ABA-The Appendix- 4th year Lectures

Dr A. Badrek-Amoudi Dr A. Badrek-Amoudi FRCSFRCS

ABA-The Appendix- 4th year Lectures

1. How do you diagnose appendicitis.2. What are the classical and atypical features of

appendicitis3. Are investigations always needed and what is their role4. How do you prepare your patient prior to surgery5. What are the surgical approaches6. How do you care for your patient after surgery

A 15 year old girlA 15 year old girl presents with a right lower abdominal presents with a right lower abdominal pain. pain.

A 6 year old boyA 6 year old boy with a history of sore throat presents with a history of sore throat presents with lower abdominal pain with lower abdominal pain

A 45 year old manA 45 year old man presents with a sudden onset of presents with a sudden onset of epigastric pain localised to RIF epigastric pain localised to RIF

ABA-The Appendix- 4th year Lectures

The Appendix

Introduction

1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.

ABA-The Appendix- 4th year Lectures

The Appendix

Surgical Anatomy

Surface anatomy

Development: diverticulum of ceacum appearing in the 8th week of life

Positions: constant base, tip varies (retroceacal, pelvic, subcaecal, preileal, pericolic)

Blood supply

Location during surgery

Surrounding anatomical structures

Part of the gut lymphoid tissue.

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix

Acute Appendicitis Epidemiology

Most common surgical emergency.

Slightly more common in men.

Incidence are falling from 100 to 50 in 100 000 (1975-1991).

1 in 6 of the population will have an appendectomy.

In Saudi Arabia incidence are comparable to western figures

? More common in European societies (Diet).

? Relation to class status.

Age > 2 yrs, (associated with lymphoid development).

Up to 16% of appendicectomies are normal 75% are in women

ABA-The Appendix- 4th year Lectures

The Appendix

Acute Appendicitis Pathology I

Luminal obstruction.• Lymphoid hyperplasia 60%• Faecolith 35%.• Inspissated barium.• Fruit seeds. }<4%• Worms. < 1%• Extra-luminal obstruction eg Ca Cecum

Raised intra-luminal pressure• Mucus accumulation• Multiplication of bacteria. ( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)

• Venous and lymphoid congestion and.

ABA-The Appendix- 4th year Lectures

The Appendix

Acute Appendicitis Pathology II

Impaired arterial flow, thrombosis and gangrene.Perforation may occur through devitalized tissue.

Histological terms used:

Catarrhal appendicitisSuppurative ;;;Necrotic ;;;Gangrenous ;;;Perforated ;;;Appendicular mass

The risk of perforation is not inevitable.

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis Clinical Features I

Only 55% have classical features.Atypical 45%History 24-36 hoursAbdominal pain:

(diffuse and periumbilical, localizing to the RIF)Anorexia (almost always).Vomiting (75%).Low grade fever.

• If >38 suspect perforationTenderness, guarding and rebound: Be gentleRovsing’s, psoas, obturator signs: unreliable and late

Full History Duration, severity, onset, System review. and examination: General, throat, chest…..etc

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis Clinical Features II

Tender Appendicular mass

Atypical:• (loin, high RUQ, deep pelvic)• Diarrhea ( not always gastroenteritis)• Urinary frequency

The Extremes of Age:• Children < 5 rapid progression• Pain in the elderly is less intense

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis Investigations

White cell count: high sensitivity 96%, low specificityUrine analysisPlain Xray, nonspecificUltrasound highly sensitive (80-90%), excludes other pathologies. Computer Tomography: More superior to USS in diagnostic accuracy.Barium enema: Good accuracy, but technically

difficult and false positives are common.LaparoscopyActive observationComputer aided diagnosis.Peritoneal lavage

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis The Very Young

Diagnosis may be more difficult to establish, WBC is likely to be normal (12% are normal).

Children are more likely to progress to perforated appendix

(? Under-developed Greater Omentum).

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis The Very Old

Greater morbidity and mortalityLess typical presentationCancer may be a possibility as an underlying cause.Perforation of 50% and mortality of 20% has been reported

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis The Pregnant

Implications: Clinical Findings, Lab Ix, SurgeryImplications: Clinical Findings, Lab Ix, Surgery1: 2000 pregnancies.More common in the first two trimestersThe appendix is pushed superiorly and laterallyWBC > 15 Premature Labor 10-15% with surgeryPerforated appendix leads to fetal death in 20%Rapid diagnosis and treatment is advised.

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis In AIDS Patients

Be aware of CMV or Kaposi sarcoma as the underlying cause

WBC may not rise

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis The Management

Preop: • IVI, • analgesia,• IV antibiotics

Conventional appendicectomyTypes of incisionsLaparoscopic appendicectomy:

(questions regarding pain, hospital stay, operation time, to daily activity, wound infection)

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis Post-Operative

1. Check the vitals

2. Check the abdominal signs and bowel movement

3. Check the wound

4. Advise on mobilization

5. In OPD:1. Check wound

2. Check the Histology

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis Prognosis

Mortality: from 0.2% to 1%Complications increase with perforation Morbidity:

• Wound abscess, • Wound infection (less with MacBurney’s incision),• Wound dehiscence• Intra-abdominal abscess, • Faecal fistula, • Intestinal obstruction, • Adhesive band, • inguinal hernia. • Fertility

ABA-The Appendix- 4th year Lectures

ABA-The Appendix- 4th year Lectures

The Appendix - Acute Appendicitis Problems

Mass palpable pre-operatively

Appendix is normal at operation

Tumor is found in appendix

Prophylactic appendicectomy

ABA-The Appendix- 4th year Lectures

The Appendix – Chronic Appendicular Conditions Chronic Appendicitis

A loose term referring to a multitude of conditions associated with RIF pain and in which pathology of the appendix has been found.

ABA-The Appendix- 4th year Lectures

The Appendix – Chronic Appendicular Conditions Appendicular Mass

Results from either:1. Localized by edematous, adherent omentum

and loops of small bowel2. Appendicular abscess

Incidence is 10% Higher in childrenManagement controversy:

Interval vs Immediate appendicectomy

ABA-The Appendix- 4th year Lectures

The Appendix – Chronic Appendicular Conditions Tumors of The Appendix

Carcinoid:• Arise from Kluchitsky cells• Mean age 20-40• Yellow bulbar mass• In F>M• In third decade of life• Usually lies near the tip• In the absence of LN spread with <2 cm in

diameter appendicectomy is sufficient. Otherwise a R hemicolectomy is necessary.

Adenocarcinoma and Lymphoma.

ABA-The Appendix- 4th year Lectures

Differential diagnosis: Intraperitoneal Extraperitoneal

Gastroenteritis Mesenteric adenitis

Lobar Pneumonia

Ileocaecal Pathology: Regional ilitis Crohns Meckels diverticulitis Intussusceptions Carcinoma FB perforation Constipation Appendices epiplocae torsion

Osteomyelitis

Female pelvis: Ovarian: ruptured follicle Torsion of cyst Haemorrhagic cyst Acute salpingitis (PID) Ruptured ectopic pregnancy Uterine fibroid Endometriosis

Haematoma of the rectus sheath

Genitourinary disorders: Pyelonephritis Ureteric calculi Cystitis

Neuralgic pains

Others Perforated DU Pancreatitis Acute cholecystitis Diverticulitis

Ruptured aortic/iliac aneurysm