acute appendicitis ii

8/4/2019 Acute Appendicitis II

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ACUTE APPENDICITISACUTE APPENDICITIS

Basharat Ali KhanBasharat Ali Khan


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Case PresentationCase Presentation

A 9-year-old male child presented toA 9-year-old male child presented to

the emergency room with 4 hoursthe emergency room with 4 hours

history of moderate to severehistory of moderate to severe

epigastric/periumbilical pain whichepigastric/periumbilical pain which

shifted to RIF . O/E he had tendernessshifted to RIF . O/E he had tenderness

and rebound tenderness in RIF.HE hadand rebound tenderness in RIF.HE hadnausea and looked ill. His WCC wasnausea and looked ill. His WCC was

14x10(9)per litre14x10(9)per litre


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AnatomyAnatomy

Present only in humans .Present only in humans . 5mm , 5 -15cm5mm , 5 -15cm

A blind muscular tube withA blind muscular tube with mucosamucosa,,

submucosa , muscle and serosasubmucosa , muscle and serosa

RetrocaecalRetrocaecal, subcaecal, paracaecal,, subcaecal, paracaecal, pelvicpelvic,,preileal, postileal.preileal, postileal. Six PositionsSix Positions

Appendicular artery is a branch of ilieocolicAppendicular artery is a branch of ilieocolic

arteryartery


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Etiology / PathologyEtiology / Pathology

Caused byCaused by obstructionobstruction of theof the

appendiceal lumen by aappendiceal lumen by a faecolithfaecolith,,

inspissated material, a foreign bodyinspissated material, a foreign body

or lymphoid hyperplasiaor lymphoid hyperplasia whichwhich

causes progressivecauses progressive inflammationinflammation,,

ischemia andischemia and necrosisnecrosis of theof theappendiceal wall.appendiceal wall.


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PathologyPathology

The disease progresses more rapidlyThe disease progresses more rapidly

in childrenin children than in adultsthan in adults.. IfIf

perforation(5-60%)perforation(5-60%) occurs the youngoccurs the young

infant isinfant is more likelymore likely to getto get

generalizedgeneralized peritonitisperitonitis because theybecause they

have a diminished capacity to wallhave a diminished capacity to walloff the infection than older children.off the infection than older children.


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Clinical Features ofClinical Features of

AppendicitisAppendicitis

Periumblical / Epigastric colic or dull achePeriumblical / Epigastric colic or dull ache

Pain shifts to right iliac fossa(70%)Pain shifts to right iliac fossa(70%)

Anorexia , Nausea & VomitingAnorexia , Nausea & Vomiting

Diarrhea , LUTS ,GynaecologicalDiarrhea , LUTS ,Gynaecologicalsymptomssymptoms


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Clinical Signs in AppendicitisClinical Signs in Appendicitis

Pyrexia, Tachycardia ,looks illPyrexia, Tachycardia ,looks ill

Localized tenderness in the rightLocalized tenderness in the rightiliac fossailiac fossa

Muscle guardingMuscle guarding

Rebound tendernessRebound tenderness


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Signs to Elicit in AppendicitisSigns to Elicit in Appendicitis

Pointing signPointing sign

Rovsings signRovsings signPsoas signPsoas sign

Obturator signObturator signCough SignCough Sign


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Risk Factors for Perforation ofRisk Factors for Perforation of

the Appendixthe Appendix

Extremes of ageExtremes of age

ImmunosuppressionImmunosuppressionDiabetes mellitusDiabetes mellitus

Faecolith obstructionFaecolith obstruction

Pelvic appendixPelvic appendix Previous abdominal surgeryPrevious abdominal surgery


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Differential DiagnosisDifferential Diagnosis

ChildrenChildren: gastroenteritis, mesentric: gastroenteritis, mesentricadenitis, meckels diverticulitis,adenitis, meckels diverticulitis,intussusception.intussusception.

AdultAdult: Regional enteritis, ureteric colic,: Regional enteritis, ureteric colic,

perforated ulcer, torsion testis.perforated ulcer, torsion testis. Adult femaleAdult female:: Mittelschmerz, salpingitis,Mittelschmerz, salpingitis,

pyelonephritis, ectopic pregnancy, torsionpyelonephritis, ectopic pregnancy, torsionof ovaries, endometriosis.of ovaries, endometriosis.

ElderlyElderly:: Diverticulitis , intestinalDiverticulitis , intestinalobstruction, colonic carcinoma, mesentricobstruction, colonic carcinoma, mesentricinfarction.infarction.


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Preoperative Investigations inPreoperative Investigations in

AppendicitisAppendicitis RoutineRoutine ::

- Full blood count- Full blood count

- Urinalysis- Urinalysis

Selected casesSelected cases ::

- Pregnancy test- Pregnancy test

- Urea and electrolytes- Urea and electrolytes

- Supine abdominal X-Ray- Supine abdominal X-Ray

- X-Ray Chest- X-Ray Chest

- Ultrasound abdomen/pelvis- Ultrasound abdomen/pelvis

- CT Scan Abdomen- CT Scan Abdomen

- Diagnostic Laparoscopy- Diagnostic Laparoscopy


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Complications of AcuteComplications of Acute

AppendicitisAppendicitis Appendix AbscessAppendix Abscess Appendix MassAppendix Mass Perforation & Generalized PeritonitisPerforation & Generalized Peritonitis

Intraperitoneal AbscessIntraperitoneal Abscess Faecal FistulaFaecal Fistula Intestinal ObstructionIntestinal Obstruction

Portal PyemiaPortal Pyemia Sterility in WomenSterility in Women Overwhelming Sepsis & DeathOverwhelming Sepsis & Death


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TreatmentTreatment

AppendicectomyAppendicectomy

Conventional appendicectomyConventional appendicectomy

Laparoscopic appendicectomyLaparoscopic appendicectomy


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Problems Encountered DuringProblems Encountered During

AppendicectomyAppendicectomy

A normal appendix is foundA normal appendix is found

The appendix cannot be foundThe appendix cannot be found

An appendicular tumor is foundAn appendicular tumor is found

An appendix abscess is foundAn appendix abscess is found


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Checklist for an unwell patientChecklist for an unwell patient

following appendicectomyfollowing appendicectomy Examine theExamine the wound and abdomenwound and abdomen for an abscessfor an abscess Consider aConsider a pelvic abscesspelvic abscess - perform a rectal- perform a rectal

examinationexamination Examine the lungs-Examine the lungs-pneumonitispneumonitis or collapseor collapse Examine the legs,considerExamine the legs,consider venous thrombosisvenous thrombosis Examine the urine for organisms(Examine the urine for organisms(pyelonephritispyelonephritis)) Examine the conjuctivae for an icteric tinge andExamine the conjuctivae for an icteric tinge and

the liver for enlargement,and enquire if thethe liver for enlargement,and enquire if the

patient has had rigors (pylephlebitis)patient has had rigors (pylephlebitis) SuspectSuspect subphrenic abscesssubphrenic abscess


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Postoperative ComplicationsPostoperative Complications

Wound infectionWound infection Intra-abdominal abscessIntra-abdominal abscess

Ileus or Adhesive Intestinal ObstructionIleus or Adhesive Intestinal Obstruction RespiratoryRespiratory Venous thrombosis and embolismVenous thrombosis and embolism

Portal pyaemia (pylephlebitis)Portal pyaemia (pylephlebitis) Faecal fistulaFaecal fistula Right inguinal herniaRight inguinal hernia

What is the ConservativeWhat is the Conservative


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What is the ConservativeWhat is the Conservative

Treatment of Appendix MassTreatment of Appendix Mass

and when would you stop itand when would you stop it

A rising pulse rateA rising pulse rate Increasing or spreading abdominalIncreasing or spreading abdominal

painpain

Increasing size of the massIncreasing size of the massVomiting or copious gastric aspirateVomiting or copious gastric aspirate


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HomeworkHomework

Management of anManagement of an appendix massappendix mass

RecurrentRecurrent acuteacute appendicitisappendicitis

MucoceleMucocele of the appendixof the appendix

NeoplasmsNeoplasms of the appendixof the appendix

acute appendicitis ii

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