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

34. THANK YOU