APPENDICITIS DR KULWANT SINGH

Contents 1 Definition 2 Pathophysiology 3 Clinical Features 4 Diagnosis 4 Differential Diagnosis 5 Treatment 6 Dr Kulwant Singh

Commonest abdominal surgical emergency. Incidence Commonest abdominal surgical emergency. One person in six develops appendicitis at some time. It is relatively uncommon in developing rural communities. Dr Kulwant Singh

INFLAMMATION OF APPENDIX IS APPENDICITIS Generally Caused by an obstruction: Faecalith. Lymphoid obstruction, Infection. Dr Kulwant Singh

Surgical Anatomy The appendix is attached at the point of convergence of the three taeniae coli of the caecum on its posteromedial wall - The meso-appendix is a peritoneal fold containing fat & appendicular artery - Commonly behind the caecum (Retrocaecal) - On psoas muscle at or below pelvic brim (Pelvic) - Rarely : Pre-ileal – Post-ileal – Paracaecal - Length less than 1 to greater than 30cm (most are 6-9 cm in length) - After age of 60 no lymphoid tissue remains Dr Kulwant Singh

Surgical Anatomy Predisposing factors : 1- Obstructive agents 2- Infective agents Obstructive agents Foreign bodies : animal (e.g. thread worms ,round worms) , vegetables (e.g. seeds , date stones) mineral (faecalith = common cause) submucous lymphoid tissue hyperplasia leads to obstruction Dr Kulwant Singh

POSITIONS OF APPENDIX Dr Kulwant Singh

CAUSES Infective agents : Primary infection leading to lymphoid hyperplasia Secondary infection caused by pressure of an obstructed agent leads to epithelial erosion and bacteria gain access to the wall Both aerobic & anaerobic organisms are involved including ( coliforms , enterococci , bacteroids & other intestinal commensals ) Dr Kulwant Singh

APPENDICITIS PATHOPHYSIOLOGY Acute appendicitis is thought to begin with obstruction of the lumen Obstruction can result from food matter, adhesions, or lymphoid hyperplasia Mucosal secretions continue to increase intra luminal pressure Dr Kulwant Singh

APPENDICITIS PATHOPHYSIOLOGY Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed. With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs. Dr Kulwant Singh

APPENDICITIS PATHOPHYSIOLOGY Increased pressure also leads to arterial stasis and tissue infarction End result is perforation and spillage of infected appendiceal contents into the peritoneum Dr Kulwant Singh

APPENDICITIS PATHOPHYSIOLOGY As inflammation continues, serosa and adjacent structures become inflamed This triggers somatic pain fibers, innervating the peritoneal structures. causing pain in the RLQ Dr Kulwant Singh

APPENDICITIS PATHOPHYSIOLOGY The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the peri-umbilical area to the RLQ seen with acute appendicitis. Dr Kulwant Singh

APPENDICITIS PATHOPHYSIOLOGY Exceptions exist in the classic presentation due to anatomic variability of the appendix Appendix can be retrocecal causing the pain to localize to the right flank In pregnancy, the appendix ca be shifted and patients can present with RUQ pain Dr Kulwant Singh

APPENDCITIS WITH PERITONITIS APPENDICITIS TYPE ACUTE APPENDCITIS APPENDCITIS WITH MASS APPENDCITIS WITH PERITONITIS Dr Kulwant Singh

Acute appendicitis - Organisms enter the wall & lodge in sub mucosa , proliferate , wall becomes red & turgid - Rate of acceleration of inflammation increase in presence of obstruction to lumen of appendix Dr Kulwant Singh

Acute appendicitis with mass Obstruction + infection lead to distension with pus hence increase intraluminal pressure lead to venous occlusion , oedema , arterial occlusion , gangrene and perforation follows , rapidly localised by defence mechanism (greater omentum & coils of bowel ) . Appendix mass is formed , can undergo suppuration to produce an appendix abscess Dr Kulwant Singh

Acute appendicitis with peritonitis - Free perforation following obstruction + infection allows infected material to disperse widely in peritoneal cavity lead to intense peritoneal reaction with outpouring of fluid - Serosal surfaces of bowel become injected flaked with clotted lymph Dr Kulwant Singh

Clinical Features 1 3 2 Abdominal pain periumblical at first , then to right iliac fossa within a few hours it becomes persistent . Onset is usually sudden , may arise in right iliac fossa and remains there Anorexia nearly always accompanies appendicitis Vomiting occurs in about 75% of patients (most vomit once or twice ) Retrocaecal appendix may cause flank or back pain Pelvic appendix may cause suprapubic pain Dr Kulwant Singh

Clinical Features 5 4 6 Most patients give history of constipation before onset of pain , diarrhea in some particularly children Fever Low grade Around 100 degee F Oc. Haematuria Murphy’s Triad Pain Vomiting Fever Dr Kulwant Singh

Clinical Features 1 3 2 Appendicitis with peritonitis : three stages Stage of shock pale , sweating & anxious - Elevated pulse rate - Low blood pressure - Temperature is subnormal - Respiration is rapid & shallow - Tenderness in the RIF Stage of perritoneal reaction Severe local tenderness in the RIF - Rebound tenderness - Board –like rigidity - Marked rectal tenderness RIF Stage of flank peritonitis Abdominal distension Absent bowel sounds Faecal vomitus Dehydration Appendicitis with peritonitis : three stages Dr Kulwant Singh

CLINICAL FEATURES LOCAL SIGNS Tenderness of a localised & persistent nature is the most important abdominal finding , situated at RIF , classically at McBurney’s point ( junction of middle & outer third of a line from umbilicus to anterior superior iliac spine Rigidity over RIF Rebound tenderness (best elicited by percussion) Tenderness on right side during rectal examination (may be only sign with pelvic appendicitis ) Dr Kulwant Singh

CLINICAL FEATURES ROVSING’S SIGN Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise along the colon) may cause pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. This is the Rovsing’s sign. Dr Kulwant Singh

CLINICAL FEATURES PSOA’S SIGN Psoas sign is right lower-quadrant pain that is produced with the patient extending the hip due to inflammation of the peritoneum overlying the psoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes the pain because it stretches the muscles, and flexing the hip into the "fetal position" relieves the pain. caecum CAECUM Iliacus muscle Iliacus muscle inflamed appenix Inflamed appendx Psoas muscle Psoas muscle Dr Kulwant Singh

CLINICAL FEATURES OBTURATOR’S SIGN Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.. Dr Kulwant Singh Iliac tuberosity Caecum Inflamed appendix Obturator internus Ischial tubersosity

CLINICAL FEATURES BLOOMBERG’S SIGN Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes severe pain on the site indicating positive Blumberg's sign and peritonitis. Dr Kulwant Singh

CLINICAL FEATURES MCBURNEY’S SIGN To elicit Mcburney’s sign patient should be in supine position with his knees slightly flexed and his abdominal muscles relaxed. Palpate deeply and slowly in the right lower quadrant over McBurney’s point located about 2” from the Rt. Ant. Sup. Iliac Spine. On a line between the spine and umbilicus (1/3rd outer side). Point pain and tenderness is a positive sign and indicates appendicitis. Dr Kulwant Singh

Clinical Features SIGNS B A C F D E UNWELL LOOK COATED TONGUE FOUL BREATH COUGH TENDERNESS TACHYCARDIA POINTING SIGN Dr Kulwant Singh

Rt Iliac Fossa Tender (2) Alvarado Score Above 8-9: Sure Below 5: negative 5-8: investigate Anorexia Nausea and Vomiting Fever Leucocytosis (2) Shift to left Rebound Tenderness Rt Iliac Fossa Tender (2) Rt Iliac Fossa Pain Dr Kulwant Singh

Differential Diagnosis Ca Caecum Perforated P.U. Empyema GB Renal Mass Ovarian cyst Fibroid uterus Crohn’s disease Ureteric calculus Ileo caecal TB Liver and GB inflamm. Eterocolitis Pancreatitis Rt Lobar Pneumonia Ectopic gestation Worm Ball Oophoritis Dr Kulwant Singh

Differential Diagnosis Gastroenteritis, Mesenteric adenitis, Meckel’s diverticulum, Intussception Regional enteritis, Ureteric Colic, Perforated P.U., Torsion of Testis, Pancreatitis Pelvic Inflammatory Diseases, Pyelonephritis, Ectopic Pregnancy, Ovarian Cyst, Endometriosis, uterine fibroids. Diverticulitis, intestinal obstruction, carcinoma colon etc. CHILD ADULT FEMALE OLD Dr Kulwant Singh

Homoeopathic Medicines Specific. Severe Pain Rt Groin. > warmth, Dryness of mouth and eyes Pain RIF, >rest <motion, Constipation, Dryness of m.m., Thirst ++. Vomiting. Pain RIF, Dyspepsia, Constipation, <4-8 PM, sedentary habit, intellectual person, lack of exercise, Acute stage, severe pain, violent, unbearable, sudden onset. Vomiting. High Fever Iris Tenax Bryonia Lycopod Bell Dr Kulwant Singh

Homoeopathic Medicines Chronic, suppurative and inflammation persists, pain with fever Violent and Active. Caecal region painful. Tenesmus. Hot urine passed drop wise. Pain RIF, dysenteric stool, bruised sensation, tender lump in RIF, perspiration ++ Sepsis, Chills, Restlessness, Prostration, Diarrhoea, Fever, Fear of Death Echin. Merc Cor Merc Sol Ars. Alb Dr Kulwant Singh

BOERICKE APPENDICITIS TOTAL MEDICINES: 30 QUICK REPERTORISATION BOERICKE APPENDICITIS TOTAL MEDICINES: 30 Dr Kulwant Singh

KENT APPENDICITIS TOTAL MEDICINES: 22 QUICK REPERTORISATION KENT APPENDICITIS TOTAL MEDICINES: 22 Dr Kulwant Singh

PHATAK APPENDICITIS TOTAL MEDICINES: 20 QUICK REPERTORISATION PHATAK APPENDICITIS TOTAL MEDICINES: 20 Dr Kulwant Singh

CLARKE APPENDICITIS TOTAL MEDICINES: 19 QUICK REPERTORISATION CLARKE APPENDICITIS TOTAL MEDICINES: 19 Dr Kulwant Singh

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