APPENDIX

HOUSSAM OSMAN

ANATOMY AND FUNCTION

Develops as protuberance of the terminal portion of the cecum. the growth rate of the cecum exceeds that of the appendix, displacing the appendix medially toward the ileocecal valve. Appendix / cecum relationship: the relation of the base of the appendix to the cecum is constant, while the tip can be found: 1- retrocecal 2-pelvic 3-subcecal 4- peri-ileal 5- right pericolic position Length range 1-30 cm with average 6-9. Immunological organ that actively participate in secretion of Ig (IgA) and component of GALT, but its functional is not esential.

ACUTE APPENDICITIS

Incidence 0.1-0.2% Appendectomy for appendicitis is the most common performed emergency operation in the world. Disease of young with 40 % of cases being between 10-24 Yr

A.A:EITIOLOGY AND PATHOGENESIS

Obstruction of the lumen is the dominant causal factor. The obstructing object can be: *fecalith ; the most common *lymphoid tissue hypertrophy *inspisated barium from previous study *tumors *seeds

The proximal obstruction of the appendiceal lumen produces a closed-loop obstruction, and continuing normal secretion by the appendiceal mucosa rapidly produces distention. with the progressive distention, the venous return and subsequently the arteriolar inflow compromise and ellipsoidal infarcts develop in the antimesenteric border. As distention, bacterial invasion, compromise of vascular supply, and infarction progress, perforation occurs, usually through one of the infarcted areas on the antimesenteric border. Perforation generally occurs just beyond the point of obstruction rather than at the tip because of the effect of diameter on intraluminal tension.

A.A:BACTERIOLOGY

Bacteria cultured in cases of appendicitis are similar to those seen in other colonic infection. The principal organisms seen are E. coli and Bacteroid fragilis.

A.A:CLINICAL MANIFESTATIONS
Symptoms

Pain: begins as visceral diffuse steady moderately severe periumblical pain, sometimes accompanied by intermittent crampy pain. Then, shifting of to localized pain in RLQ manifest the somatic component. Somatic pain depends on the location of the tip of the appendix. LLQ LLQ pain retrocecal flank or back pain pelvic suprapubic pain retroileal testicular pain Anorexia: nearly always Vomiting: once or twice Obstibation: prior to the onset of the pain. Some might c/o diarrhea.

A.A:CLINICAL MANIFESTATIONS
Signs:

VS : minimally changed by uncomplicated appendix. If not think of either complicated appendicitis or other diagnosis. Pt prefers to stay in R thigh flexion position. McBurneys point tenderness and rebound tenderness. Rovsings sign Cutaneous hyperesthesia T10,11,12. Psoas sign and obturator sign. Guarding and rigidity appear with more severe inflammatory process. Retrocecal : tenderness more in the flank. Pelvic: painful rectal exam.

A.A:LABS

Mild leukocytosis 10-18 WBC > 18 increase the possibility of perforation UA to r/o UTI

A.A:IMAGING STUDY

Plain X ray: not helpful *non specific abnormal gas pattern. *fecalith if present id highly suggestive of the diagnosis. CXR: r/o referred pain from lower lobe pneumonia. Barium enema and radioactive labeled leukocyte scan : filing of the appendix excludes the diagnosis, otherwise insignificant. U/S: *enlarged diameter, presence of fecalith, wall thickening and periappendicular fluid. *normal: exclude the diagnosis. *not visualized: inconclusive study. CT: dilatation, wall thickening, thick mesoappendix, arrow head sign.

ALVARADO SCALE

9-10: almost certain appendicitis and should go to OR. 7-8: high likelihood of appendicitis, imaging study. 5-6: compatible but not diagnostic, CT scan is appropriate. 0-4: extremely unlikely.

A.A:APPENDICEAL RUPTURE

Overall rate is 25.8% Higher rates in children < 5 (45%) and pt > 65 (51%). Suspect if: *fever > 102 *WBC > 18 In majority of cases ,rupture is contained and pt display localized tenderness. Generalized peritonitis occurs when the walling-off process is ineffective.

PHLEGMON AND ABSCESS

Ill defined mass on physical exam Phlegmon : matted loops of bowel adherent to adjacent inflamed appendix. CT
Phlegmon and small abscess: conservative management and IV Abx. Well localized abscess: percutaneous drainage. Complex abscess: extraperitoneal surgical drainage . Interval appendectomy done at least 6 weeks following the acute event.

A.A:DIFFERENTIAL DIAGNOSIS

Acute mesenteric adenitis:

More common in children. Current or recent Hx of URTI. Generalized lymphadenopathy may be noted. Tenderness is not sharply localized Relative lymphocytosis may be present Self-limited disease.

Acute gastroenteritis:

Childhood disease. Profuse watery diarrhea, N/V. Hyperperistaltic abdominal cramp.

Testicular torsion. Acute epididymitis. Seminal vesiculitis.

Male urogenital system:

Surgically treated.

Meckels diverticulitis:
Intussusceptions:

Children younger than 2 Yr, well nourished suddenly doubled up by apparent colicky pain. Infant looks well between attacks Bloody mucoid stool. Sausage shaped mass in RLQ Empty RLQ Barium enema if no signs of peritonitis

Difficult to differentiate clinically. Diagnosis may be made intraoperatively.

Crohns enteritis:

Perforated PU:

Occur when the spilled contents gravitate down the right gutter with spontaneous sealing of perforation.

colonic lesion:

Diverticulitis or perforating cecal cancer. Elderly. CT.

Epiploic appendagitis:

Infarction of the colonic appendage secondary to torsion.

Right acute pyelonephritis: associated with chills, R CVA tenderness, pyuria, and bacteruria. Ureteral stone: referred pain down to the genatilia and hematuria.

UTI:

Hx of liver or renal disease. Diagnosed by peritoneal aspiration G+ve Flora, G-ve rods suspect secondary peritonitis

Primary peritonitis:

2-3 weeks after strep infection. Joint pain, purpura, and nephritis.

Henoch schonlein purpura:

Fecal oral Mesenteric adenitis, ileitis, colitis, and acute appendicitis Majority are mild and self-limited.

Yesiniosis:

PID:

Esp if confined to R tube. Purulent vaginal discharge. Cervical motion tenderness.

Ruptured Graafian follicle:

Ovulation. Brief mild, diffuse lower abdominal pain and tenderness. Midpoint of menstrual cycle ( Mittelschmerz)

Ruptured ectopic pregnancy:

Missing menses. Vaginal bleeding. Pelvic mass + high HCG + low Hct Cervical motion and adnexal tenderness Emergency surgery.

Twisted ovarian cyst:

Vaginal exam may reveal pelvic mass. Transvaginal U/S and CT Torsion needs emergent operative intervention while rupture can be managed conservatively.

A.A:APPENDICITIS IN PREGNANCY

1:2000 Pregnancies. More frequent during 1st and 2nd trimesters. Appendix displaced laterally and superiorly. Less frequent rebound and guarding. WBC > normal pregnancy level ( 15-20 ). U/S: if equivocal, laparoscopy can be done esp early in pregnancy. Any operation has 10-15% premature labor risk.

A.A:APPENDICITIS IN AIDS

Incidence 0.5% No absolute leukocytosis. High risk of rupture (which can be related to delay in presentation). Low CD4 correlate with increased risk of rupture. Consider opportunistic infection in D.D ( CMV,kaposi,TB,lymphoma). If the pt presents with classic symptoms and signs: appendectomy. When diarrhea is the prominent symptom: c-scope may be considered. Equivocal presentation: CT

A.A:TREATMENT
Prepare pt for operation: Hydration. Correct electrolytes disturbances. Address pre-existing cardiac,renal and pulmonary issues. Abx coverage for 24 hrs in simple appendectomy. In case of perforation continue abx till pt afebrile and normal WBC.

Open appendectomy: Incision: *McBurney incision or Rocky Davis incision. *if abscess suspected: laterally displaced incision to allow retroperitoneal drainage. *if diagnosis in doubt: lower midline incision Taeniae coli converge at the base of the appendix. Divide mesoappendix and mobilize the appendix with ligation of the appendiceal artery. Stump can be simply ligated or ligated with inversion.

Laparoscopy

Prognosis

Mortality rate is 0.06% in unruptured appendix. 3% in case of rupture. 15% in case of rupture in elderly

CHRONIC APPENDICITIS

Long lasting pain and less intense than that of acute appendicitis. Normal WBC count CT generally nondiagnostic. Appendectomy is curative in 82-93% of pt. many of those whose symptoms are not cured or recur are ultimately diagnosed with Crohns.

Appendiceal parasites:

Ascaris lumbricoides is the most common. Enterobius vermicularis, Strongyloides stercoralis, Echinococcus granulosis. Anti helminth showed follow recovery from appendectomy.

Incidental appendectomy:

Generally neither clinically nor economically appropriate. It should performed under special circumstances: *children about to undergo chemotherapy. *disables who can not describe or react normally to abdominal pain. *Crohns pt in whom the cecum is free of macroscopic disease. *travelers to remote places with no access to medical or surgical care.

TUMORS
Carcinoid:

Appendix is the most common GIT site. Rarely associated with carcinoid syndrome ( 2.9 % of cases ). Intraoperative finding of firm, yellow, bulbar mass in the appendix. Less than 1 cm: simple appendectomy is sufficient. With extension into mesoappendix or tumor larger than 1.5 cm: RHC

Adenocarcinoma:

3 histological type: mucinous, colonic, and adnenocarcinoma. Most mode of presentation is acute appendicitis, but may also present with ascites or palpable mass, or may be discovered incidentally. RHC is the recommended treatment.

Mucocele:

Lead to progressive enlargement of the appendix. 4 histological types: retention cysts, mucosal hyperplasia, cystadenoma, cystadenocarcinoma. Benign etiology: simple appendectomy. Pseudomyxoma peritonei: *diffuse collections of gelatinous fluid are associated with mucinous implants on peritoneal surfaces and omentum. *caused by neoplastic mucous-secreting cells within the peritoneum with the appendix being the site of origin for most cases. *CT is the preferred imaging modality. *surgical debulking is the mainstay of treatment and appendectomy routinely performed. Hysterectomy and bilateral salpingiooopheorectomy is performed in women.

Lymphoma:

Extremely uncommon. Non-Hodgkins, Burkitts, and leukemia. Usually present as acute appendicitis. Appendiceal diameter 2.5 cm or surrounding soft tissue thickening are suspicious. If confined to appendix: appendectomy. Extension to cecum or mesentery: RHC. A postoperative staging workup is indicated prior to adjuvant therapy.