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James Taclin C. Banez, MD, FPSGS,FPCS

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Presentation on theme: "James Taclin C. Banez, MD, FPSGS,FPCS"— Presentation transcript:

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

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

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

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

5 Appendicitis Pathogenesis:
Sequence of events in Luminal Obstruction Proximal occlusion ---> Closed loop Obst > rapid distention due to: Continuing secretion of the mucosa Rapid multiplication of normal flora ---> elevate pressure ---> capillary/venous occlusion (CONGESTION 1st 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. Infiltration of PMN (SUPPURATIVE 2nd stage) 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 3rd stage) ---> (PERFORATION 4th stage) This process is not inevitable. Some subside spontaneously

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

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

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

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

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

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

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

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

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

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

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

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

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

20 Open Appendectomy:

21 TREATMENT Laparoscopy:

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

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

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

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

26 Appendicitis in the Young
Difficult to establish diagnosis: Inability of a child to give accurate history Diagnostic delays by both parents & physicians Rapid progression to rupture: Underdeveloped greater omentum ----> higher morbidity < 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 Most frequent during the 1st & 2nd trimesters S/Sx: Abdominal pain, tenderness Rebound tenderness and guarding less due to laxity of abdominal wall Increase WBC; abdominal ultrasound Dx is difficult due to displacement of the appendix

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

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

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

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

32 Tumors of the Appendix MUCOCELE:
Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance Histologic type: Retention cyst Mucosal hyperplasia Cystadenomas Cystadenocarcinoma 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 MUCOCELE: Treatment: Benign - appendectomy
Malignant - right hemicolectomy for cystadenoCA of the appendix; THABSO and appendectomy for ovarian cystadenoCA Adjuvant Tx: Radiation, intraperitoneal and systemic chemotherapy recommended but it’s role is unclear 57% local recurrence at appendiceal primary site Death ensues due to progresive obstruction and renal failure


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