Acute appendicitis PPT

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 1- Obstructive 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 McBurney’s 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 : - Rovsing’s sign (deep pressure in the left iliac fossa causing pain the RIF - Blumberg’s sign ( crossed rebound tenderness ) - Cope’s 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 – Meckel’s diverticulitis – Intussusception – Regional enteritis – Perforated peptic ulcer – Acute pyelonephritis – Ureteral stone – Primary peritonitis – Hench-Schonlein 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 3- Empyema of gall bladder 4- Renal mass (perinephric abscess , hydronephrosis) 5- Ovarian cyst 6- Fibroid uterus 7- Psoas abscess 8- Crohn’s 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

Meckel’s diverticulum : 

Meckel’s 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 - Meckel’s diverticulitis - Perforation - Chronic peptic ulcer - Intestinal obstruction (when attached to umblical skin ,volvulus or kinking) - Herniation (Littre’s 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 Meckel’s diverticulectomy

THANK YOU : 

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