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The Appendix. Dr A. Badrek-Amoudi FRCS. 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

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Dr a badrek amoudi frcs

The Appendix

Dr A. Badrek-Amoudi FRCS

ABA-The Appendix- 4th year Lectures


Dr a badrek amoudi frcs

  • 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


The appendix introduction

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


The appendix surgical anatomy

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


Dr a badrek amoudi frcs

ABA-The Appendix- 4th year Lectures


Dr a badrek amoudi frcs

ABA-The Appendix- 4th year Lectures


Dr a badrek amoudi frcs

ABA-The Appendix- 4th year Lectures


Dr a badrek amoudi frcs

ABA-The Appendix- 4th year Lectures


The appendix acute appendicitis epidemiology

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


The appendix acute appendicitis pathology i

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


    The appendix acute appendicitis pathology ii

    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


    The appendix acute appendicitis clinical features i

    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


    The appendix acute appendicitis clinical features ii

    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


    The appendix acute appendicitis investigations

    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


    Dr a badrek amoudi frcs

    ABA-The Appendix- 4th year Lectures


    Dr a badrek amoudi frcs

    ABA-The Appendix- 4th year Lectures


    The appendix acute appendicitis the very young

    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


    The appendix acute appendicitis the very old

    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


    The appendix acute appendicitis the pregnant

    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


    The appendix acute appendicitis in aids patients

    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


    The appendix acute appendicitis the management

    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


    Dr a badrek amoudi frcs

    ABA-The Appendix- 4th year Lectures


    The appendix acute appendicitis post operative

    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


    The appendix acute appendicitis prognosis

    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


    Dr a badrek amoudi frcs

    ABA-The Appendix- 4th year Lectures


    The appendix acute appendicitis problems

    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


    The appendix chronic appendicular conditions chronic appendicitis

    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


    The appendix chronic appendicular conditions appendicular mass

    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


    The appendix chronic appendicular conditions tumors of the appendix

    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


    Dr a badrek amoudi frcs

    ABA-The Appendix- 4th year Lectures


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