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APPENDIX

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APPENDIX HOUSSAM OSMAN CHRONIC APPENDICITIS Long lasting pain and less intense than that of acute appendicitis. Normal WBC count CT generally nondiagnostic. – PowerPoint PPT presentation

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Title: APPENDIX


1
APPENDIX
  • HOUSSAM OSMAN

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ANATOMY AND FUNCTION
  • Develops as protuberance of the terminal portion
    of the cecum.
  • the growth rate of the cecum exceeds that of the
    appendix, displacing the appendix medially toward
    the ileocecal valve.
  • Appendix / cecum relationship
  • the relation of the base of the appendix to the
    cecum is constant, while the tip can be found
  • 1- retrocecal 2-pelvic 3-subcecal
  • 4- peri-ileal 5- right pericolic position
  • Length range 1-30 cm with average 6-9.
  • Immunological organ that actively participate in
    secretion of Ig (IgA) and component of GALT, but
    its functional is not esential.

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ACUTE APPENDICITIS
  • Incidence 0.1-0.2
  • Appendectomy for appendicitis is the most common
    performed emergency operation in the world.
  • Disease of young with 40 of cases being between
    10-24 Yr

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A.AEITIOLOGY AND PATHOGENESIS
  • Obstruction of the lumen is the dominant causal
    factor. The obstructing object can be
  • fecalith the most common
  • lymphoid tissue hypertrophy
  • inspisated barium from previous study
  • tumors
  • seeds

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  • The proximal obstruction of the appendiceal lumen
    produces a closed-loop obstruction, and
    continuing normal secretion by the appendiceal
    mucosa rapidly produces distention.
  • with the progressive distention, the venous
    return and subsequently the arteriolar inflow
    compromise and ellipsoidal infarcts develop in
    the antimesenteric border. As distention,
    bacterial invasion, compromise of vascular
    supply, and infarction progress, perforation
    occurs, usually through one of the infarcted
    areas on the antimesenteric border. Perforation
    generally occurs just beyond the point of
    obstruction rather than at the tip because of the
    effect of diameter on intraluminal tension.

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A.ABACTERIOLOGY
  • Bacteria cultured in cases of appendicitis are
    similar to those seen in other colonic infection.
  • The principal organisms seen are E. coli and
    Bacteroid fragilis.

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A.ACLINICAL MANIFESTATIONS
  • Symptoms
  • Pain begins as visceral diffuse steady
    moderately severe periumblical pain, sometimes
    accompanied by intermittent crampy pain. Then,
    shifting of to localized pain in RLQ manifest the
    somatic component. Somatic pain depends on the
    location of the tip of the appendix.
  • LLQ ? LLQ pain
  • retrocecal ? flank or back pain
  • pelvic? suprapubic pain
  • retroileal ? testicular pain
  • Anorexia nearly always
  • Vomiting once or twice
  • Obstibation prior to the onset of the pain. Some
    might c/o diarrhea.

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A.ACLINICAL MANIFESTATIONS
  • Signs
  • VS minimally changed by uncomplicated appendix.
    If not think of either complicated appendicitis
    or other diagnosis.
  • Pt prefers to stay in R thigh flexion position.
  • McBurneys point tenderness and rebound
    tenderness.
  • Rovsings sign
  • Cutaneous hyperesthesia T10,11,12.
  • Psoas sign and obturator sign.
  • Guarding and rigidity appear with more severe
    inflammatory process.
  • Retrocecal tenderness more in the flank.
  • Pelvic painful rectal exam.

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A.ALABS
  • Mild leukocytosis 10-18
  • WBC gt 18 increase the possibility of perforation
  • UA to r/o UTI

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A.AIMAGING STUDY
  • Plain X ray not helpful
  • non specific abnormal gas pattern.
  • fecalith if present id highly suggestive of the
    diagnosis.
  • CXR r/o referred pain from lower lobe pneumonia.
  • Barium enema and radioactive labeled leukocyte
    scan filing of the appendix excludes the
    diagnosis, otherwise insignificant.
  • U/S
  • enlarged diameter, presence of fecalith, wall
    thickening and periappendicular fluid.
  • normal exclude the diagnosis.
  • not visualized inconclusive study.
  • CT dilatation, wall thickening, thick
    mesoappendix, arrow head sign.

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ALVARADO SCALE
  • 9-10 almost certain appendicitis and should go
    to OR.
  • 7-8 high likelihood of appendicitis, imaging
    study.
  • 5-6 compatible but not diagnostic, CT scan is
    appropriate.
  • 0-4 extremely unlikely.

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A.AAPPENDICEAL RUPTURE
  • Overall rate is 25.8
  • Higher rates in children lt 5 (45) and pt gt 65
    (51).
  • Suspect if
  • fever gt 102
  • WBC gt 18
  • In majority of cases ,rupture is contained and pt
    display localized tenderness. Generalized
    peritonitis occurs when the walling-off process
    is ineffective.

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PHLEGMON AND ABSCESS
  • Ill defined mass on physical exam
  • Phlegmon matted loops of bowel adherent to
    adjacent inflamed appendix.
  • CT
  • Phlegmon and small abscess conservative
    management and IV Abx.
  • Well localized abscess percutaneous drainage.
  • Complex abscess extraperitoneal surgical
    drainage .
  • Interval appendectomy done at least 6 weeks
    following the acute event.

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A.ADIFFERENTIAL DIAGNOSIS
  • Acute mesenteric adenitis
  • More common in children.
  • Current or recent Hx of URTI.
  • Generalized lymphadenopathy may be noted.
  • Tenderness is not sharply localized
  • Relative lymphocytosis may be present
  • Self-limited disease.
  • Acute gastroenteritis
  • Childhood disease.
  • Profuse watery diarrhea, N/V.
  • Hyperperistaltic abdominal cramp.

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  • Male urogenital system
  • Testicular torsion.
  • Acute epididymitis.
  • Seminal vesiculitis.
  • Meckels diverticulitis
  • Surgically treated.
  • Intussusceptions
  • Children younger than 2 Yr, well nourished
    suddenly doubled up by apparent colicky pain.
    Infant looks well between attacks
  • Bloody mucoid stool.
  • Sausage shaped mass in RLQ
  • Empty RLQ
  • Barium enema if no signs of peritonitis
  • Crohns enteritis
  • Difficult to differentiate clinically.
  • Diagnosis may be made intraoperatively.

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  • Perforated PU
  • Occur when the spilled contents gravitate down
    the right gutter with spontaneous sealing of
    perforation.
  • colonic lesion
  • Diverticulitis or perforating cecal cancer.
  • Elderly.
  • CT.
  • Epiploic appendagitis
  • Infarction of the colonic appendage secondary to
    torsion.
  • UTI
  • Right acute pyelonephritis associated with
    chills, R CVA tenderness, pyuria, and bacteruria.
  • Ureteral stone referred pain down to the
    genatilia and hematuria.

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  • Primary peritonitis
  • Hx of liver or renal disease.
  • Diagnosed by peritoneal aspiration ? Gve
  • Flora, G-ve rods ? suspect secondary peritonitis
  • Henoch schonlein purpura
  • 2-3 weeks after strep infection.
  • Joint pain, purpura, and nephritis.
  • Yesiniosis
  • Fecal oral
  • Mesenteric adenitis, ileitis, colitis, and acute
    appendicitis
  • Majority are mild and self-limited.

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  • PID
  • Esp if confined to R tube.
  • Purulent vaginal discharge.
  • Cervical motion tenderness.
  • Ruptured Graafian follicle
  • Ovulation.
  • Brief mild, diffuse lower abdominal pain and
    tenderness.
  • Midpoint of menstrual cycle ( Mittelschmerz)
  • Ruptured ectopic pregnancy
  • Missing menses.
  • Vaginal bleeding.
  • Pelvic mass high HCG low Hct
  • Cervical motion and adnexal tenderness
  • Emergency surgery.

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  • Twisted ovarian cyst
  • Vaginal exam may reveal pelvic mass.
  • Transvaginal U/S and CT
  • Torsion needs emergent operative intervention
    while rupture can be managed conservatively.

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A.AAPPENDICITIS IN PREGNANCY
  • 12000 Pregnancies.
  • More frequent during 1st and 2nd trimesters.
  • Appendix displaced laterally and superiorly.
  • Less frequent rebound and guarding.
  • WBC gt normal pregnancy level ( 15-20 ).
  • U/S if equivocal, laparoscopy can be done esp
    early in pregnancy.
  • Any operation has 10-15 premature labor risk.

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A.AAPPENDICITIS IN AIDS
  • Incidence 0.5
  • No absolute leukocytosis.
  • High risk of rupture (which can be related to
    delay in presentation).
  • Low CD4 correlate with increased risk of rupture.
  • Consider opportunistic infection in D.D (
    CMV,kaposi,TB,lymphoma).
  • If the pt presents with classic symptoms and
    signs appendectomy.
  • When diarrhea is the prominent symptom c-scope
    may be considered.
  • Equivocal presentation CT

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A.ATREATMENT
  • Prepare pt for operation
  • Hydration.
  • Correct electrolytes disturbances.
  • Address pre-existing cardiac,renal and pulmonary
    issues.
  • Abx coverage for 24 hrs in simple appendectomy.
    In case of perforation continue abx till pt
    afebrile and normal WBC.

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  • Open appendectomy
  • Incision
  • McBurney incision or Rocky Davis incision.
  • if abscess suspected laterally displaced
    incision to allow retroperitoneal drainage.
  • if diagnosis in doubt lower midline incision
  • Taeniae coli converge at the base of the
    appendix.
  • Divide mesoappendix and mobilize the appendix
    with ligation of the appendiceal artery.
  • Stump can be simply ligated or ligated with
    inversion.
  • Laparoscopy

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  • Prognosis
  • Mortality rate is 0.06 in unruptured appendix.
  • 3 in case of rupture.
  • 15 in case of rupture in elderly

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CHRONIC APPENDICITIS
  • Long lasting pain and less intense than that of
    acute appendicitis.
  • Normal WBC count
  • CT generally nondiagnostic.
  • Appendectomy is curative in 82-93 of pt. many of
    those whose symptoms are not cured or recur are
    ultimately diagnosed with Crohns.

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  • Appendiceal parasites
  • Ascaris lumbricoides is the most common.
  • Enterobius vermicularis, Strongyloides
    stercoralis, Echinococcus granulosis.
  • Anti helminth showed follow recovery from
    appendectomy.
  • Incidental appendectomy
  • Generally neither clinically nor economically
    appropriate.
  • It should performed under special circumstances
  • children about to undergo chemotherapy.
  • disables who can not describe or react normally
    to abdominal pain.
  • Crohns pt in whom the cecum is free of
    macroscopic disease.
  • travelers to remote places with no access to
    medical or surgical care.

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TUMORS
  • Carcinoid
  • Appendix is the most common GIT site.
  • Rarely associated with carcinoid syndrome ( 2.9
    of cases ).
  • Intraoperative finding of firm, yellow, bulbar
    mass in the appendix.
  • Less than 1 cm simple appendectomy is
    sufficient.
  • With extension into mesoappendix or tumor larger
    than 1.5 cm RHC
  • Adenocarcinoma
  • 3 histological type mucinous, colonic, and
    adnenocarcinoma.
  • Most mode of presentation is acute appendicitis,
    but may also present with ascites or palpable
    mass, or may be discovered incidentally.
  • RHC is the recommended treatment.

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  • Mucocele
  • Lead to progressive enlargement of the appendix.
  • 4 histological types retention cysts, mucosal
    hyperplasia, cystadenoma, cystadenocarcinoma.
  • Benign etiology simple appendectomy.
  • Pseudomyxoma peritonei
  • diffuse collections of gelatinous fluid are
    associated with mucinous implants on peritoneal
    surfaces and omentum.
  • caused by neoplastic mucous-secreting cells
    within the peritoneum with the appendix being the
    site of origin for most cases.
  • CT is the preferred imaging modality.
  • surgical debulking is the mainstay of treatment
    and appendectomy routinely performed.
    Hysterectomy and bilateral salpingio-oopheorectomy
    is performed in women.

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  • Lymphoma
  • Extremely uncommon.
  • Non-Hodgkins, Burkitts, and leukemia.
  • Usually present as acute appendicitis.
    Appendiceal diameter 2.5 cm or surrounding soft
    tissue thickening are suspicious.
  • If confined to appendix appendectomy.
  • Extension to cecum or mesentery RHC.
  • A postoperative staging workup is indicated prior
    to adjuvant therapy.
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