ACUTE APPENDICITISCHAIR OF FACULTY SURGERY # 2

FIRST MOSCOW STATE MEDICAL UNIVERSITY

NATROSHVILI A.G.

ANATOMY AND FUNCTION

• FIRST VISIBLE IN THE 8TH WEEK OF LIFE – PROTUBERANCE OFF THE TERMINAL ILEUM

• BASE OF THE APPENDIX ARISES FROM THE POSTEROMEDIAL ASPECT OF THE CECUM

• TIP OF THE APPENDIX – RETROCECAL, PELVIC, SUBCECAL, PREILEAL, PERICOLIC, RETROPERITONEAL, SUBHEPATIC

• 3 TAENIA COLI CONVERGE AT JUNCTION OF CECOM WITH THE APPENDIX

• LENGTH – 6-9 CV

• FUNCTION – IMMUNOLOGIC ORGAN, SECRETES IG A

• LYMPHOID TISSUE FIRST APPEARS ABOUT 2 WEEKS AFTER BIRTH

• INCREASES THROUGHOUT PUBERTY

• AFTER 60 YO – NO LYMPHOID TISSUE REMAINS WITHIN THE APPENDIX AND COMPLETE OBLITERATION OF THE LUMEN

ETHIOLOGY

• CAUSE OF APPENDICITIS – OBSTRUCTION OF THE LUMEN• CAUSE OF OBSTRUCTION:• LYMPHOID HYPERPLASIA (ASSOCIATED WITH A VARIETY OF

INFLAMMATORY AND INFECTIOUS DISORDERS)

• FECALITHS

• LESS COMMONLY – PARASITES, FOREIGN MATERIAL, TUBERCULOSIS, TUMORS

PATHOPHYSIOLOGY (1/2)

Obstruction of the lumen

Mucus accumulates in the lumen, intraluminal pressure increases

Bacteria convert mucus into pus

Obstruction of the lymphatic drainage ensues-edema of the appendix, beginning diapedesis of the bacteria and appearance of mucosal ulcers

Venous obstruction & further edema & ischemia in the appendix

Symptoms:o Poorly localized visceral pain –

periumbilical or epigastrico Anorexiao Nausea & vomitingo (small bowel and appendix

have the same nerve supply)

PATHOPHYSIOLOGY (2/2)

Bacterial invasion spreads thru the wall of the appendix

Compromise of the arterial blood supply

Midportion of the antimesenteric border undergoes gangrene with the appearance of the ellipsoidal infarcts

Excape of bacteria from the lumen of the appendix and contamination of the peritoneal cavity

Cntinued high intraluminal pressure – perforation thru gangrenous infarct, spilling accumulated pus lead to local and then generalized peritonitisInflammatory site is bordered from abdominal cavity – appendiceal phlegmon develops

Symptoms:o Inflamed serosa of the

appendix contacts the parietal peritoneum – somatic pain – perceived as classic shift and localization of pain in RLQ

o Fevero Tachycardiao Leukocytosiso Muscle defence o Positive Blumberg sign

CLINICAL MANIFESTATION

• CONSTANT MODERATE PERIUMBILICAL PAIN WITH SHIFT IN 4-6 HOURS TO SHARP RLQ

• MILD TACHYCARDIA

• TEMPERATURE ELEVATION OF 1°C

• ANOREXIA

• ANTERIOR APPENDIX – MAXIMAL TENDERNESS, GUARDING AND REBOUND AT MCBURNEY’S POINT (BLUMBERG SIGN POSITIVE)

• ROVSING’S SIGN

• PSOAS SIGN (SLOWLY EXTENDING PATIENT’S RIGHT THIGH – NEARBY INFLAMMATION WHEN STRETCHING THE ILIOPSOAS MUSCLE CAUSES PAIN)

• CBC – MILD LEUKOCYTOSIS WITH MODERATE NEUTROPHIL PREDOMINANCE

• U/A: LEUCOCYTES ARE PRESENT WHEN THE INFLAMED APPENDIX LIES NEAR THE URETER/BLADDER

CLINICAL MANIFESTATION

Typical clinical manifestation in 50-

70% of patients

Possible diagnostic pitfalls

Negative appendectomy rate

up to 25-45%

IMAGING

• ABDOMINAL X-RAY – LOW SENSITIVITY, POSSIBLE FECALITH IN THE RLQ

• BARIUM ENEMA – NONFILLING OF THE APPENDIX AND MASS EFFECT ON THE MEDIAL&INFERIOR BORDERS OF CECUM (RARELY USED)

• GRADED COMPRESSION ULTRASONOGRAPHY – NONCOMPRESSIBLE APPENDIX 6 MM OR GREATER IN DIAMETER, WALL THICKNESS MORE THEN 2 MM

• OPERATOR-DEPENDENCY (ACCURACY VARY FROM 50 TO 95%)

• LESS USEFUL IN PERFORATION – DECREASING DIAMETER AND APPENDIX BECOMES COMPRESSIBLE

IMAGING

• ENHANCED CT

• ADVANTAGES• HIGH SENSITIVITY, SPECIFICITY AND ACCURACY (90-98%)

• DISADVANTAGES:• RADIATION

• ALLERGIC REACTION

• COST

• CANNOT BE DONE IN SOME PATIENTS (PREGNANT WOMEN, CRITICALLY ILL ETC.)

LAST DIAGNOSTIC STEP – DIAGNOSTIC LAPAROSCOPY

• ADVANTAGES• HIGH SENSITIVITY, SPECIFICITY AND ACCURACY (95-99%)

• CAN TRANSFORM TO LAPAROSCOPIC APPENDECTOMY

• DISADVANTAGES

• INVASION

• SURGICAL AND ANESTHESIOLOGICAL RISK

TREATMENT• ONLY ONE FORM OF APPENDICITIS CAN BE TREATED

WITH ANTIBIOTICS AND NSAIDS – APPENDICEAL PHLEGMON (HARD INFILTRATE), IN WHICH INFLAMED APPENDIX IS BORDERED FROM ABDOMINAL CAVITY WITH SURROUNDING TISSUES AND BOWELS.

• PALPABLE MASS IN RLQ

• PAIN FOR MORE THEN 5-7 DAYS

• ABSENCE OF PERITONEAL SIGNS

• APPENDECTOMY IN SUCH CIRCUMSTANCES WILL LEAD TO BOWEL PERFORATION

• DYNAMIC EXAMINATION SHOULD BE PERFORMED FOR POSSIBLE ABSCESS FORMATIOIN AND ADEQUATE DRAINAGE

• APPENDECTOMY IS RECOMMENDED IN 4-6 MONTHS

TREATMENT • OPEN APPENDECTOMY (INCISION)

TREATMENT • OPEN APPENDECTOMY (ANTEGRADE)

TREATMENT • OPEN APPENDECTOMY (RETROGRADE)

TREATMENT • LAPAROSCOPIC APPENDECTOMY [B.NAVEZ, C.SOLANO (WWW.WEBSURG.COM)]

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