appendicitis intussusception
TRANSCRIPT
Appendicitis
60,000 appendectomies/yr
20,000 ruptured
100 deaths/year
History
Paseo Iliaca
Reginald Fitz - 1886
“Perforating Inflammation of the Vermiform Appendix: with special
reference to its early diagnosis and treatment” Am J Med Sci 1:321-46, 1886.
Reginald Heber Fitz
B. 5/5/1843 D. 9/30/1913
MD Harvard 1868 - Prof. Pathology
25 appendectomies
Charles McBurney
B. 2/17/1845, D. 11/7/1913
BA Harvard 1866
MD 1870 College of Physicians and Surgeons
Charles McBurney
McBurney had a point
T.G. Morton - 1887
Pathophysiology
Obstruction
Increased intraluminal pressure
Stages
Simple
Suppurative
Gangrenous
Ruptured
Abscessed
Microbiology
Intraoperative cultures are useless !
Bacteroides Fragilis: #1
Diagnosis
> 90% accurac
y
Pain
Shift
ANV
Physical Exam
Gestalt
Posture
Point tenderness
Laboratory Results
Signs of Perforation
AXR
BE
US
CT
MGH AJR 2005 Jun;184(6):1802-8.
40% scanned had appendicitis
Sens 99%, Specif 95%
• 88% suspected appy
• n = 753: had CT
• False neg rate dropped: 20% to 3%
Differential diagnosis
GastroenteritisConstipation
GUGYN
Mesenteric Adenitis
Pneumonia
Antibiotics
Treatment
Operation
Irrigation
Drainage (rarely)
Wound closure
Medical management
Interval appendectomy
Complications
Appendiceal stump blow-out
Abscess
Phlegmon
Dehiscence
Infertility
SBO
Wound problems
Abscess
Wound infection
Obstruction
Mortality
CMH Research Appendicitis - recent
1. St Peter SD, Sharp SW, Ostlie DJ. Influence of histamine receptor antagonists on the outcome of perforated appendicitis: analysis from a prospective trial. Arch Surg. 2010 Feb;145(2):143-6.
2. St Peter SD, Aguayo P, Fraser JD, Keckler SJ, Sharp SW, Leys CM, Murphy JP, Snyder CL, Sharp RJ, Andrews WS, Holcomb GW 3rd, Ostlie DJ. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg. 2010 Jan;45(1):236-40.
3. Fraser JD, Aguayo P, Sharp SW, Snyder CL, Rivard DC, Cully BE, Sharp RJ, Ostlie DJ, St Peter SD. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg. 2010 Jan;45(1):231-4; discussion 234-4.
4. Fraser JD, Aguayo P, Sharp SW, Snyder CL, Holcomb GW 3rd, Ostlie DJ, St Peter SD. Physiologic predictors of postoperative abscess in children with perforated appendicitis: Subset analysis from a prospective randomized trial. Surgery. [Epub ahead of print]
5. St Peter SD, Sharp SW, Holcomb GW 3rd, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg. 2008 Dec;43(12):2242-5.
6. St Peter SD, Tsao K, Spilde TL, Holcomb GW 3rd, Sharp SW, Murphy JP, Snyder CL, Sharp RJ, Andrews WS, Ostlie DJ. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun;43(6):981-5.
1913: LaddBismuth enema
1927 Barium
1948: Ravitch & McCune
32% Op Mortality
1953: Gross opposed Nonoperative reduction
1959 - air enema China
intuss = "within" (Lat.)
suscipere = "to receive" (Lat.)
1 in 2,000
2:1 m:f
3 mo < 50% < 9 mo
May - July
? Viral
1 in 5 + prior illness
Pathogenesis
*ceptum goes into the *cipiens ="recipient"
*ceptum swells, bleeds (currant jelly)
ASx /incidental Intussusception:
Watch
[PP are on antimesenteric border*]
*Except @ Ti
95% of Intussusception:
Ileocolic area
No PLP
20% + PLP > 2 yr old
Ileoileocolic:
4% all casesHard to reduce (25% success)
40% PLP
Pathologic Leadpoints
Meckel’s diverticulum # 1
Intestinal polyps & duplications # 2
Appendix
Ectopic gastric or pancreatic mucosa
Henoch-Schonlein purpura
Suture line
Neoplasms: leukemia, lymphoma
Hemangioma
Neurofibromas
Foreign body / Ascaris
Cystic fibrosis
Abdominal trauma
> 5yr old = > 50% chance of PLP
4% PLP 1st recurrence
14% PLP if > 1 recurrence
1200 Canadian Kids:11 Lymphomas / intussusception
Postoperative Intussusception:
1% all Int.
5 - 10% of all ped SBO
Intrauterine Intussusception
Clinical Presentation
Classic Symptoms:Intermittent colicky abdominal pain (85%)
Vomiting (50%)
Classic Signs:Abdominal Mass (25 - 50%)Rectal bleeding (25 - 50%)*
* late sign, currant jelly
Plain films 50% accuracy
Ultrasound >98% accuracy
US: ? irreducibility
Thick outer rimFree peritoneal fluid
Trapped fluid in *septumBig mesenteric LN
No flow in in*septum (Doppler) # 1
Medical Mgmt - HSP
Steroids?
Radiologic reduction (90% success)
CI’s...
Pneumatic reduction with US or Fluoroscopic guidance
Start with 50 mm Hg - > up to 110 - 120 mm Hg
Pneumatic Reduction
? sedation? glucagon? abdominal manipulation? delayed repeat enema
? home after successful reduction
Perforation < 1%
Success of air enema > 90%
Gou 19866,396 air reductions
0.14% perf rate
Gu 19939,000 pts
0.16% perf rate
Increased perf risk
< 6 mo oldSx > 36 hrs
Operation
Open or Lap
Recurrence - 5% overall
p BE 5 - 10% (AE ?)p Op reduct 3 - 5%
p Op resect 1%
Mean t (recur) = 8 months
CMH Research Intussusception
• Fraser JD, Aguayo P, Ho B, Sharp SW, Ostlie DJ, Holcomb GW 3rd, St Peter SD. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. 2009 Aug;19(4):563-5.