APPENDICITIS

Anatomy and physiology of

appendix

The appendix is a slender, worm-shaped pouch, averaging 5—10cm in length, that protrudes from the top of the colon in the lower right abdomen

Location

• McBurney’s point:one-third of the way from the anterior,superior iliac spine to the umbilicus.

• Pelvis and right ilac fossa appendix

• Anterior or posterior ileum appendix

• Retrocaceal appendix

• Right lateral caceal appendix

Retrocaceal appendix

Supply & nerve

• Appendix artery: a final artery ,from ileocolic artery

• Appendix vein : portal vein

• sympathetic nerve :celiac plexus and lesser splanchnic nerve T10,T11

 Acute appendicitis

Appendicitis is a common cause of abdominal pain

life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation

Etiology

• Obstruction:

anatomy :wormed-shaped

narrow

plenty of lymph glands

mechanical reason:

food residue, ascarid,

tumor,etc.

Etiology

• Gastrointestial disease

• Bacteria invasion:

all kinds of G- bacilus

Pathology

Four type:

• Acute simple appendicitis

• Acute purulent appendicitis

• Perforation and gangrenous

• Appendiceal abscess

Acute simple appendicitis

Acute purulent appendicitis

Perforation and gangrenous

Gangrenous

Perforation

Appendiceal abscess

Results

• Inflammation disappear

• Inflammation localization

• Inflammation diffusion

Clinical manifestation

symptoms :

• abdominal pain :

Periumbilical or epigastric pain that migrates to right lower quadrant

Pain becomes persistent and well localized. It worsens with moving, breathing deeply, coughing, sneezing, walking, or being touched

Symptoms :

• Gastrointestinal symptoms:

Anorexia, nausea, and vomiting occur after the onset of pain

Constipation

Diarrhea

bladder and rectum stimulus symptoms

Symptoms

• General symptoms :

tired ,headach

fever

Rapid pulse • SIRS (systemic inflammatory response

syndrome)

Signs

• Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone

peritoneal irritation sign : muscular rigidity Blumberg sign bowel sounds disappear

Others

• Rovsing’s sign:pain in the right lower quadrant upon palpation of the left lower quadrant.

• Psoas sign :pain on active elevation of the legs

• The obturator sign: pain on internal and external rotation of the hip

• Rectal exam & vaginal exam

Lab test

• Mild to moderately elevated WBC with left shift is typical but rarely may be normal, range of 11000-17000/mm3

over 20000/ mm3 perforation

• UA may show ketonuria or a few RBCs or WBCs

• pregnancy test (women only)

Lab test

• B-us

• X-ray

• Diagnostic abdominal puncture

Diagnosis

• Periumbilical or epigastric pain that migrates to right lower quadrant

• Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone

Differential diagnosis

Two type :

A: required surgery

B: not required surgery

Differential diagnosis

Required surgery:

• Perforation of gastointestinal tract

ulcer,tumor, diverticulitis

• obstetrics and gynecologic disease:

ectopic pregancy,ovarion torsion

• Meckel diverticulitis

• Tumor

Differential diagnosis

Not required surgery• Pelvic inflammation

• Mesenteric adenitis:at exploration a normal appendix and enlarged lymph nodes in the mesentery

• Viral & bacterial gastroenteritis

• Pneumonia, pleurisy

Treatment

• Early operation:

surgical removal(appendectomy)

• Acute simple appendicitis: appendectomy

• Acute purulent and gangrenous appendicitis:

appendectomy and/or drainage

Treatment

Appendiceal abscess:

• if local in right low quadrant

antibiotic therapy and general treatment

• if infection diffusion

incision and drainage

Treatment

Operation

• Incision :

incision over the point of maximal tenderness,generally at McBurny point

true McBurney’s incision

tansvers skin incision

3—6cm long

Incision

• McBurney’s

incision

Incision

• tansvers skin incision

Treatment

Operation

• Process:

The taenia of the colon are followed to the base of the appendix

Treatment

Operation

• Process:

Mesoappendix is divided between clamps and ligated

Treatment

Operation • Process:The base of

appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string

a

b c

Treatment

• Suspected case: not definite.

Admit the patient to hospital for further observation 12-24hrs

Operation

exploration incision

Treatment

Antibiotic thearpy:

• Acute simple appendicitis

• Contraindication of operation

• Appendiceal abscess

Treatment

Antibiotic thearpy

antibiotics: broadspectrum antibiotics

ampicillin-sulbactam

gentamycin triad drugs

metronidazol

3rd generation cefotides

Treatment

• New method :

laparoscopy appendectomy

Complication

Acute appendicitis:

• Abdomen abscess

• Inter or extra fistula

• Phylephlebitis

Complication

Operation :

• Incision infection

• Peritonitis and abdomen abscess

• Bleeding

• Stool fistula

• Stump infection

• Adhesive intestinal obstruction

Appendicitis in neonate

• Seldom

• Non-specific clinical manifestation Anorexia, nausea, and vomiting diarrhea

dehydration

• Difficult in early diagnosis

• High rate of perforation

• High mortality

Appendicitis in neonate

Diagnosis &Treatment

• Carefully physical exam

• Early operation

Appendicitis in child

• Quick onset and severe

high fever and vomiting present early

• Non-typical tenderness at right low quadrant

• High rate of perforation

• High mortality

• More complication

Appendicitis in child

Treatment:

• Early operation• Transfusion and correct dehydration

• Broadspectrum antibiotics

Appendicitis in pregnancy

Uterus enlargement

elevation of abdominal

wall

Tenderness site upper shift

appendix displaced

superiorly

Inconspicuous oftenderness

rebound tendernessmuscular rigidity

Without adherent blanket of

omentum

Peritonitis diffusion

Appendicitis in pregnancy

Treatment :• Operation :appendectomy• To late pregancy :early operation• Superior Incision • No drainage• Broadspectrum antibiotics• Parturient with perforation : cesarean section and appendectomy

Appendictis in the elderly

• Less well-defined symptoms and signs

• Severe pathologic type

• Error diagnosis easily

• High rate of perforation

• Pay attention to tumor

Chronic appendicitis

• Etiology and pathology

• Clinic feature and diagnosis

right low quadrant pain

local tenderness

x-ray

• Treat

appendectomy