Appendix, Appendicitis: Acute

Appendix, APPENDICITIS

ACUTE APPENDICITIS

►LEARNING OBJECTIVES

Acute appendicitis • What is it? • What are the symptoms of it? • How is it diagnosed? • Why can it be difficult to diagnose appendicitis? • What other conditions mimic appendicitis? • How is appendicitis treated?

APPENDICITIS, ACUTE

►INTRODUCTION BACKGROUND Appendicitis is a common and urgent surgical illness with protean manifestations

Appendicitis, Acute ►INTRODUCTION BACKGROUND No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases

APENDICITIS, ACUTE BACKGROUND INCIDENCE (FREQUENCY) ► Incidence of appendicitis is lower in cultures with a

higher intake of dietary fiber

• AGE Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years

APENDICITIS, ACUTE BACKGROUND INCIDENCE (FREQUENCY)

SEX The incidence of appendicitis is approximately 1.4 times greater in men than in women

Anatomy recall: lateral anterior wall of abdomen, and vermiform appendix

RIGHT LOWER QUADRANT • CECUM

• APPENDIX • RIGHT OVARY AND TUBE • RIGHT URETER

WHAT’S APPENDIX • Located in the RLQ . Out pouching • Narrow tube • Rises from the cecum. 2.5 cm below the ileocecal junction • worm shaped • Generally 6-10 cm long, 1.5 cm wide • The taeniae coli converge at the base of the appendix • Wall contained lymphatic follicles

APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY • Appendicitis: • What is it? • Appendicitis means inflammation of the appendix • What is inflammation?

A basic way in which the body reacts to infection, irritation or other injury, the key feature being redness, warmth, swelling and pain

How is appendicitis happened? • Obstruction of the appendiceal lumen is the primary cause of appendicitis • *Obstruction of the lumen leads to distension of the appendix due to accumulated intraluminal fluid • * Ineffective lymphatic and venous drainage allows bacterial invasion of the appendiceal wall. perforation and spillage of pus into the peritoneal cavity

APPENDICITIS, ACUTE

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►PATHOPHYSIOLOGY

•

► Causes:

•

The blockage (obstruction) may be due: 1) to thick mucus within the vermiform appendix 2) to stool (hard, fecalith) that enters the appendix from the cecum 3) the lymphatic tissue in the appendix may swell and block the appendix

APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY • ► Causes: • ► Parasites: e.g. :Schistosomes species • Strongyloides species • ► Diseases: Tuberculosis, and Tumors

APPENDICITIS, ACUTE ► CLINICAL DIAGNOSIS • HISTORY: Common symptoms of appendicitis Typically history, begins with anorexia and periumbilical pain followed by: • Low-grade fever 38ºC or more , nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases ► Migration of pain from the periumbilical area to the RLQ is the most discriminating feature of the patient's history

APPENDICITIS, ACUTE ► CLINICAL DIAGNOSIS • HISTORY • Remember

•

When vomiting occurs, it nearly always follows the onset pain

• Vomiting that precedes pain is suggestive of intestinal obstruction, and the diagnosis of appendicitis should be reconsidered •

Absence of fever or high fever can occur

APPENDICITIS, ACUTE

• ► CLINICAL DIAGNOSIS • • • •

HISTORY: Remember Nausea is present in 61-92% of patients Anorexia is present in 74-78% of patients

• Diarrhea or constipation is noted in as many as 18% of patients and should not be used to discard the possibility of appendicitis

APPENDICITIS, ACUTE

• ► CLINICAL DIAGNOSIS HISTORY: Remember

• Duration of symptoms is less than 48 hours in approximately 80% of adults but tends to be longer in elderly persons • Approximately 2% of patients report duration of pain in excess of 2 weeks

• A history of similar pain is reported in as many as 23% of cases

APPENDICITIS, ACUTE • ► CLINICAL DIAGNOSIS PHYSICAL EXAMINATION

► General Appearance (Inspection) ► Patient’s well built or not ► well or poorly nourished ► Mental state: Normal ► Facial expression: feel uncomfortable ► Skin and mucous membranes: pallor, Cyanosis, Eruptions, Pigmentation .

APPENDICITIS, ACUTE • CLINICAL DIAGNOSIS • PHYSICAL EXAMINATION

• ► Abdomen: • INSPECTION • • • • • •

Symmetric or not Postoperative scars (or not) Respiratory movements Visible peristalsis or not Dilatation of superficial veins (or not) Inguinal regions on both sides

PHYSICAL EXAMINATION • ► Palpation: Gentle palpation (beginning at a site distant from the pain) • RLQ tenderness is present in 96% of patients, but this is a nonspecific finding (McBurney' Point)

• Rarely, left lower quadrant (LLQ) tenderness has been the major manifestation in patients with *situs inversus or •

in patients with *a lengthy appendix that extends into the LLQ

APPENDICITIS, ACUTE • CLINICAL DIAGNOSIS • PHYSICAL EXAMINATION • ► Palpation

• The most specific physical findings are: ►

Rebound tenderness

► Pain on percussion ► Guarding (tensing of the abdominal wall muscles)

APPENDICITIS, ACUTE • CLINICAL DIAGNOSIS • PHYSICAL EXAMINATION

• ► Other confirmatory peritoneal signs • The Rovsing sign

• ► RLQ pain with palpation of the LLQ

Other confirmatory peritoneal signs • The psoas sign: Pain on passive extension of the right thigh (► retroperitoneal retrocecal appendix) • Patient lies on left side • Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk)

Other confirmatory peritoneal signs The obturator sign Pain on passive internal rotation of the flexed thigh (►pelvic appendix) Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur

APPENDICITIS, ACUTE • CLINICAL DIAGNOSIS • PHYSICAL EXAMINATION • ► Confirmatory peritoneal signs • Dunphy’s sign: increased pain with coughing • Flank tenderness: in lower quadrant (retroperitoneal retrocecal appendix)

APPENDICITIS, ACUTE CLINICAL DIAGNOSIS • PHYSICAL EXAMINATION • ► Percussion: • Point tenderness (RUQ) • ► Auscultation • Not helpful in making diagnosis ► Rectal examination Is helpful in making clinical diagnosis of localized and generalized peritonitis

APPENDICITIS, ACUTE • ► Differential Diagnosis • The differential diagnosis of appendicitis is broad • Gastrointestinal, Gynecologic, Pulmonary, Genitourinary, Systemic and other diseases can mimic appendicitis. ► Gastrointestinal: e.g. (Abdominal pain: cause unknown, Cholecystitis, Crohn's disease, Diverticulitis, Duodenal ulcer, Gastroenteritis, Intestinal obstruction Intussusception, Meckel's diverticulitis and etc… )

APPENDICITIS, ACUTE • ► Differential Diagnosis • ► Gynecologic: e.g.

• Entopic pregnancy, Endometriosis, Ovarian torsion, Pelvic inflammatory disease, Ruptured ovarian cyst and etc…

► Systemic e.g.: Diabetic, ketoacidosis, Porphyria ,Sickle cell disease etc.. •

► Pulmonary e.g.: Pleuritis, Pulmonary infarction

APPENDICITIS, ACUTE

• ► Differential Diagnosis • ► Genitourinary e.g.: Kidney stone , Prostatitis Pyelonephritis, Testicular torsion, Urinary tract infection

etc.. • ► Other e.g.: Parasitic infection, Psoas abscess Rectus sheath hematoma

APPENDICITIS, ACUTE ► Laboratory Tests (studies) (white blood cell ) • The white blood cell (WBC) count is elevated (greater than 10,000 per mm3) in 80% of cases with Appendicitis • Unfortunately, the WBC is elevated in up to 70% of patients with other ► causes of right lower quadrant pain •

Thus, an elevated WBC has a low predictive value

APPENDICITIS, ACUTE • ► Laboratory Tests (Blood C-reactive protein

level)

• An elevated C-reactive protein level (greater than 0.8 mg per dL) is common in appendicitis • Not sensitive and specific Elevated C-reactive protein level in combination with an elevated WBC are highly sensitive (97 to 100 percent) •

If all these findings are absent, the chance of appendicitis is low

APPENDICITIS, ACUTE • Laboratory Studies (Tests) (Urinalysis) • ► The test may demonstrate changes such as: • Mild pyuria • Proteinuria • Hematuria • This test serves more to exclude urinary tract causes of abdominal pain than to diagnose appendicitis

• ► Imaging Studies (Radiologic Evaluation)

• The options for radiologic evaluation of patients with appendicitis have expanded in recent years A) Computer tomography scan B) Ultrasonography (US scan) C) Plain film (visualization of appendicolith) Other test: Barium enema Radionuclide scanning Diagnostic Laparatomy

SB

C

>3cm

Ileocecal valve

APPENDICITIS!

• ► Imaging Studies (Radiologic Evaluation)

• Abdominal CT- most important 1- Appendix > 6 mm diameter in diameter 2- Superior sensitivity- 97-100% 3- Specificity- 91-99% 4- Non invasive 5- Ability to detect alternative Dx’s 6- Dicrease negative laparatomy rate and appendiceal perforation

• ► Imaging Studies (Radiographic Evaluation)

• Ultrasonography (US) • 1) Outerdiametre > 6 mm • 2) Noncompressibility • 3) Presence of peritoneal fluid collection • 4) Normal appendix usually not visualized

• ► Imaging Studies (Radiographic Evaluation)

• Plain Films-KUB • 1) Visualization of appendicolith (10% of cases) • • • •

Consensus is that: 2) Not sensitive 3) Nonspecific 4) Not cost effective

APPENDICITIS, ACUTE

• Special Considerations • young children • While appendicitis is uncommon in young children, it poses special difficulties in this age group • 1) Young children are unable to relate a history • 2) Often have abdominal pain from other causes and • 3) May have more nonspecific signs and symptoms • These factors contribute to a perforation rate

APPENDICITIS, ACUTE

• Special Considerations

Pregnancy 1) In pregnancy, the location of the appendix begins to shift significantly by the fourth to fifth months of gestation 2) Common symptoms of pregnancy may mimic appendicitis 3) The leukocytosis of pregnancy renders the WBC count less useful

4) As in nonpregnant patients, appendectomy is the standard for treatment

• Special Considerations • Elderly Elderly patients have the highest mortality rates 1) The usual signs and symptoms of appendicitis may be: diminished atypical or absent in the elderly which leads to a higher rate of perforation 2) More frequent perforation combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a mortality rate

APPENDICITIS, ACUTE

• Treatment • The standard for management of nonperforated appendicitis remains appendectomy • Because prompt treatment of appendicitis is important in preventing further morbidity and mortality

•

Appendectomy may be performed by:

* laparotomy

(Open) (usually through a limited right lower quadrant incision) or

* laparoscopy

• Complications

• Appendiceal rupture • Accounts for a majority of the complications of appendicitis (peritonitis) •

• Factors that increase the rate of perforation are: • Delayed presentation to medical care • Age extremes (young and old) • Hidden location of appendix

APPENDICITIS, ACUTE

• Complications • A periappendiceal abscess • It may be treated immediately by: Surgery or by Nonoperative management • Nonoperative management consists of: Parenteral antibiotics with observation or US or CT-guided drainage •

followed by interval appendectomy six weeks to three months later

• Complications • • •

Hemorrhage Gangrene

Thanks