Acute Appendicitis by dr.S.H

7/31/2019 Acute Appendicitis by dr.S.H

1/24

GIS-K-25

ACUTE APPENDICITIS

Appendiceal Mass / Abscess

Syahbuddin Harahap

Division of Digestive Surgery

Department o urgeryFaculty of Medicine University of North Sumatera

Adam Malik Hospital


2/24

INTRODUCTION

The appendix is :

-Wormlike extension of the cecum (vermiform appendix).

-Length is 8-10 cm (ranging from 2-20 cm).

-Fifth month of gestation

-Several lymphoid follicles.


3/24

Etiology:

Obstruction of the lumen appendix followed by infection

Catarrhal appendicitis.-lymphoid hyperplasia (60% children)

-Gastro enteritis-Virus-Acute respiratory infection-Mononucleosis

Obstructive appendicitis-fecalith 35% adults.

-foreign body / parasites (4%)

- tumors (1%)


4/24

PathophysiologyWangensteen proposed1. Closed loop obstruction2. Increase in luminal pressure.3. Exceeds capillary pressure causes mucosal ischemia4. Luminal bacterial overgrowth and translocation bacteria across the

appendiceal wall result :-Inflammation

-Edema-Necrosis perforation occur about 48 hours .

If the body successfully walls off the perforation Appendiceal Mass

If the perforation is not successfully walled off Diffuse peritonitis will

develop.


5/24

Problem:

Appendicitis can mimic several abdominal conditions.

Laboratory test

Imaging investigation

Statistics report

Normal appendix is found in15-40% Emergency appendectomy.(Negative Appendectomy)


6/24

Differential diagnosis of acute appendicitis

Surgical

Acute Intestinalobstruction

Intussusception

Acute cholecystitis

Perforated peptic ulcer

Mesenteric adenitis

'

Urological

Rightureteric colic

Right pyelonephritis

Urinary tract infection

Right Acute epididymitis

Gynaecological

cu e ec e s ver cu s

Acute Pancreatitis

Medical

Gastroenteritis

Basal Pneumonia dextra Terminal ileitis

Ectopic pregnancy

Ruptured ovarian follicle

Torted ovarian cyst

Salpingitis/pelvic inflammatory disease


7/24

Differential diagnosis of appendicitis appendicitiscan mimic several abdominal conditions.


8/24

Lab Studies:

Complete blood cell countA mild elevation of WBCs (ie, >10,000/L)

Urinalysis

ureter.

Severe pyuriain UTI.

For women of childbearing age,Ectopic pregnancy test urin (beta-hCG)


9/24

On physical examination

Lying down

Flexing their hips

The most common symptom of appendicitis is :- Acute abdominal pain.

-right lower quadrant (RLQ) of the abdomen.

- Vomiting, nausea, and anorexia- Afebrile or has a low-grade fever , 38 C

Higher fevers are associated with a perforated appendix


10/24

Special maneuvers

McBurney sign

McBurney's point

it is only the area

of greatest tenderness

Blumberg sign

Rovsings Sign

Dunphy sign Cough Test

Obturator sign

Psoas sign

Markle sign


11/24

Location appendix during pregnancy


12/24

INDICATIONS

Consider an appendectomy for patients with a

history of :

Persistent abdominal ain

FeverClinical signs of localized or diffuse peritonitisEspecially if leukocytosis is present.


13/24

Imaging Studies

Abdomen plain film:Fecalith within the appendix

Urolithiasis right middle third


14/24

MANTRELS SCORE

Characteristic Score

M = Migration of pain to the RLQ 1

A = Anorexia 1

N = Nausea and vomiting 1

T = Tenderness in RLQ 2

Alvarado score 1986

R = Rebound pain 1

E = Elevated temperature 1

L = Leukocytosis 2

S = Shift of WBC to the left 1

Total 10

A score of 7 or more is strongly predictive of acute appendicitis.


15/24

Sonography

Advantages of sonography

1. Noninvasiveness,2. Short acquisition time3. Lack of radiation exposure

normal less than 6 mm

.

other causes of abdominalpain

5. Pediatric patients6. Women of childbearing age.

7. Pregnant women


16/24

CT scan

-Oral contrast medium-Rectal Gastrografin enema

Reserved for patients-

more than 6 mm

-Severe obesity.


17/24

If the clinical picture is unclear

Short period (4-6 h) of watchful waiting

USG / CT scan-May improve diagnostic accuracy

Without a definite diagnosis- return for continued or recurrent symptoms- follow-up examination in 24 hours.


18/24

Complications

Perforation

General Secondary Peritonitis

Appendiceal Mass

Appendiceal Abscess

portal venous system

Hepatic absces

Chills High fever

Jaundice


19/24

TREATMENTMedical therapy

Resuscitated adequately with fluids .

Preoperative prophylactic antibiotics-Acute Appendicitis single agent second-generation

cephalosporin.-Perforated a endix tri le antibiotic thera

Ampicillin , gentamycin , metronidazol

Antibiotic prophylaxis should be administered before everyappendectomy.

Antibiotic treatment may be stopped.-Becomes afebrile-WBC count normalizes


20/24

Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)

2. Laparoscopic appendectomy

If normal appendix removed need to look for:

- Meckel's diverticulum

- Acute salpingitis

- Crohn's disease


21/24

If the body successfully walls offthe localized perforation

Appendiceal Mass

RLQ massThe pain may actually improve.Symptoms do not completely resolve.

Decreased appetiteChange in bowel habits (eg, diarrhea, constipation)Intermittent low-grade fever.


22/24

Treatment of

Appendiceal MassNonoperative managementBecomes walled off by omentum and ajacent viscera.Initially treated with intravenous broad-spectrum antibiotic

Appendiceal Abscess USG or CT scan

-Percutaneous aspiration-Drain placement

Intravenous antibiotics are continued until the patient- afebrile for 24 hours- return of normal gastrointestinal function- normal WBC count with a normal differential.

At this time, patients are switched to oral antibiotics for a total antibiotic

course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weekslater.


23/24


24/24

Acute Appendicitis Appendicitis Perforation

Date post:	05-Apr-2018
Category:	Documents
Upload:	kevinharahap26
View:	243 times
Download:	0 times

Acute Appendicitis by dr.S.H

Documents