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Acute appendicitis

Acute appendicitis. SURGICAL ANATOMY. Part of large intestine Size 7-10 cm long and lumen .2cm in diameter LOCATION Base is attached to posteriomedial aspect of cecum2.5 cm below the ileocecal junction Body n tip; Rectocecal 74% Pelvic 21% Paracecal 2% Subcecal 1.5% Preileal 1%

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Acute appendicitis

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  1. Acute appendicitis

  2. SURGICAL ANATOMY • Part of large intestine • Size 7-10 cm long and lumen .2cm in diameter • LOCATION • Base is attached to posteriomedial aspect of cecum2.5 cm below the ileocecal junction • Body n tip; • Rectocecal 74% • Pelvic 21% • Paracecal 2% • Subcecal 1.5% • Preileal 1% • Post ileal .5%

  3. PERITONEAL COVERINGS • Complete • Attached to lower layer of mesentry of small intestine to form a mesntry of its own the mesoappendix

  4. BLOOD SUPPLY • ARTERIAL • Appendicular artery a branch of lower division of ileocolic artery • An accessory appendicular artery may b present • VENOUS • Appendicular vein joins posterior cecal vein

  5. Blood supply

  6. LYMPHATIC DRAINAGE • 4,6 or more lymphatics traverse the mesoappendix to empty into ileocecal lymph nodes

  7. ACUTE APPENDICITIS

  8. Definition • Acute inflammation of appendix • Histologically characterized by the presence of neutrophylls in the muscularis propria

  9. ETIOLOGY • Exact etiology unknown • DIET • Rich in meat n refined CHO low in fibre • OBSTRUCTION • Of lumen by a fecolith,stricture foreign body,worms • Of the orrifice by ca cecum

  10. PATHOGENESIS • In 50-80% of cases inflammation of the appendix is associated with obstruction • OBSTRUCTION BY A FECOLITH,GALLSTONES,BALL OF WORMS • INFLAMMATION N CONTINUOS SECRETION OF MUCINOUS FLUIDS • INC.INTALUMINAL PRESSURE • COLLAPSE OF DRAINING VEINS • STASIS N ISCHEMIA FAVOURS BACTERIAL PROLIFERATION

  11. PATHOGENESIS Minority of inflammed appendix have no luminal obstruction and pathogenesis in such cases remain unknown

  12. CLINICAL PRESENTATION • SYMPTOMS • Colicky abdominal pain; initially in periumbilical or epigastrium then after few hrs shift to RIF • Anorexia • Vomiting---infreqent

  13. Referred pain

  14. SIGNS • GENERAL SIGNS • FEVER 99-100 F • TACHYCARDIA 80-90 beats/min

  15. Pointing sign • Patient is asked to point where the pain begin & where it moved

  16. Cough sign • Ask the patient to cough will elicite tenderness in rt. Iliac fossa

  17. McBurney sign • A sign of acute appendicitis • Deep tenderness at mcBurney point

  18. Psoas sign • When inflammed appendix lies on psoase msl, pt. lie with rt. Hip flexed for pain relief.an attempt to hyperextend the hip will result in tenderness

  19. Obturator sign • When hip is flexed & internally rotaded, pt. will experience pain in hypogastrium.if inflammed appendix is in contact with obturator internus

  20. Rovsing sign • Pressure on left iliac fossa may cause pain in right iliac fossa

  21. OUT COME OF ACUTE APPENDICITIS • RESOLUTION • ULCERATION • SUPPORATION • FIBROSIS • GANGRENE • PHLEGMONOUS MASS • APPENDICULAR ABSCESSES • MUCOCELE OF APPENDIX • GENERAL PERITONITIS

  22. DIFFERENTIAL DIAGNOSIS • IN CHILDREN • MESENTERIC LYMPHADENITIS • MECKEL’S DIVERTICULITIS • INTUSSUCEPTION • HENOCH SCHOLEN’S PURPURA • LOBAR PNEUMONIA

  23. D/Ds IN CHILDREN • MESENTERIC LYMPHADENITIS • Colicky abdominal pain • Cervical lymph nodes may b enlarged • MIECKEL’S DIVERTICULITIS • Colicky abdominal pain may b left sided • May b history of lower GI bleeding

  24. DIFFERENTIAL DIAGNOSIS Henoch- scholenpurpura 1. Severe abdominal pain 2. often preceded by sore throat 3. echymotic rash on extensor surfase

  25. Differential diagnosis in adults • Terminal ilietis • Perforated peptic ulcer • Acute pancreatitis • Rectus sheath hematoma • Testicular tortion • Rt. Side acute pyelonephritis

  26. Differential diagnosis in adults • Rt. Side acute pyelonephritis tenderness in loin fever increased frequency of micturation • Acute pancreatitis dx by serum or urine amylase measurement

  27. Differential diagnosis in adults females • PID • Mittelschmerz • Ectopic pregnency • Rupture ovarian cyst • Endometriosis

  28. Differential diagnosis in adults females PID bilateral pain vaginal discharge dysmenorrhea burning pain on micturation cervical & adenexal tenderness

  29. Differential diagnosis in adults Rupture ovariancyst pelvic U/S & gynecological opinion helpful in DX

  30. Mittelschmerz 1. pain subside within hour 2. systemic upset is rare

  31. Differential diagnosis in adult female Ectopic pregnency usually rt sided hx of missed menstural period positive pregnency test cervical excitation positive pelvic U/S

  32. Differential diagnosis in elderly • Diverticulitis • Intestinal obstruction • Ceacal carcinoma • Aortic aneurism

  33. Differential diagnosis

  34. INVESTIGATION • CBC • URINE ANALYSIS • IMAGING STUDIES • XRAY • U/S • CT • PREGNENCY TEST IN CHILD BEARING AGE

  35. D/D’s IN ELDERLY • SIGMOID DIVERTICULITS • Abdominal CT in all pts over the age of 60 yrs • CA CECUM • Previous hx of abdominal discomfort • Alteration of bowel habits • Wt loss • Palpable mass • Barium enema is usually diagnostic

  36. CBC moderate leukocytosis 10,000 to 16,000 Sensitivity (70 to 90%) Specificity is very low

  37. Urine analysis • Abnormal UA result found to be in 19 to 40% • Abnormalities include pyuria hematuria & bactereuria

  38. ABDOMINAL X RAY PLAIN ABDOMINAL XRAY localized rt. Lower quadrant ileius or radio opaque fecolith XRAY WITH BARIUM ENEMA filling defect in ceacum indicate appendicitis Abnormal findings: fecalith, appendiceal gas, localized paralytic ileus, blurred right psoas, and free air

  39. XRAY

  40. U/S • ABDOMINAL • accuracy is 90% • PELVIC U/S • to exclude tubal or ovarian disease

  41. U/S • Limitations of US: 1. retrocecal appendix may not be visualized 2. perforations may be missed due to return to normal diameter

  42. U/S

  43. CT • best choice • Greater sensitivity,98% accurate • Show • inflammed appendix • fecolith • abscess • perforation • Exclude diverticulitis & intestinal obstruction & neoplasms

  44. Pregnancy test • Beta HCG & pelvic U/S • to exclude ectopic pregnency PID & ovarian disease

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