Diseases of the Appendix בס"ד Diseases of the Appendix יונתן אברהם דמה

Appendicitis Disease of the young Incidence Rare in very young children and elderly Overall mortality 0.25% Higher mortality in age extremes

Plan Introduction Diagnosis Treatment preop, op and post op Special consideration Complication Neoplasm

Introduction Embryology Normal anatomy Pathophysiology Bacteriology

Embryology

Embryology

Anatomy

Anatomy

Pathophysiology

Diagnosis Clinical History Physical examination Laboratory Imaging Plain abdominal film US CT

History 1889: Chester McBurney Only 55% have classical features. History 24-36 hours Abdominal pain: (diffuse and periumbilical, localizing to the RLQ) Anorexia (almost always). Vomiting (75%). Low grade fever. If >38 suspect perforation Only 55% have classical features.

Physical exam

Peritoneal inflamation sign Dunphy's sign Rovsing's sign Guarding Rebound sign Obturator sign Psoas sign

Dunphy

Rovsing

Guarding

Rebound

Obturator

Psoas

Diffuse Peritonitis כשהמצב מתקדם

Laboratory settings WBC Urinalysis

אבחנה של דלקת בתוספתן היא קודם כל קלינית

Scoring

אבל עם אנחנו לא בטוחים....

Diagnosis - US Noninvasive Available Operator dependant Sensitivity 80% Specificity 90% Positive Findings Noncompressible tubular structure >7 mm Fluid appendicolith

CT Requires contrast - oral and IV Radiation Sensitivity 90-95% Specificity 90% Findings Nonfilling tubular structure (target) >7 mm Pericecal inflammation and Fluid appendicolith

Target

>7 מ"מ

Fecalith

DD Go by organ systems or by category Consider symptoms, Age and Sex Concomitant conditions

Differential diagnosis

Diagnostic laparoscopy If you are not sure…

Treatment Medical Periappendicular abscess Surgical

Surgical Treatment Appendectomy : Laparoscopic versus open Sex Habitus Diagnostic uncertain NOTES, SILS, Lap assisted

Lap versus open appendectomy

After the surgery

Complication In op: Lap converted to open Bowel resection Post op: Wound infection Deep space infection/abcess Small bowel obstruction Infertility Enterocutaneous Fistula

Special issues Normal appearing appendix Meckels diverticulum Interval appendectomy Chronic or recurrent appendicitis Children Pregnancy Crohns dis FMF

Neoplasms Rare Mucocele benign, malignant, pseudomyxoma Treatment (Rt colectomy vs appendectomy) Survival rate 55% vs 20% Adenocarcinoma Carcinoid Treatment: size, location Survival

Laparoscopic Appendectomy

תודה