Acute appendicitis
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Acute Appendicitis. Dr. Mirzaei. One of the most common surgical emergencies Highest incidence in the second and third decades. Anatomy. Location: three taeniae coli converge at the base (fix) Length: <1cm to >30cm (average 6-9)

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Acute Appendicitis

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Acute appendicitis

Acute Appendicitis

  • Dr. Mirzaei


Acute appendicitis

  • One of the most common surgical emergencies

  • Highest incidence in the second and third decades


Anatomy

Anatomy

  • Location: three taeniae coli converge at the base (fix)

  • Length: <1cm to >30cm (average 6-9)

  • Tip: retrocecal, pelvic, subcecal, preileal, right pericolic


Function

Function?

  • Secretion of immunoglobulin A

  • Appendectomy and U.C protection?

  • As a reservoir to recolonize the colon with healthy bacteria


Pathogenesis

Pathogenesis

  • Obstruction

    - Fecalith

    - Hypertrophy of lymphoid

    - Inspissated barium

    - Tumors

    - Vegetable and fruit

    - Intestinal parasites


Pathogenesis1

Pathogenesis

  • Normal luminal capacity 0.1 ml

  • Proximal obstruction => closed-loop obstrucation

  • Normal secretion of mucosa => distention

  • 0.5 ml secretion => intraluminal pressure 60cm H2O


Pathogenesis2

Pathogenesis

  • Secretion + rapid multiplication of bacteria => venous pressure increased => occlusion of capillaries

  • Arteriolar inflow continue => vascular congestion


Pathogenesis3

Pathogenesis

  • Impairment of blood supply => mucosal integrity compromised => bacterial invasion

  • Infarction in antimesentric border => perforation


Appendiceal rupture

Appendiceal Rupture

  • Overall Rate: 25.8%

  • Children < 5 years: 45%

  • Patients > 65: 51%


Appendiceal rupture1

Appendiceal Rupture

  • Walling-off process -> Phlegmon: Adherence of bowel loops to the inflamed appendix or a periappendiceal abscess.

  • Mass in exam:2-6%

  • Duration: At least 5-7 days


Symptoms

symptoms

  • Distention => visceral nerve endings stimulation => vague, dull, diffuse pain in the mid abdomen or lower epigastrium

  • Distention => reflex nausea &vomiting

  • Inflammation of serosa & parietal peritoneum => shift in pain to the right lower quadrant


Symptoms1

Symptoms

  • Abdominal pain

    - Moderately severe

    - steady, sometimes intermittent

    cramp

    - 1-12 h (4-6h) pain => R.L.Q


Symptoms2

Symptoms

  • Pain variation

    - Begins in the R.L.Q

    - Shift to the L.L.Q (tip in the L.L.Q)

    - Retrocecal => flank or back pain

    - Pelvic => suprapubic

    - Retroileal => testicular pain (irritation of the spermatic artery & ureter)


Symptoms3

Symptoms

  • Intenstinalmalrotation

    -Visceral: normal location

    - Somatic: where the cecum has been arrested


Symptoms4

Symptoms

  • Anorexia (nearly always)

    - loss of anorexia: diagnosis should be questioned


Symptoms5

Symptoms

  • Vomiting

    - 75% of patients

    - neither prominent nor prolonged

    - only once or twice


Sequence of symptoms

Sequence of Symptoms

  • 95% anorexia – pain - vomiting

  • Vomiting – pain: diagnosis should be questioned


Signs

Signs

  • Temperature : rarely > 1ºC

  • PR: normal or slightly elevated

  • More change: complication?


Signs1

Signs

  • Lie supine

  • Right thigh drawn up

  • Any motion increases pain

  • Move slowly with caution


Signs2

Signs

  • McBurney point tenderness


Signs3

Signs

  • Local tenderness

  • rebound tenderness

  • Voluntary guarding

  • True reflex (involuntary) rigidity (irritation progress)


Signs4

Signs

  • Flank tenderness

  • Local tenderness in rectal exam (pelvic)

  • psoas sign

  • Obturator sign

  • Rovsings sign


Lab test

Lab test

  • W.B.C 10,000 – 18,000

  • Moderate P.M.N predominance

  • W.B.C > 18,000 => possibility of complication

  • CRP

  • U/A: several W.B.C or R.B.C (ureteral or bladder irritation)

  • Bacteriuria generally not seen


Imaging

Imaging

  • Plain film (rarely helpful)

    - abnormal bowel gas pattern

    - fecalith (highly suggestive)

  • C.X.R (R/O right lower lobe pneumonia)


Imaging1

Imaging

  • Sonography (inexpensive, rapid, no contrast medium, even in pregnancy

  • Noncompressible appendix > 6mm

  • Appendicolith

  • Thickening of appendiceal wall & periappendiceal fluid

  • Remainder of abdominal cavity


Imaging sono

Imaging - Sono

  • Exclude Gyn pathology

  • Effective in children & pregnancy


Imaging sono1

Imaging - sono

  • Limitations

    - user dependent

    - false – positive: dilated fallopian tube,

    inspissated stool can mimic

    appendicolith, obesity,

    - false – negative: appendicitis in tip,

    retrocecal, markedly enlarged,

    perforation


Imaging c t

Imaging – C.T

  • Dilated appendix>5mm + wall thickening

  • thickened mesoappendix

  • Phlegmon

  • Periappendiceal fat stranding

  • Free fluid

  • Other inflammatory processes


Imaging c t1

Imaging – C.T

  • Expensive, exposes to radiation, cannot be used during pregnancy, allergy to contrast, intolerance of oral contast


Laparoscopy

Laparoscopy

  • Most useful in females (30 – 40% normal appendix)

  • Differentiating acute Gyn pathology


M isdiagnosis

Misdiagnosis

  • highest rate: child-bearing women,veryyoung,very old

  • Accuracy of preoperative diagnosis should be: 85%

  • Accuracy>90%: Missed some patients

  • Depends on: anatomic location of the appendix, simple or ruptured, age, sex


Alvarado scale

Alvarado scale


Alvarado scale1

Alvarado scale

  • 7-10 high likelihood

  • 4-6 consider further imaging

  • 1-3 low likelihood


Acute appendicitis

Differential diagnosis


Acute mesenteric adenitis

Acute Mesenteric Adenitis

  • Most in Children

  • Upper respiratory tract infection is present or has recently subsided.

  • Pain is diffuse

  • Tenderness is not sharply localized

  • Guarding sometimes present


Acute mesenteric adenitis1

Acute Mesenteric Adenitis

  • True rigidity is rare

  • Generalized lymphadenopathy (may)

  • Relative lymphocytosis suggestive

  • Self limited

  • May need immediate exploration


Gynecologic disorders

Gynecologic Disorders

  • Pelvic Inflammatory Disease

  • Usually bilateral

  • Nausea & Vomiting: 50%

  • Tenderness Usually lower

  • Motion of cervix is painful

  • Diplococci on smear of purulent vaginal discharge

  • Higher during early phase of cycle


Gynecologic disorders1

Gynecologic Disorders

  • Ruptured Graafian Follicle

  • Spillage of follicular fluid

  • Pain and tenderness diffuse

  • Leukocytosis & fever: minimal

  • Midcycle: Mittelschmerz


Gynecologic disorders2

Gynecologic Disorders

  • Twisted Ovarian Cyst

  • Sudden pain

  • CT & Sono (transvaginal)

  • Need emergent operation

  • Leakage of ovarian cyst: Treated nonoperatively


Gynecologic disorders3

Gynecologic Disorders

  • Ectopic pregnancy

  • Abnormal menses

  • Missing one or two periods or only slight vaginal bleeding

  • Elevated level of human chorionic gonadotropin(B-HCG)

  • Hct level falls

  • Vaginal exam:cervical motion tenderness

  • culdocentesis


Acute gastroenteritis

Acute Gastroenteritis

  • Diarrhea, nausea, vomiting

  • Abdominal Cramps

  • Soft Abdomen between cramps

  • No localizing sign

  • Vomiting - Pain


Acute appendicitis

  • Cecum or sigmoid Diverticulitis

  • Meckel’s Diverticulitis

  • Perforating Carcinoma of the cecum

  • Epiploicappendagitis

  • Pleuritis of the right lower chest

  • Acute Cholecystitis

  • Acute Pancreatitis

  • Hematoma of the abdominal wall

  • Epididymitis, Testicular torsion, U. T. I, Ureteral Stone


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