APPENDIX

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APPENDIX

• HOUSSAM OSMAN

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ANATOMY AND FUNCTION

• Develops as protuberance of the terminal portion
  of the cecum.
• the growth rate of the cecum exceeds that of the
  appendix, displacing the appendix medially toward
  the ileocecal valve.
• Appendix / cecum relationship
• the relation of the base of the appendix to the
  cecum is constant, while the tip can be found
• 1- retrocecal 2-pelvic 3-subcecal
• 4- peri-ileal 5- right pericolic position
• Length range 1-30 cm with average 6-9.
• Immunological organ that actively participate in
  secretion of Ig (IgA) and component of GALT, but
  its functional is not esential.

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ACUTE APPENDICITIS

• Incidence 0.1-0.2
• Appendectomy for appendicitis is the most common
  performed emergency operation in the world.
• Disease of young with 40 of cases being between
  10-24 Yr

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A.AEITIOLOGY AND PATHOGENESIS

• Obstruction of the lumen is the dominant causal
  factor. The obstructing object can be
• fecalith the most common
• lymphoid tissue hypertrophy
• inspisated barium from previous study
• tumors
• seeds

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• The proximal obstruction of the appendiceal lumen
  produces a closed-loop obstruction, and
  continuing normal secretion by the appendiceal
  mucosa rapidly produces distention.
• with the progressive distention, the venous
  return and subsequently the arteriolar inflow
  compromise and ellipsoidal infarcts develop in
  the antimesenteric border. As distention,
  bacterial invasion, compromise of vascular
  supply, and infarction progress, perforation
  occurs, usually through one of the infarcted
  areas on the antimesenteric border. Perforation
  generally occurs just beyond the point of
  obstruction rather than at the tip because of the
  effect of diameter on intraluminal tension.

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A.ABACTERIOLOGY

• Bacteria cultured in cases of appendicitis are
  similar to those seen in other colonic infection.
• The principal organisms seen are E. coli and
  Bacteroid fragilis.

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A.ACLINICAL MANIFESTATIONS

• Symptoms
• Pain begins as visceral diffuse steady
  moderately severe periumblical pain, sometimes
  accompanied by intermittent crampy pain. Then,
  shifting of to localized pain in RLQ manifest the
  somatic component. Somatic pain depends on the
  location of the tip of the appendix.
• LLQ ? LLQ pain
• retrocecal ? flank or back pain
• pelvic? suprapubic pain
• retroileal ? testicular pain
• Anorexia nearly always
• Vomiting once or twice
• Obstibation prior to the onset of the pain. Some
  might c/o diarrhea.

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A.ACLINICAL MANIFESTATIONS

• Signs
• VS minimally changed by uncomplicated appendix.
  If not think of either complicated appendicitis
  or other diagnosis.
• Pt prefers to stay in R thigh flexion position.
• McBurneys point tenderness and rebound
  tenderness.
• Rovsings sign
• Cutaneous hyperesthesia T10,11,12.
• Psoas sign and obturator sign.
• Guarding and rigidity appear with more severe
  inflammatory process.
• Retrocecal tenderness more in the flank.
• Pelvic painful rectal exam.

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A.ALABS

• Mild leukocytosis 10-18
• WBC gt 18 increase the possibility of perforation
• UA to r/o UTI

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A.AIMAGING STUDY

• Plain X ray not helpful
• non specific abnormal gas pattern.
• fecalith if present id highly suggestive of the
  diagnosis.
• CXR r/o referred pain from lower lobe pneumonia.
• Barium enema and radioactive labeled leukocyte
  scan filing of the appendix excludes the
  diagnosis, otherwise insignificant.
• U/S
• enlarged diameter, presence of fecalith, wall
  thickening and periappendicular fluid.
• normal exclude the diagnosis.
• not visualized inconclusive study.
• CT dilatation, wall thickening, thick
  mesoappendix, arrow head sign.

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ALVARADO SCALE

• 9-10 almost certain appendicitis and should go
  to OR.
• 7-8 high likelihood of appendicitis, imaging
  study.
• 5-6 compatible but not diagnostic, CT scan is
  appropriate.
• 0-4 extremely unlikely.

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A.AAPPENDICEAL RUPTURE

• Overall rate is 25.8
• Higher rates in children lt 5 (45) and pt gt 65
  (51).
• Suspect if
• fever gt 102
• WBC gt 18
• In majority of cases ,rupture is contained and pt
  display localized tenderness. Generalized
  peritonitis occurs when the walling-off process
  is ineffective.

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PHLEGMON AND ABSCESS

• Ill defined mass on physical exam
• Phlegmon matted loops of bowel adherent to
  adjacent inflamed appendix.
• CT
• Phlegmon and small abscess conservative
  management and IV Abx.
• Well localized abscess percutaneous drainage.
• Complex abscess extraperitoneal surgical
  drainage .
• Interval appendectomy done at least 6 weeks
  following the acute event.

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A.ADIFFERENTIAL DIAGNOSIS

• Acute mesenteric adenitis
• More common in children.
• Current or recent Hx of URTI.
• Generalized lymphadenopathy may be noted.
• Tenderness is not sharply localized
• Relative lymphocytosis may be present
• Self-limited disease.
• Acute gastroenteritis
• Childhood disease.
• Profuse watery diarrhea, N/V.
• Hyperperistaltic abdominal cramp.

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• Male urogenital system
• Testicular torsion.
• Acute epididymitis.
• Seminal vesiculitis.
• Meckels diverticulitis
• Surgically treated.
• Intussusceptions
• Children younger than 2 Yr, well nourished
  suddenly doubled up by apparent colicky pain.
  Infant looks well between attacks
• Bloody mucoid stool.
• Sausage shaped mass in RLQ
• Empty RLQ
• Barium enema if no signs of peritonitis
• Crohns enteritis
• Difficult to differentiate clinically.
• Diagnosis may be made intraoperatively.

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• Perforated PU
• Occur when the spilled contents gravitate down
  the right gutter with spontaneous sealing of
  perforation.
• colonic lesion
• Diverticulitis or perforating cecal cancer.
• Elderly.
• CT.
• Epiploic appendagitis
• Infarction of the colonic appendage secondary to
  torsion.
• UTI
• Right acute pyelonephritis associated with
  chills, R CVA tenderness, pyuria, and bacteruria.
• Ureteral stone referred pain down to the
  genatilia and hematuria.

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• Primary peritonitis
• Hx of liver or renal disease.
• Diagnosed by peritoneal aspiration ? Gve
• Flora, G-ve rods ? suspect secondary peritonitis
• Henoch schonlein purpura
• 2-3 weeks after strep infection.
• Joint pain, purpura, and nephritis.
• Yesiniosis
• Fecal oral
• Mesenteric adenitis, ileitis, colitis, and acute
  appendicitis
• Majority are mild and self-limited.

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• PID
• Esp if confined to R tube.
• Purulent vaginal discharge.
• Cervical motion tenderness.
• Ruptured Graafian follicle
• Ovulation.
• Brief mild, diffuse lower abdominal pain and
  tenderness.
• Midpoint of menstrual cycle ( Mittelschmerz)
• Ruptured ectopic pregnancy
• Missing menses.
• Vaginal bleeding.
• Pelvic mass high HCG low Hct
• Cervical motion and adnexal tenderness
• Emergency surgery.

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• Twisted ovarian cyst
• Vaginal exam may reveal pelvic mass.
• Transvaginal U/S and CT
• Torsion needs emergent operative intervention
  while rupture can be managed conservatively.

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A.AAPPENDICITIS IN PREGNANCY

• 12000 Pregnancies.
• More frequent during 1st and 2nd trimesters.
• Appendix displaced laterally and superiorly.
• Less frequent rebound and guarding.
• WBC gt normal pregnancy level ( 15-20 ).
• U/S if equivocal, laparoscopy can be done esp
  early in pregnancy.
• Any operation has 10-15 premature labor risk.

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A.AAPPENDICITIS IN AIDS

• Incidence 0.5
• No absolute leukocytosis.
• High risk of rupture (which can be related to
  delay in presentation).
• Low CD4 correlate with increased risk of rupture.
• Consider opportunistic infection in D.D (
  CMV,kaposi,TB,lymphoma).
• If the pt presents with classic symptoms and
  signs appendectomy.
• When diarrhea is the prominent symptom c-scope
  may be considered.
• Equivocal presentation CT

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A.ATREATMENT

• Prepare pt for operation
• Hydration.
• Correct electrolytes disturbances.
• Address pre-existing cardiac,renal and pulmonary
  issues.
• Abx coverage for 24 hrs in simple appendectomy.
  In case of perforation continue abx till pt
  afebrile and normal WBC.

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• Open appendectomy
• Incision
• McBurney incision or Rocky Davis incision.
• if abscess suspected laterally displaced
  incision to allow retroperitoneal drainage.
• if diagnosis in doubt lower midline incision
• Taeniae coli converge at the base of the
  appendix.
• Divide mesoappendix and mobilize the appendix
  with ligation of the appendiceal artery.
• Stump can be simply ligated or ligated with
  inversion.
• Laparoscopy

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• Prognosis
• Mortality rate is 0.06 in unruptured appendix.
• 3 in case of rupture.
• 15 in case of rupture in elderly

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CHRONIC APPENDICITIS

• Long lasting pain and less intense than that of
  acute appendicitis.
• Normal WBC count
• CT generally nondiagnostic.
• Appendectomy is curative in 82-93 of pt. many of
  those whose symptoms are not cured or recur are
  ultimately diagnosed with Crohns.

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• Appendiceal parasites
• Ascaris lumbricoides is the most common.
• Enterobius vermicularis, Strongyloides
  stercoralis, Echinococcus granulosis.
• Anti helminth showed follow recovery from
  appendectomy.
• Incidental appendectomy
• Generally neither clinically nor economically
  appropriate.
• It should performed under special circumstances
• children about to undergo chemotherapy.
• disables who can not describe or react normally
  to abdominal pain.
• Crohns pt in whom the cecum is free of
  macroscopic disease.
• travelers to remote places with no access to
  medical or surgical care.

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TUMORS

• Carcinoid
• Appendix is the most common GIT site.
• Rarely associated with carcinoid syndrome ( 2.9
  of cases ).
• Intraoperative finding of firm, yellow, bulbar
  mass in the appendix.
• Less than 1 cm simple appendectomy is
  sufficient.
• With extension into mesoappendix or tumor larger
  than 1.5 cm RHC
• Adenocarcinoma
• 3 histological type mucinous, colonic, and
  adnenocarcinoma.
• Most mode of presentation is acute appendicitis,
  but may also present with ascites or palpable
  mass, or may be discovered incidentally.
• RHC is the recommended treatment.

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• Mucocele
• Lead to progressive enlargement of the appendix.
• 4 histological types retention cysts, mucosal
  hyperplasia, cystadenoma, cystadenocarcinoma.
• Benign etiology simple appendectomy.
• Pseudomyxoma peritonei
• diffuse collections of gelatinous fluid are
  associated with mucinous implants on peritoneal
  surfaces and omentum.
• caused by neoplastic mucous-secreting cells
  within the peritoneum with the appendix being the
  site of origin for most cases.
• CT is the preferred imaging modality.
• surgical debulking is the mainstay of treatment
  and appendectomy routinely performed.
  Hysterectomy and bilateral salpingio-oopheorectomy
  is performed in women.

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• Lymphoma
• Extremely uncommon.
• Non-Hodgkins, Burkitts, and leukemia.
• Usually present as acute appendicitis.
  Appendiceal diameter 2.5 cm or surrounding soft
  tissue thickening are suspicious.
• If confined to appendix appendectomy.
• Extension to cecum or mesentery RHC.
• A postoperative staging workup is indicated prior
  to adjuvant therapy.