1.  Dr. Mirzaei

2.  One of the most common surgical emergencies  Highest incidence in the second and third decades

3.  Location: three taeniae coli converge at the base (fix)  Length: 30cm (average 6-9)  Tip: retrocecal, pelvic, subcecal, preileal, right pericolic

4.  Secretion of immunoglobulin A  Appendectomy and U.C protection ?  As a reservoir to recolonize the colon with healthy bacteria

5.  Obstruction - Fecalith - Hypertrophy of lymphoid - Inspissated barium - Tumors - Vegetable and fruit - Intestinal parasites

6.  Normal luminal capacity 0.1 ml  Proximal obstruction => closed-loop obstrucation  Normal secretion of mucosa => distention  0.5 ml secretion => intraluminal pressure 60cm H2O

7.  Secretion + rapid multiplication of bacteria => venous pressure increased => occlusion of capillaries  Arteriolar inflow continue => vascular congestion

8.  Impairment of blood supply => mucosal integrity compromised => bacterial invasion  Infarction in antimesentric border => perforation

9.  Overall Rate: 25.8%  Children < 5 years: 45%  Patients > 65: 51%

10.  Walling-off process -> Phlegmon: Adherence of bowel loops to the inflamed appendix or a periappendiceal abscess.  Mass in exam:2-6%  Duration: At least 5-7 days

14.  Distention => visceral nerve endings stimulation => vague, dull, diffuse pain in the mid abdomen or lower epigastrium  Distention => reflex nausea &vomiting  Inflammation of serosa & parietal peritoneum => shift in pain to the right lower quadrant

15.  Abdominal pain - Moderately severe - steady, sometimes intermittent cramp - 1-12 h (4-6h) pain => R.L.Q

16.  Pain variation - Begins in the R.L.Q - Shift to the L.L.Q (tip in the L.L.Q) - Retrocecal => flank or back pain - Pelvic => suprapubic - Retroileal => testicular pain (irritation of the spermatic artery & ureter)

17.  Intenstinal malrotation -Visceral: normal location - Somatic: where the cecum has been arrested

18.  Anorexia (nearly always) - loss of anorexia: diagnosis should be questioned

19.  Vomiting - 75% of patients - neither prominent nor prolonged - only once or twice

20.  95% anorexia – pain - vomiting  Vomiting – pain: diagnosis should be questioned

21.  Temperature : rarely > 1ºC  PR: normal or slightly elevated  More change: complication ?

22.  Lie supine  Right thigh drawn up  Any motion increases pain  Move slowly with caution

23.  McBurney point tenderness

24.  Local tenderness  rebound tenderness  Voluntary guarding  True reflex (involuntary) rigidity (irritation progress)

25.  Flank tenderness  Local tenderness in rectal exam (pelvic)  psoas sign  Obturator sign  Rovsings sign

26.  W.B.C 10,000 – 18,000  Moderate P.M.N predominance  W.B.C > 18,000 => possibility of complication  CRP  U/A: several W.B.C or R.B.C (ureteral or bladder irritation)  Bacteriuria generally not seen

27.  Plain film (rarely helpful) - abnormal bowel gas pattern - fecalith (highly suggestive)  C.X.R (R/O right lower lobe pneumonia)

29.  Sonography (inexpensive, rapid, no contrast medium, even in pregnancy  Noncompressible appendix > 6mm  Appendicolith  Thickening of appendiceal wall & periappendiceal fluid  Remainder of abdominal cavity

30.  Exclude Gyn pathology  Effective in children & pregnancy

31.  Limitations - user dependent - false – positive: dilated fallopian tube, inspissated stool can mimic appendicolith, obesity, - false – negative: appendicitis in tip, retrocecal, markedly enlarged, perforation

32.  Dilated appendix>5mm + wall thickening  thickened mesoappendix  Phlegmon  Periappendiceal fat stranding  Free fluid  Other inflammatory processes

33.  Expensive, exposes to radiation, cannot be used during pregnancy, allergy to contrast, intolerance of oral contast

34.  Most useful in females (30 – 40% normal appendix)  Differentiating acute Gyn pathology

35.  highest rate: child-bearing women,very young,very old  Accuracy of preoperative diagnosis should be: 85%  Accuracy>90%: Missed some patients  Depends on: anatomic location of the appendix, simple or ruptured, age, sex

37.  7-10 high likelihood  4-6 consider further imaging  1-3 low likelihood

38. Differential diagnosis

39.  Most in Children  Upper respiratory tract infection is present or has recently subsided.  Pain is diffuse  Tenderness is not sharply localized  Guarding sometimes present

40.  True rigidity is rare  Generalized lymphadenopathy (may)  Relative lymphocytosis suggestive  Self limited  May need immediate exploration

41.  Pelvic Inflammatory Disease - Usually bilateral - Nausea & Vomiting: 50% - Tenderness Usually lower - Motion of cervix is painful - Diplococci on smear of purulent vaginal discharge - Higher during early phase of cycle

42.  Ruptured Graafian Follicle - Spillage of follicular fluid - Pain and tenderness diffuse - Leukocytosis & fever: minimal - Midcycle: Mittelschmerz

43.  Twisted Ovarian Cyst - Sudden pain - CT & Sono (transvaginal) - Need emergent operation - Leakage of ovarian cyst: Treated nonoperatively

45.  Ectopic pregnancy  Abnormal menses  Missing one or two periods or only slight vaginal bleeding  Elevated level of human chorionic gonadotropin(B-HCG)  Hct level falls  Vaginal exam:cervical motion tenderness  culdocentesis

46.  Diarrhea, nausea, vomiting  Abdominal Cramps  Soft Abdomen between cramps  No localizing sign  Vomiting - Pain

47.  Cecum or sigmoid Diverticulitis  Meckel’s Diverticulitis  Perforating Carcinoma of the cecum  Epiploic appendagitis  Pleuritis of the right lower chest  Acute Cholecystitis  Acute Pancreatitis  Hematoma of the abdominal wall  Epididymitis, Testicular torsion, U. T. I, Ureteral Stone