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Appendicitis Aa

Appendicitis Aa

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CHAPTER 1

Acute appendicitis (AA)
Latin - appendicitis acutathis is an acute inflammatory disease of appendix, the causal organism of this disease, as a rule, is unspecific purulent infection. Patients with AA make 20-50% of all sick persons in surgical departments Appendectomy makes 70-80% of all surgical interventions in patients with urgent pathology. The disease is more frequent met in the age of 10-40 years. Level of postoperative lethality is 0,2-0,3% Reasons of death at AA: -late resort for medical aid - doctors errors in diagnostics of AA (primary care physician make 55%, doctors of first-aid - 35%, surgeons - 10%)

Anatomy and physiology of the appendix

The ileocecal part of intestine includes: - terminal part of iliac intestine; - cecum; - Baouginiy’s valve; -appendix (Fig 1.1). Appendix joins to cecum on postero-medial wall, in a place, where three ribbons of longitudinal muscles of colon(tenia coli) meet and represents a cylinder, it’s length is 6-12 cm. and the diameter is 0,5 cm. Appendix is covered by peritoneum from all sides, it has its own mesentery - mesoappendix, Fig.1.1 Blood supply :( Fig, 1.1) Vessels and nerves pass in mesoappendix. The wall of appendix consists of serous layer, muscular layer, and submucous layer, where the lymphatic follicles are located, and mucous layer the

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superior mesenteric artery gives the ileocolic artery, and this gives the appendicular artery.

2 Veins - the vein of appendix runs into the ileocolic vein, and this runs into the superior mesenteric vein. The last with the inferior mesenteric and splenic veins form the portal vein. Innervation of ileocecal part of intestine is provided by solar plexus, by upper and lower mesenteric plexus.
Fig.1.2 Inflamed appendix

Variants of location of appendix in the abdominal cavity 1. Retrocecal (12 o'clock). 2. Pelvic in 20% of cases (4 o'clock). 3. Pre ileal and post ileal in about 70% patients (2 o'clock). 4. Subcecal (6 o'clock). 5. Paracecal. 6. Subhepatic appendix is associated with subhepatic caecum. It occurs due to malrotation of the gut.
Fig.1.3 Variants of location of appendix in the abdominal cavity

Physiology of appendix

- Secretory - mucus layer produces juice, which contains mucus, traces of enzymes such as amylase, lipase; - Retractive - the poorly expressed peristalsis provides evacuation of contents; - Hemopoietic, lymphopoietic, - Immune, thanks to accumulation of lymphoid tissue;
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which can be activated at favorable terms (stagnation.Nonclostridial anaerobes that inhabit the colon (Peptococcus. proteus and other enterobacteria). -Hematogenous way in bacteriemia. The supporters of this theory consider that the reason of beginning of inflammation and of defeat of mucus layer is allergic reaction antigen-antibody. bacteroids and others). Neuro reflex (nervous-trophic). tumors of appendix.I. Theories of pathogeny of AA 1. that inhabit large intestine (intestinal bacillus.Specific infection: tuberculosis. its amount. 3. foreign body). The ischemia is caused by the long-standing spasms (appendiceal bauginio spasm). . Allergic (immunological). Classification of AA by V. actinomycosis.Colesov 3 . excrement stones. streptococcus. virulence. sometimes Crown’s illness. helminths. when appendix with its lymphoid tissue becomes the target organ . fousobacterias. . It is possible in women on right-side adnexitis through the Clado’s ligament.Lymphogenous way is rare. . Allergization is caused by penetration of alimentary and microbic antigens into the immune components of mucus layer (lymphatic follicles). 2. abdominal typhus.is rare too. pathogeny of AA The microbes of purulent infection: .Etiology. or spasms of vessels of this region.Aerobes.from the lumen of appendix through mucus layer as a result of loss of barrier function. .to lymphatic vessels from the nearby organs. salmonella. Leading role in the development of disease the supporters of this theory give to the infection of appendix. Peptostreptococcus. Ways of penetration of infection: • • • .Mixed aerobic-anaerobic infection. Infectious. The reason of all is necrosis of mucus layer of appendix which is the result of its durable ischemia. . staphylococcus.Enterogenous way .

Temperature of body subfebrile is marked. Residual chronic appendicitis. 2. as a rule. 3. from stomach-ache. c) Peritonitis of appendiculars origin.Spontaneous pain in the right iliac fosse. moderate intensity. neutrophilia. Local symptomatology: The most informing from them are: 1. d) Empyema of appendix. Delay of defecation. b) Gangrenous. In children with toxic forms of AA diarrhea can appear. Acute simple (superficial) appendicitis. but can be localized from the beginning in right iliac region. vomit is more frequent single. d) Other complications (pylephlebitis. Clinic’s of AA General symptomatology: The attack of acute appendicitis begins. (II). absence of irradiation.(I). sepsis and others). c) Perforative. Acute destructive appendicitis: а) Phlegmonous. Recurrent chronic appendicitis. gases is expressed. 2-3 hours from the beginning of disease in 50% of patients nausea appears. For AA are characteristic gradual progression of pain and its permanent character. At objective examination of patients tachycardia is determined. Acute appendicitis 1. then it moves to right iliac region (s-m of Volcovich-Koher). Chronic appendicitis Primary chronic appendicitis. Complicated acute appendicitis: а) Appendicular infiltrate. In 20-40% of cases the pain arises up at first in epigastric region. b) Appendicular abscess. too. In clinical blood test moderate leukocytosis is marked (up to 10-12X10/l). 4 . shift of neutrophils to the left are marked. D'elofoua’s triad (classic triad of AA) .

In clinical picture there is only pain syndrome and there are no expressed signs of inflammatory process . 6.pain on palpation in the right iliac fosse is more expressed. . 2. or even gangrenous appendicitis.pain in right iliac fossa on impulse motion in the projection of descending part of large intestine with fixing of sigmoid intestine. This phase is called by some authors an epi gastral phase. Bartom'e-Mihelson’s symptom .functional phase of AA. Sitcovskit’s symptom . • • Appendicular colic . 8.Phase of local inflammatory or inflammatory-destructive changes.it is strengthening of pain at pressure in right iliac fosse during the bending of right leg in coxofemoral joint. Three phases of the AA by Rusanov A. Coup’s symptom 1 – it is appearance of pain in right iliac fossa at passive overextension of right leg in the coxofemoral joint.increase of temperature of body. because the pains in this phase are more frequent localized in the epi gastral region. phlegmonous.A. but the feature of it consists in that inflammatory process is limited to the right iliac fosse.it is appearance of pain at the palpation in the region of Petit’s triangle from the right side (at retrocecal AA). 5 .Hyperesthesia of skin of right iliac region. and local peritoneal symptoms are absent. when patient lies on the left side. leucocytosis. when ischemia of mucus layer of appendix does not result in necrosis.Tension of muscles of right iliac region on palpation of abdomen. it does not go outside of it. Yaoure-Rozanov’s symptom . . Voscresenskiy’s symptom 1 . if a patient lies on the left side than on the back. 4.. 3.it is appearance of dragging pain in the right iliac fossa.it is strengthening of pain in right iliac fosse during the sliding palpation through the strained shirt from the epigastrium to the right iliac region (symptom of shirt). Pathomorphologically the process can look likes superficial. 7. 5. Obraztsov’s symptom . Rovsing’s Symptom .

Diagnostics of AA.4 Abdominal ultrasound examination showing features of acute appendicitis.longitudinal scan (left) & transverse scan (right). Sitcovskiy’s. In the analysis of blood leucocytosis.• Clinically both general and local symptoms are expressed in this phase of appendicitis. Bartom'e-Mihelson’s symptoms.4) 6 . In this phase the symptoms of endogenous peritoneal intoxication are on the first plan. disended edematous appendix (open arrows).1. local and spread peritoneal symptoms in other departments of the abdomen take very important role. too.A fecalith is seen (closed arrow).1. increase of temperature of body. Additional examinations . Voscresenskiy’s. neutrophilia. but they are determined only in the right iliac fosse. Obraztsov’s. For the confirmation of diagnosis clinical blood test and analysis of urine are done. including the local symptoms of irritation of peritoneum. at objective examination –positive Rovsing’s. nausea. -Abdominal ultrasound (Fig. Diagnostics of AA is based on revealing of characteristic complaints about permanent pain in the right iliac fosse.Laparoscopy -Diagnostic laparotomy Fig. neutrophil shift to the left are determined. Phase of spreading of inflammation on peritoneum. or Volcovich-Koher’s symptom.

not enough developed lymphoid system and large omentum which achieves the right iliac fosse only in 7 years.5 Abdominal contrast-enhanced CT scan Clinical Features and peculiarities of AA and surgical tactic’s in children AA in children of the first year of life meets very rarely. Fig. and AA is more frequent complicated by the perforation of appendix and peritonitis.Fig.5 Abdominal contrast-enhanced CT scan showing a fecalith (open arrow) at the base of a distended (>0. Quite often AA in children of the first year of life pain and strain of muscles of right iliac fosse are the single 7 . That is why there are no cases of forming of appendicular infiltrate in children of early age. The clinical picture and run of AA in children are caused by the anatomo physiological features of child's organism: not enough developed nervous and blood system.1. The disease begins often with the high temperature of body (3940°C). The diagnostics of AA in children of early age is very difficult because it is impossible to collect the anamnesis and to define pain symptoms which are used for adults.1. It is necessary to carry out the palpation on mother’s hands. With repeated vomits.6 cm) appendix with intramural gas (white arrows). quite often it is accompanied by diarrhea. The examination of child is difficult because the palpation of abdomen results in crying and in active strain of muscles of the abdomen walls.

5th month the increased uterus displaces upwards the cecum and appendix. 8 . Darter’s symptom percussion of the right heel at peritonitis at child results in bringing child’s hands to the lower part of abdomen. Appearance of pain. Rovsing’s symptoms are rarely determined at objective examination. but by 4th. For AA in pregnant the acute beginning of disease with the pain in lower part of right half of abdomen is characteristic.1. or the strengthening of pain in the right iliac fosse at pressure on the left rib of pregnant uterus (Brenda’s symptom).a child pushes away the hand of surgeon. Operation .6 (Peculiarities of female pelvis) Pregnancy of the first three months has no influence on clinic of AA. Tension of muscles of abdomen and also Shotcin-Bltomberg’s. AA at children is accompanied by high leucocytosis (up to 18-20*10/9) with the shift of neutrophils to the left. when he carries out the palpation of the right half of abdomen.symptoms. Clinical Features and peculiarities of AA and surgical tactic’s in a pregnant women Fig. A pain feeling on palpation of the right iliac fossa is determined by the symptom of "pushing away of hand" .appendectomy in children is carried out under general anesthesia and just ligation method is used due to fragile caecum.

Endotracheal narcosis is the main method of anaesthetization. Anesthesia – mainly local infiltration anesthesia. In the blood test the amount of leucocytes can be normal. Artificial breaking of pregnancy in such cases is the rough tactical error. tension of muscles of abdomen is absent in 50% of cases. Shotcin-Blumberg’s symptom is poorly expressed. but it is displaced upwards the more. There are different operating accesses 9 . In the second half of pregnancy Volcovich-D'yaconov’s operational access is used. and more constant sign of AA is the neutrophil shift to the left. In acute peritonitis of appendicular nature medical tactic does not differ from tactic in other case. or it is normal. when the patient lies on the right side (Michelson symptom. or Sitcovskiy’s reverse symptom). are exposed to immediate appendectomy. AA in old age The temperature of body rises insignificantly. Early operation is the single method of treatment. Leucocytosis is not always observed in the blood test because the reduction of reactivity of organism is present. prescribing of sufficient anesthetic and spasmolytic therapy in postoperative period are necessary for saving of pregnancy. than the term of pregnancy is greater. the special symptoms are poorly expressed. Appendectomy is the single method of treatment of AA. More frequent there is paresis of intestine. narcosis is used only in case of peritonitis. Carefulness of manipulations in the area of uterus and appendages.Strengthening of pain in the right half of abdomen. Surgical tactic consists in all patients with AA. but often the expressed neutrophil shift to the left in leukogram is determined.

it is carried out in case of doubt in the diagnosis (AA or cholecystitis. as well as the previous. and ascitis. Incidence 2. Lenander’s access .Fig. but avoiding traumas of muscles. 3. it is parallel to the inguinal ligament. 2. PYLEPHLEBITS (portal pyemia) Pylephlebitis can be defined as a pus-producing inflammation of the wall of the portal vein that drains blood from the abdominal part of the gastrointestinal tract. 5.8 1. AA or urgent diseases of appendages of uterus).1.1. Lekser’s access . 4.Minimum invasive surgery carried out with the help of videolaparoscope creating pneumoperitoneum with the help of probes. It usually occurs as a complication of abdominal or pelvic infections such as diverticulitis and appendicitis. . Lower middle laparotomy – it is carried out in case of spread peritonitis of appendicular origin.000 Etiology 10 .1. like liver damage fever. and the center of this cut is Mac-Barney’s point. Or septic inflammation and thrombosis of the hepatic portal vein.8) .right-side pararectal cut. 3 per 100.7 Fig. This is a rare result of spread of infection within the abdomen (as from appendicitis) this condition causes severe illness.through the Spigeliy’s line. Volcovich-Dyaconov’s (Mac-Barney’s) access (Fig1. abscesses.through the Mac-Barney’s point. The infection is often fatal. Laparoscopic Appendectomy (Fig.7) Cut in the right iliac fosse.

The superior mesenteric vein is involved in 34 percent of cases series. Mesenteric vein involvement can lead to bowel ischemia. (mild) nausea Epigastric pain or pain in the upper abdominal quadrant Tenderness in right hypochondrium due to hepatomegaly There may be unexplained sepsis with few early localizing signs. diverticulitis and chronic cholecystitis Pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system. Pathogenesis Pylephlebitis begins with thrombophlebitis of small veins draining an area of infection. also aerobic gram negative bacteria are common Underlying causes can be appendicitis. then rapid progression to gangrene and perforation of the gallbladder 11 . Clinical features Chills High Fever Vomiting. frequently polymicrobial Most common organism: B. infarction and death. which can extend further to involve the mesenteric veins. fragilis.88% of cases are associated with bacteremia. Extension of the thrombophlebitis into larger veins leads to septic thrombophlebitis of the portal vein.

1.1.Fig. Complications Mortality (11%-32%) Portal hypertension Fetal death in pregnant women PERI-APPENDICULAR MASS (APPENDIX MASS/INFILTRATE) The mass is composed mainly of greater omentum.9 Fig. & in its middle is a perforated or otherwise inflamed vermiform appendix.10 Medical history can be used as a basis for diagnosis CT scan (Fig. Surgical Treatment Surgical drainage of abscess and dead tissue removal. Treatment Conservative treatment a. edematous portions of small intestine. 12 .1. Ligation of inflamed vein.10) shows increase in size of liver and changes in portal vein (e. edematous cecal wall. Thrombosis) Blood cultures help to determine the causative agent. Treatment of underlying cause such as appendicitis.1. Anticoagulation therapy In cases of portal vein thrombosis Heparin initially 5000 to 10000units IV push. then adjust dose according to result and give 4000 to 5000units 4 hours.9) usually reveals signs of septic thrombophlebitis Ultrasound (Fig. Antibiotic treatment: Broad spectrum antibiotics that cover gram-negatives and anaerobes until definitive ID of organism is detected: b.g. Removal of thrombosis. cholecystitis and diverticulitis.

Clinical Features Symptoms History of acute appendicitis. NOTE: Diffrential diagnosis should be carried out making sure carcinoma caecum is outlined with the help of irrigography before starting conservative therapy. & as the rigidity passes off its periphery can be defined clearly. then conservative treatment is performed as follows: (1) Charting :(a) every four hours Pulse. (2) Diet (a) Water. every four hours (b) Temperature. & subsides slowly as inflammation resolves.10th day (a) Swelling becomes larger. (2) By 4th or 5th day Mass becomes more circumscribed.Sherren regimen If the condition of patient is satisfactory. & an appendix abscess results. 30 ml hourly. TREATMENT CONSERVATIVE TREATMENT (A) Ochsner . 3-4 days back. Signs (1) On 3rd day after the onset of acute appendicitis (a) A tender mass is felt in right iliac fossa (or in pelvis). (c) Watch for vomiting. 13 . or (b) It becomes smaller. transnasal gastric aspiration is performed. (b) Some rigidity of overlying musculature. if excessive or recurrent. (3) During 5th . given by mouth.

usually about 4th-5th days. is an indication that satisfactory progress is being made. & metronidazole. gentamicin. OPERATIVE TREATMENT (B) Operative treatment Appendicectomy is indicated if in spite of conservative treatment there is: (1) Increasing or spreading abdominal pain due to perforation. (4) Drugs (5) Antibiotic therapy (a) Parenteral ampicillin. (2) Abscess formation. a glycerin suppository is given. 14 to fluid balance chart & daily assay of . & that oral feeding may be started. (6) Bowels If bowels are not opened naturally by 4th or 5th day. (b) Oral antibiotics when oral feeding is resumed.(b) Desire for food. (7) Antithromboembolic therapy Prophylaxis against thrombosis of pelvic & leg veins should be given with compression stockings & subcutaneous low-dose heparin or fraxiparin. ATTN: There may be two ways of development/course of this condition. (3) Intravenous fluids Given according electrolytes.

Patient should be discharged & called back after 2-3 months for conduction of planned appendectomy. (2) Secondly if the appendicular infiltrate does not respond to conservative treatment & the infiltrate convert to abscess. Appendiceal polyps are similar to those in the rest of 15 . pain & size of infiltrate-are signs of appendicular abscess formation. USG provides additional evidence/assessment of the condition of the appendicular infiltrate during the conservative treatment. paraganglioma. Leucocyte count also helps to assess the condition of the patient. Primary appendiceal tumors Table: Primary appendiceal malignancies Type of tumor Frequency (%) Carcinoid 85 Mucinous cystadenocarcinoma 8 Adenocarcinoma 4 Adeno carcinoid 2 Others: sarcoma. Patient feels unwell with increased temperature. And granular cell tumors 1 Benign tumors Benign tumors are also rare and comprise two groups: polyps and adenomas. Extraabdominal drainage of appendicular abscess to be done by retroperitoneal approach & the incision is closed by secondary intention in 2-3 weeks depending on patient’s recovery. The patient fells well & symptoms disappear. (3) Appendicular perforation is an indication of lower midline emergency laparotomy.(1) Firstly if the appendicular infiltrate responds well to the conservative treatment & regress or disappears completely within 2-3 weeks.

the colon and may therefore have varying degrees of malignant transformation. At least 50 per cent of all carcinoid tumors originate in the appendix. an adenoma of the appendix tends to be diffuse and villous. Preoperative ultrasonography. They are common 16 . but the mucus is usually contained in the right iliac fossa (localized pseudomyxoma peritonei). Benign lesions of the appendix are usually asymptomatic and are usually found incidentally at exploration or pathologic examination. Localized pseudomyxoma peritonei usually resolves after appendectomy and excision of local mucin deposits. those with appendiceal polyps should undergo colonoscopy to rule out synchronous colorectal adenomas or carcinoma. On pathologic examination. occurring in up to 0. or magnetic resonance imaging (MRI) of patients with a cystadenoma should reveal a fluid-filled. Cystadenomas may present with acute appendicitis or a palpable mass. Cystadenomas can occasionally rupture. computed tomography (CT). Excessive production of mucus by an adenoma causes a large sausage-shaped cystic mass referred to as a cystadenoma. Malignant tumors Carcinoid tumors The most common tumor of the appendix is a carcinoid. Similar to patients with colonic polyps. unlike its colorectal counterpart. thin-walled structure in the right lower quadrant containing low density contents.5 per cent of appendectomy specimens and accounting for 85 per cent of all appendiceal tumors. Benign tumors Benign tumors are cured by appendectomy provided that the resection margin is negative. variableshaped.

Adenocarcinoma Adenocarcinoma of the appendix is much less common than carcinoids and accounts for 0. Patients usually present with symptoms of acute appendicitis or a right lower quadrant mass. Mucinous cystadenocarcinoma Cystadenocarcinoma is the second most common appendiceal malignancy and one that many times can be diagnosed preoperatively.1 per cent of all performed appendectomies. DIFFRENTIAL DIAGNOSIS Perforated Peptic Ulcer 17 .in young women and are detected incidentally at abdominal exploration or present with signs of acute appendicitis. Adeno carcinoid Patients with adeno carcinoid tumors are usually symptomatic presenting with acute appendicitis. About 50 per cent of these patients will have intra-abdominal metastases and pseudomyxoma peritonei. A barium enema may show a non-filling appendix with a globular mass. CT demonstrates a mass near water density with calcium in its wall. an abdominal mass. or an ovarian mass. The mean age of presentation is 50 years and men are affected more than women. Mucocele An appendiceal mucocele leads to progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance. Most patients are 40 to 50 years old.

may mimic a retroileal acute appendicitis. thus minimizing upper abdominal findings. even significant signs and symptoms. Recurrent chronic appendicitis SIGNS AND SYMPTOMS Chronic appendicitis is rare and not only that. scrotum.Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents gravitate down the right gutter to the cecal area and if the perforation spontaneously seals fairly soon. or penis. primary chronic appendicitis b. and particularly bacteria in the urine usually suffice to differentiate the two. Ureteral Stone If the calculus is lodged near the appendix. and/or absence of fever or leukocytosis suggest stone. Pain referred to the labia. pus cells. it is slower in its progress and less intense. Pyelography usually confirms the diagnosis. right costovertebral angle tenderness. Residual chronic appendicitis c. on the right side particularly. it may simulate retrocecal appendicitis. Chills. Urinary Tract Infection (right sided renal colic) Acute pyelonephritis. CHRONIC APPENDICITIS CHRONIC APPENDICITIS :Chronic appendicitis usually refers to a milder form of the illness and almost UN perceivable symptoms this may include inflammation of the vermiform appendix with recurring attacks of right-sided abdominal pain over an extended period of time or simply Recurring inflammation of the appendix. Chronic appendicitis is classified as: A. hematuria. Symptoms of chronic appendicitis include patient merely feeling 18 .

Other symptoms include: Lethargy. A partial obstruction of the appendix and milder bacterial infection are the main components in the chronic appendicitis making it important symptoms of chronic appendicitis. In many patients. Blood tests: Complete Blood Count with Blood Biochemistry Urine analysis. Laproscopy TREATMENT AND MANAGEMENT 19 . CT scan Abdomen. the pain is mild as the patient is quite accustomed with the abdominal pain. nausea and fatigue. Apart from its normal symptoms. Colonoscopy.exhausted and generally unwell. The symptoms resolve with appendectomy. compatible with acute appendicitis. stool Analysis Diagnosis Abdominal and Pelvic Ultrasound. Change in bowel habit DIAGNOSIS Complete History and Physical Examination including pelvic and rectal examination The history usually includes an acute illness at some time in the past. the appendix is chronically inflamed or fibrotic. particularly in children. which was managed nonoperatively. On examination. Barium x-rays are sometimes helpful. the diagnosis is not obvious.

Instead.Treatment of chronic appendicitis usually doesn't involve surgical removal of the appendix. relaxation. Supportive Therapy. Of course. IV Fluids Specific Therapy Antibiotics ( Cefoxitin/ Ampicillin/Gentamicin/Metronidazole amoxicillin/clavulanate potassium 1 gram. intra venous initially and then orally for one or two weeks because of relapsing nature a constant and long term antibiotic therapy is required. 3 times a day. doctors will probably opt for its removal Rest. despite such measures being common for the acute form of the disease. Sufferers of chronic appendicitis may have to take the drugs over time to help beat their disease. one dose of antibiotics won't do the trick. since chronic appendicitis can be somewhat tough to treat. and pain-killers are the usual steps involved in the recovery process following surgery. Surgical Management Laparoscopic Appendectomy Management of Complications Abscess  Drainage Perforation  Laparotomy 20 . Yet. doctors prescribe powerful antibiotics to help fight the infection. if there is a threat that the chronic appendicitis may actually make the appendix burst.

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