2 ACUTE APPENDICITISAppendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay.
6 Variations in topographic position of the appendix From its base at the cecum, the appendix may extend (A) upward, retrocecal and retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to the left, ileocecal (may pass anterior or posterior to the ileum)
8 Blood supply to the appendix. A and B. Usual type with a single appendicular artery. C. Paired appendicular arteries.
9 IncidenceThe lifetime rate of appendectomy is 12% for men and 25% for women, with approximately 7% of all people undergoing appendectomy for acute appendicitis during their lifetimDespite the increased use of ultrasonography, computed tomography (CT), and laparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture.The percentage of misdiagnosed cases of appendicitis is significantly higher among women than among men
11 EtiologyObstruction of the lumen is the dominant etiologic factor in acute appendicitis.– Submucosal lymphoid hyperplasia– Faecolith / faecal stasis– Inspissated barium– Vegetable/fruit seeds– Worms (Entrobius vermicularis– Tumours of caecum/appendix
13 Common organisms seen in patients with acute appendicitis BacteriologyCommon organisms seen in patients with acute appendicitis
14 Classification (by V.I. Kolesnikov) 1. Appendiceal colic.2. Simple superficial appendicitis.3. Destructive appendicitis:а) phlegmonous;б) gangrenous;в) perforated.4. Complicated appendicitis:а) appendicular infiltrate;б) appendicular abscess;в) diffuse purulent peritonitis.5. Other complications of acute appendicitis (pylephlebitis, sepsis, retroperitoneal phlegmon, local abscesses of abdominal cavity).
15 Symptoms of simple appendicitis 1. Pain localized in a right iliac area.In 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of acute appendicitis. In 2-4 hours it migrates to the area of appendix (the Kocher’s sign).2. Single nausea and vomiting.3. Fever to C.4. Retention of stool or single diarrhea.5. Muscular tension in a right iliac area.Rovsing's sign - pain in right lower quadrant during palpation of left lower quadrantSitkovsky’s sign - increase of pain in a right iliac area when the patient lies on the left sideBartomier’s sign - the increase of pain intensity during the palpation of right iliac area when the patient lies on the left side.Dunphy's sign-increased pain with coughing
16 Symptoms of phlegmonous appendicitis 1. Expressed pain in a right iliac area.2. Fever to C.3. Muscular rigidity in a right iliac area.4. Peritoneal signsBlumberg’s sign. After gradual pressing by fingers of anterior abdominal wall quick taking off the hand causes the sharp increase of pain.Voskresenky’s sign. The increase of pain during quick sliding movements by the tips of fingers from epigastric to right iliac area.Rozdolsky’s sign. Painfulness in a right iliac area during percussion.
17 Symptoms of gangrenous appendicitis 1. Pain in a right iliac area.2. Grave condition of the patient.3. Signs of local peritonitis.4. Signs of intoxication
18 Symptoms of retrocaecal appendicitis 1. Non-expressive abdominal clinic.2. Expressed pain in a right lumbar area.3. Pain and muscular rigidity in a right iliac area during palpation.Yaure-Rozanov sign - Painfullness during palpation of Petit triangleGabay’s sign - Blumberg’s sign in Petit trianglePasternatsky’s sign - tapping of lumbar region cause the painPsoas sign - pain on extension of right thigh
19 Symptoms of retrocaecal retroperitoneal appendicitis 1. Clinic of retroperitoneal phlegmon.2. The signs of retrocaecal appendicitis.3. Flank tenderness in right lower quadrant.
20 Symptoms of pelvic appendicitis 1. Clinic of irritation of pelvic organs (dysuria, pulling rectal pain, tenesmi).2. Absence of muscular tenderness.3. Painfullness of anterior rectal wall and posterior vaginal vault.
24 Graded compression Ultrasound Depends on the technique and experienceNormal appendix– a blind-ended, tubular structure with a maximum wall thickness of 2 mm with an outer diameter of 6 mm,– No peristalsis– Originates from the base of the cecum
26 CT variable degree of distension (diameter 6–40 mm) wall thickness of 1–3 mm.Wall - asymmetrically thickened enhances with intravenous contrast medium.periappendiceal inflammatory massThickening and enhancement with intravenous contrast - adjacent wall of the cecum or ileum
30 Differential diagnostics of acute appendicitis with perforative peptic ulcer Pain in the right iliac regionMuscular tenderness in the right iliac regionSingle vomiting and diarrheaSharp acute diffuse painUlcerative anamnesisAbsence of hepatic dullnessOn X-ray of the abdomen air above the liver (air sickle)Rigidity of anterior abdominal wall
31 Differential diagnostics of acute appendicitis with intestinal obstruction Constant pain in the right iliac regionMuscular tenderness in the right iliac regionSingle vomiting and diarrheaPeriodic acute diffuse painConstant vomiting and nausea without any reliefRetention of stool and gasesAbdominal distensionOn X-ray of the abdomen Kloiber's cups (air-fluid levels)Splashing sound, increased peristalsis
33 Open Appendicectomy • Incission (transverse, Mc Burney’s point) • Open in layers. (muscle split along its fibres)• Check for fluid (+/-c&S)• Identify caecum and exteriorized – follow taeniae to appendix• Mesoappendix divided + ligated• Clamp appendix 5mm above caecum and ligated• Cauterise residual mucosa +/- purse string (not req)• Return caecum, wash with warm saline• Close in layers