Acute Appendicitis

Dr. Mirzaei

One of the most common surgical emergencies

Highest incidence in the second and third decades

Anatomy

Location: three taeniae coli converge at the base (fix)

Length: <1cm to >30cm (average 6-9) Tip: retrocecal, pelvic, subcecal,

preileal, right pericolic

Function?

Secretion of immunoglobulin A

Appendectomy and U.C protection?

As a reservoir to recolonize the colon with healthy bacteria

Pathogenesis

Obstruction - Fecalith - Hypertrophy of lymphoid - Inspissated barium - Tumors - Vegetable and fruit - Intestinal parasites

Pathogenesis

Normal luminal capacity 0.1 ml Proximal obstruction => closed-loop

obstrucation Normal secretion of mucosa =>

distention 0.5 ml secretion => intraluminal

pressure 60cm H2O

Pathogenesis

Secretion + rapid multiplication of bacteria => venous pressure increased => occlusion of capillaries

Arteriolar inflow continue => vascular congestion

Pathogenesis

Impairment of blood supply => mucosal integrity compromised => bacterial invasion

Infarction in antimesentric border => perforation

Appendiceal Rupture

Overall Rate: 25.8% Children < 5 years: 45% Patients > 65: 51%

Appendiceal Rupture

Walling-off process -> Phlegmon: Adherence of bowel loops to the inflamed appendix or a periappendiceal abscess.

Mass in exam:2-6%

Duration: At least 5-7 days

symptoms

Distention => visceral nerve endings stimulation => vague, dull, diffuse pain in the mid abdomen or lower epigastrium

Distention => reflex nausea &vomiting

Inflammation of serosa & parietal peritoneum => shift in pain to the right lower quadrant

Symptoms

Abdominal pain - Moderately severe - steady, sometimes intermittent

cramp - 1-12 h (4-6h) pain => R.L.Q

Symptoms

Pain variation - Begins in the R.L.Q - Shift to the L.L.Q (tip in the L.L.Q) - Retrocecal => flank or back pain - Pelvic => suprapubic - Retroileal => testicular pain

(irritation of the spermatic artery & ureter)

Symptoms

Intenstinal malrotation

-Visceral: normal location - Somatic: where the cecum has been

arrested

Symptoms

Anorexia (nearly always) - loss of anorexia: diagnosis should

be questioned

Symptoms

Vomiting - 75% of patients - neither prominent nor prolonged - only once or twice

Sequence of Symptoms

95% anorexia – pain - vomiting

Vomiting – pain: diagnosis should be questioned

Signs

Temperature : rarely > 1ºC

PR: normal or slightly elevated

More change: complication?

Signs

Lie supine

Right thigh drawn up

Any motion increases pain

Move slowly with caution

Signs

McBurney point tenderness

Signs

Local tenderness

rebound tenderness Voluntary guarding True reflex (involuntary) rigidity

(irritation progress)

Signs

Flank tenderness Local tenderness in rectal exam

(pelvic) psoas sign Obturator sign Rovsings sign

Lab test

W.B.C 10,000 – 18,000 Moderate P.M.N predominance W.B.C > 18,000 => possibility of

complication CRP U/A: several W.B.C or R.B.C (ureteral or

bladder irritation) Bacteriuria generally not seen

Imaging

Plain film (rarely helpful) - abnormal bowel gas pattern - fecalith (highly suggestive)

C.X.R (R/O right lower lobe pneumonia)

Imaging

Sonography (inexpensive, rapid, no contrast medium, even in pregnancy

Noncompressible appendix > 6mm Appendicolith Thickening of appendiceal wall &

periappendiceal fluid Remainder of abdominal cavity

Imaging - Sono

Exclude Gyn pathology

Effective in children & pregnancy

Imaging - sono

Limitations - user dependent - false – positive: dilated fallopian

tube, inspissated stool can mimic

appendicolith, obesity, - false – negative: appendicitis in tip, retrocecal, markedly enlarged, perforation

Imaging – C.T

Dilated appendix>5mm + wall thickening

thickened mesoappendix Phlegmon Periappendiceal fat stranding Free fluid Other inflammatory processes

Imaging – C.T

Expensive, exposes to radiation, cannot be used during pregnancy, allergy to contrast, intolerance of oral contast

Laparoscopy

Most useful in females (30 – 40% normal appendix)

Differentiating acute Gyn pathology

Misdiagnosis

highest rate: child-bearing women,very young,very old

Accuracy of preoperative diagnosis should be: 85%

Accuracy>90%: Missed some patients Depends on: anatomic location of the

appendix, simple or ruptured, age, sex

Alvarado scale

Alvarado scale

7-10 high likelihood

4-6 consider further imaging

1-3 low likelihood

Differential diagnosis

Acute Mesenteric Adenitis

Most in Children Upper respiratory tract infection is

present or has recently subsided. Pain is diffuse Tenderness is not sharply localized Guarding sometimes present

Acute Mesenteric Adenitis

True rigidity is rare Generalized lymphadenopathy (may) Relative lymphocytosis suggestive Self limited May need immediate exploration

Gynecologic Disorders

Pelvic Inflammatory Disease- Usually bilateral - Nausea & Vomiting: 50%- Tenderness Usually lower- Motion of cervix is painful- Diplococci on smear of purulent vaginal

discharge- Higher during early phase of cycle

Gynecologic Disorders

Ruptured Graafian Follicle- Spillage of follicular fluid - Pain and tenderness diffuse- Leukocytosis & fever: minimal - Midcycle: Mittelschmerz

Gynecologic Disorders

Twisted Ovarian Cyst- Sudden pain - CT & Sono (transvaginal)- Need emergent operation - Leakage of ovarian cyst: Treated

nonoperatively

Gynecologic Disorders

Ectopic pregnancy Abnormal menses Missing one or two periods or only slight

vaginal bleeding Elevated level of human chorionic

gonadotropin(B-HCG) Hct level falls Vaginal exam:cervical motion tenderness culdocentesis

Acute Gastroenteritis

Diarrhea, nausea, vomiting Abdominal Cramps Soft Abdomen between cramps No localizing sign Vomiting - Pain

Cecum or sigmoid Diverticulitis Meckel’s Diverticulitis Perforating Carcinoma of the cecum Epiploic appendagitis Pleuritis of the right lower chest Acute Cholecystitis Acute Pancreatitis Hematoma of the abdominal wall Epididymitis, Testicular torsion, U. T. I,

Ureteral Stone