Presentation on theme: "GIS-K-25 ACUTE APPENDICITIS Appendiceal Mass / Abscess"— Presentation transcript:
1 GIS-K-25 ACUTE APPENDICITIS Appendiceal Mass / Abscess Syahbuddin HarahapDivision of Digestive SurgeryDepartment of SurgeryFaculty of Medicine University of North SumateraAdam Malik Hospital
2 The appendix is : INTRODUCTION Wormlike extension of the cecum (vermiform appendix).-Length is 8-10 cm (ranging from 2-20 cm).-Fifth month of gestation-Several lymphoid follicles.
3 Etiology: Obstruction of the lumen appendix followed by infection Catarrhal appendicitis.-lymphoid hyperplasia (60% children)-Gastro enteritis-Virus-Acute respiratory infection-MononucleosisObstructive appendicitis-fecalith 35% adults.-foreign body / parasites (4%)- tumors (1%)
4 Pathophysiology Wangensteen proposed Closed loop obstruction Increase in luminal pressure.Exceeds capillary pressure causes mucosal ischemiaLuminal bacterial overgrowth and translocation bacteria across the appendiceal wall result :-Inflammation-Edema-Necrosis perforation occur about 48 hours .If the body successfully walls off the perforation Appendiceal MassIf the perforation is not successfully walled off Diffuse peritonitis will develop.
5 Problem:Appendicitis can mimic several abdominal conditions.Laboratory testImaging investigationStatistics report1 of 5 cases is misdiagnosedNormal appendix is found in15-40% Emergency appendectomy.(Negative Appendectomy)
7 Differential diagnosis of appendicitis appendicitis can mimic several abdominal conditions.
8 Lab Studies:Complete blood cell countA mild elevation of WBCs (ie, >10,000/µL)UrinalysisMild pyuria relationship of the appendix with the right ureter.Severe pyuria in UTI.For women of childbearing age,Ectopic pregnancy test urin (beta-hCG)
9 On physical examination Lying downFlexing their hipsThe most common symptom of appendicitis is :- Acute abdominal pain.- Epigastric or Periumbilical pain migrating to the right lower quadrant (RLQ) of the abdomen.- Vomiting, nausea, and anorexia- Afebrile or has a low-grade fever , 38 º CHigher fevers are associated with a perforated appendix
10 Special maneuvers it is only the area McBurney sign McBurney's point of greatest tendernessBlumberg signRovsing’s SignDunphy sign Cough TestObturator signPsoas signMarkle sign
12 INDICATIONSConsider an appendectomy for patients with a history of :Persistent abdominal painFeverClinical signs of localized or diffuse peritonitisEspecially if leukocytosis is present.
13 Imaging Studies Abdomen plain film: Fecalith within the appendix Urolithiasis right middle third
14 A score of 7 or more is strongly predictive of acute appendicitis. Alvarado score 1986MANTRELS SCORECharacteristicScoreM = Migration of pain to the RLQ1A = AnorexiaN = Nausea and vomitingT = Tenderness in RLQ2R = Rebound painE = Elevated temperatureL = LeukocytosisS = Shift of WBC to the leftTotal10A score of 7 or more is strongly predictive of acute appendicitis.
15 Sonography Advantages of sonography Noninvasiveness, normal less than 6 mmSonographyAdvantages of sonographyNoninvasiveness,Short acquisition timeLack of radiation exposurePotential for diagnosis of other causes of abdominal painPediatric patientsWomen of childbearing age.Pregnant women
16 CT scan -Oral contrast medium -Rectal Gastrografin enema Reserved for patients-Uncertain diagnosis-Severe obesity.more than 6 mm
17 If the clinical picture is unclear Short period (4-6 h) of watchful waitingUSG / CT scan-May improve diagnostic accuracyWithout a definite diagnosis- return for continued or recurrent symptoms follow-up examination in 24 hours.
18 Complications Perforation General Secondary Peritonitis Appendiceal MassAppendiceal AbscessPylephlebitis is suppurative thrombophlebitis of the portal venous systemHepatic abscesChillsHigh feverJaundice
19 TREATMENTMedical therapyResuscitated adequately with fluids .Preoperative prophylactic antibiotics-Acute Appendicitis single agent second-generation cephalosporin.-Perforated appendix triple antibiotic therapy Ampicillin , gentamycin , metronidazolAntibiotic prophylaxis should be administered before every appendectomy.Antibiotic treatment may be stopped.-Becomes afebrile-WBC count normalizes
20 Two approaches to appendectomy Open Emergency Appendicectomy ( Appendectomy)Laparoscopic appendectomyIf normal appendix removed need to look for:- Meckel's diverticulum- Acute salpingitis- Crohn's disease
21 If the body successfully walls off the localized perforation Appendiceal MassRLQ massThe pain may actually improve.Symptoms do not completely resolve.Still have right lower quadrant painDecreased appetiteChange in bowel habits (eg, diarrhea, constipation)Intermittent low-grade fever.
22 Treatment of Appendiceal Mass Nonoperative management Becomes walled off by omentum and ajacent viscera.Initially treated with intravenous broad-spectrum antibioticAppendiceal Abscess USG or CT scan-Percutaneous aspiration-Drain placementIntravenous antibiotics are continued until the patient- afebrile for 24 hours- return of normal gastrointestinal function- normal WBC count with a normal differential.At this time, patients are switched to oral antibiotics for a total antibiotic course of days.Traditionally, interval appendectomy is performed 6-8 weeks later.