Acute appendicitis :

Acute appendicitis By Dr.Sami abd alhameid University of Dongola SUDAN

Incidence :
Incidence - Commonest abdominal surgical emergency. - One person in six develops appendicitis at some time. - It is relatively uncommon in developing rural communities.

Surgical anatomy :
Surgical anatomy - The appendix is attached at the point of convergence of the three taeniae coli of the caecum on its posteromedial wall - The meso-appendix is a peritoneal fold containing fat & appendicular artery - Commonly behind the caecum (Retrocaecal) - On psoas muscle at or below pelvic brim (Pelvic) - Rarely : Pre-ileal Post-ileal Paracaecal Length less than 1 to greater than 30cm (most are 6-9 cm in length) - Appendix is an immunological organ( IgA ) - After age of 60 no lymphoid tissue remains

Surgical pathology :
Surgical pathology Predisposing factors : 1- Obstructive agents 2- Infective agents 1Obstructive agents : - Foreign bodies : animal (e.g. thread worms,round worms) , vegetables (e.g. seeds , date stones) , mineral (faecolith = common cause) and submucous lymphoid tissue hyperplasia leads to obstruction

Surgical pathology :
Surgical pathology 2- Invective agents : - Primary infection leading to lymphoid hyperplasia Secondary infection caused by pressure of an obstructed agent leads to epithelial erosion and bacteria gain access to the wall - Both aerobic & anaerobic organisms are involved including ( coliforms , enterococci , bacteroids & other intestinal commensals )

Types of acute appendicitis :

Types of acute appendicitis 1- Acute appendicitis 2- Acute appendicitis with an inflammatory mass 3- Acute appendicitis with generalised peritonitis

1- Acute appendicitis :
1- Acute appendicitis - Organisms enter the wall & lodge in submucosa , proliferate , wall becomes red & turgid - Rate of acceleration of inflammation increase in presence of obstruction to lumen of appendix

2- Acute appendicitis with an inflammatory mass :

2- Acute appendicitis with an inflammatory mass - Obstruction + infection lead to distension with pus hence increase intraluminal pressure lead to venous occlusion , oedema , arterial occlusion , gangrene and perforation follows , rapidly localised by defence mechanism (greater omentum & coils of bowel ) . Appendix mass is formed , can undergo suppuration to produce an appendix abscess

3- Acute appendicitis with generalised peritonitis :

3- Acute appendicitis with generalised peritonitis - Free perforation following obstruction + infection allows infected material to disperse widely in peritoneal cavity lead to intense peritoneal reaction with outpouring of fluid - Serosal surfaces of bowel become injected flaked with clotted lymph

Clinical features :
Clinical features Symptoms : - Abdominal pain : periumblical at first , then to right iliac fossa within a few hours where becomes persistent . Onset is usually sudden , may arise in right iliac fossa and remains there - Retrocaecal appendix may cause flank or back pain - Pelvic appendix may cause suprapubic pain - Anorexia nearly always accompanies appendicitis Vomiting occurs in about 75% of patients ( most vomit once or twice ) - Most patients give history of constipation before onset of pain , diarrhea in some particularly children - 95% of patients anorexia is the first symptom

Signs :
Signs General : - Patient looks unwell - Coated tongue , foul breath - Moderate pyrexia Tachycardia ( There absence does not exclude appendicitis )

Signs :
Signs Local : - Tenderness of a localised & persistent nature is the most important abdominal finding , situated at RIF , classically at McBurneys point ( junction of middle & outer third of a line from umblicus to anterior superior iliac spine ) - Rigidity over RIF - Rebound tenderness (best elicited by percussion ) - Tenderness on right side during rectal exammination (may be only sign with pelvic appendicitis )

Signs :
Signs Special : - Rovsings sign (deep pressure in the left iliac fossa causing pain the RIF Blumbergs sign ( crossed rebound tenderness ) - Copes sign (flexion & internal rotation of right hip may cause pain ) - Psoas sign (extension of right hip may cause pain if psoas close

to appendix ) - Straight leg raising sign (digital pressure over tender spot , elevation of right leg may cause increase in pain)

Investigations :
Investigations - Mild leukocytosis 10,000 to 18,000/mm3 usually present - Leukocytes above this level possibility of perforation with or without abscess - Urine should be exammined in doubtful cases - U/S scan show dilated lumen & thickened wall of appendix , a mass or rule out gynaecological pathology - Laparoscpy = diagnostic & therapeutic (most useful in females)

Differential diagnosis :
Differential diagnosis # Exra-abdominal: ( right basal pneumonia & diaphragmatic pleurisy ) # Abdominal : Mesentric adenitis (5%) Acute gastroentritis Acute epididymitis Acute seminal vesiculitis Meckels diverticulitis Intussusception Regional enteritis Perforated peptic ulcer Acute pyelonephritis Ureteral stone Primary peritonitis HenchSchonlein purpura Pelvic inflammatory disease Rupture graafian follicle Twisted ovarian cyst or tumour Endometriosis Rupture ectopic pregnancy

Extradiagnostic techniques :
Extradiagnostic techniques 1- Computer assistance 2- Fine catheter aspiration of abdominal cavity 3- Laparoscopy ( These tests used when evaluation not certain )

Acute appendicitis with an inflammatory mass :

Acute appendicitis with an inflammatory mass Symptoms : - Similar to those of acute appendicitis - Pain is often more severe - Patient feels ill & nauseated Signs : - Tender mass RIF , not well defined , after 5 days with little rigidity - Tender mass on rectal exammination

Differential diagnosis :
Differential diagnosis 1- Carcinoma of the caecum 2- Carcinoma of left colon with competent iliocaecal valve , caecum will be distended results in compressible & tympanitic mass 3Empyema of gall bladder 4- Renal mass (perinephric abscess , hydronephrosis) 5- Ovarian cyst 6- Fibroid uterus 7- Psoas abscess 8- Crohns disease 9- Iliocaecal tuberculosis

Acute appendicitis with generalised peritonitis :

Acute appendicitis with generalised peritonitis - Spreading abdominal pain - Signs of peritonitis (rebound tenderness , rigidity & abdominal distension from paralytic ileus ) Patient becomes more toxic - Three stages follow

Stage of shock :
Stage of shock - Patient is pale , sweating & anxious - Elevated pulse rate - Low blood pressure - Temperature is subnormal - Respiration is rapid & shallow - Tenderness in the RIF

Stage of peritoneal reaction :

Stage of peritoneal reaction - Severe local tenderness in the RIF - Rebound tenderness Board like rigidity - Marked rectal tenderness

Stage of frank peritonitis :

Stage of frank peritonitis - Abdominal distension - Absent bowel sounds - Faecal vomitus Dehydration

Treatment of acute appendicitis :

Treatment of acute appendicitis - Treatment is open appendicectomy - Recently laparoscopic appenicectomy may also be appropriate

Treatment Acute appendicitis with an inflammatory mass :

Treatment Acute appendicitis with an inflammatory mass - Early mass comprising inflamed appendix with surrounding coils of bowel & greater omentum - Later frank abscess may form - Treatment policy : Non-operative & Operative

Non operative treatment :

Non operative treatment - Ensure the patient is in the semi-upright (in bed) - Administer fluids only by mouth or I.V - Pulse rate 4 hourly , temperature twice daily - Palpate & mark the mass daily (U/S increase accuracy of measurement ) - Broad-spectrum antibiotic + metrnidazole - Following may happen : Resolution(80%) , Deterioration(10%) , Abscess formation , No change for days or weeks (? Wrong diagnosis) - Appendicectomy about 3 months later

Operative treatment :
Operative treatment - Performed by many surgeons - Appendicectomy & drainage of an abscess - Drainage alone if appendicectomy is hazardous - Disadvantages : dissemination of infected material , haemorrhage , faecal fistula , wound infection & residual abscess

Treatment of acute appendicitis with generalised peritonitis :

Treatment of acute appendicitis with generalised peritonitis - Treatment is operative after short period of resuscitation (NG suction & I.V replacement therapy ,analgesic&antibiotic) At operation , peritoneal toilet - Appendix removed & tube drain is placed at appendix bed Intraoperative peritoneal lavage with saline - Grossly contaminated cases leave the wound open

Meckels diverticulum :
Meckels diverticulum - Present in 2% of population - 2 feet from the iliocaecal valve ( on antimesentric border ) - Usually 2 inches long - Symptomatic in 2% of adults - 20% of cases the mucosa contains : gastric , colonic or pancreatic tissue - Is the most common true diverticulum of GIT (congenital) - Most common symptom in childhood is bleeding

Symptoms :
Symptoms - Severe haemorrhage - Intussusception - Meckels diverticulitis - Perforation Chronic peptic ulcer - Intestinal obstruction (when attached to umblical skin ,volvulus or kinking) - Herniation (Littres hernia)

Investigations :
Investigations - Small bowel enema is the most accurate investigation - In repeated GIT haemorrhage image by gamma camera using Technetium 99m

Slide 31:
Treatment Meckels diverticulectomy

THANK YOU :
THANK YOU