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APPENDIX. James Taclin C. Banez, MD, FPSGS,FPCS. Anatomy / Function. Location, position Function: Immunologic organ Secrets IgA, component of the GUT associated lymphoid tissue (GALT) Not essential; it’s removal ----> (-) sepsis. Appendiceal Conditions of Surgical Importance.

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APPENDIX

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Appendix

APPENDIX

James Taclin C. Banez, MD, FPSGS,FPCS


Anatomy function

Anatomy / Function

  • Location, position

  • Function:

    • Immunologic organ

      • Secrets IgA, component of the GUT associated lymphoid tissue (GALT)

      • Not essential; it’s removal ----> (-) sepsis


Appendiceal conditions of surgical importance

Appendiceal Conditions of Surgical Importance

Appendicitis:

  • Inflammation of the appendix

  • 1500 – perityphlitis – inflammation of the cecal region

  • Most common acute surgical disease of the abdomen

  • Peak ----> puberty / early adulthood

  • Male > female (1.3 : 1)


Appendicitis

Appendicitis

Pathogenesis:

  • Obstruction (dominant causal factor)

    • Fecalith – usual cause

    • Hypertrophy of the lymphoid tissue

    • Inspissated barium

    • Vegetable and fruit seeds

    • Intestinal worms (Ascaris)

    • Tumor


Appendicitis1

Appendicitis

Pathogenesis:

  • Sequence of events in Luminal Obstruction

    Proximal occlusion ---> Closed loop Obst. -------> rapid distention due to:

    • Continuing secretion of the mucosa

    • Rapid multiplication of normal flora

      ---> elevate pressure ---> capillary/venous occlusion (CONGESTION 1st stage):

      S/Sx: (+) visceral afferent pain fibers (vague, dull, diffuse pain in mid-abdomen or lower epigastrium. Increase peristalsis (crampy pain); N/V and anorexia


Appendicitis2

Appendicitis

Pathogenesis

  • Inflammatory process involves the serosa of appendix and in turns parietal peritoneum in the region.

  • Infiltration of PMN (SUPPURATIVE 2nd stage)

    • Damage of the lining epithelium ---> entrance of bacteria to the wall.

  • Impairment of blood supply (inc. pressure than arterial pressure)---> ellipsoidal infarct at antimesenteric border near the tip. (GANGRENOUS 3rd stage) ---> (PERFORATION 4th stage)

  • This process is not inevitable. Some subside spontaneously


Appendicitis3

Appendicitis

Pathogens:

  • Anaerobes, aerobes

  • Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus


Appendicitis4

Appendicitis

Clinical Manifestation:

  • Abdominal pain:

    • Classic pain sequence ……….

    • Right lower quadrant pain

    • Others:

      • Left lower quadrant pain (long appendix)

      • Flank or back pain (retro-cecal)

      • Supra-pubic (pelvic)

      • Testicular pain (retro-ileal ----> irritates the spermatic artery and ureter

  • Anorexia: nearly always present

  • Vomiting 75%

  • Obstipation / diarrhea

  • Usual sequence (95%) : ANOREXIA ---> ABD. PAIN ---> VOMITING


Appendicitis5

Appendicitis

Signs: PE depends on the location of the appendix and presence of rupture

  • Direct and rebound tenderness at Mc Burney’s point. ROVSING sign ---> indicate muscles peritoneal irritation.

  • Involuntary muscle guarding (true reflex rigidity).

  • Psoas / Obturator signs ---> retrocecal appendix

  • Para-rectal tenderness

    Stages I & II – uncomplicated

    Stages III & IV – complicated


Appendicitis6

Appendicitis

Laboratory Findings:

  • WBC: leucocytosis

    simple = 10,000 to 18,000/mm3

    perforated = >18,000/mm3

  • Urinalysis :

    • Hematuria and pyuria due to irritation of the ureter and urinary bladder

    • w/o bacteriuria

  • FPA: rarely helpful; (+) fecalith – rare,

    highly suggestive of the dx.


  • Appendicitis7

    Graded Compression sonogram:

    78–96% sensitivity; 85–98% specificity

    (+) non-compressible appendix, 6mm or > at AP view

    (-) easily compressible 5mm; not visualized a & (-) pericecal fluid or mass

    False (-):

    Appendicitis confined at the tip

    Retrocecal position

    Perforated appendix

    False (+):

    Periappendicitis from surrounding inflammation

    Dilated fallopian tube

    Inspissated stool can mimic an appendicitis

    Obese pt., appendix not compressed

    Appendicitis


    Appendicitis8

    Appendicitis

    • CT scan:

      • Shd. not delay or substitute for prompt operative intervention when clinically indicated

      • Used primarily for percutaneous drainage


    Appendicitis9

    Laparoscopy

    Diagnostic /therapeutic

    Useful for female to diferrentiate gynecological pathology

    Appendicitis


    Appendix

    Appendiceal Rupture:

    • Increase morbidity / mortality

    • No accurate way to determine the occurrence of rupture

    • Suspected:

      • Fever > 39 C

      • WBC of > 18,000/mm3

      • Localized rebound, involuntary muscle guarding

      • Signs of genralized peritonitis

      • Ill defined mass (PHLEGMON – motted loops of bowel adherent to the inflamed appendix)


    Appendix

    Differential Diagnosis:

    • Most common erroneous pre-op diagnosis:

      • Acute mesenteric lymphaditis

      • No organic pathologic condition

      • Acute pelvic pathologic condition

      • Twisted ovarian cyst / ruptured graafian follicle

      • Acute gastroenteritis

  • Acute mesenteric adenitis:

    • w/ present or recent URTI

    • Diffuse pain, tenderness not sharp, (-) rigidity

    • Self limited -----> observe


  • Differential diagnosis

    Differential Diagnosis:

    • Acute gastroenteritis:

      • Childhood, viral gastroenteritis

      • Chills, fever, profuse watery diarrhea, N/V

      • Hyper-peristaltic abdominal cramps w/o localizing sign

    • Disease of the male:

      • Torsion of the testes and acute epididymitis

      • Diagnosed by palpating the enlarged tender seminal vesicle

    • Meckel’s diverticulitis:

      • Same clinical picture w/ AP

      • Associated w/ same complication of AP, hence needs prompt surgical intervention.


    Differential diagnosis1

    Differential Diagnosis:

    • Intussusceptions:

      • Shd. Be differentiated pre-operatively due to different management.

      • Char:

        • Common under 2 y/o

        • Occur in well nourished infant who suddenly doubled up due to colicky pain. Hrs. later pass out bloody mucoid stool

        • Sausage shape mass in the RLQ

    • Regional enteritis (Crohn’s dse):

      • s/sx is almost the same w/ AP this is dx. in celiotomy


    Differential diagnosis2

    Differential Diagnosis:

    • UTI / Ureteral stone:

      • Referred pain to the labia, scroyum or penis

      • Chills, fever (+) R costo-vertebral angle tenderness, hematuria, leucocytosis

      • Dx: -----> pyelography

    • Gynecological disorders:

      • Rate of erroneous diagnosis of AP is highest in young adult female

      • Order of frequency:

        • PID -----> ruptured grafian follicle ----> twistd ovarian cyst or tumor -----> endometriosis -----> ruptured ectopic pregnancy


    Treatment

    TREATMENT

    • Adequate hydration, correct electrolyte imbalance

    • Manage other medical problems

    • Pre-operative antibiotics:

      • Simple AP - hrs antibiotic

      • Ruptured AP - antibiotic until fever

      • Peritonitis - 10 days antibiotics

    • Surgery:

      • Open appendectomy:

        • McBurney (oblique); Rocky Davis (transverse);

          right paramedian; midline incision


    Appendix

    Open Appendectomy:


    Treatment1

    TREATMENT

    • Laparoscopy:


    Treatment2

    TREATMENT

    • Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic

    • Well localized abscess ---> percutaneous drainage

    • Complex abscess ---> surgical drainage

    • Interval appendectomy – 6 wks. Following an acute event treated either non-operatively or w/ simple drainage of an abscess.

      • 0-37% recurrent appendicitis


    Prognosis

    PROGNOSIS

    Mortality:

    • 9.9% -------> 0.2%

    • Factors:

      • Ruptured prior to surgery

        • Simple - 0.06%

        • Ruptured - 3%

      • Age of pt.:

        • Ruptured - 15%

    • Death due to:

      • Uncontrolled sepsis (peritonitis, intra-abdominal abscess, gm (-) septicemia.

      • Cardiac / pulmonary insufficiency (elderly)

      • Pulmonary embolism

      • aspiration


    Prognosis1

    PROGNOSIS

    Morbidity:

    • Simple - 3%Ruptured - 47%

    • Early:

      • Septic :

        • Wound infection / abscess

        • Intra-abdominal abscess (appendiceal fossa, pouch of Douglas, sub-hepatic space, multiple intestinal loops.

      • Fecal fistula:

      • Wound dehiscence

      • Intestinal obstruction: due to locculated abscess & exuberant adhesive formation


    Prognosis2

    PROGNOSIS

    Morbidity:

    • Late:

      • Adhesived bands

      • Inguinal hernia (3x greater in pt. who had appendectomy)

      • Incisional hernia (paramedian / midline incision)


    Appendicitis in the young

    Appendicitis in the Young

    • Difficult to establish diagnosis:

      • Inability of a child to give accurate history

      • Diagnostic delays by both parents & physicians

    • Rapid progression to rupture:

      • Underdeveloped greater omentum ----> higher morbidity

      • < 8y/o had a twofold increase rate of perforation as compared to older children


    Appendicitis during pregnancy

    Appendicitis during Pregnancy

    • AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnancy

    • Most frequent during the 1st & 2nd trimesters

    • S/Sx:

      • Abdominal pain, tenderness

      • Rebound tenderness and guarding less due to laxity of abdominal wall

    • Increase WBC; abdominal ultrasound

    • Dx is difficult due to displacement of the appendix


    Appendicitis during pregnancy1

    Appendicitis during Pregnancy

    • Dx is difficult due to displacement of the appendix


    Appendicitis during pregnancy2

    Appendicitis during Pregnancy

    • Risk of surgery:

      • Premature labor - 10-15% both for negative laparotomy and appendectomy for uncomplicated AP

      • Appendiceal perforation is significant factor associated w/ fetal and maternal death.

        • Fetal mortality - 3-5% w/ early appendicitis

        • 20% perforation

    • Suspicion of appendicitis during pregnancy shd prompt rapid diagnosis and surgical intervention


    Tumors of the appendix

    Tumors of the Appendix

    • Appendiceal malignancy is rare

    • Discovered during laparotomy or in association w/ acute inflammation of the appendix

    • CARCINOID:

      • Firm, yellow, bulbar mass in the appendix

      • Located: appendix ---> small bowel ----> rectum

      • Carcinoid syndrome is rare in appendiceal carcinoid unless widespread metastases are present

      • Malignant potential related to it’s SIZE ---> > 2cm

      • Treatment:< 2cm appendectomy

        > 2cm right hemicolectomy


    Tumors of the appendix1

    Tumors of the Appendix

    • ADENOCARCINOMA:

      • Rare

      • Histologic type:

        • Mucinous adenocarcinoma

        • Colonic adenocarcinoma

        • Adenocarcinoid

      • Manifestation:

        • Acute appendicitis

        • RLQ mass

      • Treatment: right hemicolectomy

      • Prognosis:

        • 55% ----> 5yr. survival


    Tumors of the appendix2

    Tumors of the Appendix

    • MUCOCELE:

      • Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance

      • Histologic type:

        • Retention cyst

        • Mucosal hyperplasia

        • Cystadenomas

        • Cystadenocarcinoma

      • Rarely occurs w/ gelatinous ascites (Pseudomyxoma Peritonei) usually associated w/ malignant ovarian or appendiceal mucinous CA. if present survival is decreased


    Tumors of the appendix3

    Tumors of the Appendix

    • MUCOCELE:

      • Treatment:

        • Benign - appendectomy

        • Malignant - right hemicolectomy for cystadenoCA of the appendix; THABSO and appendectomy for ovarian cystadenoCA

          • Adjuvant Tx:

            • Radiation, intraperitoneal and systemic chemotherapy recommended but it’s role is unclear

            • 57% local recurrence at appendiceal primary site

            • Death ensues due to progresive obstruction and renal failure


    Thank you

    THANK YOU


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