APPENDIX

1. APPENDIX James Taclin C. Banez, MD, FPSGS,FPCS

2. Anatomy / Function • Location, position • Function: • Immunologic organ • Secrets IgA, component of the GUT associated lymphoid tissue (GALT) • Not essential; it’s removal ----> (-) sepsis

3. 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)

4. Appendicitis Pathogenesis: • Obstruction (dominant causal factor) • Fecalith – usual cause • Hypertrophy of the lymphoid tissue • Inspissated barium • Vegetable and fruit seeds • Intestinal worms (Ascaris) • Tumor

5. 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

6. 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

7. Appendicitis Pathogens: • Anaerobes, aerobes • Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus

8. 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

9. 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

10. 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.

11. 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

12. Appendicitis • CT scan: • Shd. not delay or substitute for prompt operative intervention when clinically indicated • Used primarily for percutaneous drainage

13. Laparoscopy Diagnostic /therapeutic Useful for female to diferrentiate gynecological pathology Appendicitis

14. 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)

15. 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

16. 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.

17. 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

18. 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

19. 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

20. Open Appendectomy:

21. TREATMENT • Laparoscopy:

22. 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

23. 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

24. 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

25. PROGNOSIS Morbidity: • Late: • Adhesived bands • Inguinal hernia (3x greater in pt. who had appendectomy) • Incisional hernia (paramedian / midline incision)

26. 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

27. 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

28. Appendicitis during Pregnancy • Dx is difficult due to displacement of the appendix

29. 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

30. 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

31. 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

32. 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

33. 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

34. THANK YOU