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VERMICULAR APPENDIX

5. History
• CLASSIC VISCERAL-SOMATIC SEQUENCE OF PAIN
1. Blind muscular tube
§ Abdominal pain that has shifted and change in crahacter
2. 7.5cm – 10cm
§ Poorly localized colicky abdominal wall
3. Base of appendix
Ø Midgut visceral discomfort
• at confluence of three taeniae coli of caecum, which fuse to form
Ø Periumbilical region
outer longitudinal muscle coat of appendix
Ø Anorexia, nausea, Murphy (vomiting that follows onset
4. Mesoappendix
of pain)
• arise from lower surface of mesentery or terminal ileum § Right iliac fossa pain
5. Appendicular Artery Ø Due to progressive inflammation of appendix
• branch of lower division of ileocolic artery, passes behind terminal Ø Parietal peritoneum irritation
ileum to enter mesoappendix Ø More intense, constant and localized
• end-artery à thrombosis à gangrenous appendicitis Ø Cough / movement exacerbates the pain
6. Lymphatic channels
• Transverse the mesoappendix to empty into ileocaecal lymph node • ATYPICAL PAIN
7. Microscopic § ELDERLY
• Columnar cell intestinal mucosa if colonic type Ø Predominantly somatic or visceral and poorly localized
• Crypts § INFLAMED APPENDIX IN PELVIS
• Argentaffin cells (Kulchitsky cells) à carinoid tumor Ø Never produce somatic pain involving anterior
• Mucosal, submucosal (lymphatic aggregation . follicle) and serosal abdominal wall
layer Ø Suprapubic discomfort and tenesmus
8. Location Ø Tenderness may only elicited in per rectal examination
• Retrocaecal 74%
• Pelvic 21% • Slight fever, slight tachycardia à after 6 hours
• Paracaecal 2%
• Subcaecal 1.5% • CLINICAL SYNDROMES
• Preilial 1% § ACUTE CATARRHAL (NON-OBSTRUCTIVE)
• Postileal 0.5% § ACUTE OBSTRUCTIVE
Ø Acute / sudden
Ø Generalized abdominal pain
ACUTE APPENDICITIS Ø Temperature may normal
Ø Vomiting common
1. Infants (rare), childhood (common), teens & early 20s (very common) Ø May mimic acute instestinal obstruction
2. Male: female à 3:2 ( after puberty) Ø Once confirmed à UURGENT SURGERY!

3. AETIOLOGY 6. SIGNS
• ↓ dietary fiber & ↑ refined carbohydrate • Unwell
• Associated with bacterial proliferation • low grade pyrexia
§ mixed aerobic and anaerobic • localized abdominal tenderness
• Luminal obstruction • limitation of respiratory movement in lover abdomen
§ Faecolith à inspissated faecal material, calcium phosphate, • MUSCLE GUARDING (over point of maximum tenderness
bacteria, epithelial debris, foreign body (McBurney point))
§ Fibrotic stricture à indicates previous appendicitis that • REBOUND TENDERNESS (cough or gentle percussion over site
resolved without surgical intervention maximum tenderness)
§ Caecum carcinoma à obstruct appendiceal orifice • POINTING SIGN à point where pain began and where it moved
§ Intestinal parasites à Oxyuris vermicularis (pinworm) • ROVSING’S SIGN à deep palpation of left iliac fossa (pain in
right iliac fossa)
4. Pathology • PSOAS SIGN à right hip flexed (relief pain)
• Obstruction of lumen • OBTURATOR SIGN à hip flexed nad internal rotate (pain in
• Mucosal inflammation hypogastrium)
• Lymphoid hyperplasia à obstruct lymphatic drainage à edema • CUTANEOUS HYPERAESTHESIA à right iliac fossa
§ Resolution à spontaneous / antibiotic
§ Progress 7. SPECIAL FEATURES (SITE)
Ø further distension à venous obstruction & ischemia à • RETROCAECAL
bacterial invasion à ACUTE APPENDICITIS à § Rigidity absent
ischemic necrosis à GANGEROUS APPENDICITIS § Silent appendix (deep palpation fail to elicit tenderness)
à bacterial contamination of peritoneal cavity § Deep tenderness in loin
Ø greater omentum & loops pof small bowel à adhere to § Rigidity of quadrates lumborum
inflamed appendix à walling off spread of of § Psoas spasm (positive psoas sign)
peritoneal contamination à PHLEGMONOUS MASS § Hyperextension of hip joi n induce abdominal pain (due to
/ PARACAECAL ABSCESS contact with psoas)
• PERITONITIS • PELVIC
§ Due to free migration of bacteria through § Early diarrhea
Ø ischemic appendicular wall § Absent abdominal rigidity
Ø frank perforation of gangrenous appendix § Lacking tenderness over McBurney point
Ø delayed perforation of appendix abscess § Tenderness just above and to the right of symphisis pubis
§ factors § Rectal examination à tenderness in rectovesical puch /
Ø extremes age pouch of Douglas
Ø immunosuppresion § Psoas sign and obturator sign
Ø DM § Frequency of micturition (contact with bladder)
Ø Faecoliths obstruction of appendical lumen • POST-ILEAL
Ø Free-lying pelvic appendix § Rare
Ø Previous abdominal surgery à limits ability of greater § Pain not shifted
omentum to walling off spread of peritoneal § Diarrhea
contamination § Marked retching
§ Tenderness, if any, is ill defined
8. DIFFERENTIAL DIAGNOSIS 9. INVESTIGATION
(REFER BAILEY AND LOVE FOR DETAILS)

• CHILDREN
• ROUTINE
§ Acute Gastroenteritis
§ FBC
§ Mesenteric Lymphadenitis
§ Urinalysis
§ Meckel’s diverticulum

§ Intussusception
• SELECTIVE
§ Henoch-Scholein Purpura
Ø UPT
§ Lobar pneumonia and pleurisy (right base)
Ø Urea & electrolytes
• ADULTS
Ø Supine abdominal radiograph
§ Terminal ileitis (in acute form)
Ø u/s abdomen/pelvis
§ Yersinia Enterolitica
ü children, thin adult,suspect gynaecological pathology
§ Ureteric Colic
Ø contrast enhanced CT scan of abdomen
§ Right-sided acute pyelonephritis
ü elderly if uncertainty
§ Perforated Peptic Ulcer

§ Testicular Torsion
• ALVARADO SCORE
§ Acute Pancreatitis

§ Rectus sheath haematoma

• ADULTS FEMALE

§ Pelvic inflammatory disease

§ Mittelschmerz

§ Torsion / haemorrhage of ovarian cyst

§ Ectopic pregnancy

• ELDERLY

§ Sigmoid diverticulitis

§ Intestinal obstruction
ü 9-10 : definite
§ Carcinoma of caecum
ü ≥ 7 : strongly predictive of acute appendicitis
• RARE
ü 5-6 : equivocal (proceed with abdominal u/s or contrast-
§ Preherpetic pain of right 10th and 11th dorsal nerves
enhanced CT)
§ Tabetic crises
ü ≤4 : very unlikely
§ Spinal conditions

§ Tuberculosis of spine

§ Metastatic carcinoma

§ Osteoporotic vertebral collapse

§ Multiple myeloma

§ Abdominal crises of porphyria

§ Abdominal crises of diabetis mellitus

§ Typhlitis or leukaemic ileocaecal syndrome


10. TREATMENT 13. SPECIAL

• Appendicectomy • APPENDICITIS + CROHNS DISEASE

§ Open § Conservative : IV corticosteroid + systemic antibiotic

§ laparoscopic

• IV fluid • APPENDIX ABSCESS

• Appropriate antibiotic § Pus within phlegmonous appendix mass

• Peritonitis Ø Failure of resolution of appendix mass

§ IV antibiotic (gram –ve bacilli & anaerobic cocci) Ø continued spiking pyrexia

• Hyperpyrexia in children § management

§ Salicylates + antibiotic + IV fluid Ø Identify site of insertion for drainage by u/s or

abdominal CT

11. POST-OP COMPLICATION Ø If failedà laparotomy

• Wound infection

• Intraabdominal abscess • PELVIC ABSCESS

• Ileus (normal if < 4 days) § Spiking pyrexia several days following appendicitis

• Respiratory (rare in the absence of concurrent pulmonary disease) § Pelvic pressure or discomfort + tenesmus + loose stool

§ Rectal à boggy mass in pelvis, anterior to rectum


• Venous thrombosis and embolism (elderly, OCP)
§ Confirmed by pelvic u/s or CT scan
• Portal pyemia (pylephlebitis)
§ Management à transrectal drainage under GA
§ Rare but serious cx of gangrenous appendicitis

§ High fever, rigor, jaundice

§ Septicemia in portal venous system à intrahepatic abscess • APPENDIX MASS

§ Take note!
§ Systemic antibiotic + percutaneous drainage
Ø Inflammatory process already localized
• Faecal fistula
Ø Surgery difficult(to find appendix!) and dangerous
• Adhesive intestinal obstruction
(faecal fistula may form)
• Right inguinal hernia
§ CONSERVATIVE OCHSNER-SHERREN REGIMEN

Ø Careful record condition and extent of mass


12. RECURRENT ACUTE APPENDICTIS
• Appendicitis is notoriously recurrent Ø Contrast enhanced CT examination
• History of milder but similar attacks of pain
• Shows fibrosis of appendix Ø Antibiotic therapy
• Evidence of altered neuroimmune function in myenteric nerves
(Buchler) Ø If abscess à drained radiologically

Ø Temperature & pulse rate 4 hourly

Ø Fluid balance record

Ø sequalae

ü Improvement à 24-48 hours

ü Clinical deterioration / peritonitisà early

laparotomy

ü Failure to resolve à carcinoma or crohns disease

Ø Remove appendix after 6-8 weeks interval