King Faisal University 24.may.2006 King Faisal University College of Medicine Surgery I 4th year Acute Appendicitis Done by: Fatima A. Al-Hashim Iman Al-Mukhtar Supervised by: Dr. A. Al-Mulhim Dr. H. Wadani

Objectives Introduction History taking Anatomy Physical examination Etiology pathogenesis Signs & Symptoms Differential Diagnosis History taking Physical examination Preoperative complication Investigation Appendectomy Postoperative complication

Introduction

What is appendicitis?? Appendicitis is the inflammation of appendix. appendicitis is the most common cause of the intra-abdominal infection in developed countries. & it is the most common emergency surgical operation appendicitis can occur at any age but is most common below 40 yrs , especially between the ages of 8 & 14 yr &it is very rare below the age of 2.

Anatomy

Peritoneal covering of the appendix Site Rt iliac fossa , attached to the posteromedial aspect of caecum 2cm below the iliocaecal valve. Size 2-20 cm long (average 10cm) & about 1\2 cm wide Peritoneal covering of the appendix It is completely covered with peritoneum & is suspended to the back of the mesentery of terminal ileum by a triangular fold of peritoneum called mesoappendix

Branch of ilio-colic artery Nerve supply T10 supplies the peritoneal covering of the appendix referred pain of the appendix is felt at the umbilicus which has the same nerve supply. Venous drainage appendicular vein ileocolic vein superior mesenteric vein  portal vein Arterial supply: Appendicular artery Branch of ilio-colic artery It runs in the free border of the mesoappendix towards the tips.

Position The base of the appendix is fixed , its tip points to one of the following positions 5-post-ileal (1\2 %): the appendix lies behined the terminal part of ileum, in contact with the ileocolic V. it is the most dangerous position because spread of the infection to the vien may lead to portal pyaemia. 1- Retrocecal ( 74% ): behined the caecum ( in the retrocaecal recess) 3-subcaecal (3.5%): the appendix lies below the caecum. 2-pelvic (21%): the appendix hangs over the pelvic brim where it is related to external iliac vessels , ovary & uterine tube. 4-pre-ilial (1%): infront of the terminal part of the ileum

Idintification of appendix at operation Microscopically the submucosa of the appendix is rich in lymphoid tissue Idintification of appendix at operation inside the abdomen the base of the appendix is easly found by identifying the tenia coli of the cecum & following them to the base of the appendix where they coverage to form complete longitudinal muscular coat conginital abnormalities )-1-absence of appendix (agenesis -2-double appendix -3-appendix lying in the Lt iliac fossa

Surface anatomy of the base of appendix ( McBurney's point ) It is a point at the junction of the lateral 1\3 & medial 2\3 of a line extending from the anterior superior iliac spine to the umbilicus (spino-umbilical line)

Etiology

Infection of appendix by 2 routs hematogenous rare endogenous common obstructed non-obstructed appendix By: 1-faecolith commonest 2-foreign body 3-lymphoid hyperplasia due to viral infection 4-stricture 5-carcinoid tumor 6-chron's disease 7-parasetic infection particularly by oxyuris vermicularis (pin warm) due to direct infection of lymphoid follicle from appendicular lumen

pathogenesis

prolofiration of the gas forming bacteria bacterial flora located within the lumen of appendix include both aerobic & anaerobic organism typical of those found in the large intestine obstructed appendix stasis prolofiration of the gas forming bacteria increase intralumenal pressure acute inflamation of mucosa acute appendicitis with edema , lymphoid obstruction, & necrotizing ulceration of the mucosa

If the diagnosis of appendicitis is not made early the process will continue

extension of inflammation across appendicael wall involvment of serosa by inflammation visceral peritonitis obstruction of venous & lymphatic drainage & arterial thrombosis Gangrene of appendix wall perforation

the outcome of perforation depend on the ability of the omentum to contain the infection adequate omemtum apendicular mass or abcess will result Inadequate generalized peritonitis

Symptoms

Periumblical pain  migrate to Common symptoms: 1-Abdominal pain Periumblical pain  migrate to Rt lower quadrent 2-Anorexia 3-Nausea 4-Vomiting 5-low-grade fever

Signs

1-Right lower quadrant pain on palpation (the single most important sign) 2- Low-grade fever (38°C [or 100.4°F]) --absence of fever or high fever can occur 3-Localized tenderness to percussion 4-Guarding 5-Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis) • Psoas sign • Obturator sign • Rovsing's sign • Dunphy's sign--increased pain with coughing • Flank tenderness in right lower quadrant

Differential Diagnosis

Children Elderly -Gastroenterits -Mesenteric adenitis -Meckel`s diverticulitis -Intussusception -Lobar pneumonia Elderly -Sigmoid diverticulitis -Intestinal obstruction -Colonic carcinoma -Mesenteric infarction -Aortic aneurysm

Adult male Adult female -Regional enteritis -Ureteric colic -Perforated ulcer -Torsion testis -Pancreatitis -Rectus sheath hematmoa Adult female -Salpingitis -Pyelonephritis -Ectopic pregnancy -Torsion/rupture of ovarian cyste -Endometriosis

History Taking

The components of the surgical history are that of any other history, including; An introduction Presenting complaint History of presenting complaint Past history ( medical & surgical ) Drugs/allergies Family history Social history Occupational history Systems enquiry

Age & Sex : Appendicitis does occur at any age but most often affects young adults or teenagers of either sex.  Ask about The site of the pain Onset Severity Pattern Is it localized in a particular area or not Radiation Duration Progression Aggregating Factors Relieving Factors Associated Symptoms

Physical examination

General Appearance : Head & Neck : Patient looks unwell with flushed cheeks Tongue “ white & furred with foetor oris “ Pale ( especially in children ) Tachycardia Low grade fever Head & Neck : Observe the tonsils & Palpate the lymph nodes

Chest : Abdomen : Examine the Lungs Inspection Palpation Usually normal shape , the abdomen is slowly moves with respiration due to pain Palpation The Rt iliac fossa is tender with or without guarding Rebound Tenderness: +ve in Mcburneys point

Signs : I- Rovsing`s sign : II- Psoa`s sign : Pain in the Rt iliac fossa on palpation or percussion on Lt iliac fossa. II- Psoa`s sign : Pain when extending the Rt hip joint due to spasm of the psoa`a muscle .

The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip asterisk Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver

III-Obturator`s sign : Pain with passive internal rotation of the flexed Rt thigh it indicated inflammation overlying that muscle .

V-Straight leg arising sign : IV-Blumberg`s sign : Crossed Rebound tenderness in the Rt iliac fossa after pressing and sudden release on Lt iliac fossa . V-Straight leg arising sign : +ve in retrocecal appendix

Rectal Examination : Tenderness in pelvic appendix or if there is inflammation or pus in Douglas pouch

Preoperative complication

Systemic Complications : Acute toxemia Septicemia Portal pyemia

Local Complications : Appeddicular Abscess Appedidicular fistula Rupture  supportive peritonitis Turns to chronic appendicitis

Investigation

Complete Blood Count ( CBC ) : Leukocytes Count especially neutrophiles Urine Analysis Albuminuria , Hematuria (25-40% of patient). Plain X-ray Ultra Sound CT scan

Appendectomy

Conventional Open Operation Grid-iron incision Lower midline abdominal incision Laparoscopic Technique

Problems encountered during Appendictomy: A normal appendix is found The Appendix can not be found An Appendicular Tumor is found An Appendix Abscess is found

Postoperative complication

Wound Infections Postoperative complication Intra-abdominal Abscesses Venous Thrombus & Embolism Portal Pyemia ( Pylephlebitis ) Faceal Fistula Adhesive intestinal obstruction Right inguinal hernia Postoperative complication

Treatment of postoperative complication Antibiotic prophylaxis If perforation has occurred, IV antibiotics should be continued for 5-10 days.

..Thank You..