Anatomy and Physiology | Clinical Medicine | Medical Specialties

ANATOMY and PHYSIOLOGY

Arteries of cecum and vermiform appendix. (Appendix visible at lower right, labeled as "vermiform process").

Vermiform appendix In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum is a pouchlike structure of the colon. The appendix is near the junction of the small intestine and the large intestine. The term "vermiform" comes from Latin and means "worm-shaped". Size and location The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm. The longest appendix ever removed measured 26 cm in Zagreb, Croatia. 1.The appendix is located in the lower right quadrant of the abdomen, or more specifically, the right iliac fossa.2Its position within the abdomen corresponds to a point on the surface known as McBurney's point (see below). While the base of the appendix is at a fairly constant location, 2 cm below the ileocaecal valve [2], the location of the tip of the appendix can vary from being retrocaecal (74% [2]) to being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower left side. Maintaining gut flora Although it was long accepted that the immune tissue, called gut associated lymphoid tissue, surrounding the appendix and elsewhere in the gut carries out a number of important functions The digestive tract's immune system is often referred to as gut-associated lymphoid tissue (GALT) and works to protect the body from invasion. GALT is an example of mucosa-associated lymphoid tissue. The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung, salivary glands, eye, and skin.

D i s e a s

e s The most common diseases of the appendix (in humans) are appendicitis and carcinoid tumors. Appendix cancer accounts for about 1 in 200 of all gastrointestinal malignancies. Adenomas also (rarely) present. Appendicitis (or epityphlitis) is a condition characterized by inflammation of the appendix. Pain often begins in the center of the abdomen, corresponding to the appendix's development as part of the embryonic midgut. This pain is typically a dull, poorly localised, visceral pain. As the inflammation progresses, the pain begins to localise more clearly to the right lower quadrant, as the peritoneum becomes inflamed. This peritoneal inflammation, or peritonitis Diseases , results in rebound tenderness (pain upon removal of pressure rather than application of pressure). In particular, it presents at McBurney's point, 1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus. Typically, point (skin) pain is not present until the parietal peritoneum is inflamed as well. Fever and an immune system response are also characteristic of appendicitis. Many cases of appendicitis require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, the appendix may rupture, leading to peritonitis, followed by shock, and, if still untreated, death. The surgical removal of the vermiform appendix is called an appendicectomy (or appendectomy). This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated non-operatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a relative contraindication to surgery.

A) Importance of the Case Study

The importance case presentation is to help the general public to be aware of the disease/condition. The study will try to enlighten facts concerning the case itself through simple information about health condition, its cause and risk factors, and also the management for patients with appendicitis

B) Objectives

Nurse Centered Objectives

The case finding will try to enlighten the readers especially the nursing students, what are the causes of appendicitis. It will also give the readers the chance to the different types management that a patient undergoes as to give them the knowledge on the measures needed to cure such condition. This also serves as a guide to the students to know the appropriate interventions to be carried out whenever faced with the same condition.

Patient Centered Objectives

To be able to help and educate the patient and the relatives about the condition process and the curative measures that might be used appropriately for the condition of the patient. It is also intended to educate the relatives what are the causes of the disease/condition and what are the preventive measures that can be used in order to prevent such.

Case Study Presented to the Faculty of College of Nursing Dee Hwa Liong College Foundation Sapang Maisac, Duquit, Mabalacat, Pampanga

In Partial Fulfillment of the Requirements for the Bachelor of Science in Nursing

Presented by: Group 7

Anicete, Jomel D. Bernardo, Arjay D. Capio, Michelle Jeaned P. Cuyugan, Arianne Grace T. Dimalanta, James Gregor G. Indiongco, Ramonaliza M. Macaspac, Gerald P. Morales, Bernard C. Pamintuan, Scharmen Kaye M. Pascual, Rowena S. Tuazon, Karen Joy T.

July 2009

Treatment
The treatment begins by keeping the patient Nil per os (stopping them eating and drinking), even water, in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours) general anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

The surgical procedure for the removal of the appendix is called an appendicectomy (also known as an appendectomy). Often now the operation can be performed via a laparoscopic approach, or via three small incisions with a camera to visualize the area of interest in the abdomen. If the findings reveal suppurative appendicitis with complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy incision if required most often centers on the area of maximum tenderness, McBurney's point, in the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly. In March 2008, an American woman had her appendix removed via her vagina, in a medical first.[23] According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic and open procedures, laparoscopic procedures seem to have various advantages over the open procedure. Wound infections were less likely after laparoscopic appendicectomy than after open appendicectomy (odds ratio 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (odds ratio 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after laparoscopic procedures than after open procedures. While the operation costs of laparoscopic procedures were significantly higher, the costs outside hospital were reduced. Young female, obese, and employed patients seem to benefit from the laparoscopic procedure more than other groups. [24] There is debate whether emergent appendicectomy (within 6 hours of admission) reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6 hours after admission). According to a retrospective case review study [25] no significant differences in perforation rate among the two groups were noted (P=.397). Various complications (abscess formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to the next day does not significantly increase the risk of perforation or other complications. These findings may fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are two distinct disease processes. Findings at the time of surgery suggest that perforation occurs at the onset of symptoms in atypical cases. Surgery may last from 15 minutes in typical appendicitis in thin patients to several hours in complicated cases. Hospital lengths of stay usually range from overnight to a matter of days (rarely weeks in complicated cases.)

Differential diagnosis
In children:
• Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, HenochSchönlein purpura, lobar pneumonia regional enteritis, renal colic, perforated peptic ulcer, testicular torsion, pancreatitis, rectus sheath hematoma, and in women: pelvic inflammatory disease, ectopic

In adults:

pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of an egg in the ovaries approximately two weeks before an expected menstruation cycle)

In elderly:
• diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking aortic aneurysm.

Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old) the recovery takes three weeks. The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e. outside of a proper hospital), when a timely medical evaluation was impossible. Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more difficult to diagnose and is more apt to be complicated even when operated early. In either condition prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated. Another entity known as appendicular lump is talked about quite often. It happens when appendix is not removed early during infection and omentum and intestine get adherent to it forming a palpable lump. During this period operation is risky unless there is pus formation evident by fever and toxicity or by USG. Medical management treats the condition. An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior, incomplete appendectomy

Surgery
Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected, a doctor will often suggest surgery without conducting extensive diagnostic testing. Prompt surgery decreases the likelihood the appendix will burst. Surgery to remove the appendix is called appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time. Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis.

Occasionally, surgery reveals a different problem, which may also be corrected during surgery. Sometimes an abscess forms around a burst appendix—called an appendiceal abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix. Nonsurgical Treatment Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.

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