Appendicitis PDF - Mohammad Jundy

Appendicitis Mohammad Jundy ANATOMY: Appendicitis: inflammation of the appendix due to obstruction of lumen - a narrow blind-ended tube, cecum diverticulum....

Appendicitis Mohammad Jundy ANATOMY: Appendicitis: inflammation of the appendix due to obstruction of lumen - a narrow blind-ended tube, cecum diverticulum. - Acute appendicitis: Develops very fast, hours to days. - Intraperitoneal structure, vermiform shape, midgut origin. - Chronic Appendicitis: Very rare condition, partially obstructed lumen. - Vestigial?! Location: ACUTE appendicitis: - At right iliac fossa (right iliac crest, RLQ). Epidemiology MC cause of acute - 2 cm below ileocecal valve. - Any age (8% risk), Peak in teens & young adults. abdomen. - Length: 7.5 - 10 cm, width: 3-5 cm. - Male >female. Parts & landmarks: - Base (Proximal appendix): Pathophysiology (Oral exam): ‫(حفظ ر‬ - Detailed: (‫بالتتيب‬ ➔ Constant in location, posteromedial cecum. ➔ At confluence of 3 taeniae coli (surgical importance) ➔ Obstruction of lumen: continued mucous secretion & Stasis. ➔ At McBurney’s point. ➔ Mucus accumulation: ↑ intraluminal pressure. ▪ 1/3 of distance from ➔ Stasis: bacterial multiplication & local inflammation. ASIS to umbilicus 2/3 ➔ ↑ intraluminal pressure: 1st compress veins then arteries. ▪ in open incision (gridiron) 1/3 ➔ Ischemia: necrosed + gangrenous wall = weak wall. - Tip of appendix: (Variable): ➔ Weak wall >> rupture >> perforation >> peritonitis. ➔ MC: Retrocecal intraperitoneal (65%) - SUMMARY: ➔ 2nd MC: pelvic (30%) ➔ Obstruction & Stasis, Bacteria multiplication & inflammation - Mesoappendix: ➔ ↑ intraluminal pressure & Vascular compression (Veins → Artery) ▪ own mesentery, enclose appendix & supplying ➔ Ischemia & necrosis structures (appendicular artery & vein, lymphatics, nerves) - Causes of obstruction: Histology: ➔ Fecalith: MC cause of obstruction in adults. (50%) - Same as GI: (Mucosa, Submucosa, muscularis propria, Serosa) ➔ Lymphoid hyperplasia: MC cause in children - Sub-mucosa: rich in lymphoid follicles ➔ Parasites: Enterobius vermicularis, Entamoeba histolytica, Taenia - Argentaffin cells (Kulchitsky cells) in crypts >> carcinoid tumor. ➔ Foreign body. 3 ➔ Malignancy (carcinoid tumor) Blood supply: 2 - Arterial: (appendicular artery) - Bacteria found in appendicitis: ➔ Superior mesenteric > Inferior ➔ Mixed growth of anaerobic and aerobic organisms. ileocolic > Posterior cecal > ➔ Bacteroides fragilis & E.coli (Most common) appendicular artery. ➔ Other anaerobes: enterococcus, Klebsiella, streptococcus. - Veins: appendicular vein, etc. - Lymphatic drainage: 4 Clinical presentation: ➔ LNs in mesoappendix > ileocolic lymph nodes. - Typical C/P (50-60%) - Nerves: 1) Migrating abdominal pain: (Periumbilical → RLQ) ➔ sympathetic & vagus nerve (superior mesenteric plexus) Function: Immunological (IgA secretion) ➔ Most common & specific, usually shift after 6 hours.  Appendicitis Mohammad Jundy 2) Associated nonspecific Sx: Physical examination: ➔ Nausea & Vomiting: - Vitals: Low grade fever. ▪ Vomiting 1 – 2 times, not profuse nor projectile. - Inspection: Lying still & avoids movement, Avoid taking deep breaths. ▪ Come after pain. - Palpation: ➔ Anorexia. (80%) ➔ McBurney point tenderness (point of max. tenderness). ▪ If absent, appendicitis is unlikely. ➔ RLQ guarding. ▪ (+) Hamburger sign: Pt. refuses favorite food ➔ Rigidity (Board- like rigidity): peritonitis ➔ Low grade fever: (around 37.5) - Special tests ▪ If High grade: complications or DDX ➔ Rebound tenderness (Blumberg's sign): Pain increase ➔ Constipation or diarrhea. ▪ Pain ↑ after removal of pressure. Migrating pain: (Why does the pain shift)? (Oral) ➔ Rosving sign: Visceral pain: Somatic (parietal) pain: ▪ Deep palpation of left iliac fossa location Periumbilical region Right lower quadrant causes pain in right iliac fossa. Pain Dull & poorly localized Severe, localized, constant ➔ Psoas sign: Innervation Autonomic innervation: Somatic innervation: ▪ RLQ pain elicited on passive extension visceral peritoneum parietal peritoneum of right hip when pt. is positioned on Mid-gut origin, Aδ, fast fibers left side with knees fully extended. slow fibers. (c-fibers) ▪ In retrocecal appendix ▪ https://rb.gy/68cety - Atypical C/P: ➔ Obturator sign: ➔ Extreme of ages or according to appendix position: ▪ RLQ pain on passive internal rotation of right hip with the hip & knee flexed ▪ In pelvic appendix. ▪ https://rb.gy/7qmsjp Postilial ➔ Pointing sign: (‫(هاي حاول ما تحكيها باالورال النه يف احتمال تتبهدل‬ Preilial ▪ Ask pt. to point: where the pain began & where it moved. ▪ Point to max. pain area (MC at McBurney) Investigations: - Appendicitis diagnosis = Clinical diagnosis in most times SUBCECAL - Assessed via Alvarado score (Max. Score of 10)  Alvarado score (MANTRELS) Appendicitis Mohammad Jundy Symptom: SCORE ➔ Ultrasound: - Migratory RIF pain 1 ▪ First-line for pregnant females & children. - Anorexia 1 ▪ Not sensitive =70%, but specific = ~ 90%, - Nausea & vomiting 1 Score Likelihood of appendicitis ▪ Lower radiation & cost, but operator dependent. Signs: - Tenderness (RIF) 2 ≤4 Low ▪ Findings: CT findings & non-compressible appendix. 5-6 Moderate (equivocal result) - Rebound Tenderness 1 - Need imaging (CT or U/S). ➔ MRI. - Elevated temperature >37.3 1 ≥7 High. Laboratory: Differential diagnosis: (Oral ‫(حفظ بصم‬ - Leukocytosis >10 k 2 Children (GI-MM) Adult Elderly - Shift to left (>75% PMN) 1 Gastroenteritis Regional enteritis Diverticulitis Total 10 (Vomiting before pain) Pancreatitis Mesenteric adenitis Perforated peptic ulcer Intestinal obstruction - Laboratory studies: (CBC+ ESR+ B-HCG+ urine analysis). (Hx of URTI) (Valentino sign) Meckel’s diverticulum Ureteric colic Mesenteric infarction ➔ CBC: mild leukocytosis with left shift Intussusception pyelonephritis Leaking aortic aneurism ➔ ESR +CRP (Acute phase reactants): elevated Henoch Schönlein purpura Rectus sheath hematoma Epiploicae ➔ Urinalysis: (fat appendages) Lobar pneumonia Male Female ▪ Typically, normal in appendicitis. Testicular Mittelschmerz History notes: ▪ Mild pyuria /hematuria in pelvic appendicitis. torsion (mid-cycle If sudden RLQ pain ovulatory pain) don’t mention ▪ Done to rule out renal DDx. Ectopic appendicitis at first. ➔ Urine/serum β-hCG test: pregnancy If adult female don’t ▪ Perform in all women of reproductive age (Hx of missed forget to ask about period) missing period & ▪ Rule out pregnancy (normal/ectopic) Ruptured relation to menstrual cycle ➔ KFT & LFT ovarian cyst. - Imaging: (not always needed, clinical diagnosis) Endometriosis ➔ CT abdomen: Complications: ▪ 1st line in non-pregnant adults. - Perforation: ▪ Both sensitive & specific > 90% ➔ Risk At 36 hours of symptoms=2% ▪ view many structures, Rule other DDX. ➔ After that it may increase about 5% every 12 hours. ➔ Management: ▪ Early presentation: Emergency appendectomy. ▪ Delayed & complications: Conservative + interval surgery.  Appendicitis ➔ Risk factors for perforation: ➔ Laparoscopy: ▪ Extreme of ages. ▪ multiple small incisions ▪ DM, Immunosuppression. ▪ one in midline under umbilicus (Linea alba) ▪ Fecalith obstruction. ▪ less hospital stays, less postoperative pain. ▪ Pelvic appendix. ▪ less wound infection, better cosmetic. ▪ Previous abdominal surgery. ➔ Appendectomy complications: - Peritonitis: ▪ wound infection (MC & most early) ▪ Rigidity (Board- like abdomen) ▪ Intestinal obstruction by adhesions. - Delayed complications: Notes & Summary: Valentino sign: Appendicitis in obese: - RLQ pain In perforated peptic ulcer. ➔ Appendiceal mass (phlegmon): - local signs may be obscured - Gastric juice pass through paracolic gutter ▪ Omentum (police man of abdomen) tries to - difficult to assess by U/S - Green/yellow liquid in RLQ. (ORAL) collect the perforated materials. ➔ Appendiceal abscess: Appendix hernia: Amyand hernia ▪ Acutely ill patient & signs of sepsis. (high fever) ▪ Need drainage. ➔ caused by delayed presentation of perforated appendix ➔ both treated conservatively & interval surgery Treatment: - Non-operative Tx (conservative, supportive) (for any acute abdomen). Done by Mohammad jundy. ➔ NPO (nil per oral) ➔ NG tube ‫هي_قضية_الشرفاء‬# ➔ IV fluids ➔ IV Abx. (metronidazole & 3rd g cephalosporin) ➔ IV analgesics - Operative (surgical) Tt: ➔ IV fluids ➔ Appendicectomy. (Definitive Tt) ➔ Open or laparoscopic approach. ➔ Open approach: ▪ Lanz incision. (MC) ✓ Transverse at RLQ, better cosmetics. ▪ Gridiron incision: ✓ at McBurney point, less cosmetics.