APPENDICITIS

Anatomy and physiology of appendix

The appendix is a slender, worm-shaped pouch, averaging 5—10cm in length, that protrudes from the top of the colon in the lower right abdomen

Location McBurney’s point:one-third of the way from the anterior,superior iliac spine to the umbilicus. Pelvis and right ilac fossa appendix Anterior or posterior ileum appendix Retrocaceal appendix Right lateral caceal appendix

Retrocaceal appendix

Supply & nerve Appendix artery: a final artery ,from ileocolic artery Appendix vein : portal vein sympathetic nerve :celiac plexus and lesser splanchnic nerve T10,T11

Acute appendicitis Appendicitis is a common cause of abdominal pain life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation

Etiology Obstruction: anatomy :wormed-shaped narrow plenty of lymph glands mechanical reason: food residue, ascarid, tumor,etc.

Etiology Gastrointestial disease Bacteria invasion: all kinds of G- bacilus

Pathology Four type: Acute simple appendicitis Acute purulent appendicitis Perforation and gangrenous Appendiceal abscess

Acute simple appendicitis

Acute purulent appendicitis

Perforation and gangrenous

Gangrenous Perforation

Appendiceal abscess

Results Inflammation disappear Inflammation localization Inflammation diffusion

Clinical manifestation symptoms : abdominal pain : Periumbilical or epigastric pain that migrates to right lower quadrant Pain becomes persistent and well localized. It worsens with moving, breathing deeply, coughing, sneezing, walking, or being touched

Symptoms : Gastrointestinal symptoms: Anorexia, nausea, and vomiting occur after the onset of pain Constipation Diarrhea bladder and rectum stimulus symptoms

Symptoms General symptoms : tired ,headach fever Rapid pulse SIRS (systemic inflammatory response syndrome)

Signs Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone peritoneal irritation sign : muscular rigidity Blumberg sign bowel sounds disappear

Others Rovsing’s sign:pain in the right lower quadrant upon palpation of the left lower quadrant. Psoas sign :pain on active elevation of the legs The obturator sign: pain on internal and external rotation of the hip Rectal exam & vaginal exam

Lab test Mild to moderately elevated WBC with left shift is typical but rarely may be normal, range of 11000-17000/mm3 over 20000/ mm3 perforation UA may show ketonuria or a few RBCs or WBCs pregnancy test (women only)

Lab test B-us X-ray Diagnostic abdominal puncture

Diagnosis Periumbilical or epigastric pain that migrates to right lower quadrant Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone

Differential diagnosis Two type : A: required surgery B: not required surgery

Differential diagnosis Required surgery: Perforation of gastointestinal tract ulcer,tumor, diverticulitis obstetrics and gynecologic disease: ectopic pregancy,ovarion torsion Meckel diverticulitis Tumor

Differential diagnosis Not required surgery Pelvic inflammation Mesenteric adenitis:at exploration a normal appendix and enlarged lymph nodes in the mesentery Viral & bacterial gastroenteritis Pneumonia, pleurisy

The Alvarado score MATERIALS AND METHODS • Symptoms • Score  migratory right iliac fossa pain 1  nausea/vomiting 1  anorexia 1 • Signs  RIF tenderness 2  fever >37.30C 1  rebound pain in RIF 1 • Laboratory test  leucocytosis (>10 X 109/L) 2  neutrophilic shift to the left >75% 1 • Total score 10

CONCLUSION

Treatment Early operation: surgical removal(appendectomy) Acute simple appendicitis: appendectomy Acute purulent and gangrenous appendicitis: appendectomy and/or drainage

Treatment Appendiceal abscess: if local in right low quadrant antibiotic therapy and general treatment if infection diffusion incision and drainage

Treatment Operation Incision : incision over the point of maximal tenderness,generally at McBurny point true McBurney’s incision tansvers skin incision 3—6cm long

Incision McBurney’s incision

Incision tansvers skin incision

Treatment Operation Process: The taenia of the colon are followed to the base of the appendix

Treatment Operation Process: Mesoappendix is divided between clamps and ligated

Treatment Operation Process: The base of appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string

a b c

Treatment Suspected case: not definite. Admit the patient to hospital for further observation 12-24hrs Operation exploration incision

Treatment Antibiotic thearpy: Acute simple appendicitis Contraindication of operation Appendiceal abscess

Treatment Antibiotic thearpy antibiotics: broadspectrum antibiotics ampicillin-sulbactam gentamycin triad drugs metronidazol 3rd generation cefotides

Treatment New method : laparoscopy appendectomy

Complication Acute appendicitis: Abdomen abscess Inter or extra fistula Phylephlebitis

Complication Operation : Incision infection Peritonitis and abdomen abscess Bleeding Stool fistula Stump infection Adhesive intestinal obstruction

Appendicitis in neonate Seldom Non-specific clinical manifestation Anorexia, nausea, and vomiting diarrhea dehydration Difficult in early diagnosis High rate of perforation High mortality

Appendicitis in neonate Diagnosis &Treatment Carefully physical exam Early operation

Appendicitis in child Quick onset and severe high fever and vomiting present early Non-typical tenderness at right low quadrant High rate of perforation High mortality More complication

Appendicitis in child Treatment: Early operation Transfusion and correct dehydration Broadspectrum antibiotics

Appendicitis in pregnancy Uterus enlargement appendix displaced superiorly Without adherent blanket of omentum elevation of abdominal wall Tenderness site upper shift Inconspicuous of tenderness rebound tenderness muscular rigidity Peritonitis diffusion

Appendicitis in pregnancy Treatment : Operation :appendectomy To late pregancy :early operation Superior Incision No drainage Broadspectrum antibiotics Parturient with perforation : cesarean section and appendectomy

Appendictis in the elderly Less well-defined symptoms and signs Severe pathologic type Error diagnosis easily High rate of perforation Pay attention to tumor

Chronic appendicitis Etiology and pathology Clinic feature and diagnosis right low quadrant pain local tenderness x-ray Treat appendectomy