Dr. Rabah a.Hussein F.I.M.B.S Appendix Dr. Rabah a.Hussein F.I.M.B.S

Congenital Anomalies Agenesis Duplication Left sided appendix

function The function of the appendix is unknown , but the abundance of organized lymphoid tissue within it suggests an immunologic role.

Acute appendicitis It is the most common surgical emergency, more common in the western countries d/t their diet. Appendicitis is a disease of young adults and children but can occur in elderly patient. Peak age of the disease is 15 years (adolescence).

Pattern: Colicy pain obstructed appendix. Constant painnon obst appendix. Duration: usually few hours but it can be 2-3 days. Progression: increases with time. Relieving: by bending the leg to the abdomen(flexion) or by lying down Association: with other symptoms: 1.vomiting: vomiting after the onset of pain because vomiting before pain suggests gastroenteritis.   2.constipation: majority of cases state that they have been constipated for few days before the attack of pain. 3.diarrhea: few of the patients especially when it is pelvic appendicitis (d/t irritation to the rectum) 4.anorexia 5.low grade fever: (37.2 – 37.7 C ) if higher fever think about complicated appendicitis ( by peritonitis and abscess) in the Hx you have to exclude other GIT symptoms.  symptoms of DDx.

Physical Examination   General examination: pale (esp. in children) tachycardia ( d/t spread of infection) low grade fever tongue: white and furred with foetor oris ( bad breath) Neck: palpate glands and look at the tonsils to exclude mesenteric adenitis Chest: Examine the lung for right basal pneumonia Abdomen: inspection: normal, the abdomen is slowly moving with respiration due to pain. palpation: right iliac fossa is tender with or without guarding (voluntary contraction of abdominal muscle when palpate) Rebound tenderness : +ve in McBurney’s point

Signs: Rovsing’s Sign: Pain in the Right iliac fossa RIF d/t pressing or palpating the Left iliac fossa LIF. Because either - transmission of air Or: - by pressing on the left side you are moving the intestine to touch the inflammewd organ Psoas Sign: Pain when extending the right hip joint d/t spasm of the psoas muscle. So, you observe hip flexing slightly by patient to decrease the pain. Obturaror internus sign: Pain with passive internal rotation of the flexed Rt. Thigh  it indicates inflammation overlying the muscle. Blumberg’s sign: Pressing and releasing suddenly in LIF feels pain in the RIF [ crossed rebound tenderness] Straight leg raising sign: +ve with retrocecal appendix. Rectal Examination; Tenderness ( in the pelvic position, or when there is pus in Douglas Pouch).

signs Psoas sign Obturetor sign

DDx: (according to the location of pain) I - RIF pain & tenderness II- Central abd. Colic (Discussed below) Intra abdominal diseases: Mesenteric adenitis: Especially in children following upper respiratory tract infection URTI. It looks like appendicitis in their symptoms. You must ask about previous Hx of URTI tonsillitis or enlarged L.N. Meckel’s diverticulitis: Often indistinguishable from appendicitis, you have to look for Meckle’s when you do appendectomy. Acute crohn ileitis: Affect young adult & usually there is Hx of recurrent pain. Mass of inflamed ilieum can be felt. Acute cholecystitis: Sometimes pain of inflamed Gall bladder descends into RIF. Murphy’s sigh (+ve in cholecystitis). Vomiting & jaundice may be present.

Perforated peptic ulcer: Hx. Of dyspepsia. Sudden pain on epigastrium  shifted to RIF. Gas under diaphragm on X-ray. Pancreatitis: (rare) Diffuse abd. Pain & sometimes central or RIF pain. Associated with copious vomiting & back pain. The urinary tract diseases: Renal colic & acute pyelonephritis: You should ask about hematuria or loin pain which radiate to the groin region. Ask if there is any change in (color / frequent / volume) of urine. Testicular torsion or undescended testis: Very rare.

investigation

  II- DDx of Central abd pain: In the early stages of appendicitis may suggest: Gastroenteritis: Nausea, vomiting and diarrhea proceeds the pain. Intestinal obstruction: High level obstruction characterized by profuse vomiting and little abdominal distension. Low level obstruction causes mark distention & late onset vomiting. On X-ray you will see fluid level. Noisy bowel sounds

Diagnostic Accuracy: Clinically: Alvarado Scoring System: Symptoms: Migratory Rt. Iliac fossa pain. 1 Nausea & vomiting. 1 Anorexia 1 Signs: Tenderness in ht. iliac fossa 2 Rebound tenderness in ht. iliac fossa 1 Elevated temperature. 1 Laboratory findings: Leukocytosis 2 Shift to the left of neutorphils 1 Total 10

Alvarado scoring system is the most famous scoring system used to help with the clinical diagnosis of acute appendicitis and is very easy to apply. The score is based on three symptoms, three signs and one investigation as. The classic Alvarado Score included left shift of neutrophil maturation (score 1) yielding a total score of 10, but Kalan et al. omitted this parameter which is not routinely available in many laboratories, and produced a modified score. 1-Patients with a score of (1-4) are considered unlikely to have acute appendicitis. 2- those with a score of (5-6 )have a possible diagnosis of acute appendicitis, not convincing enough to have urgent surgery. 3- those with score of( 7-9) are regarded as probably having acute appendicitis. Application of Alvarado scoring system in diagnosis of acute appendicitis can provide a high degree of positive predictive value and thus diagnostic accuracy.

Types of incisions: Grid Iron incision: When the Dx is certain, an incision is made aright angle to a line joining the superior iliac spine to the umbilicus. Its center being the line at McBurney’s point Has less postoperative complication Superficial circumflex artery usually need ligation Pramedian incision: It is a vertical incision lying parallel to the mid line just 1.25-2.5 cm Commonly 2.5 cm below the umbilicus and just above the pubis. Advantage: Done when the Dx is doubt and you should operate. It gives a good access to the pelvic organs in females. It can extend upward to deal with a perforated duodenal ulcer or other intraabdominal pathology. Disadvantage: Give limited access to retrocecal appendix. High incidence of infection. High Chance of incisional hernia May injure the bladder. Lanz incision: Transverse incision made approximately 2 cm below the umbilicus centered in the midclavicular line. The external oblique aponeurosis,internal oblique and transverses muscles are split in the direction. The exposure is better and extension if needed is easier Recently this incision became so popular and it is performed in most of the patients.

Complications: Complications of the operations: 1. Bleeding. * You can do Laparoscopic appendectomy Complications: Complications of the operations: 1. Bleeding. 2. wound infection: * anaerobic bacteria (flagyl) * gram –ve bacteria (gentamycine) * gram +ve bacteria (ampicilline) 3. residual abscess: * local. * Pelvic.(common) * Paracolic. 4. Intestinal obstruction from adhesions. 5. Incisional hernia ( esp. Para median incision) 6. Rt. Inguinal hernia (following the grid iron incision)

1. localized peritonitis or generalized after perforation: Complications of the appendicitis: 1. localized peritonitis or generalized after perforation: symptoms include: * generalized abdominal pain. * Nausea and vomiting. * Sweating and sometimes rigors. * With pyrexia.

2.Appendicular mass 3.appendicular abscess: An appendix mass is a common surgical clinical entity, encountered in 2-6% of patients presenting with acute appendicitis . Patients presenting late in the course of acute appendicitis are complicated by the development of an inflammatory mass in right iliac fossa . This inflammatory mass is composed of the inflamed appendix, omentum and bowel loops . non-operative management for the appendix mass ,followed by interval appendectomy 6-8 weeks after successful conservative management .Conservative treatment (Ochsner–Sherren regimen) comprises hospitalization, intravenous fluids, antibiotics, analgesics and a strict watch on the vitals and general state of the patient. In 90-80% of the patients, the mass resolves without complications. The remaining 10-20% need emergency operation due to spreading infection , which is comparatively more difficult 3.appendicular abscess: Need drainage.May give pelvic abscess or portal pyemia through ilio colic vein.

DDx of a mass in the RIF: 1. appendicular mass or abscess. 2. carcinoma of the cecum : * not tender. * Blood in stool. * Deterioration in health over month Pt. usually old. Signs of metastasis e.g. to the liver [ enlarged/ tender] 3. Crohn’s disease: * Diarrhea. * Wt. loss. * Abdominal pain, rectal bleeding. * Occult blood in stool. * Increased ESR. 4. Ovarian carcinoma. 5. Iliocecal T.B. 6. Iliac L.N enlargement. 7. Iliac artery aneurysm. 8. psoas abscess. 9. distended gall bladder