Appendix – Doc Trespeces  Ruptured

o Localized
Judeilan A. Macahilo
o Generalized
Appendix
Congestive – obstruction, dilatation, hyperemic; CBC:
- Immunologic organ that actively participates in 10-12
secretion of IgA
Suppurative – purulent exudate is still inside the lumen
- Appendectomy may protect against subsequent
of appendix
development of inflammatory bowel disease
Gangrenous – infarct, ischemia
Pathophysiology:
Ruptured – microperforation
Proximal obstruction  luminal distension replication
of resident bacteria  increased luminal pressure Generalized – pain in >1 quadrant
(venous pressure exceeded)  mucosal ischemia 
bacterial invasion  infarction  appendiceal rupture Diagnosis:

Midgut – superior mesenteric artery Hx and PE

o Direct tenderness on RLQ
Hindgut – inferior mesenteric artery Bacteriology
o E. coli and B. fragilis
*obstruction anywhere in the appendix
Diagnostic and ancillary procedures:
*normal flora – Gram (-) and some Gram (+) o CBC and urinalysis
o Ultrasound – “target” sign
Symptomatology: o CT scan
 Vague, dull, diffuse, mid-abdomen pain o Diagnostic laparoscopy
 Crampy abdominal pain Urinalysis – rule out UTI, pyelonephritis
 Anorexia, nausea&vomiting
Differentials:
 Localization to RLQ
 Generalized abdominal pain  Acute gastroenteritis
- Visceral pain  Peptic ulcer disease
- Parietal pain  Meckel’s diverticulitis
- Localized pain due to distension of the appendix  Acute mesenteric adenitis
 Urinary problems
Tip of the appendix – mostly located at the retrocecal
 Gynecologic disorder
area; changes in location
o PID
Direct tenderness – most definitive sign of appendicitis o Ectopic pregnancy

Rectal Exam – right anterior pain if tip of appendix is at Treatment:

the retrocecal area
 Hydration
- If appendix is antececal?, there will be no pain  Antibiotic regimen:
- If appendix is ruptured, pain on all quadrants o Prophylactic Tx
 Emergency appendectomy
Stages:
Incidental Appendectomy:
 Congestive
 Suppurative early stage - Children about to undergo chemotherapy
 Gangrenous - Disabled
 - With Crohn’s
- About to travel to remote area
Clean, contaminated – early stages of appendicitis
- Prophylactic antibiotic
- Broad-spectrum antibiotic 1 hour prior to
surgery
Contaminated – ruptured
- Therapeutic antibiotic
- Gram (+), (-), anaerobes
- Metronidazole, 2nd generation cephalosporin
- Emergency appendectomy
Pain reliever – if already diagnosed with appendicitis
- NO if still observing
20-45 y.o – appendicitis is common
Early appendicitis – Mc Burney’s incision
Generalized – midline incision
Gangrenous – therapeutic antibiotic
Ruptured – use of a monofilament thread, with a drain
Periappendiceal Abscess
 With a Hx of symptoms of appendicitis
 Presence of an ill-defined mass
 May be tender or non-tender
 +/- of systemic symptoms
Treatment:
o Percutaneous aspiration
o Observation
o Surgery
o Interval appendectomy
No symptoms, just a mass: diagnostic, barium,
observation
Percutaneous aspiration if:
Cannot tolerated surgery
Antibiotic
Interval appendectomy
* do the incision right in the mass
*put a drain – if you can’t find the appendix
Chronic Appendicitis
- Appendicitis in the young
- Appendicitis in the elderly
- Appendicitis with HIV infection
In young and elderly – do not expect the classic signs
and symptoms
With HIV – same Tx
Acute Appendicitis during pregnancy
 Surgical risk: 10-15%
 Fetal mortality in ruptured cases: 20%
 Location of appendiceal tip varies
 Any suspicion of appendicitis during pregnancy,
prompt surgery is indicated
Carcinoid of the appendix
 Incidental finding
 Management:
o Appendectomy
 <1cm
 No metastases
o Right hemicolectomy - >1.5 cm
 Involvement of meso-appendix
Mucocele
- Due to: retention cysts, mucosal hyperplasia,
cystadenoma, cystadenocarcinoma
- Surgery: appendectomy with wide resection of
mesoappendix
- Right hemicolectomy for (+) margins at the base
or (+) periappendiceal lymph node