Professional Documents
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Blood supply:
Arteries
Appendicular artery branch of posterior
cecal artery, which is in turn a branch of the
ileocecal artery, a branch of the superior
mesenteric artery
Veins:
posterior cecal vein
Lymphatic drainage:
Drains to lymph nodes in the mesoappendix and eventually into superior
mesenteric lymph node.
Nerve supply:
The appendix is supplied by the sympathetic and vagus nerves from the
superior mesenteric plexus . afferent nerve fibers concerned with
conduction of visceral pain from appendix accompany the sympathetic
nerves and enter the spinal cord at the level of the tenth thoracic segment .
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Appendicitis:
Inflammation of the appendix. Acute appendicitis is the most common
cause of acute abdomen in young adults, and appendectomy is the most
frequently performed urgent abdominal operation.
Epidemiology:
The individual lifetime risk of appendicectomy is 8.6 and 6.7 percent among
males and females, respectively.
Acute appendicitis is relatively
rare in infants, and becomes
increasingly common in
childhood and early adult life,
reaching a peak incidence in the
teens and early 20s.
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The incidence between female and male equal before puberty, at teen-ages
and young adulthood the male to female ratio increase to 3:2 at 25 then
start to decline.
Etiology:
Decreased dietary fiber and increased consumption of refined
carbohydrates may be important, but no unifying hypothesis.
Appendicitis is clearly associated with bacterial proliferation within the
appendix, but no single organism is responsible. A mixed growth of aerobic
and anaerobic organisms is usual. The initiating event causing bacterial
proliferation is controversial. Obstruction of the appendix lumen has been
widely held to be important.
Types of obstruction:
Faecoliths most common, a hard stony mass of feces in the
intestinal tract
Fibrotic stricture.
Tumor (esp carcinoid).
Parasites (esp Oxyuris vermicularis/pinworm).
Lymphoid hyperplasia.
Pathophysiology:
Obstruction of the appendix lumen increase the mucus secretion and
inflammatory exudate increase in intraluminal pressure leads to
obstruction of lymph drainage edema and mucosal ulceration develop
with bacterial translocation to the submucosa If the condition
progresses, further distension of the appendix may cause venous
obstruction and ischaemia of the appendix wall with ischaemia, bacterial
invasion occurs through the muscularis propria and submucosa, producing
acute appendicitis.
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Complications:
Mortality rate and complications in acute appendicitis are very minimal if
the doctor treats the condition early. The optimum time to treat acute
appendicitis is within (24-48 hrs) from the time that the patient developed
signs and symptoms in.
Perforation of the appendix can lead to:
1. Multiple abscesses inside the peritoneal cavity (This could lead to
septicemia and death).
2. Multiple adhesions inside the abdomen. (The patient will constantly
come complaining of intestinal obstruction then)
3. peritonitis , occurs as a result of:
Free migration of bacteria through an ischemic wall
Frank perforation of a gangrenous appendix
Delayed perforation of an appendix abscess
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Examination:
Pyrexia low grade
Localised tenderness in the right iliac fossa
Rebound tenderness : When doing the rebound tenderness test, you
must bevery gentle. Also you should not repeat the examination
many times; for that would irritate the patient and sometimes even
perforate the appendix. If the patient didn't have rebound
tenderness at the first time, we can repeat the test again after 6-12
hours.
Muscle guarding over the point of maximal tenderness
2. Usually, the patient may point to the area of most tenderness when
asked (pointing sign).
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Special cases
1. Retrocecal
The presentation might not be fast and straight forward, Rigidity often
absent, and even deep pressure may fail to elicit tenderness (silent
appendix), because the appendix is hiding behind the cecum, , there may
be rigidy of quadratus lumborum, and deep tenderness often present in
loin, so there won't be any clear features on examination for the first time.
But after 2-3 days the presentation will become very prominent. So don't
ignore the patient even if the presentation is not typical or clear because at
the time that the presentation gets clear, it might be too late and the
patient will suffer more than he has to.
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Diagnosis
The diagnosis of acute appendicitis is essentially clinical
A number of clinical and laboratory-based scoring systems have been
devised to assist diagnosis "the most widely used is the Alvarado score
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Treatment
Urgent appendicectomy;
o Gridiron incision "Mc Burney's incision".
o Lanz incision " A variation of the traditional Mc Burney's incision,
which was made at McBurney's point on the abdomen: The Lanz
incision is made at the same point along the transverse plane and
deemed cosmetically better. It is typically used to perform an
open appendectomy"
o Laparoscopic.
Short intensive preoperative prep:
- IV fluid
- Antibiotics - Hyperpyrexia
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