Appendicitis DONE BY DR KURAKIN VICTOR

The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. Its average length is 8-10 cm (ranging from 2-20 cm Appendicitis is inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This illness is one of the more common surgical emergencies, and it is one of the most common causes of abdominal pain.

American C. McBurney published a series of reports that constituted the basis of the subsequent diagnostic and therapeutic management of acute appendicitis. Currently, appendectomy, either open or laparoscopic, remains the treatment for noncomplicated appendicitis.

Frequency: The incidence of acute appendicitis is around 7% of the population in the United States and in European countries.

Etiology: Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the obstruction include lymphoid hyperplasia secondary to irritable bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms

Pathophysiology: Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading to venous outflow obstruction.

Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins, leading to perforation and gangrene of the appendix.

Clinical: The most common symptom of appendicitis is abdominal pain Clinical: The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of the abdomen. Later, a worsening progressive pain along with vomiting, nausea, and anorexia are described by the patient. Usually, a fever is not present at this stage.

The differential diagnosis The differential diagnosis include cholecystitis gastroenteritis, enterocolitis, diverticulitis, pancreatitis, perforated duodenal ulcer, renal colic, and urinary tract infection (UTI). In pediatric patients, consider mesenteric lymphadenitis and intussusception. In women include ovarian cyst torsion, mittelschmerz, ectopic pregnancy, and pelvic inflammatory disease (PID). Small bowel obstruction, Crohn disease, Meckel diverticulitis, tumors, rare conditions that mimic appendicitis.

Tenderness in the RLQ over the McBurney point is the most important sign in these patients. Signs such as increasing pain with cough (ie, Dunphy sign), rebound tenderness (ie, Blumberg sign), and guarding may or may not be present . ROVSING’S SIGN PSOAS SIGN OBTURATOR SIGN

Patients with appendicitis may not have the reported classic clinical picture 37-45% of the time, especially when the appendix located in an unusual place

If diagnosis of appendicitis is clear- appendectomy need consider. If picture is not clear- waiting and follow up – 4-6 hours and doing CT-scan of abdomen

Relevant Anatomy: The appendix is a wormlike extension of the cecum, and its average length is 8-10 cm (ranging from 2-20 cm). its wall has an inner mucosal layer, 2 muscular layers, and a serosa. Several lymphoid follicles are scattered in its mucosa.

Many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Appendicular artery, is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found.

Lab Studies: Complete blood cell count Urinalysis Liver and pancreatic function tests (eg, transaminases, bilirubin, alkaline phosphatase, serum lipase, amylase) may be helpful to determine the diagnosis in patients with an unclear presentation.

Imaging Studies: Abdomen plain film: Occasionally, a plain film of the abdomen may demonstrate fecalith within the appendix, but this study is rarely indicated.

Barium enema Although barium enema is currently performed only rarely, in the past this examination was used to diagnose appendicitis. Ultrasound Vaginal ultrasound The main limitation of US scan is that its reliability is completely user-dependent.

Computed tomography scan Recently, helical CT scan has demonstrated high sensitivity and specificity in differentiating appendicitis from other conditions, and it may be cost efficient with regards to limiting the number of unnecessary operations. Because of its cost, CT scans are generally reserved for patients with uncertain diagnosis or severe obesity.

Diagnostic laparoscopy may be useful in selected cases (eg, infants, elderly patients, female patients) to confirm the diagnosis. If findings are positive, such procedures should be followed by definitive surgical treatment at the time of laparoscopy.

Staging: Appendicitis usually has 3 stages. Edematous stage Purulent (phlegmonous) stage Gangrenous stage

Medical therapy Appendectomy remains the only curative treatment for appendicitis Antibiotic prophylaxis should be administered before every appendectomy and must offer full aerobic and anaerobic coverage

Surgical therapy Operation of choice-appendectomy-open or laparoscopic. Since 1987, many surgeons have begun to treat appendicitis laparoscopically. This procedure has now been improved and standardized.

The reported results of both laparoscopic and open-procedure appendectomies seem to be overlapping. In fact, the average rate of abdominal abscesses, negative appendectomies, and hospital stays are very similar according to a recent overview of 17 retrospective studies.

Laparoscopy has some advantages, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. This procedure is cost effective but may require more operative time compared with open appendectomy.

Open appendectomy McBurney point

Laparoscopic appendectomy Some variations are possible, 3 cannulae are placed during the procedure. Two of them have a fixed position (ie, umbilical , suprapubic or lt lower quadrant). The third is placed in the right or left lower region, and its position may vary greatly depending on the patient’s anatomy.

short umbilical incision is made to allow the placement of a Hasson cannula or Veress needle that is secured with 2 absorbable sutures. Pneumoperitoneum (10-14 mm Hg) is established and maintained by insufflating carbon dioxide.

Postoperative details Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient. In complicated appendicitis, antibiotics may be required for many days or weeks.

 complications   Complications may occur in patents with appendicitis, accounting for an average morbidity near 10%. Death is rare but can occur in patients who have profound peritonitis and sepsis.

The outcome of appendicitis, whether it is complicated or simple, is good. Patients may return to their activities soon after the operation, and, once the patient has recovered, no changes in lifestyle (eg, diet, exercise) are required after appendectomy.