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Bernard M. Jaffe, MD Professor of Surgery, Emeritus

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Presentation on theme: "Bernard M. Jaffe, MD Professor of Surgery, Emeritus"— Presentation transcript:

1 Bernard M. Jaffe, MD Professor of Surgery, Emeritus
APPENDICITIS Bernard M. Jaffe, MD Professor of Surgery, Emeritus

2 INCIDENCE Very Common, 1 in 10,000/year 12% of Men, 25% of Women
Mean Age 31 Years Rare in Infancy M:F Ratio to 1.0 Misdiagnosis 22% in Women, 9% in Men

3 CAUSES Appendiceal Obstruction Children- Lymphoid Hyperplasia
Adults- Fecalith Carcinoid Mucinous Carcinoma Cecal Carcinoma Parasites

4 PATHOGENESIS Obstruction of Appendiceal Lumen ↓
Appendiceal Distention (Mucus) Venous Ischemia/Gangrene Perforation at Base (Widest Portion)

5 BACTERIOLOGY Aerobes Anaerobes E. coli Klebsiella Species
Pseudomonas aeroginosa Staphylococcal Species Enterococcus Bacteroides fragilis Fusobacterium Species Peptostreptococcus Clostridium Species

6 SYMPTOMS Abdominal Pain
Classically, Peri-Umbilical to Right Lower Quadrant Constant, Not Colicky Increased With Increased Intra- Abdominal Pressure Comes on Fairly Abruptly

7 SYMPTOMS Anorexia, Nausea, Vomiting Bowel Movements Unpredictable
Pain on Walking and Moving Abdominal Muscles Fever, Chills, Sweating Shortness of Breath

8 PHYSICAL FINDINGS Right Lower Quadrant and Referred Tenderness
Involuntary Guarding Psoas, Obturator Signs Decreased Diaphragmatic Excursion Direct and Referred Rebound Distention, Decreased Bowel Sounds Tachycardia, Tachypnea, Flushing

9 DIAGNOSIS Made on Clinical Findings
Anorexia as First Symptom Fairly Suggestive White Blood Cell Count Unreliable Additional Studies Rarely Necessary Imaging Grossly Overused and Rarely Helpful

Crohn’s Disease Meckel’s Diverticulitis Sigmoid/Cecal Diverticulitis Pelvic Inflammatory Disease Cholecystitis Mesenteric Adenitis Ruptured Ectopic Pregnancy, Ovarian Cyst, Torsion

11 ALVARADO SCALE Migration of Pain Value 1 Anorexia 1 Nausea, Vomiting 1
Right Lower Quadrant Tenderness 2 Rebound Elevated Temperature 1 Leukocytosis Left Shift

12 ALVARADO SCALE Often Used as Diagnostic Tool
Add Up Values to Determine Likelihood 9-10 Positive 7-8 High Liklihood 5-6 Equivocal 0-4 Very Unlikely

13 IMAGING For Equivocal Presentations To Detect Complications
CT Equal Results as Ultrasound Has Not Lowered Rates of False Pos/Neg Diagnosis Perforation

14 IMAGING Findings- Dilated Appendix (>7cm) Thick Walled Appendix
Peri-Appendiceal Fluid/Edema Adjacent Mesenteric Fat Stranding Free Air Uncommon After Perforation Failure to Fill With Contrast Unreliable

Higher Rates in Children < % Elderly > % Perforation Difficult to Diagnose Increases with Length of Symptoms Suspicion- T > 39 WBC >18,000

16 PROGNOSIS Mortality Rate Overall 0.2/100,000 Ruptured Appendix 3%
Ruptured in Elderly 15% Death Usually from Uncontrolled Sepsis Morbidity Nonperforated 3% Perforated 47% Wound Infection Most Common

? More Effective Than Open Compared to Open- More Expensive Longer Operation Fewer Wound Infections 3-X More Abcesses Same Mortality Rate

18 ABCESS More Common After Perforation Gangrene
Sites- Interloop (Often Multiple) Appendiceal Fossa Subhepatic Space Pelvis (Pouch of Douglas)

19 PELVIC ABCESSES Common After Perforated Appendicitis
Usually Recognized 5-8 Days After Operation Drainage- Surgical (Open or Lap) Percutaneous (Can Be Tough) Transrectal- Most Direct Most Effective Transvaginal in Women

20 PREGNANCY Incidence 1 in 2,000 Pregnancies
More Common First, Second Trimesters Appendix Rises as Uterus Grows Leukocytosis Confusing ,000 Normally in Pregnancy Perforation Doubles Rate of Fetal Mortality Operation % Premature Labor

21 RLQ MASS Imaging Determines Therapeutic Plan
Abcess- Percutaneous Drainage Antibiotics Phlegmon- Operation More Dangerous Operate for Acute Abdomen For Both, Once Well- Perform Interval Appendectomy

More Expensive Two Hospitalizations, Each 1-3 Days Morbidity 3% Can Be Done Laparoscopically Controversy If It Is Necessary???

Pro- 40% Need Appendectomy Earlier Than Planned Late Failure, Persistent, Recurrent Appendicitis 35% At Operation, 80% Have Peri-Appendiceal Abcess or Adhesions Occasional Appendiceal Tumor

Con- 50% Never Have Subsequent Clinical Appendicitis 25-50% Have Normal Histology Despite Minimal Procedure, It is Another Operation Requires Recuperation

25 CHRONIC APPENDICITIS Pain Same Location, Less Intense, Lasts Longer
Anorexia, Nausea, Less Vomiting Normal WBC Counts, Imaging Surgeons Establish Diagnosis With 94% Specificity, 78% Sensitivity Good Correlation Symptoms With Findings Appendectomy Cures 94%

Need 36 Appendectomies to Prevent One Appendicitis Spend $20 Million to Save $6 Million Special Circumstances- Disabled Patients Crohn’s Disease (at Other Operation) Children About to Start Chemotherapy Travel to Remote Places

27 APPENDICEAL TUMORS Rare, 0.9 to 1.4% Appendectomies
0.12 Per 1,000,000 People/Year Rarely Suspected Pre-Op Only 50% Diagnosed at Operation Mucocele (Benign or Malignant) More Common Than Carcinoid Also Lymphoma- Very Rare

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