7/30/2019 Chapter 30 - Appendix
1/51
7/30/2019 Chapter 30 - Appendix
2/51
Anatomy and Function
The appendix begins to bud
off from the cecum at around
the 6th week of
embryological development. The base of the appendix
remains in a fixed position
with respect to the cecum,
whereas the tip can end upin various positions
7/30/2019 Chapter 30 - Appendix
3/51
Anatomy and Function
The appendix is composed of
the same layers as the colon
wall.
Mucosa, submucosa, inner circular
muscle, outer longitudinal muscle,serosa.
The 3 distinct bands of outer
longitudinal muscle, the taeniae
coli, converge on the appendix.
After you locate the cecum,
you can easily find the
appendix by ff the 3 taenia coli
until they converge at the base
of the appendix
7/30/2019 Chapter 30 - Appendix
4/51
Anatomy and Function
Although many have claimedthat the appendix is merely avestigial organ, it is actuallyan immunological organ and
secretes IgA. However, it isnot an essential organ andcan be removed withoutimmunological compromise.
length: 2 to 20 cm butaverages 69 cm.
Luminal capacity is < 1 mL.
7/30/2019 Chapter 30 - Appendix
5/51
Incidence
Highest in early adulthood, at the peak of lymphoidtissue growth.
Second peak in the incidence of appendicitis occurs inthe elderly.
There is a higher incidence of appendicitis in males thanfemales (1.3:1), although females are more commonlymisdiagnosed with acute appendicitis than males.
7/30/2019 Chapter 30 - Appendix
6/51
Pathophysiology
The probable sequence of events in acute appendicitis is:1. Luminal obstruction In young patients, more commonly by lymphoid tissue hyperplasia.
In older patients, fecalith is an increasingly common cause ofobstruction.
2. Distention and increased intraluminal pressure The appendiceal mucosa continues to secrete normally despite being
obstructed.
The resident bacteria multiply rapidly, further increasing intraluminalpressure.
3. Venous congestion The intraluminal pressure eventually exceeds capillary and venule pressures. Arteriolar blood continues to fl ow in, causing vascular congestion and
engorgement.
4. Impaired blood supply renders the mucosa ischemic andsusceptible to bacterial invasion.
5. Inflammation and ischemia progress to involve the serosalsurface of the appendix.
7/30/2019 Chapter 30 - Appendix
7/51
Bacteriology
bacterial pop. of the normal appendix is similar to that of thenormal colon.
appendiceal flora remains constant throughout (exc.Porphyromonas gingivalis only in adults)
principal organisms: (acute & perforated appendicitis):
Escherichia coli and Bacteroides fragilis.
7/30/2019 Chapter 30 - Appendix
8/51
Clinical Manifestations
7/30/2019 Chapter 30 - Appendix
9/51
Symptoms
1. Abdominal pain- prime symptom initially diffusely centered in the lower epigastrium or umbilical area
moderately severe, steady, sometimes with intermittent crampingsuperimposed.
After 1-12 hours (usually 4-6hrs), pain localizes to the RLQ.
Variations in the anatomic location of the appendixaccount for many of the variations in the principal locusof the somatic phase of the pain.
2. Anorexia
3. Vomiting 75%
neither prominent nor prolonged
caused by both neural stimulation and presence of ileus
7/30/2019 Chapter 30 - Appendix
10/51
Symptoms
4. constipation
beginning before the onset of abdominal pain
(many feel that defecation would relieve their abdominal pain)
5. Diarrhea particularly children
pattern of bowel function is of little differential diagnostic value.
The sequence of symptom appearance has greatsignificance for the DD.
7/30/2019 Chapter 30 - Appendix
11/51
Signs
1. Vital signs are minimally changed by
uncomplicated appendicitis
temp elevation is rarely >1C (1.8F)
pulse rate is normal or slightly elevated
2. Patients with appendicitis usually prefer to lie
supine, with the thighs, particularly the R thigh,
drawn up, because any motion increases pain.
If asked to move, they do so slowly and with caution.
7/30/2019 Chapter 30 - Appendix
12/51
Signs
3. The classic RLQ physical signs arepresent when the inflamedappendix lies in the anteriorposition.
max tenderness at or near the McBurney
point referred tenderness is felt maximally in
the RLQ localized peritoneal irritation
Rovsing signpain in the RLQ whenpalpatory pressure is exerted in the LLQ site of peritoneal irritation.
4. Cutaneous hyperesthesia (T10,T11, T12)
elicited either by needle prick or by gentlypicking up the skin between the forefingerand thumb.
7/30/2019 Chapter 30 - Appendix
13/51
Signs
5. Muscular resistance to palpation of the abdominal
wall roughly parallels the severity of the
inflammatory process.
6. Anatomic variations in the position of the inflamedappendix lead to deviations in the usual physical
findings.
retrocecal appendix: less striking anterior abdominal findings
and flank tenderness inflamed appendix hangs into the pelvis: absent abdominal
findings and the dx may be missed unless the rectum is
examined.
7/30/2019 Chapter 30 - Appendix
14/51
Alvarado Scale
lists the 8 specific indicators identified. scores: 9-10: certain to have appendicitis
7-8: high likelihood of appendicitis
5-6: compatible with, but not diagnostic of, appendicitis (requires CT
scan)
7/30/2019 Chapter 30 - Appendix
15/51
Signs
Clinical algorithm for suspected cases of acute appendicitis. If gynecologicdisease is suspected, a pelvic and endovaginal ultrasound examination isindicated
7/30/2019 Chapter 30 - Appendix
16/51
Differential Diagnosis
Gastrointestinal Conditions Gastroenteritis
Mesenteric adenitis
Meckels diverticulum
Intussusception
Typhoid fever Primary peritonitis
Genitourinary Conditions Ectopic pregnancy
Pelvic infl ammatory disease Ovarian torsion/cyst/tumor
Urinary tract infection/
Ureteral stone
7/30/2019 Chapter 30 - Appendix
17/51
Laboratory and
Diagnostic
Imaging
7/30/2019 Chapter 30 - Appendix
18/51
Labs
Complete blood count:
Leukocytosis (> 10,000 in 90% of cases), usually with
concomitant left shift (polymorphonuclear neutrophil [PMN]
predominance).
Consider perforation or abscess if WBC > 18,000.
Urinalysis:
Helpful in ruling out genitourinary causes of symptoms.
RBCs and WBCs may be present secondary to extension of
appendiceal inflammation to the ureter.
Significant hematuria or pyuria, and bacteriuria from a
catheterized specimen should suggest underlying urinary tract
pathology.
7/30/2019 Chapter 30 - Appendix
19/51
Diagnostic imaging
Abdominal x-ray: Not particularly useful in most cases.
May reveal appendicolith/fecalith (< 15% of cases).
Abdominal CT with contrast:
Very sensitive (9598%) and somewhat specific (8390%).
Useful in identifying several other inflammatory processes that may presentsimilarly to appendicitis.
Positive findings include: Dilatation of appendix to > 6 mm in diameter.
Thickening of appendiceal wall (representing edema).
Periappendiceal streaking (densities within perimesenteric fat).
Presence of appendicolith
Graded compression ultrasonography: Sensitivity of 85% and specifi city of 92% for diagnosing appendicitis.
Positive fi nding: Enlarged (> 6 mm), noncompressible appendix.
Especially useful in ruling out gynecologic pathology.
7/30/2019 Chapter 30 - Appendix
20/51
Appendicial Rupture
Immediate appendectomy has long been the
recommended tx for acute appendicitis because of
the presumed risk of progression to rupture.
overall rate of perforated appendicitis: 25.8%. Highest rate of perforation:
65 years of age
delays in presentation are responsible for themajority of perforated appendices
7/30/2019 Chapter 30 - Appendix
21/51
Appendicial Rupture
no accurate way of determining when and if an
appendix will rupture before resolution of the
inflammatory process.
occurs most frequently distal to the point of luminalobstruction along the antimesenteric border of the
appendix.
Rupture should be suspected in the presence of
fever (>39C) WBC count (>18,000 cells/mm3)
7/30/2019 Chapter 30 - Appendix
22/51
ACUTE MESENTERIC ADENITIS
a disease most often confused with acute
appendicitis in children.
The pain usually is diffuse, and tenderness is not as
sharply localized as in appendicitis. Generalized lymphadenopathy may be noted.
Human infection with Yersinia enterocolitica or
Yersinia pseudotuberculosis, transmitted through
food contaminated by feces or urine, causesmesenteric adenitis as well as ileitis, colitis, and
acute appendicitis.
sensitive to tetracyclines, streptomycin, ampicillin, and
kanamycin.
7/30/2019 Chapter 30 - Appendix
23/51
ACUTE MESENTERIC ADENITIS
A preoperative suspicion of the diagnosis should not
delay operative intervention, because appendicitis
caused by Yersinia cannot be clinically distinguished
from appendicitis due to other causes.
Salmonella typhimurium infection causes mesenteric
adenitis and paralytic ileus with symptoms similar to
those of appendicitis.
7/30/2019 Chapter 30 - Appendix
24/51
GYNECOLOGIC DISORDERS
Pelvic Inflammatory Disease
an infection usually bilateral but, if confined to the R
tube, may mimic acute appendicitis.
S&s manifested Nausea and vomiting (50%)
Pain and tenderness are lower, and motion of the cervix is
painful.
Intracellular diplococci may be demonstrable onsmear of the purulent vaginal discharge.
7/30/2019 Chapter 30 - Appendix
25/51
GYNECOLOGIC DISORDERS
Ruptured Graafian Follicle Ovulation commonly results in the spillage of sufficient
amounts of blood and follicular fluid to produce brief, mildlower abdominal pain.
If the amount of fluid is unusually copious and is from the R
ovary, appendicitis may be simulated. Pain and tenderness are diffuse.
Leukocytosis and fever are minimal or absent.
Twisted Ovarian Cyst
When R-sided cysts rupture or undergo torsion, themanifestations are similar to those of appendicitis.
Patients develop RLQ pain, tenderness, rebound, fever, andleukocytosis.
If the mass is palpable on PE, the dx can be made easily.
7/30/2019 Chapter 30 - Appendix
26/51
GYNECOLOGIC DISORDERS
Ruptured Ectopic Pregnancy Blastocysts may implant in the fallopian tube (usually the
ampullary portion) and in the ovary.
Rupture of R tubal or ovarian pregnancies can mimic
appendicitis. The development of RLQ or pelvic pain may be the first symptom.
The dx of ruptured ectopic pregnancy should berelatively easy. presence of a pelvic mass and elevated levels of chorionic
gonadotropin. presence of blood and particularly decidual tissue is pathognomonic.
Vaginal examination reveals cervical motion and adnexaltenderness, and a more definitive diagnosis can be established byculdocentesis.
tx: emergency surgery.
7/30/2019 Chapter 30 - Appendix
27/51
OTHER INTESTINAL DISORDERS
Acute Gastroenteritis
can be easily distinguished from acute appendicitis.
characterized by profuse diarrhea, nausea, and
vomiting. Hyperperistaltic abdominal cramps precede the
watery stools.
abdomen is relaxed bw cramps, and there are no
localizing signs.
7/30/2019 Chapter 30 - Appendix
28/51
OTHER INTESTINAL DISORDERS
Meckel's Diverticulitis
clinical picture is similar to that of acute appendicitis.
Meckel's diverticulum is located within the distal 2 ft
of the ileum. Meckel's diverticulitis is asso with the same
complications as appendicitis and requires the same
txprompt surgical intervention.
7/30/2019 Chapter 30 - Appendix
29/51
OTHER INTESTINAL DISORDERS
Crohn's Enteritis
manifestations of acute regional enteritisfever,
RLQ pain and tenderness, and leukocytosisoften
simulate acute appendicitis.
(+) diarrhea and (-) anorexia, nausea, and vomiting favor a dx
of enteritis, but this is not sufficient to exclude acute
appendicitis.
In cases of an acutely inflamed distal ileum with no
cecal involvement and a normal appendix,
appendectomy is indicated.
7/30/2019 Chapter 30 - Appendix
30/51
OTHER INTESTINAL DISORDERS
Colonic Lesions Diverticulitis or perforating carcinoma of the cecum,
or of that portion of the sigmoid that lies in the Rside, may be impossible to distinguish from
appendicitis. Symptoms may be minimal, or there may be
continuous abdominal pain in an area corres to thecontour of the colon
Pain shift is unusual pt does not look ill, nausea and vomiting are unusual, and
appetite generally is unaffected.
Localized tenderness over the site is usual and often is assowith rebound without rigidity.
7/30/2019 Chapter 30 - Appendix
31/51
OTHER INTESTINAL DISORDERS
Colonic Lesions Diverticulitis or perforating carcinoma of the cecum,
or of that portion of the sigmoid that lies in the Rside, may be impossible to distinguish from
appendicitis. Symptoms may be minimal, or there may be
continuous abdominal pain in an area corres to thecontour of the colon
Pain shift is unusual pt does not look ill, nausea and vomiting are unusual, and
appetite generally is unaffected.
Localized tenderness over the site is usual and often is assowith rebound without rigidity.
7/30/2019 Chapter 30 - Appendix
32/51
APPENDICITIS IN SPECIAL POPULATION
7/30/2019 Chapter 30 - Appendix
33/51
Acute Appendicitis in the Young
dx is more difficult in young children than in the adult. Inability of young children to give accurate hx
diagnostic delays by both parents and physicians,
frequency of GI upset in children are all contributing factors.
PE (highest sensitivity for appendicitis)
maximal tenderness in the RLQ inability to walk or walking with a limp
pain with percussion, coughing, and hopping.
The incidence of major complications after appendectomy inchildren is correlated with appendiceal rupture.
tx regimen for perforated appendicitis: immediate appendectomy
irrigation of the peritoneal cavity.
Antibiotic coverage is limited to 24-48 hrs, IV usually are given until thewbc is normal and the patient is afebrile for 24 hours.
7/30/2019 Chapter 30 - Appendix
34/51
Acute Appendicitis in the Elderly
Compared with younger patients, elderly patients aremore difficult to dx
Tend to present atypically, leading to delayed
diagnosis.
Present later in the course and with less pain, may present as
a small bowel obstruction.
Delayed leukocytosis.
Higher risk of perforation and higher mortality than in
younger patients.
7/30/2019 Chapter 30 - Appendix
35/51
Acute Appendicitis during Pregnancy
Appendicitis is the mc surgical emergency inpregnant patients.
Fetal mortality increases 38% with appendicitis and
30% with perforation.
Difficult to diagnose
particularly true in the late 2nd - 3rd trimester, when many
abdominal symptoms may be considered pregnancy related.
Surgery is the standard tx, though 1015% ofwomen will experience premature labor.
7/30/2019 Chapter 30 - Appendix
36/51
7/30/2019 Chapter 30 - Appendix
37/51
Appendicitis in Pts w/ AIDS or HIV Infection
The presentation of acute appendicitis in HIV-infected patients is similar to that in noninfected
patients.
fever, periumbilical pain radiating to the RLQ (91%), RLQ
tenderness (91%), and rebound tenderness (74%).
Although they may not have absolute leukocytosis,
compared to baseline WBC count, they will
demonstrate relative leukocytosis.
The Dd is expanded to include opportunistic
infections such as CMV-related bowel perforation
and neutropenic colitis.
7/30/2019 Chapter 30 - Appendix
38/51
Treatment
7/30/2019 Chapter 30 - Appendix
39/51
Once the decision to operate for presumed acuteappendicitis has been made, the patient should beprepared for the operating room.
Adequate hydration should be ensured, electrolyteabnormalities should be corrected, and pre-existing
cardiac, pulmonary, and renal conditions should beaddressed.
For intra-abdominal infxns of GI tract origin that are ofmild to moderate severity, the Surgical Infection Societyhas recommended single-agent therapy with cefoxitin,
cefotetan, or ticarcillin-clavulanic acid. For more severe infections, single-agent therapy with
carbapenems or combination therapy with a third-generation cephalosporin, monobactam, oraminoglycoside plus anaerobic coverage with
clindamycin or metronidazole is indicated.
7/30/2019 Chapter 30 - Appendix
40/51
Surgical Procedures
7/30/2019 Chapter 30 - Appendix
41/51
Open appendectomy
most surgeons use either a McBurney(oblique) or Rocky-Davis (transverse)
RLQ muscle-splitting incision in
patients with suspected appendicitis.
incision should be centered over either thepoint of maximal tenderness or a palpable
mass.
If an abscess is suspected
laterally placed incision (allows
retroperitoneal drainage and avoid generalizedcontamination of the peritoneal cavity)
If the diagnosis is in doubt
lower midline incision (allows more
extensive examination of the peritoneal cavity)
7/30/2019 Chapter 30 - Appendix
42/51
Open appendectomy
Several techniques can be used to locate the appendix since cecum is visible within the incision, the convergence of the
taeniae can be followed to the base of the appendix.
limited mobilization of the cecum is needed to aid in adequatevisualization.
Once identified, the appendix is mobilized by dividing themesoappendix, with care taken to ligate the appendicealartery securely.
The appendiceal stump can be managed by simple
ligation or by ligation and inversion with either a purse-string or Z stitch.
The mucosa is frequently obliterated to avoid thedevelopment of mucocele.
The peritoneal cavity is irrigated and the wound closed inlayers.
7/30/2019 Chapter 30 - Appendix
43/51
Open appendectomy
If appendicitis is not found, a methodical searchmust be made for an alternative diagnosis.
cecum and mesentery is inspected.
Next, small bowel is examined in a retrograde fashion
beginning at the ileocecal valve and extending at least 2 ft.
If purulent fluid is encountered, it is imperative that
the source be identified.
medial extension of the incision (Fowler-Weir), with
division of the A and P rectus sheath for further
evaluation of abdomen
7/30/2019 Chapter 30 - Appendix
44/51
Laparoscopic Appendectomy
performed under general anesthesia. nasogastric tube and a urinary catheter are placed
before obtaining a pneumoperitoneum.
requires the use of three ports. surgeon stands to patient's L. One assistant is required to operate
the camera. 1st trocar placed in the umbilicus (10 mm)
2nd trocar is placed in the suprapubic position.
3rd trocar (5 mm) is variable and usually either in LLQ, epigastrium,or RUQ.
Initially, the abdomen is thoroughly explored to excludeother pathology.
The appendix is identified by following the anteriortaeniae to its base.
7/30/2019 Chapter 30 - Appendix
45/51
Laparoscopic Appendectomy
Dissection at the base of theappendix enables the surgeon tocreate a window between themesentery and the base of theappendix (A)
mesentery and base of theappendix are then secured anddivided separately.
When the mesoappendix is involvedwith the inflammatory process, it is
often best to divide the appendixfirst with a linear stapler and then todivide the mesoappendiximmediately adjacent to theappendix with clips, electrocautery,
Harmonic Scalpel, or staples (B,C)
7/30/2019 Chapter 30 - Appendix
46/51
Laparoscopic Appendectomy
A principal proposed benefit of laparoscopicappendectomy has been decreased postoperative pain.
Hospital length of stay also is statistically significantlyless after laparoscopic appendectomy.
In nearly all studies, laparoscopic appendectomy isassociated with a shorter period before return to normalactivity, return to work, and return to sports.
Laparoscopic appendectomy may be beneficial in obesepatients, in whom it may be difficult to gain adequate
access through a small RLQ incision. Fertile women with presumed appendicitis constitute the
group of patients most likely to benefit from diagnosticlaparoscopy.
Natural Orifice Transluminal Endoscopic
7/30/2019 Chapter 30 - Appendix
47/51
Natural Orifice Transluminal Endoscopic
Surgery (NOTES)
Still experimental In this procedure the appendix is removed via upper
gastrointestinal endoscopy with the surgeon
operating through the gastric wall and ultimately
removing the appendix through the mouth without
any external scar.
The gastrotomy is closed from within the stomach.
7/30/2019 Chapter 30 - Appendix
48/51
Interval Appendectomy
The accepted approach for the tx of appendicitisassociated with a palpable or radiographically
documented mass (abscess or phlegmon) is
conservative therapy with interval appendectomy 6-
10 weeks later.
initial tx consists of IV antibiotics and bowel rest.
7/30/2019 Chapter 30 - Appendix
49/51
Prognosis
Principal factors influencing mortality rupture occurs before surgical tx
the age of the patient
overall mortality rate in acute appendicitis w/ rupture
is approx 1%.
mortality rate of appendicitis w/ rupture (elderly) is
approx 5%
Death is usually attributable to uncontrolled sepsisperitonitis, intra-abdominal abscesses, or gram-
negative septicemia.
7/30/2019 Chapter 30 - Appendix
50/51
Chronic appendicitis
Characteristically, the pain lasts longer and is lessintense than that of acute appendicitis but is in the
same location.
lower incidence of vomiting, but anorexia and
occasionally nausea, pain with motion, and malaise
are characteristic.
Leukocyte counts are normal and CT scans are
nondiagnostic. Laparoscopy can be used effectively in the
management of this clinical entity.
Appendectomy is curative.
7/30/2019 Chapter 30 - Appendix
51/51
Appendceal Neoplasms
Top Related