a comprehensive review on appendicitis
TRANSCRIPT
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ACUTE APPENDICITISBy: Prabhjot P. Singh, M.D.Xavier University School Of Medicine
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ANATOMY • The appendix becomes visible in the 8th week
of embryologic development as a
protuberance off the terminal portion of the
cecum
• The growth rate of the cecum exceeds thatof the appendix, so that the appendix is
displaced medially toward the ileocecal valve.
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ANATOMY ( c o n t d . ) • The base of the appendix to the cecum remains constant,
whereas the tip can be found in a retrocecal, pelvic,subceacal, preileal, or right pericolic position.
• length varies from >1 cm to <30 cm; mostly 6 to 9 cm
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• The three taeniae coli
converge at the junction
of the cecum with the
appendix and can be a
useful landmark to
identify the appendix.
• These anatomic considerations have significant clinical
importance in the context of acute appendicitis.
ANATOMY ( c o n t d . )
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ANATOMY ( c o n t d . ) • Lymphoid tissue first appears in the appendix
approximately 2 weeks after birth. The amount of lymphoid tissue increases throughout puberty, remains
steady for the next decade, and then begins a steady
decrease with age.
• After the age of 60 years, virtually no lymphoid tissue
remains within the appendix, and complete obliteration of
the appendiceal lumen is common.
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• Recent studies have shown Appendix is an immunologic
organ that actively participates in the secretion of
immunoglobulins, particularly immunoglobulin A.
• Earlier it was believed that there is a potential
correlation between appendectomy and the development
of inflammatory bowel disease; Crohn's disease &ulcerative colitis.
• But recent data suggests that appendectomy may
protect against the subsequent development of
inflammatory bowel disease; however, the mechanism isunclear.
Vestigial organ ??
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INCIDENCE (contd.)
of appendiceal rupture.
The percentage of misdiagnosed cases is significantly higher among
women than among men (22.2 vs. 9.3%).
Despite the increased
use of ultrasonography,
CT, and laparoscopy, the
rate of misdiagnosis of
appendicitis has
remained constant(15.3%), also the rate
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• Obstruction of the lumen is the dominant etiologic factor in
acute appendicitis. The frequency of obstruction rises with the
severity of the inflammatory process.
• Most common cause of obstruction : Fecaliths.
• Less common-
• Tumors (1̊ or metastatic cancer & carcinoid syndrome),• vegetable and fruit seeds,
• inspissated barium from previous x-ray studies,
• intestinal parasites,
•
foreign bodies,• Crohn's disease.
PATHOGENESIS
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• Lymphoid hyperplasia of submucosal follicles:
-viral illnesses including upper respiratory infection,-mononucleosis,
- gastroenteritis
Lymphoid hyperplasia is more common in children andyoung adults, accounting for the increased incidence of
appendicitis in these age groups. This is known as
Catarrheal Appendicitis.
PATHOGENESIS ( c o n t d . )
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• Fecaliths are found in
• 40% of cases of simple acute appendicitis,
• 65% of cases of gangrenous appendicitis without
rupture and
• nearly 90% of cases
with rupture.
PATHOGENESIS (c o n t d .)
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• The proximal obstruction of the lumen produces a closed-loop .
• Continuing normal secretion by the mucosa rapidly
produces . Luminal capacity of the normal
appendix is only 0.1 mL. Secretion of 0.5 mL of fluid distal
to an obstruction raises the intraluminal pressure to 60
cm H2O.
• also is stimulated by distention.
PATHOGENESIS (c o n t d .) obstruction
distention
Peristalsis
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• increases from continued mucosal secretion and rapid multiplication of the resident bacteria of the
appendix.
• Distention stimulates the nerve endings of visceral
afferent stretch fibers
in the midabdomen or lower
epigastrium.
• Distention of this magnitude usually causes
PATHOGENESIS (c o n t d .)
vague, dull, diffuse pain
reflex nausea and vomiting.
Distention
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• As pressure in the organ increases, capillaries and venules are occluded
• The inflammatory process soon involves the serosa of
the appendix and parietal peritoneum in the region
PATHOGENESIS (c o n t d .)
pain to the right lower quadrant.
engorgement and vascular congestion.
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usually through one of the infarcted areas
beyond the point of obstruction
PATHOGENESIS (c o n t d .)
Compromise of
Vascular Supply
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Focal (Acute) - increase luminal presure & lymphatic obs’n
leads to edematous appendix.
Suppurative
Gangrenous
- venous thrombosis, arterial compromise
leads to Gangrene formation.
Ruptured
(Perforation)
- further increase in pressure, & venous obstruction leads to
bacterial invasion
-usually through one of the infarcted areas on the
antimesenteric border, beyond the point of
obstruction.
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SYMPTOMS ( c o n t d . ) Retrocolic appendix
: flank or back painRetroileal appendix
: testicular pain
Pelvic appendix
: suprapubic pain
If the appendix lies entirely within the pelvis, there is usually
complete absence of the abdominal rigidity.
A Digital Rectal Examination elicits tenderness
in the rectovesical pouch.
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SYMPTOMS ( c o n t d . ) 3. Nausea
4. Vomitting
5. Diarrhea
6. hx of obstipation
In >95% of patients with acute appendicitis,
anorexia is the first symptom,
followed by abdominal pain
followed by vomiting
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S IGNS Coughing causes point tenderness in McBurney's point
(also known as Dunphy's sign).
Direct rebound Tenderness:
there is severe pain on suddenly releasing a deep pressure in
lower abdomen
Referred or indirect rebound tenderness:
This referred tenderness is felt maximally in the right lower
quadrant, which indicates localized peritoneal irritation.
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Rovsing's sign:
continuous deep palpation starting from the left iliac fossa
upwards may cause pain in the right iliac fossa.
Psoas sign:
Patient lies on the left side as the examiner slowly extends the
patient's right thigh, thus stretching the iliopsoas muscle.
Obturator sign:
hypogastric pain on stretching of obturator internus muscle by
flexing and passive internal rotation of the hip while patient issupine.
S IGNS ( c o n t d . )
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Abdominal guarding:
tensing of the abdominal wall muscles to guard inflamed organswithin the abdomen.
Cutaneous hyperesthesia :
abnormal increase in sensitivity to stimuli of sense, in the area
supplied by the spinal nerves on the right at T10, T11, and T12.
S IGNS ( c o n t d . )
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LABS
- Plain radiographs can be beneficial to R/O other pathology.
- In patients with acute appendicitis, abnormal bowel gas pattern is
seen, which is a nonspecific finding.
- The presence of a fecalith is rarely noted on plain films but, if
present, is highly suggestive of the diagnosis.
- A chest radiograph is sometimes indicated to rule out referred painfrom a right lower lobe pneumonic process.
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• With acute, uncomplicated appendicitis
– Mild leukocytosis, 10,000 to 18,000 cells/mm3, – Often accompanied by moderate polymorphonuclear
predominance.
• perforated appendix with or without an abscess
– white blood cell count >18,000 cells/mm3 – U/A is useful to r/o Urinary Tract Infection.
– several white or red blood cells can be present from
ureteral or bladder irritation, bacteriuria is not seen in
acute appendicitis.
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LABS ( c o n t d . ) Barium enema examination and radioactively labeled leukocytescans:
-If the appendix fills on barium enema, appendicitis is excluded.
- If the appendix does not fill, no determination can be made.
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LABS ( c o n t d . ) - an accurate way to establish the diagnosis.
- inexpensive, can be performed rapidly.
- does not require a contrast medium.
- can be used even in pregnant patients.
The appendix is identified as:
- blind-ending, nonperistaltic bowel loop originating from the cecum.
-easily compressible, blind-ending tubular structure.
-measures ≤5 mm in diameter.
- The presence of an appendicolith establishes the diagnosis.
Ultrasonography :
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results are positive, if a
noncompressible appendix
≥6 mm in the
anteroposterior direction.Thickening of the
appendiceal wall and the
presence of
periappendiceal fluid is
highly suggestive of appendicitis.
LABS ( c o n t d . ) Ultrasonography :
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In females of childbearing age, the pelvic organs must be
adequately visualized either by transabdominal or endovaginal
ultrasonography to exclude gynecologic pathology as a cause of
acute abdominal pain.
The sonographic diagnosis of acute appendicitis has a reportedsensitivity of 55 to 96% and a specificity of 85 to 98%.
Sonography is similarly effective in children and pregnant women,
although its application is somewhat limited in late pregnancy.
LABS ( c o n t d . ) Ultrasonography :
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Location of the
appendixduring
pregnancy.
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Acute appendicitis.scan through an inflamed appendix(between electronic calipers) show that itis enlarged. Note the central echogenicmucosal lining
Acute appendicitis with target sign.
scan through an inflamed appendixshows an intact echogenic submucosallayer and a fluid-filled lumen (F),resulting in a “target” appearance
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Sonography can identify abscesses in cases of perforation !!!
Acute appendicitis with an appendicolith.Scan through an inflamed appendix showan echogenic appendicolith with acousticshadowing.
Perforated appendicitis with intraperitonealabscess.Scan through the pelvis demonstrates anoval, complex mass immediately above thebladder (B ), which proved to be anabscess. Note the echogenic appendicolith
within the mass
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A false-positive scan result can occur in the presence of:
- periappendicitis from surrounding inflammation,
- a dilated fallopian tube can be mistaken for an inflamed appendix,
- inspissated stool can mimic an appendicolith,
- in obese patients may not be compressible because of overlying fat.
LABS ( c o n t d . ) Ultrasonography :
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False-negative sonogram results can occur:
- if appendicitis is confined to the appendiceal tip,
- the appendix is retrocecal,
- is markedly enlarged and mistaken for small bowel,-or is perforated and therefore compressible.
Ultrasonography :
LABS ( c o n t d . )
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CT SCAN
Normal Appendix Abnormal appendix with appendicolith
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Abnormally dilated appendix ndemonstrates a thickened enhancingwall and no filling w contrast
Perforated appendicitis.The appendix (solid arrows) is abnormallydilated with a thickened enhancing wall.Small pockets of extraluminal air (dashedarrows) indicate perforation
ALVARADO SCALE
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This scoring system was designed to
improve the diagnosis of appendicitis by
giving relative weight to specific clinical
manifestation.
Scores of 9 or 10 are almost certain
to have appendicitis.
(no further work up required)
scores of 7 or 8 have a high
likelihood of appendicitis.
scores of 5 or 6 are compatible with,
but not diagnostic of, appendicitis(CT scanning is appropriate)
scores of 0 to 4 make it extremely
unlikely (but not impossible) that they
have appendicitis.
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Delay in presentation are responsible for the majority of perforated appendices.
There is no accurate way of determining when and if an
appendix will rupture before resolution of the inflammatory
process The overall rate of perforated appendicitis is 25.8%.
Children <5 years of age and patients >65 years of age have
the highest rates of perforation (45 and 51%, respectively)
CT scan may be beneficial in guiding therapy.
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Rate of appendiceal rupture by age group.
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Appendiceal rupture occurs most frequently distal to thepoint of luminal obstruction along the antimesenteric border
of the Appendix.
Rupture should be suspected in the presence of
fever with a temperature of >39 °C (102 °F)
a wbc count of >18,000 cells/mm3
Mostly rupture is contained and patients display localized
rebound tenderness.
Generalized peritonitis will be present if the walling-off
process is ineffective in containing the rupture.
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Phlegmons and small abscesses can be treated conservatively with
IV antibiotics.
Well-localized abscesses managed by percutaneous drainage.
Complex abscesses considered for surgical drainage.
If operative drainage is required, should be performed using an
extraperitoneal approach (with appendectomy reserved for cases inwhich the appendix is easily accessible).
Interval appendectomy performed at least 6 weeks after the acute
event has classically been recommended for all patients treated
either nonoperatively or with simple drainage of an abscess.
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Preoperative Preparations
Adequate hydration should be ensured
electrolyte abnormalities should be corrected
pre-existing cardiac, pulmonary, and renal conditions
should be addressed.
Preoperative antibiotics are used to lowering the
infectious complications in appendicitis.
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Post-operative : Simple acute appendicitis is encountered, there is no benefit
in extending antibiotic coverage beyond 24 hours. If perforated or gangrenous appendicitis is found, antibiotics
are continued until the patient is afebrile and has a normal
white blood cell count.
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For intra-abdominal infections of GI tract origin that are of
mild to moderate severity – single agent therapy with
cefoxitin, cefotetan, or ticarcillin-clavulanic acid.
For more severe infections, single agent therapy with
carbapenems or combination therapy with a third-generationcephalosporin, monobactam, or aminoglycoside plus
anaerobic coverage with clindamycin or metronidazole is
indicated.
The recommendations are similar for children.
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• Schwartz’s Principles of Surgery
• F Charles Brunicardi, Dana, & co-authors, 9th
edition, USA
• Textbook of Surgery
• S Das, 5th edition, India
• Wikipedia
• http://en.wikipedia.org/wiki/Appendicitis
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