NITMED TUTORIALS

1. NITMED TUTORIALS

2. ACUTE APPENDICITIS

3. LEARNING OBJECTIVES • Describe the appendix and appendicitis along with its pathophysiology. • Identify the clinical manifestations of appendicitis. • Discuss assessment and diagnostic findings of appendicitis. • Describe the medical and surgical care of a patient with appendicitis. • Discuss the possible complications of appendicitis

4. OUTLINE • INTRODUCTION • ANATOMY • PHYSIOLOGY • DEFINITION • EPIDEMIOLOGY • AETIOLOGY • PATHOPHYSIOLOGY • CLINICAL PRESENTATIONS • SYMPTOMS • PHYSICAL EXAMINATION • MANAGEMENT • MEDICAL • SURGICAL • COMPLICATIONS

5. INTRODUCTION • Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay.

6. ANATOMY • The appendix is a small, finger-like tube about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis). • NB: The appendix can vary in length from <1 cm to >30 cm;

7. Variations in topographic position of the appendix ANATOMY • From its base at the cecum, the appendix may extend (A) upward, retrocecal and retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to the left, ileocecal (may pass anterior or posterior to the ileum)

8. PHYSIOLOGY • Generally believed to have no function • GALT-gut associated lymphoid tissue • Although, function is not essential

9. EPEDIOMIOLOGY • Most common cause of acute surgical abdomen in children and adolescents • 7-10% of the population develop acute appedencitis • Peak incidence at early adolescence/ adulthood. • Increased rate of perforation in children • Commoner in male ( M:F 2: 1)

10. ETIOPATHOGENESIS • Obstruction of the Lumen ( 2/3) • Fecalith (hardened faeces) • Hypertrophy of lymphoid tissue • Vegetable and fruit seeds • Intestinal worms ( enteriobiousvermicularis) • Insipissated barium • Tumor ( primary/ metastatic/ carcinoid) • No obstruction of the Lumen (1/3)

11. AETIOPATHOGENESIS • Proximal obstruction>>distal distension>>compromised blood supply>>progression to gangrene>> peforation>>peritonitis ( generalized or localized (abscess) Distention causing Ischemia obstruction Gangrene Distention Irritation of parietal peritoneum (localised) Appendiceal obstruction/early appendicitis – visceral peritoneal irritation Perforation, localised/generalised peritonitis, mass Appendiceal distension

12. CLINICAL PRESENTATION SYMPTOMS • Abdominal pain is the prime symptom of acute appendicitis. Classically, pain is initially diffusely centered in the lower epigastrium or umbilical area, is moderately severe, and is steady, sometimes with intermittent cramping superimposed. • After a period varying from 1 to 12 hours, but usually within 4 to 6 hours, the pain localizes to the right lower quadrant • Anorexia nearly always accompanies appendicitis. It is so constant that the diagnosis should be questioned if the patient is not anorectic. • Vomiting occurs in nearly 75% of patients NB: The sequence of symptom appearance has great significance for the differential diagnosis. In >95% of patients with acute appendicitis, anorexia is the first symptom, followed by abdominal pain, which is followed, in turn, by vomiting (if vomiting occurs). If vomiting precedes the onset of pain, the diagnosis of appendicitis should be questioned.

13. CLINICAL PRESENTATION • SIGNS • Temperature elevation is rarely >1°C ( Fever) • Pulse rate is normal or slightly elevated • Marked tenderness often is maximal at or near the McBurney point • Direct/Indirect rebound tenderness • Dehydration • Reduced abdominal movt • Rovsingsign—Palpate LIF patient feels pain in the RIF • Obturator sign- RIF pain when the flexed and internally rotated • Psoas sign- patient assumes a position of a flexed hip and feels pain when the hip is extended. • Pointing sign- patient locates the are of maximal pain at the McBurney’s Point

14. LAB INVESTIGATIONS • “ No single evaluation can substitute for the diagnostic accuracy of the experienced physician.”

15. Investigations • FBC • Raised WBC ( neutrophils) • PCV may be normal • Urinalysis • Pregnancy test • Abdominopelvic uss • E/U/Cr • Chest x-ray R/O bowel perforation • Others • Plain abdominal x-ray R/O intestinal obstruction • ALVARADO SCORE-MANTRELS

16. ALVARADO SCORE (MANTRELS)

17. MANTRELS SCORE contd. • APPLICATION • 0-4 = Not likely Appendicitis • 5-6 = Equivocal ( Observe patient, further investigations) • 7-10 = Appendicitis most likely ( Intervene)

18. DIFFERENTIALS Dx • Peforated PUD • Acute intestinal obstruction • Perforated thyphiod enteritis • Merkel derviticulitis • Regional ileitis e.g Crohn’s dx • Acute pyelonephritis • Renal/ureteric Colic • Acute pancreatitis • Messenteric adenitis • Ruptured ectopic pregnancy • Accidented ovarian cysts • AccidentedFibriod • Acute PID • Abd crisis in HBSS • Gastroenteritis • Right basal pneumonia

19. MANAGEMENT- clinical approach

20. TREATMENT • Once the decision to operate for presumed acute appendicitis has been made, the patient should be prepared for the operating room. Ensure the following • Adequate hydration • Electrolyte abnormalities should be corrected • pre-existing cardiac, pulmonary, and renal conditions should be addressed. • Administer antibiotics to all patients with suspected appendicitis

21. APPENDECTOMY • OPEN • For open appendectomy most surgeons use either a McBurney (oblique) or Rocky-Davis (transverse) right lower quadrant muscle-splitting incision in patients with suspected appendicitis. The incision should be centered over either the point of maximal tenderness or a palpable mass • LAPAROSCOPIC • Laparoscopic appendectomy usually requires the use of three ports. Four ports may occasionally be necessary to mobilize a retrocecal appendix. The surgeon usually stands to the patient's left. • One assistant is required to operate the camera. One trocar is placed in the umbilicus (10 mm), and a second trocar is placed in the suprapubic position. Some surgeons place this second port in the left lower quadrant. The suprapubic trocar is either 10 or 12 mm, depending on whether or not a linear stapler will be used. • The placement of the third trocar (5 mm) is variable and usually is either in the left lower quadrant, epigastrium, or right upper quadrant.

22. APPENDECTOMY contd. Location of McBurney's point (1), located two thirds the distance from the umbilicus (2) to the anterior superior iliac spine (3).

23. COMPLICATIONS OF APPENDICITIS • Gangrene • Appendix mass • Appendix abscess • Perforation • Peritonitis • Intrabdominal abscess • Pelvic • Retroceacal • Subhepatic • Subphrenic • Reccurent appendicitis • Chronic appendicitis

24. APPENDIX MASS • When inflamed appendix, terminal ileum and caecum is wrapped up in omentum • Mgt is conservative ( OCHNERS-SHERRENS REGIMEN) • A = Aspiration with NG TUBE if patient • B= BD ( twice daily) assessment of the patient • C= Charts i.e 4hourly temp, pulse, resp rate, diameter of mass marked and measured BD • D= Drugs i.e antibiotics and analgesics • E= Electrolytes correction • F= Fluid rehydration ( NPO to allow inflammation subsides) • Then Interval Appendectomy @6-8weeks

25. APPENDIX ABSCESS • MGT is via • Incision and Drainage of abscess • If appendix seen excise otherwise interval appendectomy at 6-8weeks

26. RUPTURED APPENDIX • Exploratory Lap or Mini lap • Peritoneal toileting/ lavage with saline • If appendix stump is seen excise it.

27. CONCLUSION • Appendicitis is a common surgical emergency with a varied clinical presentation • Several patient groups are at high risk of misdiagnosis • Lab and imaging studies are helpful, but no single study is a substitute for good clinical judgement

28. THANKS