Presentation on theme: "APPENDICITIS - WHAT WE ALL FORGOT (or never knew in the first place!)"— Presentation transcript:
1 APPENDICITIS - WHAT WE ALL FORGOT (or never knew in the first place!)
2 APPENDICITIS History Berengario DaCarpi, a physician-anatomist, made the first description of the appendix in 1521Leonardo DaVinci demonstrated the appendix in drawings made in 1492 but not published until the 18th century.Lorenz Heister gave the first unequivocal account of appendicitis in 1711The appendix is clearly illustrated in De Humani Corporis Febrica Liber V by Andreas Vesalius published in 1543Vesalius A. De Humani Corporis Fabrica Liber V. Basel: Iohannis Oporini; 1543.
3 APPENDICITISHistoryHeister, a student of Boerhaave, described a perforation of the appendix with a small abscess adjacent to a gangrenous appendixHeister speculated that the appendix might be the site of acute inflammation. He described the autopsy on the body of a criminalFrancois Melier, a Parisian physician, described 6 cases of appendicitis at autopsy and first suggested the possibility of removing the appendix in 1827
4 APPENDICITISHistoryClaudius Amyand, Sergeant Surgeon to George II, performed the first known appendectomy in He operated on an 11-year-old boy with a right scrotal hernia and a fistula. He identified the appendix, perforated by a pin, within the scrotum. He ligated the appendix and removed it.Shepherd JA. Acute appendicitis: a historical survey. Lancet 1954;2:
5 APPENDICITIS History Fitz – 1886 Proposed that the appendix is the cause of most inflammatory disease of the right lower quadrant. He went on to describe the clinical features of appendicitis and, importantly, proposed early surgical removal of the appendixFitz RH. Perforating inflammation of the vermiform appendix: with specialreference to its early diagnosis and treatment. Am J Med Sci 1886;92:
6 APPENDICITISHistoryIn 1889, McBurney of New York published the first of several important papers regarding the appendix. He suggested early operative intervention and developed the muscle-splitting incision that bears his name and is commonly used todayMcBurney C. Experience with early operative interference in cases of disease of thevermiform appendix. NY Med J 1889;50:McBurney C. The incision made in the abdominal wall in cases of appendicitis,with a description of a new method of operation. Ann Surg 1894;20:38-43.
7 APPENDICITIS Introduction Lifetime risk – 6% to 7% Peak age – Adolescents and young adultsUncommon <5 and >50 yrs1 in 35 men1 in 50 womenMale:Female 1.3:1
8 APPENDICITIS Introduction More common in industrialised nations (refined, low fibre diet)Presumably, this diet leads to hard stool, higher intracolic pressure and faecolith formationFamilial association is simply due to similar environment and dietary habits
9 APPENDICITIS Pathophysiology Small lumen to length ratio Predisposed to closed loop obstruction, especially with proximal swelling or faecolithOngoing mucosal secretion leads to elevated intraluminal pressureVenous pressure is exceeded andischaemia developsHypoxic mucosa begins to ulcerateBacterial translocation
11 APPENDICITIS Clinical Features Begins as peri-umbilical discomfort – poorly localised and unrelieved by stools.Loss of Appetite (80%)Nausea (+- vomiting)Diarrhoea (uncommon)6-12 hours later localised to RIF (localised peritonism)Less tenderness in retrocaecal or pelvic appendixPyrexia (37.5 to 38) – 25% to 50% have temp <37.5
12 APPENDICITIS Clinical Features Leukocytosis… Cardall and colleagues showed that fever and leukocytosis were not always present and cannot be wholly relied upon in the diagnosisPieper and colleagues reported 493 patients in which only 67% had a leukocyte count greater than 11.0CRPCardall T, Glasser J, Guss DA. Clinical value of the total white blood cell count andtermperature in the evaluation of patients with suspected appendicitis. Acad EmergMed 2004;11:1021-7Pieper R, Kager L, Nasman P. Acute appendicitis: a clinical study of 1018 cases ofemergency appendectomy. Acta Chir Scand 1982;48:51-62.
14 APPENDICITIS Clinical Features PSOAS SIGN The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip.Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this manoeuvre.
15 APPENDICITIS OBTURATOR SIGN Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee resulting in internal rotation of the femur.Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this manoeuvre.
16 Perforation - Clinical Features APPENDICITISPerforation - Clinical FeaturesOccurs in 20%-30%Longer duration of symptoms before presentationAge <3yrs and >50yrsIncreasing abdominal pain (severity and sight)Temperature > 38The morbidity of a negative appendectomy is preferable to the morbidity of perforated appendicitis
17 Peri-appendiceal Abscess - Clinical Features APPENDICITISPeri-appendiceal Abscess - Clinical FeaturesOccurs in 10%Scenario – Develops RIF pain and fever for 1-2 days then resolves, then recurs 7-10 days laterPalpable massUltrasound or CT to confirm diagnosisAvoid surgery if possible, especially if appendix is difficult to find (discussed later)
18 Recurrent Appendicitis Debatable existenceSinanan has shown it to be a real entityRecurrent attacks of RIF painIf interval appendectomy not done after medical Rx, 10-80% recurrenceHistology in recurrent pain pts- chronic AND acute inflammationSinanan M. Acute Abdomen and Appendix. In: Greenfield LJ, Mulholland MW,Oldham KT, Zelenock GB, editors. Surgery: Scientific Principles and Practice.Philadelphia: JB Lippincott; 1993, pp
19 APPENDICITIS Chronic Appendicitis Chronic RIF pain If appendectomy relieves pain, and histology shows chronic inflammation – Diagnosis is made retrospectively
21 Atypical Presentations APPENDICITISAtypical Presentations3 factors…1) Extremes of ageAge 1-5 has 70% perforation rateAge < 1yr has almost 100% perforation rateREASONS…CommunicationShorter, incompletely formed omentum
22 Atypical Presentations APPENDICITISAtypical Presentations3 factors…3) Associated conditions (e.g. pregnancy, Crohn’s, antibiotics, steroids, recent abdominal surgery)Pregnancy causes delays in diagnosisAbdominal pain, nausea, vomiting, leukocytosis all ‘normal’ for pregnancyAppendix moves to RUQ in 3rd trimester
23 Differential Diagnosis APPENDICITISDifferential DiagnosisCHILDREN…Extra-abdominal – (Otitis, pneumonia, meningitis, URTI – can all present with abdominal pain, nausea, vomiting.Diarrhoea – usually suggestive of gastroenteritisMesenteric LymphadenitisMeckel’s diverticulitisIntussusception (Tender mass and red-currant stools)Typhlitis (neutropaenic child)
24 APPENDICITIS Imaging A SHORT NOTE… If the diagnosis is apparent from the history, examination and lab findings – then surgery is indicated without imaging.Imaging is reserved for doubtful diagnosis
25 APPENDICITIS Imaging PLAIN RADIOGRAPHS… Faecolith (5-8%) Gas in the appendixLocalised paralytic ileusLoss of caecal shadowBlurring of R PsoasR scoliosis of lumbar spineFree air (rare)
26 APPENDICITIS Imaging PLAIN RADIOGRAPHS… Study of 821 patients… no x-ray was sensitive or specificUse to rule out other condition (obstruction, renal calculus, perforation)Overall – not cost effectiveRao PM, Rhea JT, Rao JA, Conn AK. Plain abdominal radiography in clinicallysuspected appendicitis: diagnostic yield, resource use, and comparison with CT.Am J Emerg Med 1999;17:325-8.
27 APPENDICITIS Imaging ULTRASOUND Deutsch and Leopold visualised appendix in 1981Graded pressure technique (compresses the bowel overlying the appendix)Immobile, non-compressible, blind-ending structure consisting of an anechoic lumen surrounded by an echogenic mucosa and hypoechoic thickened wall adjacent to the caecum.Deutsch A, Leopold GR. Ultrasonic demonstration of the inflamed appendix: casereport. Radiology 1981;140:163-4.
28 APPENDICITIS Imaging ULTRASOUND The diagnostic accuracy of graded compression ultrasound has been reported to range from 71% to 97%, with sensitivities and specificities in the 76% to 96% and 47% to 94% ranges, respectivelyOperator dependentNormal appendix must be visualised to rule out appendicitis (60-82%)Retrocaecal appendix difficult to visualise
29 APPENDICITIS Imaging ULTRASOUND Appendicitis features – Appendiceal diameter > 6-7mm (sensitivity 100%, specificity 64%)Target signLoculated peri-caecal fluid (rupture)AppendicolithAbsence of gas in appendix lumen
31 APPENDICITIS Imaging ULTRASOUND - summary Disadvantages… Low specificityDiscomfort for patient with probe pressureAdvantages…InexpensiveNon-invasiveNo radiationCan find other abdominal pathology
32 APPENDICITIS Imaging CT SCAN… Accuracy of 93-98% Sensitivity 87-100% Specificity 95-99%Enlarged appendixAppendiceal wall thickeningPeri-appendiceal fat strandingAppendiceal wall enhancementRao PM, Rhea JT, Novelline RA. Sensitivity and specificity of the individual CTsigns of appendicitis: experience with 200 helical appendiceal CT examinations.J Comput Assist Tomogr 1997;21:
33 APPENDICITIS Imaging CT SCAN… Study of 908 patients… Drop in perforation rate (22% to 14%)Drop in negative appendectomy rate (20% to 7%)Rao P, Rhea JT, Rattner DW, Wenus LG, Novelline RA. Introduction ofappendiceal CT: impact on negative appendectomy and appendiceal perforationrates. Ann Surg 1999;229:344-9..
36 APPENDICITIS Antibiotics Large meta-analysis of 9576 patients Proven to prevent wound infection and intra-abdominal abscessCover Gram negative and anaerobic organismsAndersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo forprevention of postoperative infection after appendicectomy. Cochrane DatabaseSyst Rev 2004;4:1-64
37 APPENDICITIS Surgery Generally indicated unless… Symptoms resolved when patient presentsPeri-appendiceal abscess without peritonitis – percutaneous drainageInterval appendectomyOptimise patient before surgery
38 APPENDICITIS Open Appendectomy Normal appendix? Check Caecum, ileum (and sigmoid) for diverticular disease.Check for Meckel’sGall BladderIiflammatory Bowel DiseasePerforated Duodenal UlcerGUT (females – PID, follicular cysts, ectopic)Mesenteric lymphadenpathyNB – if ++ pus, full exploration required
39 APPENDICITIS Open Appendectomy Normal appendix? Do appendectomy anyway (presence of the scar, etc.)Exception is diseased caecum (e.g. Crohn’s) where a fecal fistula may form
40 Peri-appendiceal Abscess APPENDICITISPeri-appendiceal AbscessCT or Sonar guided percutaneous catheter7-10 days of drainageInterval appendectomy at 6-8 weeksIf laparotomy done…Open abscessAppendectomy only if safeIf caecum friable, leave it and do interval appendectomy (10% to 80% risk of recurrence)
41 Laparoscopic Appendectomy APPENDICITISLaparoscopic AppendectomyKurt Semm 1983Major meta-analysis, still major controversyDependent on expertise and equipmentAllows for better visualisation of the abdomen
42 Laparoscopic Appendectomy APPENDICITISLaparoscopic AppendectomyCONTRA-INDICATIONS…Lack of surgeon’s experienceInability to tolerate GARefractory coagulopathyDiffuse peritonitis with haemodynamic compromisePrevious abdominal surgery (relative)Portal Hypertension (relative)Advanced pregnancy (relative)Severe cardiac failure (relative)
43 Selected randomized trials of laparoscopic versus open appendectomy ReferencenumberOR Time Conversion rate(%) LOS <days>LOLong et al (2002)9310510791162.63.4Pedersen et al (2001)2823016040232Ozmen et al (1999)352838—1.63.7Hellberg et al (1999)24425612Heikkinen et al (1998)192131415.3Klinger et al. (1998)878234Reiertsen et al (1997)4251253.53.2Minne et al (1997)27618.104.22.168Macarulla et al (1997)10610455458.34.8Ortega et al (1995)1678668586.52.8
44 Laparoscopic Appendectomy APPENDICITISLaparoscopic AppendectomyLaparoscopic longer by minutes5% - 25% conversionHospital stay same or 1 day in favour of laparoscopicReturn to normal activity 5-7 days earlierResults of complication rates mixedNo difference in cost(equipment/length vs. hospital stay)‘Jury is still out