical judgement
Slide28THANKS