NITMED TUTORIALS ACUTE APPENDICITIS - PowerPoint Presentation

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NITMED TUTORIALS

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ACUTE APPENDICITIS

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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

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OUTLINE

INTRODUCTION

ANATOMY

PHYSIOLOGY

DEFINITION

EPIDEMIOLOGY

AETIOLOGY

PATHOPHYSIOLOGY

CLINICAL PRESENTATIONSSYMPTOMS PHYSICAL EXAMINATIONMANAGEMENTMEDICAL SURGICAL COMPLICATIONS

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INTRODUCTION

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.

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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;

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ANATOMY

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

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PHYSIOLOGY

Generally believed to have no function

GALT-gut associated lymphoid tissue

Although, function is not essential

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EPEDIOMIOLOGY

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)

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ETIOPATHOGENESIS

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)

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AETIOPATHOGENESIS

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

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CLINICAL 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.

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CLINICAL 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

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LAB INVESTIGATIONS

“

No single evaluation can substitute for the diagnostic accuracy of the experienced physician.”

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Investigations

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

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ALVARADO 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

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MANTRELS SCORE contd.

APPLICATION

0-4 = Not likely Appendicitis

5-6 = Equivocal ( Observe patient, further investigations)7-10 = Appendicitis most likely ( Intervene)

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DIFFERENTIALS 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

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MANAGEMENT- clinical approach

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TREATMENT

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

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APPENDECTOMY

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.

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APPENDECTOMY contd.

Location of

McBurney's

point (1), located two thirds the distance from the umbilicus (2) to the anterior superior iliac spine (3).

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COMPLICATIONS OF APPENDICITIS

Gangrene

Appendix mass

Appendix abscessPerforation Peritonitis

Intrabdominal

abscess

Pelvic

Retroceacal

Subhepatic Subphrenic Reccurent appendicitis Chronic appendicitis

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APPENDIX 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

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APPENDIX ABSCESS

MGT is via

Incision and Drainage of abscess

If appendix seen excise otherwise interval appendectomy at 6-8weeks

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RUPTURED APPENDIX

Exploratory Lap or Mini lap

Peritoneal toileting/ lavage with saline

If appendix stump is seen excise it.

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CONCLUSION

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

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THANKS