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APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS. Anatomy / Function Location, position Location, position Function: Function: Immunologic organ Immunologic.

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Presentation on theme: "APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS. Anatomy / Function Location, position Location, position Function: Function: Immunologic organ Immunologic."— Presentation transcript:

1 APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS

2 Anatomy / Function Location, position Location, position Function: Function: Immunologic organ Immunologic organ Secrets IgA, component of the GUT associated lymphoid tissue (GALT) Secrets IgA, component of the GUT associated lymphoid tissue (GALT) Not essential; it’s removal ----> (-) sepsis Not essential; it’s removal ----> (-) sepsis

3 Appendiceal Conditions of Surgical Importance Appendicitis: Inflammation of the appendix Inflammation of the appendix 1500 – perityphlitis – inflammation of the cecal region 1500 – perityphlitis – inflammation of the cecal region Most common acute surgical disease of the abdomen Most common acute surgical disease of the abdomen Peak ----> puberty / early adulthood Peak ----> puberty / early adulthood Male > female (1.3 : 1) Male > female (1.3 : 1)

4 Appendicitis Pathogenesis: Obstruction (dominant causal factor) Obstruction (dominant causal factor) 1. Fecalith – usual cause 2. Hypertrophy of the lymphoid tissue 3. Inspissated barium 4. Vegetable and fruit seeds 5. Intestinal worms (Ascaris) 6. Tumor

5 Appendicitis Pathogenesis: Sequence of events in Luminal Obstruction Sequence of events in Luminal Obstruction Proximal occlusion ---> Closed loop Obst. ------ -> rapid distention due to: a. Continuing secretion of the mucosa b. Rapid multiplication of normal flora ---> elevate pressure ---> capillary/venous occlusion (CONGESTION 1 st stage): S/Sx: (+) visceral afferent pain fibers (vague, dull, diffuse pain in mid-abdomen or lower epigastrium. Increase peristalsis (crampy pain); N/V and anorexia

6 Appendicitis Pathogenesis Inflammatory process involves the serosa of appendix and in turns parietal peritoneum in the region. Inflammatory process involves the serosa of appendix and in turns parietal peritoneum in the region. Infiltration of PMN (SUPPURATIVE 2 nd stage) Infiltration of PMN (SUPPURATIVE 2 nd stage) Damage of the lining epithelium ---> entrance of bacteria to the wall. Damage of the lining epithelium ---> entrance of bacteria to the wall. Impairment of blood supply (inc. pressure than arterial pressure)---> ellipsoidal infarct at antimesenteric border near the tip. (GANGRENOUS 3 rd stage) ---> (PERFORATION 4 th stage) Impairment of blood supply (inc. pressure than arterial pressure)---> ellipsoidal infarct at antimesenteric border near the tip. (GANGRENOUS 3 rd stage) ---> (PERFORATION 4 th stage)  This process is not inevitable. Some subside spontaneously

7 Appendicitis Pathogens: Anaerobes, aerobes Anaerobes, aerobes Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus

8 Appendicitis Clinical Manifestation: 1. Abdominal pain: Classic pain sequence ………. Classic pain sequence ………. Right lower quadrant pain Right lower quadrant pain Others: Others: Left lower quadrant pain (long appendix) Left lower quadrant pain (long appendix) Flank or back pain (retro-cecal) Flank or back pain (retro-cecal) Supra-pubic (pelvic) Supra-pubic (pelvic) Testicular pain (retro-ileal ----> irritates the spermatic artery and ureter Testicular pain (retro-ileal ----> irritates the spermatic artery and ureter 2. Anorexia: nearly always present 3. Vomiting 75% 4. Obstipation / diarrhea Usual sequence (95%) : ANOREXIA ---> ABD. PAIN - --> VOMITING Usual sequence (95%) : ANOREXIA ---> ABD. PAIN - --> VOMITING

9 Appendicitis Signs: PE depends on the location of the appendix and presence of rupture 1. Direct and rebound tenderness at Mc Burney’s point. ROVSING sign ---> indicate muscles peritoneal irritation. 2. Involuntary muscle guarding (true reflex rigidity). 3. Psoas / Obturator signs ---> retrocecal appendix 4. Para-rectal tenderness Stages I & II – uncomplicated Stages III & IV – complicated

10 Appendicitis Laboratory Findings: 1. WBC: leucocytosis simple = 10,000 to 18,000/mm3 simple = 10,000 to 18,000/mm3 perforated = >18,000/mm3 perforated = >18,000/mm3 2. Urinalysis : Hematuria and pyuria due to irritation of the ureter and urinary bladder Hematuria and pyuria due to irritation of the ureter and urinary bladder w/o bacteriuria w/o bacteriuria 3. FPA: rarely helpful; (+) fecalith – rare, highly suggestive of the dx. highly suggestive of the dx.

11 Appendicitis 4. Graded Compression sonogram: 78–96% sensitivity; 85– 98% specificity 78–96% sensitivity; 85– 98% specificity (+) non-compressible appendix, 6mm or > at AP view (+) non-compressible appendix, 6mm or > at AP view (-) easily compressible 5mm; not visualized a & (-) pericecal fluid or mass False (-): False (-): a. Appendicitis confined at the tip b. Retrocecal position c. Perforated appendix False (+): a. Periappendicitis from surrounding inflammation b. Dilated fallopian tube c. Inspissated stool can mimic an appendicitis d. Obese pt., appendix not compressed

12 Appendicitis 5. CT scan: Shd. not delay or substitute for prompt operative intervention when clinically indicated Shd. not delay or substitute for prompt operative intervention when clinically indicated Used primarily for percutaneous drainage Used primarily for percutaneous drainage

13 Appendicitis 6. Laparoscopy Diagnostic /therapeutic Diagnostic /therapeutic Useful for female to diferrentiate gynecological pathology Useful for female to diferrentiate gynecological pathology

14 Appendiceal Rupture: Increase morbidity / mortality Increase morbidity / mortality No accurate way to determine the occurrence of rupture No accurate way to determine the occurrence of rupture Suspected: Suspected: 1. Fever > 39 C 2. WBC of > 18,000/mm3 3. Localized rebound, involuntary muscle guarding 4. Signs of genralized peritonitis 5. Ill defined mass (PHLEGMON – motted loops of bowel adherent to the inflamed appendix)

15 Differential Diagnosis: Most common erroneous pre-op diagnosis: Most common erroneous pre-op diagnosis: Acute mesenteric lymphaditis Acute mesenteric lymphaditis No organic pathologic condition No organic pathologic condition Acute pelvic pathologic condition Acute pelvic pathologic condition Twisted ovarian cyst / ruptured graafian follicle Twisted ovarian cyst / ruptured graafian follicle Acute gastroenteritis Acute gastroenteritis 1. Acute mesenteric adenitis: w/ present or recent URTI w/ present or recent URTI Diffuse pain, tenderness not sharp, (-) rigidity Diffuse pain, tenderness not sharp, (-) rigidity Self limited -----> observe Self limited -----> observe

16 Differential Diagnosis: 2. Acute gastroenteritis: Childhood, viral gastroenteritis Childhood, viral gastroenteritis Chills, fever, profuse watery diarrhea, N/V Chills, fever, profuse watery diarrhea, N/V Hyper-peristaltic abdominal cramps w/o localizing sign Hyper-peristaltic abdominal cramps w/o localizing sign 3. Disease of the male: Torsion of the testes and acute epididymitis Torsion of the testes and acute epididymitis Diagnosed by palpating the enlarged tender seminal vesicle Diagnosed by palpating the enlarged tender seminal vesicle 4. Meckel’s diverticulitis: Same clinical picture w/ AP Same clinical picture w/ AP Associated w/ same complication of AP, hence needs prompt surgical intervention. Associated w/ same complication of AP, hence needs prompt surgical intervention.

17 Differential Diagnosis: 5. Intussusceptions: Shd. Be differentiated pre-operatively due to different management. Shd. Be differentiated pre-operatively due to different management. Char: Char: a. Common under 2 y/o b. Occur in well nourished infant who suddenly doubled up due to colicky pain. Hrs. later pass out bloody mucoid stool c. Sausage shape mass in the RLQ 6. Regional enteritis (Crohn’s dse): s/sx is almost the same w/ AP this is dx. in celiotomy s/sx is almost the same w/ AP this is dx. in celiotomy

18 Differential Diagnosis: 7. UTI / Ureteral stone: Referred pain to the labia, scroyum or penis Referred pain to the labia, scroyum or penis Chills, fever (+) R costo-vertebral angle tenderness, hematuria, leucocytosis Chills, fever (+) R costo-vertebral angle tenderness, hematuria, leucocytosis Dx: -----> pyelography Dx: -----> pyelography 8. Gynecological disorders: Rate of erroneous diagnosis of AP is highest in young adult female Rate of erroneous diagnosis of AP is highest in young adult female Order of frequency: Order of frequency: PID -----> ruptured grafian follicle ----> twistd ovarian cyst or tumor -----> endometriosis -----> ruptured ectopic pregnancy PID -----> ruptured grafian follicle ----> twistd ovarian cyst or tumor -----> endometriosis -----> ruptured ectopic pregnancy

19 TREATMENT Adequate hydration, correct electrolyte imbalance Adequate hydration, correct electrolyte imbalance Manage other medical problems Manage other medical problems Pre-operative antibiotics: Pre-operative antibiotics: Simple AP - hrs antibiotic Simple AP - hrs antibiotic Ruptured AP - antibiotic until fever Ruptured AP - antibiotic until fever Peritonitis - 10 days antibiotics Peritonitis - 10 days antibiotics Surgery: Surgery: 1. Open appendectomy: McBurney (oblique); Rocky Davis (transverse); McBurney (oblique); Rocky Davis (transverse); right paramedian; midline incision

20 Open Appendectomy:

21 TREATMENT 2. Laparoscopy:

22 TREATMENT Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic Well localized abscess ---> percutaneous drainage Well localized abscess ---> percutaneous drainage Complex abscess ---> surgical drainage Complex abscess ---> surgical drainage Interval appendectomy – 6 wks. Following an acute event treated either non-operatively or w/ simple drainage of an abscess. Interval appendectomy – 6 wks. Following an acute event treated either non-operatively or w/ simple drainage of an abscess. 0-37% recurrent appendicitis 0-37% recurrent appendicitis

23 PROGNOSIS Mortality: 9.9% -------> 0.2% 9.9% -------> 0.2% Factors: Factors: 1. Ruptured prior to surgery Simple - 0.06% Simple - 0.06% Ruptured - 3% Ruptured - 3% 2. Age of pt.: Ruptured - 15% Ruptured - 15% Death due to: Death due to: 1. Uncontrolled sepsis (peritonitis, intra-abdominal abscess, gm (-) septicemia. 2. Cardiac / pulmonary insufficiency (elderly) 3. Pulmonary embolism 4. aspiration

24 PROGNOSIS Morbidity: Simple - 3%Ruptured - 47% Simple - 3%Ruptured - 47% Early: Early: 1. Septic : a. Wound infection / abscess b. Intra-abdominal abscess (appendiceal fossa, pouch of Douglas, sub-hepatic space, multiple intestinal loops. 2. Fecal fistula: 3. Wound dehiscence 4. Intestinal obstruction: due to locculated abscess & exuberant adhesive formation

25 PROGNOSIS Morbidity: Late: Late: 1. Adhesived bands 2. Inguinal hernia (3x greater in pt. who had appendectomy) 3. Incisional hernia (paramedian / midline incision)

26 Appendicitis in the Young Difficult to establish diagnosis: Difficult to establish diagnosis: 1. Inability of a child to give accurate history 2. Diagnostic delays by both parents & physicians Rapid progression to rupture: Rapid progression to rupture: Underdeveloped greater omentum ----> higher morbidity Underdeveloped greater omentum ----> higher morbidity < 8y/o had a twofold increase rate of perforation as compared to older children < 8y/o had a twofold increase rate of perforation as compared to older children

27 Appendicitis during Pregnancy AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnancy AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnancy Most frequent during the 1 st & 2 nd trimesters Most frequent during the 1 st & 2 nd trimesters S/Sx: S/Sx: Abdominal pain, tenderness Abdominal pain, tenderness Rebound tenderness and guarding less due to laxity of abdominal wall Rebound tenderness and guarding less due to laxity of abdominal wall Increase WBC; abdominal ultrasound Increase WBC; abdominal ultrasound Dx is difficult due to displacement of the appendix Dx is difficult due to displacement of the appendix

28 Appendicitis during Pregnancy Dx is difficult due to displacement of the appendix Dx is difficult due to displacement of the appendix

29 Appendicitis during Pregnancy Risk of surgery: Risk of surgery: Premature labor - 10-15% both for negative laparotomy and appendectomy for uncomplicated AP Premature labor - 10-15% both for negative laparotomy and appendectomy for uncomplicated AP Appendiceal perforation is significant factor associated w/ fetal and maternal death. Appendiceal perforation is significant factor associated w/ fetal and maternal death. Fetal mortality - 3-5% w/ early appendicitis Fetal mortality - 3-5% w/ early appendicitis 20% perforation 20% perforation Suspicion of appendicitis during pregnancy shd prompt rapid diagnosis and surgical intervention Suspicion of appendicitis during pregnancy shd prompt rapid diagnosis and surgical intervention

30 Tumors of the Appendix Appendiceal malignancy is rare Appendiceal malignancy is rare Discovered during laparotomy or in association w/ acute inflammation of the appendix Discovered during laparotomy or in association w/ acute inflammation of the appendix 1. CARCINOID: Firm, yellow, bulbar mass in the appendix Firm, yellow, bulbar mass in the appendix Located: appendix ---> small bowel ----> rectum Located: appendix ---> small bowel ----> rectum Carcinoid syndrome is rare in appendiceal carcinoid unless widespread metastases are present Carcinoid syndrome is rare in appendiceal carcinoid unless widespread metastases are present Malignant potential related to it’s SIZE ---> > 2cm Malignant potential related to it’s SIZE ---> > 2cm Treatment:< 2cm appendectomy Treatment:< 2cm appendectomy > 2cm right hemicolectomy

31 Tumors of the Appendix 2. ADENOCARCINOMA: Rare Rare Histologic type: Histologic type: a. Mucinous adenocarcinoma b. Colonic adenocarcinoma c. Adenocarcinoid Manifestation: Manifestation: a. Acute appendicitis b. RLQ mass Treatment: right hemicolectomy Treatment: right hemicolectomy Prognosis: Prognosis: 55% ----> 5yr. survival 55% ----> 5yr. survival

32 Tumors of the Appendix 3. MUCOCELE: Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance Histologic type: Histologic type: a. Retention cyst b. Mucosal hyperplasia c. Cystadenomas d. Cystadenocarcinoma Rarely occurs w/ gelatinous ascites (Pseudomyxoma Peritonei) usually associated w/ malignant ovarian or appendiceal mucinous CA. if present survival is decreased Rarely occurs w/ gelatinous ascites (Pseudomyxoma Peritonei) usually associated w/ malignant ovarian or appendiceal mucinous CA. if present survival is decreased

33 Tumors of the Appendix 3. MUCOCELE: Treatment: Treatment: Benign - appendectomy Benign - appendectomy Malignant - right hemicolectomy for cystadenoCA of the appendix; THABSO and appendectomy for ovarian cystadenoCA Malignant - right hemicolectomy for cystadenoCA of the appendix; THABSO and appendectomy for ovarian cystadenoCA Adjuvant Tx: Adjuvant Tx: Radiation, intraperitoneal and systemic chemotherapy recommended but it’s role is unclear Radiation, intraperitoneal and systemic chemotherapy recommended but it’s role is unclear 57% local recurrence at appendiceal primary site 57% local recurrence at appendiceal primary site Death ensues due to progresive obstruction and renal failure Death ensues due to progresive obstruction and renal failure

34 THANK YOU


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