logging in or signing up Acute appendicitis PPT Dr.SamiAbdalhameid Download Post to : URL : Related Presentations : Let's Connect Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 5895 Category: Science & Tech.. License: All Rights Reserved Like it (1) Dislike it (1) Added: July 21, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript 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 : THANK YOU You do not have the permission to view this presentation. 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