GIS-K-25 ACUTE APPENDICITIS Appendiceal Mass / Abscess

Syahbuddin Harahap Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik Hospital

INTRODUCTION

The appendix is :
-Wormlike extension of the cecum (vermiform appendix). -Length is 8-10 cm (ranging from 2-20 cm). -Fifth month of gestation -Several lymphoid follicles.

Etiology:
Obstruction of the lumen appendix followed by infection Catarrhal appendicitis. -lymphoid hyperplasia (60% children) -Gastro enteritis -Virus -Acute respiratory infection -Mononucleosis Obstructive appendicitis -fecalith 35% adults. -foreign body / parasites (4%) - tumors (1%)

Pathophysiology
Wangensteen proposed
1. 2. 3. 4. Closed loop obstruction Increase in luminal pressure. Exceeds capillary pressure causes mucosal ischemia Luminal bacterial overgrowth and translocation bacteria across the appendiceal wall result : -Inflammation -Edema -Necrosis perforation occur about 48 hours .

If the body successfully walls off the perforation Appendiceal Mass If the perforation is not successfully walled off develop. Diffuse peritonitis will

Problem: Appendicitis can mimic several abdominal conditions. Laboratory test Imaging investigation Statistics report 1 of 5 cases is misdiagnosed Normal appendix is found in 15-40% Emergency appendectomy.(Negative Appendectomy)

Differential diagnosis of acute appendicitis

Surgical Acute Intestinal obstruction Intussusception Acute cholecystitis Perforated peptic ulcer Mesenteric adenitis Acute Meckel's diverticulitis Acute Pancreatitis Urological Right ureteric colic Right pyelonephritis Urinary tract infection Right Acute epididymitis

Gynaecological Ectopic pregnancy Ruptured ovarian follicle Torted ovarian cyst Salpingitis/pelvic inflammatory disease

Medical Gastroenteritis Basal Pneumonia dextra Terminal ileitis

Differential diagnosis of appendicitis appendicitis can mimic several abdominal conditions.

Lab Studies: Complete blood cell count A mild elevation of WBCs (ie, >10,000/ L) Urinalysis Mild pyuria ureter. Severe pyuria relationship of the appendix with the right

in UTI.

For women of childbearing age, Ectopic pregnancy test urin (beta-hCG)

On physical examination
Lying down Flexing their hips The most common symptom of appendicitis is : - Acute abdominal pain. - Epigastric or Periumbilical pain migrating to the right lower quadrant (RLQ) of the abdomen. - Vomiting, nausea, and anorexia - Afebrile or has a low-grade fever , 38 C Higher fevers are associated with a perforated appendix

Special maneuvers
McBurney sign McBurney's point it is only the area of greatest tenderness Blumberg sign Rovsings Sign Dunphy sign Cough Test Obturator sign Psoas sign Markle sign

Location appendix during pregnancy

INDICATIONS Consider an appendectomy for patients with a history of : Persistent abdominal pain Fever Clinical signs of localized or diffuse peritonitis Especially if leukocytosis is present.

Imaging Studies
Abdomen plain film: Fecalith within the appendix Urolithiasis right middle third

Alvarado score 1986 MANTRELS SCORE Characteristic M = Migration of pain to the RLQ A = Anorexia N = Nausea and vomiting T = Tenderness in RLQ R = Rebound pain E = Elevated temperature L = Leukocytosis S = Shift of WBC to the left Total Score 1 1 1 2 1 1 2 1 10 A score of 7 or more is strongly predictive of acute appendicitis.

Sonography
Advantages of sonography 1. 2. 3. 4. Noninvasiveness, Short acquisition time Lack of radiation exposure Potential for diagnosis of other causes of abdominal pain 5. Pediatric patients 6. Women of childbearing age. 7. Pregnant women

normal less than 6 mm

CT scan -Oral contrast medium

-Rectal Gastrografin enema Reserved for patients -Uncertain diagnosis -Severe obesity.

more than 6 mm

If the clinical picture is unclear Short period (4-6 h) of watchful waiting USG / CT scan -May improve diagnostic accuracy Without a definite diagnosis - return for continued or recurrent symptoms - follow-up examination in 24 hours.

Complications
Perforation General Secondary Peritonitis Appendiceal Mass Appendiceal Abscess Pylephlebitis is suppurative thrombophlebitis of the portal venous system Hepatic absces Chills High fever Jaundice

TREATMENT Medical therapy Resuscitated adequately with fluids . Preoperative prophylactic antibiotics -Acute Appendicitis single agent second-generation cephalosporin. -Perforated appendix triple antibiotic therapy Ampicillin , gentamycin , metronidazol Antibiotic prophylaxis should be administered before every appendectomy. Antibiotic treatment may be stopped. -Becomes afebrile -WBC count normalizes

Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)

2. Laparoscopic appendectomy If normal appendix removed need to look for: -

Meckel's diverticulum

- Acute salpingitis - Crohn's disease

If the body successfully walls off the localized perforation Appendiceal Mass RLQ mass The pain may actually improve. Symptoms do not completely resolve. Still have right lower quadrant pain Decreased appetite Change in bowel habits (eg, diarrhea, constipation) Intermittent low-grade fever.

Treatment of
Appendiceal Mass Nonoperative management Becomes walled off by omentum and ajacent viscera. Initially treated with intravenous broad-spectrum antibiotic Appendiceal Abscess USG or CT scan -Percutaneous aspiration -Drain placement Intravenous antibiotics are continued until the patient - afebrile for 24 hours - return of normal gastrointestinal function - normal WBC count with a normal differential. At this time, patients are switched to oral antibiotics for a total antibiotic course of 10-14 days. Traditionally, interval appendectomy is performed 6-8 weeks later.

Acute Appendicitis

Appendicitis Perforation