Dr A. Badrek-Amoudi FRCS

1. The Appendix Dr A. Badrek-Amoudi FRCS ABA-The Appendix- 4th year Lectures

2. How do you diagnose appendicitis. • What are the classical and atypical features of appendicitis • Are investigations always needed and what is their role • How do you prepare your patient prior to surgery • What are the surgical approaches • How do you care for your patient after surgery ABA-The Appendix- 4th year Lectures

3. The Appendix Introduction 1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision. ABA-The Appendix- 4th year Lectures

4. The Appendix Surgical Anatomy • Surface anatomy • Development: diverticulum of ceacum appearing in the 8th week of life • Positions: constant base, tip varies (retroceacal, pelvic, subcaecal, preileal, pericolic) • Blood supply • Location during surgery • Surrounding anatomical structures • Part of the gut lymphoid tissue. ABA-The Appendix- 4th year Lectures

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9. The AppendixAcute Appendicitis Epidemiology • Most common surgical emergency. • Slightly more common in men. • Incidence are falling from 100 to 50 in 100 000 (1975-1991). • 1 in 6 of the population will have an appendectomy. • In Saudi Arabia incidence are comparable to western figures • ? More common in European societies (Diet). • ? Relation to class status. • Age > 2 yrs, (associated with lymphoid development). • Up to 16% of appendicectomies are normal 75% are in women ABA-The Appendix- 4th year Lectures

10. The AppendixAcute Appendicitis Pathology I • Luminal obstruction. • Lymphoid hyperplasia 60% • Faecolith 35%. • Inspissated barium. • Fruit seeds. }<4% • Worms. < 1% • Extra-luminal obstruction eg Ca Cecum • Raised intra-luminal pressure • Mucus accumulation • Multiplication of bacteria. ( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas) • Venous and lymphoid congestion and. ABA-The Appendix- 4th year Lectures

11. The AppendixAcute Appendicitis Pathology II • Impaired arterial flow, thrombosis and gangrene. • Perforation may occur through devitalized tissue. Histological terms used: • Catarrhal appendicitis • Suppurative ;;; • Necrotic ;;; • Gangrenous ;;; • Perforated ;;; • Appendicular mass The risk of perforation is not inevitable. ABA-The Appendix- 4th year Lectures

12. The Appendix - Acute AppendicitisClinical Features I Full History Duration, severity, onset, System review. and examination: General, throat, chest…..etc • Only 55% have classical features. • Atypical 45% • History 24-36 hours • Abdominal pain: (diffuse and periumbilical, localizing to the RIF) • Anorexia (almost always). • Vomiting (75%). • Low grade fever. • If >38 suspect perforation • Tenderness, guarding and rebound: Be gentle • Rovsing’s, psoas, obturator signs: unreliable and late ABA-The Appendix- 4th year Lectures

13. The Appendix - Acute AppendicitisClinical Features II • Tender Appendicular mass • Atypical: • (loin, high RUQ, deep pelvic) • Diarrhea ( not always gastroenteritis) • Urinary frequency • The Extremes of Age: • Children < 5 rapid progression • Pain in the elderly is less intense ABA-The Appendix- 4th year Lectures

14. The Appendix - Acute AppendicitisInvestigations • White cell count: high sensitivity 96%, low specificity • Urine analysis • Plain Xray, nonspecific • Ultrasound highly sensitive (80-90%), excludes other pathologies. • Computer Tomography: More superior to USS in diagnostic accuracy. • Barium enema: Good accuracy, but technically difficult and false positives are common. • Laparoscopy • Active observation • Computer aided diagnosis. • Peritoneal lavage ABA-The Appendix- 4th year Lectures

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17. The Appendix - Acute AppendicitisThe Very Young • Diagnosis may be more difficult to establish, WBC is likely to be normal • (12% are normal). • Children are more likely to progress to perforated appendix (? Under-developed Greater Omentum). ABA-The Appendix- 4th year Lectures

18. The Appendix - Acute AppendicitisThe Very Old • Greater morbidity and mortality • Less typical presentation • Cancer may be a possibility as an underlying cause. • Perforation of 50% and mortality of 20% has been reported ABA-The Appendix- 4th year Lectures

19. The Appendix - Acute AppendicitisThe Pregnant Implications: Clinical Findings, Lab Ix, Surgery • 1: 2000 pregnancies. • More common in the first two trimesters • The appendix is pushed superiorly and laterally • WBC > 15 • Premature Labor 10-15% with surgery • Perforated appendix leads to fetal death in 20% • Rapid diagnosis and treatment is advised. ABA-The Appendix- 4th year Lectures

20. The Appendix - Acute AppendicitisIn AIDS Patients • Be aware of CMV or Kaposi sarcoma as the underlying cause • WBC may not rise ABA-The Appendix- 4th year Lectures

21. The Appendix - Acute AppendicitisThe Management • Preop: • IVI, • analgesia, • IV antibiotics • Conventional appendicectomy • Types of incisions • Laparoscopic appendicectomy: (questions regarding pain, hospital stay, operation time, to daily activity, wound infection) ABA-The Appendix- 4th year Lectures

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23. The Appendix - Acute AppendicitisPost-Operative • Check the vitals • Check the abdominal signs and bowel movement • Check the wound • Advise on mobilization • In OPD: • Check wound • Check the Histology ABA-The Appendix- 4th year Lectures

24. The Appendix - Acute AppendicitisPrognosis • Mortality: from 0.2% to 1% • Complications increase with perforation • Morbidity: • Wound abscess, • Wound infection (less with MacBurney’s incision), • Wound dehiscence • Intra-abdominal abscess, • Faecal fistula, • Intestinal obstruction, • Adhesive band, • inguinal hernia. • Fertility ABA-The Appendix- 4th year Lectures

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26. The Appendix - Acute AppendicitisProblems • Mass palpable pre-operatively • Appendix is normal at operation • Tumor is found in appendix • Prophylactic appendicectomy ABA-The Appendix- 4th year Lectures

27. The Appendix – Chronic Appendicular ConditionsChronic Appendicitis • A loose term referring to a multitude of conditions associated with RIF pain and in which pathology of the appendix has been found. ABA-The Appendix- 4th year Lectures

28. The Appendix – Chronic Appendicular ConditionsAppendicular Mass • Results from either: • Localized by edematous, adherent omentum and loops of small bowel • Appendicular abscess • Incidence is 10% • Higher in children • Management controversy: • Interval vs Immediate appendicectomy ABA-The Appendix- 4th year Lectures

29. The Appendix – Chronic Appendicular ConditionsTumors of The Appendix • Carcinoid: • Arise from Kluchitsky cells • Mean age 20-40 • Yellow bulbar mass • In F>M • In third decade of life • Usually lies near the tip • In the absence of LN spread with <2 cm in diameter appendicectomy is sufficient. Otherwise a R hemicolectomy is necessary. • Adenocarcinoma and Lymphoma. ABA-The Appendix- 4th year Lectures

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