Appendix Dr. Alaa Jamel - PowerPoint Presentation

Slide1

Appendix

Dr.

Alaa

Jamel

Slide2

Vermiform appendix is present in human's musculans

only; it’s a blind muscular tube with mucosal and

submucosal

, muscular and

serosal

layers.

Acute appendicitis

is the commonest abdominal emergency in young adults

Slide3

Anatomy :

Various positions of the appendix a-

retrocaecal

74% b- pelvic 21% c-

paracaecal

2% d- sub

cecal

1.5% e-

preileal

1% f- post

ileal

0.5%.

The position of the base of appendix is constant, and found at the confluence of the three

taenia

coli of the caecum which fuse to form outer longitudinal muscle coat of the appendix.

Mesoappendix

arise from the lower surf

a

ce of mesentery or the terminal ileum. The appendicular artery is a branch of the lower division of the

iliocolic

artery .appendicular artery is an end artery, so thrombosis of the artery cause necrosis of appendix

Slide4

Slide5

Acut

appendicitis

Acute appendicitis usually occurs when the appendix is obstructed

by a-

faecolith

or

b-foreign body

in the lumen, by

c- fibrous stricture in its wall

from previous inflammation d-

by enlargement of lymphoid follicles

in its wall secondary to a catarrhal inflammation of its mucosa; rarely,

e- it is associated with a carcinoid

tumour

near its base.

Occasionally,f

- acute appendicitis occurs proximal to an obstructing lesion (usually carcinoma) in the caecum or ascending colon. As the appendix of the infant is wide mouthed and well drained, and as the lumen of the appendix is almost obliterated in old age, appendicitis at the two extremes of life is relatively rare. However, when it does occur in these age groups it is poorly

tolerated, and often diagnosed late.

Slide6

The obstructed appendix

acts as a

closed

loop; bacteria proliferate in the lumen and invade the appendix wall, which is damaged by

pressure necrosis

. The vascular supply to the appendix is made up

of end-arteries

, which are branches of the

ileocolic

artery. Once these

thrombosed

, gangrene is inevitable and is followed by perforation. There is no strict time relationship for this chain of events. An appendix may perforate

in under 12 hours,

but conversely

it is not rare to see an acutely inflamed but not perforated appendix after 3 or 4 days

.

Slide7

The effects of appendicular obstruction depend on the content of the appendix lumen. If bacteria are present, acute inflammation occurs; if as sometimes happens, the appendix is empty, then a

mucocele

of the appendix

results, due to continued secretion of mucus from the goblet cells in the mucosal wall. Appendicitis can occur in the non-obstructed appendix. Here, there may be a direct infection of the lymphoid follicles from the appendix lumen, or in some cases the infection may be

haematogenous

(e.g. the rare streptococcal appendicitis).

The non-obstructed acutely inflamed appendix is more likely to resolve than the obstructed form.

Slide8

 Pathological Course

The acutely inflamed appendix may resolve, but if so a further attack is likely. The inflamed appendix undergoes gangrene and perforates, either with general peritonitis or, more fortunately, with a

localized

appendix absces

s

Slide9

Clinical Features

History

The vast majority of patients with acute appendicitis present with marked localized pain and tenderness in the right iliac fossa.

Pain

– typically, the pain commences as a central

periumbilical

colic, which shifts after approximately 6 hours to the RIF or, more accurately, to the site of the inflamed appendix as the adjacent peritoneum becomes inflamed.

If

the appendix is in

the pelvic position

, the pain may become

suprapubic

, with

with

urinary frequency as the bladder is irritated; if it is in the high

retrocaecal

position

, the symptoms may become localized in the right loin with less tenderness on abdominal palpation

Slide10

Rarely, the tip of the inflamed appendix

extends

inflamed

appendix extends ix extends l palpation.s me suprapubic, with with urinary frequency as the bladder is irritated;

over to the left iliac fossa and pain may localize there. The colicky central abdominal pain is visceral in origin; the shift of pain is due to later involvement of the sensitive parietal peritoneum by the inflammatory process. Typically, the pain is aggravated by movement and the patient prefers to lie still with the hips and knees flexed.

Nausea and vomiting

usually occur following the onset of pain. Murphy described the diagnostic sequence as colicky central abdominal pain followed by vomiting, followed by movement of the pain to RIF.

Anorexia

is almost invariable.

Constipation

is usual, but

diarrhoea

may occur (particularly where the ileum is irritated by the inflamed appendix).

Slide11

There may be a history of previous milder attacks of similar pain.

With perforation of the appendix

, there may be temporary remission or even cessation of pain as tension in the distended organ is relieved; this is followed by more sever and more generalized pain with profuse vomiting as general peritonitis develops.

Slide12

Examination

Pyrexia

(around 37.5 °C) and tachycardia are usual.

–

- The patient id

flushed

, may appear toxic and is obviously in pain.

-

Movement

exacerbates the pain.

-

The tongue

is usually coated, and a fetor

oris

is present.

-

The abdomen

shows localized tenderness in the region of the inflamed appendix.

There is usually

guarding

of the abdominal muscles over this site with release tenderness. Coughing mimics the release test for rebound tenderness.

- Rectal examination

reveals tenderness when the appendix is in the pelvic position or when there is pus in the

rectovesical

or Douglas pouch.

-

In late cases

with generalized peritonitis, the abdomen becomes diffusely tender and rigid, bowel sounds are absent and the patient is obviously very ill. Later still, the abdomen is distended and

tympanitic

, and the patient exhibits the Hippocratic

facies

of advanced peritonitis.

Slide13

Symptoms in acute appendicitis

Periumblincal

colic

Pain shift to

rt

iliac fossa

Anorexia

Nausea

Clinical sign in appendicitis

Pyrexia, localized tenderness in the right iliac fossa

Muscle gardening, rebound tenderness

Slide14

Sign to

eleciate

in appendicitis

Pointing sign,,

rovsing

sign,,psoas

,, psoas sign ,,

obturator

sign

d.d

;

In children

E.g. mesenteric lymph adenitis,

meckels

diverticulitis,, intussusception,,

In adult

; regional enteritis,, ureteric colic,, perforated peptic ulcer, torsion testis ,,pancreatitis,,, rectus

sheat

haematoma

Adult females

,

pid

,

p.n

, ectopic pregnancy, torsion or rapture ovarian cyst,

endometritis

.

In elderly

, diverticulitis, intestinal obstruction, colonic carcinoma, torsion appendix,, mesenteric infarction., , leaking aortic aneurysm

Slide15

Investigation.

The diagnosis of acute appendicitis is essentially clinical ,whoever

descision

to do operation based on clinical exam only can lead to remove normal appendix 15—30% of cases ,

alvardo

score system is

widly

used in diagnosis of acute appendicitis.

Slide16

Symptoms

score

Migratory

rif

pain

1

Anorexia

1

Nausea and vomiting

1

Signs

Tenderness

2

Rebound tenderness

1

Elevated temp.

1

Laboratory

Leuckocytosis

2

Sheft

to the lf

1

Total

10

A score of 7 or more is

strongly

predictive of acute appendicitis.

Patient with 5-6 score, abdominal u/s or contrast c.t scan can use to reduce the rate of negative

appedicictomy

.

Slide17

 

Treatment;

The treatment of acute appendicitis is

appendicictomy

,in well diagnosed acute appendicitis urgent operation is essential to prevent the increase

morbiditiy

and

mortility

of peritonitis.

. Immediate

appendicectomy

is not indicated in the following circumstance.

is The patient is moribund with advanced peritonitis. Here the only hope

-

To improve the condition by intravenous drip and nasogastric aspiration, antibiotics and other resuscitative measures.

The attack has already resolved; in such a case, appendectomy can be

-

Advised as an elective procedure, but there is no immediate emergency.

An appendix mass has formed without evidence of general peritonitis.

-

Where circumstances make operation difficult or impossible, e.g. at sea.

Slide18

Slide19

Here reliance must be placed on a conservative regimen and the hope that resolution or local abscess will form, rather than on one's surgical skill with a razor blade and a bent spoon.

Antibiotic prophylaxis is given preoperatively. When at operation peritonitis is discovered antibiotic therapy is continued; metronidazole and gentamicin, or a cephalosporin, are effective for both the anaerobic and aerobic bowel organisms, but this regimen may need to be supplemented or changed when the bacteriological sensitivities of the cultured pus become available after 24-48 hours.

After appendectomy, a drain is inserted when;

1-there is sever inflammation of the appendix bed

2- a local abscess is present.

3- where closure of the appendix stump not perfectly done

4-Very occasionally, the inflamed and adherent appendix cannot be safely removed, and in such circumstances the area of the appendix requires adequate drainage and subsequent interval

appendicectomy

in about 3 months.

Slide20

 

Problems encountered during

appendicictomy

;

Normal appendix

; is essential to search for other possible diagnosis as

examin

terminal ileum ,

meckels,ovaries

,

Appendix cannot be found

;

examin

the caecum

curfully

befor

diagnose absent appendix 1%.

appendicular

tumour

;

if small tumor less than 2 cm can be removed by

appendicictomy

larger

tumour

should be removed by

rt

r

Appendicular abscess

and the appendix cannot be removed

; this should be treated by local peritoneal toilet ,drainage of any abscess and intravenous antibiotic.

Appendicular mass

Not uncommonly, the patient will present with a history of 4 or 5 days of abdominal pain and with a localized mass in RIF. The rest of the abdomen is soft, bowel sounds are present and the patient obviously has no evidence of general peritonitis. In these circumstances, the inflamed appendix is walled off by adhesions to the

omentum

and adjacent viscera, with or without the presence of a local abscess. Immediate surgery in such circumstances is difficult.

Slide21

Treatmen

t

Initial treatment is conservative (

ochsner

-

shrren

regimen) because surgery is difficult and may be dangerous because of inflammation and adhesion and may be difficult to find appendix and fecal fistula may occur.

Preparation for operation should occur when clinical condition of patient deteriorate.

The outlines of the mass are marked on the skin and regular examination of

abdomin.oral

fluid diet and a careful watch kept on the general condition, temperature ,pulse should recorded 4

hourly.fluid

balance record ,

Metronidazole is

commenced,pluse

broad spectrum antibiotic but prolonged antibiotics are

not

given, as these may merely produce a chronic inflammatory mass filled with abscesses (the so-called

antibioticoma

).

On this regimen, 80% of appendix masses resolve

.

Slide22

In the remaining cases, the abscess obviously enlarges over the next day or two and the temperature fails to subside in these conditions this type of regimen must discontinue., drainage of the abscess is instituted. In neglected cases, an appendix abscess may burst spontaneously through the abdominal wall, into the rectum, or into the general peritoneal cavity.

If resolution occurs,

appendicectomy

is carried out after an interval of 3 months to allow the inflammatory condition to settle completely. Unless interval

appendicectomy

is performed, there is considerable risk of a further attack of acute appendicitis.

Slide23

Appendicitis in pregnancy

Appendicitis in pregnancy is no rarer or commoner than appendicitis in the general community, but it has a higher mortality and morbidity because it is confused with other complications of pregnancy. Differentiation must be made from

pyelitis

, vomiting of pregnancy, red degeneration of a fibroid or torsion of an ovarian cyst.

Because the appendix is displaced by the enlarging uterus, pain and tenderness are higher and more lateral than in the usual circumstances.

There is considerable danger of abortion, particularly in the first trimester.

Slide24

A mass in the right iliac fossa

The causes of a mass in the right iliac fossa are best thought of by considering the possible anatomical structures in this region.

Appendix abscess or appendix mass.

-

Carcinoma of caecum

(differentiated from the above by usually an older age

-

group, a longer history, often the presence of diarrhea,

anaemia

with positive occult blood and finally the barium enema examination).

Crohn's

disease

(always to be thought of when there is a local mass in a

-

young patient with diarrhea).

A

distance gallbladder

(which may quite often extend down as far as the

-

right iliac fossa).

Slide25

- Pelvic kidney

(or transplant).

-

Ovarian or tubal mass

.

-

Aneurysm of

the common or external iliac artery.

-

Retroperitoneal

tumour

arising in the soft tissue or lymph nodes of the posterior abdominal wall or from the pelvis.

-

Ileocaecal

tuberculosis

(rare in the UK, common in India).

-

Psoas abscess

– now rare.

Post operative complications

;

Early

* wound infection *

intraabdominal

abscess * paralytic ileus * respiratory complication *venous thrombosis and embolism *portal

pyemia

Fecal fistula.

Late

* adhesive intestinal

obstraction

* RT inguinal hernia

Slide26

MUCOSELE OF APPENDIX;

This condition occurs when the proximal end of the lumen is gradually occluded and obstruct usually by fibrous stricture and

retaind

secretion remain sterile.

Neoplasm of appendix;

Carcinoid

tumour

;it

arise

from the

argentaffin

tissue (

kulchitsky

cell of the

crepts

of

lieberkuhn

),carcinoid

tumour

found as one in each 300 -400 appendices subjected to histological examination and 10 time more common than any other

tumourr

in the appendix.

Carcinoid of appendix

rarly

metastasis .treatment

When

tumour

size 2cm or more** when

caecal

wall

envolve

** when involvement of lymph node.