Appendicitis

Disorders of the appendix ANATOMY OF THE APPENDIX • Lumen is lined by colonic epithelium and the submucosa contains lymphoid follicles which are prominent in childhood but regress during adolescence • In older patients, the lumen may be obliterated by fibrosis • It develops as a colonic diverticulum which projects from the medial wall of the • Variation in positions – in order of incidence o Retrocaecal o elvic o ost ileal o re ileal o ara!caecal o "ub caecal

Aetiology and Pathophysiology
#$ %ccumulation of secretions distention and necrosis of the mucosa$ &ranslocation of gut bacteria across the wall '$ Lymphoid hyperplasia within the wall predisposes to obstruction ($ )lder patients* a$ inspissated faeces +faecoliths,, b$ fibrosis c$ adhesions d$ neoplasia -$ "ymptomatic patients may progress to gangrene and perforation of the appendix if not removed since continuing obstruction will impair blood supply .$ /efore fran0 perforation bacteria may migrate through damaged wall and cause inflammation of parietal peritoneum 1$ if infection remains contained following perforation – appendix mass or abscess but peritonitis is more common 2$ the common positions for the appendix are retrocaecal and pelvic

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occur later once peritonitis has ensued :etor oris +non!specific sign. locali3ed worse on moving or coughing Anore"ia# nausea %o&iting is rare &enderness and guarding are acute signs 4aximal tenderness at 4c/urney6s point +#7( of the way along the line from the right anterior iliac spine to the umbilicus Rebound tenderness and hyperesthesia o' the s(in :ever and tachycardia are not acute signs.Clinical Features #$ '$ ($ -$ ! $! 2$ 5$ 8$ #9$ ##$ #'$ #($ #-$ #. rectum irritated +diarrhoea.uency &here may be no tenderness in the RI: if there is a retrocaecal appendix and maximal tenderness may be in the right flan0 or loin elvic appendix! associated with bladder irritation. Per'oration o' the appendi" • Diffuse peritonitis leads to generali)ed tenderness# guarding and rigidity • &enderness is still maximal in RI: • If infections remains locali3ed. Rovsing6s sign –pressure on the left iliac fossa causing pain on the right I: soas sign! pain during passive extension of the right hip )bturator sign! internal rotation of the flexed right thigh causes pain /owel sounds! normal or reduced in fre.  ill locali3ed 4idline structure during development therefore pain starts centrally  4ild to severe ain shifts to right iliac fossa as parietal peritonitis ensues!sharp. a mass of o&entu& and neighboring viscera may become palpable on abdominal or rectal examination ' .$ #1$ #2$ ain normally begins as periumbilical colic +visceral pain due to appendiceal obstruction.

ENTIA. o erinephric abscess.ICAo %cute "alpingitis o Rupture of an ectopic pregnancy o ID ! . o /asal pneumonia o Diabetic ?etoacidosis ( .NO/I/ OF AC+TE APPENDICITI/ ! INTE/TINAo =astroenteritis o Intestinal obstruction o Acute &esenteric adenitis o In'la&&ation o' Mec(el0s di1erticulu& o Acute ter&inal ileitis o Diverticular disease o perforated colonic carcinoma o %cute cholecystitis o perforated duodenal ulcer ! . o acute pyelonephritis +all mimic retrocaecal appendicitis ! OTHE.DIA.Diagnosis • • • • • • • • rimarily a clinical one Repeated clinical assessment over a period of a few hours Do a P% e"a& and chec0 for all the gynae stuff Do a </< A*do&inal ultrasound may be used to rule out gyn conditions Pregnancy test to rule out ruptured ectopic pregnancy )ften there is a mild leu0ocytosis +rine may contain a few pus cells or red cells if inflamed appendix lies near to the urinary trac0 • A*do&inal radiography may show distended small intestinal loops due to a locali3ed ileus or a fecolith • Definite diagnosis with laparoscopy – usually unnecessary DIFFE.ENAo >reteric colic.YAECO-O.

EATMENT #$ "urgical removal of appendix before perforation and gangrene can occur '$ preop resusc is only needed when there is gen peritonitis ($ &etronida)ole and a *road spectru& cephalosporin are usu used -$ appendi" should *e sent 'or histo e"a&. to confirm and to exclude malignancy . pain and tenderness is li0ely to be abscess c$ Cote that abscesses behind the caecum or terminal ileum may produce psoas spas&$ x will lie with right hip flexed d$ >" and <& can help ID locali3ed pus or matted loops of intestine e$ %n appendi" &ass can *e treated *y I% A*"# I% 'luids and NPO 2ith an inter1al appendecto&y per'or&ed so&e 2ee(s later$ f$ Immediate surgery is made difficult by the inflammatory mass but has the benefit of a shorter hospital stay and some surgeons now prefer to do the operation one time$ Digh ris0 of relapse when the conservative approach is used$ "urgery involves - .-Y a$ gangrene and perforation are more common b$ be aware of diagnosis c$ rompt surgical treatment 5! APPENDIX MA// AND APPENDIX A6/CE// a$ Ahen presents.T.$ s2a* ta0en for bacterial culture /pecial /ituations 3! Pregnancy a$ @arly diagnosis is vital b$ /y (rd trimester the appendix is displaced upwards. therefore pain and tenderness are more superior c$ Rectal and vaginal examinations may not be helpful d$ Ahite cell count is normally elevated in pregnancy e$ B!ray is contraindicated f$ Delay is harmful to both mother and child and threshold for diagnosis is no different than for non pregnant woman – diagnose and treat 4! E-DE. the diagnosis of Crohn0s should be thought of$ b$ increasing pyrexia.

ambulating and eating a regular diet$ d$ Cote in a nonperforated appendix you give %bx for a day after surgery but when perforated you continue %bx for (!2 days$ ! Note that i' a nor&al appendi" is disco1ered8 a$ Remove to avoid later confusion when maybe appendicitis develops in a patient with an appendectomy scar b$ Inspect for other causes of pathology – =I& and gynae COMP-ICATION/ OF APPENDICITI/ • =enerali3ed peritonitis o rompt appendicectomy following IV: and IV %bx o % limited right hemicolectomy may be necessary if appendiceal base has ruptured • elvic abscess • Liver abscess • :ree perforation • ortal thrombophlebitis – very rare COMP-ICATION/ OF APPENDECECTOMY • Aound infection • "mall bowel obstruction • enterocutaneous fistula • Infertility in the case of perforation in women • Increased incidence of right inguinal hernia • "tump abscess .FO.ATED APPENDIX a$ 4ay be ass with temporary easing of the pain but the onset of diffuse abdominal pain and tenderness. fever and tachycardia  i$e$ generali3ed peritonitis b$ "urgery is immediately planned while the patient is resuscitated with IV fluids and systemic broad – spec %bx$ % limited right hemicolectomy may be necessary c$ In the case of a perforated appendix.surgical drainage and appendicecto&y 2hile a1oiding disse&ination o' pus through the a*do&inal ca1ity 7! PE. you give %bx until the pt is afebrile with a normal A/<. .