Git – part iii Dr.V.V.Shahapurkar Professor,Dept of gen.surgery D.M.I.M.S,Sawangi(meghe) WARDHA : Git – part iii Dr.V.V.Shahapurkar Professor,Dept of gen.surgery D.M.I.M.S,Sawangi ( meghe ) WARDHA Units : Units Vermiform appendix Rectum Anus and anal canal Hernias Abdominal trauma Learning objective: Learning objective To understand Surgical anatomy – position , histology Infective conditions – acute and chronic appendicitis its etiopathogenesis, clinical signs, common investigations, differential diagnosis, complications and management. units: units SURGICAL ANATOMY ACUTE APPENDICITIS CHRONIC APPENDICITIS MUCOCELE NEOPLASMS SURGICAL ANATOMY OF APPENDIX: SURGICAL ANATOMY OF APPENDIX Learning objectives Development Anatomy Blood supply Different positions Histology Location Anomalies ANATOMY: ANATOMY Cecum + Vermiform Appendix: Cecum + Vermiform Appendix Cecum sac-like, blind pouch Ileocecal valve raised edges of mucosa prevents feces going back into ileum Vermiform Appendix same layers blind tube opens into cecum masses of lymph tissue Anatomy: Anatomy Comparison with large and small bowel: Comparison with large and small bowel . Culdy sac (blind loop) Valve – “gerlach’s “ Three folds of mucous membrane Admits head of match stick anatomy: anatomy Vermiform, length:6-10cm Location: base- cecum, constant tip- variable Location of tip determines symptoms PowerPoint Presentation: Retrocaecal 74 % Pelvic 21 % spleenic a) preilial b) post ilial Para ceacal Sub ceacal Sub hepatic 5 % Appendiceal Location: Appendiceal Location Historically, many references have reported appendiceal displacement. In 2003, a study by Hodjati et al showed that pregnancy did NOT change appendiceal location. Degree of displacement, if any, is likely due to different extents of cecal fixation. Appendicitis in Pregnancy: Appendicitis in Pregnancy Anomalies : Anomalies Agenesis (absence) --- rare Duplication High up Left sided (situs inverses) Diverticula Accessory artery summary: summary Student must able to know the development , anatomical location and blood supply, different positions, histology and anomalies. Differential diagnosis depends up on the different location of the appendix. Appendicitis and tumors: Appendicitis and tumors Learning objectives Incidence Etiopathogenesis Symptomatology Differential diagnosis Investigations Complications Management Acute simple appendicitis: Acute simple appendicitis Acute purulent appendicitis : Acute purulent appendicitis Pathology : Pathology Anomalies Infective Obstructive Dilatation Tumors Infection - appendicitis: Infection - appendicitis Itis – inflammation Acute –obstructive -- non obstructive Subacute (mild) Recurrent (chronic ) Acute appendicitis: Acute appendicitis Incidence Age – 2 nd 3 rd decade (common) At any age group Rare in infants Sex – Before puberty M:F -1:1 2 nd 3 rd decade M:F – 2:1 After -- equal incidence Geographical variation : Geographical variation Common in European American AUSTRALIAN Incidence rising in developing countries . PowerPoint Presentation: Diet High protein Low residue Leads to fecal concretion Social status Upper Economical class Middle Infective organisms: Infective organisms Aerobic and non aerobic E coli commonest 60-85 % Enterococci 22-30% Non hemolytic streptococci 10-20% Obstructive type : Obstructive type Obstructive type is twice common than Non- obstructive Causes 1) in the lumen faecolith - fruit seeds parasite gall stones foreign body worms vegetable bulk skin of potato /tomato Fecolith : Fecolith 1) 40 % simple appendicitis 2) 65 % gangrenous appendicitis 3) 90 % gangrenous with perforated appendicitis In the wall : In the wall Inflammatory fibrosis and stricture . Ca caecum. Hypertrophied lymphoid follicles . Carcinoid Out side wall : Out side wall Adhesions Peri appendicitis Bands Crohn’s disease Pathogenesis(obstructive type ) : Pathogenesis(obstructive type ) Luminal capacity ------- 0.1ml 0.5 ml --- intramural pressure inc to 60 cm of h2o. Distention a) vomiting b) stimulation of. nerve ending vague dull ache pain in epigastric Para umbilical mid abdomen .. PowerPoint Presentation: Hyper peristalsis Collection of luminal fluid favors growth of organism (quantum ),--- virulence . Libaration of toxins – absorption in systemic circulation fever PowerPoint Presentation: Distention Pressure Compression Blockage of capillary and veins Stasis of tissue fluid Edema of wall Exudation of toxins through serous surface Bacterial migration --------peritonitis PowerPoint Presentation: Maximum pressure in the wall ---- pressure over artery / thrombus Gangrene / perforation As Appendicular artery is end artery having thrombus or spasm tip becomes gangrenous and perforate Site for perforation ----- base ----- tip a: a If immunity is good. Chemotaxsis (chemotaxin ) Appendicular mass Poor immunity Para caecal abscess PowerPoint Presentation: Other sequence Acute suppurative appendicitis Gangrenous appendicitis Perforated appendicitis Xanthogranulomatous appendicitis . Mucocele ---------Rupture ----------pseudo myxomatous Peritonii. Non obstructive type of appendicitis (a) : Non obstructive type of appendicitis (a) Catarrhal Ulcerative’ Interstial abscess formation . Suppurative. Gangrenous Perforative (B ) Mass formation Factors favouring perforation: Factors favouring perforation Extremes of age Obstruction by faecolith Previous laprotomy Diabetes mellitus Immunosuppresion Use of purgatives and enema Clinical presentation: Clinical presentation Presentation depends upon position Group 1 – features common for all cases Pain Vomiting Fever Constipation Tachycardia PowerPoint Presentation: Group 2 – features according too location Retrocecal Paracaecal Pelvic Inguinal Sub hepatic Preilial Postilial PowerPoint Presentation: Group 3--- obstructive type acute course Acute abdominal features of intestinal obstruction PowerPoint Presentation: Murphy’s triad – pain in RIF vomiting Fever Clinical test : Clinical test Hyperesthesia in sherrens triangle Mc burneys sign Blumberg’s sign Roving’s sign Baldwin’s sign Copes psos test Copes obturator test Alder sign in pregnancy Dunphy’s sign rectal examination: rectal examination PowerPoint Presentation: Psoas sign Obturator sign Mucocele: Mucocele Mucocele: Mucocele PowerPoint Presentation: Periappendicitis – surrounding inflammation Recurrent appendicitis – re appearing of episodes after resolution of previous attack . Chronic appendicitis – constant pain, weight loss ,site of occult for infection(perse does not exist) Xanthogranulomatous appendicitis --Unusual healing pattern , intra mural cord of granulation tissue with clusters of xanthin type cells . PowerPoint Presentation: Appendicular mass Conservative management OSCHNER SHERREN REGEIME Diffrential diagnosis: Diffrential diagnosis Gastrointestinal Causes Caecal diverticulitis Sigmoid diverticulitis Meckel's diverticulitis Epiploica appendicitis Mesenteric adenitis Omental torsion Crohn's disease PowerPoint Presentation: Caecal carcinoma Appendiceal neoplasm Lymphoma Typhlitis Small bowel obstruction Perforated duodenal ulcer Intussusception Acute cholecystitis Hepatitis Pancreatitis PowerPoint Presentation: Infectious Causes Infectious terminal ileitis ( Yersinia , tuberculosis or cytomegalovirus) Gastroenteritis Cytomegalovirus colitis Genitourinary Causes Pyelonephritis or perinephric abscess Nephrolithiasis Hydronephrosis Urinary tract infection No abdominal Causes Streptococcal pharyngitis Lower lobe pneumonia Rectus muscle hematoma PowerPoint Presentation: In Women Ovarian cyst (ruptured or not ruptured) Corpus luteal cyst (ruptured or not ruptured) Ovarian torsion Endometriosis Pelvic inflammatory disease Tubo-ovarian abscess In Pregnancy Ectopic pregnancy Round ligament pain Chorioamnionitis Placental abruption Preterm labour Diagnosis : Diagnosis Symptomatology Clinical test Lab investigation X ray findings abdomen standing USG Helical ct scan C-REACTIVE-PROTEIN Elevation PowerPoint Presentation: Patients with scores of 9 to 10 are almost certain to have appendicitis. Patients with scores of 7 to 8 have a high likelihood of appendicitis. while scores of 5 to 6 are compatible with, but not diagnostic of appendicitis. Score more than 7 surgery Management : Management Conservative Surgery as per the scale Open – good morning appendix Laparoscopic Open incision- Mc Burney's ,lance, lower rt paramedian PowerPoint Presentation: In infants Rare – as appendix has a large caliber obstructive type is rare If occur difficult to diagnose No chemo taxis Mesentery and omentum is short No mass formation and localization Generalized peritonitis + perforation is common Elderly : Elderly Atheleroslerotic vascular changes Repeated attack Appendicitis obliterans Appendicitis biscet Treatment : Treatment Early operation: surgical removal(appendectomy) Acute simple appendicitis: appendectomy Acute purulent and gangrenous appendicitis: appendectomy and/or drainage Treatment : Treatment Appendiceal abscess : if local in right low quadrant antibiotic therapy and general treatment if infection diffusion incision and drainage Treatment : Treatment Operation Incision : incision over the point of maximal tenderness, generally at McBurny point true McBurney’s incision transverse skin incision 3—6cm long Incision : Incision McBurney’s incision Incision: Incision transverse skin incision Lanz incision Treatment: Treatment Operation Process: The taenia of the colon are followed to the base of the appendix Treatment: Treatment Operation Process: Mesoappendix is divided between clamps and ligated Treatment: Treatment Operation Process: The base of appendix is divided and ligated 0.5cm from caecum and inverted using a purse-string a: a b c Treatment : Treatment Suspected case: not definite. Admit the patient to hospital for further observation 12-24hrs Operation exploration incision Treatment : Treatment Antibiotic therapy: Acute simple appendicitis Contraindication of operation Appendiceal abscess Treatment: Treatment Antibiotic therapy antibiotics: broad-spectrum antibiotics ampicillin-sulbactam gentamycin triad drugs metronidazol 3 rd generation cefalosporines Treatment : Treatment New method : laparoscopic appendectomy PowerPoint Presentation: Abdominal Film Acute appendicitis:: Acute appendicitis: PowerPoint Presentation: 1.thickened appendix 2.Caecum 3.Small amount of pericaecal fluid 4.perippendicular hyperemia Helical CT scan:: Helical CT scan: Enlarged appendix, No filling with contrast material, Periappendiceal inflammatory changes Nonpregnant patients – 98% sensitivity Pregnant - useful, noninvasive & accurate (Am J Obstet Gynecol 2001 Apr;184(5):954-7 Radiation ? TUMOURS OF THE APPENDIX: TUMOURS OF THE APPENDIX Carcinoids- -Common. Other Tumours— Benign-Cystadenoma. Endometriosis Malignant- Primary-Carcinoids Adenocarcinoids. Cystadenocarcinoma Secondary- Metastatic. PowerPoint Presentation: Carcinoid tumour Incidence- 1 in 300. 3 rd to 4 th decade. 70% at tip 20% body. 10% at base. 70% of lesion less than 1 cm in diametre. (40% OF ALL GIT CARCINOIDS SEEN IN APPENDIX.) PowerPoint Presentation: Gross Appearance---- Small, firm greyish white or yellow-brown, well- circumscribed but not encapsulated. They accure a characteristic yellow colour after formalin fixation. At the tip– A “ typical bell space clapper “ configuration. PowerPoint Presentation: Microscopic --- Cells arranged in islands, trabeculae, strand or undifferentiated, sheets. Cells are small monotonous pink granular cytoplasm, round or oval nucleus. Invasion of muscles and lymph vessels. Tumour cells are argentaffin , argyrophilic positive for diazo reaction. Immunohistochemically– reactive for neuron– specific enolase, chromagranin,serotonin and other peptides like somastostatin , glucagon, substance P, etc. PowerPoint Presentation: Carcinoid syndrome- Extremely rare. Seen only if liver metastasis. Occasionaly Appendiceal Carcinoids may secrete- ACTH. And result in CUSHING”S SYNDROME. It is primarily due to secretion of Serotonin( 5-hydroxtryptamine) which is detactable in urine. Carcinoid tumour of Appendix may be associated with carcinoid of ileum. summary: summary Clinical features in acute appendicitis depends up on position. Appendicular mass, abscess, gangrene and perforation are the complications. Appendicular mass to be treated by medical line, followed by surgery. Neoplasms are un common, adenocarcinoma and carcinoid tumors may occur. Carcinoid syndrome is seen when there are secondaries in liver.