1. APPENDICITIS

2. Anatomy and physiology of appendix

3. 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

4. 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

8. Retrocaceal appendix

9. Supply & nerve Appendix artery: a final artery ,from ileocolic artery
Appendix vein : portal vein
sympathetic nerve :celiac plexus and lesser splanchnic nerve T10,T11

10. 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

11. Etiology Obstruction: anatomy :wormed-shaped narrow
plenty of lymph glands
mechanical reason:
food residue, ascarid,
tumor,etc.

12. Etiology Gastrointestial disease Bacteria invasion:
all kinds of G- bacilus

13. Pathology Four type: Acute simple appendicitis
Acute purulent appendicitis
Perforation and gangrenous
Appendiceal abscess

14. Acute simple appendicitis

15. Acute purulent appendicitis

16. Perforation and gangrenous

17. Gangrenous
Perforation

18. Appendiceal abscess

19. Results Inflammation disappear Inflammation localization
Inflammation diffusion

20. 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

21. Symptoms :
Gastrointestinal symptoms:
Anorexia, nausea, and vomiting occur after the onset of pain
Constipation
Diarrhea
bladder and rectum stimulus symptoms

22. Symptoms General symptoms : tired ,headach fever Rapid pulse
SIRS (systemic inflammatory response syndrome)

23. 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

24. 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

25. Lab test
Mild to moderately elevated WBC with left shift is typical but rarely may be normal, range of /mm3
over 20000/ mm perforation
UA may show ketonuria or a few RBCs or WBCs
pregnancy test (women only)

26. Lab test
B-us
X-ray
Diagnostic abdominal puncture

27. 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

28. Differential diagnosis
Two type :
A: required surgery
B: not required surgery

29. Differential diagnosis
Required surgery:
Perforation of gastointestinal tract
ulcer,tumor, diverticulitis
obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsion
Meckel diverticulitis
Tumor

30. 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

31. The Alvarado score MATERIALS AND METHODS • Symptoms • Score
 migratory right iliac fossa pain
 nausea/vomiting
 anorexia
• Signs
 RIF tenderness
 fever >37.30C
 rebound pain in RIF
• Laboratory test
 leucocytosis (>10 X 109/L)
 neutrophilic shift to the left >75%
• Total score

32. CONCLUSION

33. Treatment Early operation: surgical removal(appendectomy)
Acute simple appendicitis: appendectomy
Acute purulent and gangrenous appendicitis:
appendectomy and/or drainage

34. Treatment Appendiceal abscess: if local in right low quadrant
antibiotic therapy and general treatment
if infection diffusion
incision and drainage

35. Treatment Operation Incision :
incision over the point of maximal tenderness,generally at McBurny point
true McBurney’s incision
tansvers skin incision
3—6cm long

36. Incision
McBurney’s
incision

37. Incision
tansvers skin incision

38. Treatment Operation Process:
The taenia of the colon are followed to the base of the appendix

39. Treatment Operation Process:
Mesoappendix is divided between clamps and ligated

40. Treatment Operation Process:
The base of appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string

41. a b c

42. Treatment Suspected case: not definite.
Admit the patient to hospital for further observation 12-24hrs
Operation
exploration incision

43. Treatment Antibiotic thearpy: Acute simple appendicitis
Contraindication of operation
Appendiceal abscess

44. Treatment Antibiotic thearpy antibiotics: broadspectrum antibiotics
ampicillin-sulbactam
gentamycin triad drugs
metronidazol
3rd generation cefotides

45. Treatment
New method :
laparoscopy appendectomy

46. Complication Acute appendicitis: Abdomen abscess
Inter or extra fistula
Phylephlebitis

47. Complication Operation : Incision infection
Peritonitis and abdomen abscess
Bleeding
Stool fistula
Stump infection
Adhesive intestinal obstruction

48. Appendicitis in neonate
Seldom
Non-specific clinical manifestation
Anorexia, nausea, and vomiting diarrhea
dehydration
Difficult in early diagnosis
High rate of perforation
High mortality

49. Appendicitis in neonate
Diagnosis &Treatment
Carefully physical exam
Early operation

50. 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

51. Appendicitis in child Treatment: Early operation
Transfusion and correct dehydration
Broadspectrum antibiotics

52. Appendicitis in pregnancy
Uterus enlargement
appendix displaced
superiorly
Without adherent blanket of omentum
elevation of abdominal wall
Tenderness site upper shift
Inconspicuous of
tenderness
rebound tenderness
muscular rigidity
Peritonitis diffusion

53. Appendicitis in pregnancy
Treatment :
Operation :appendectomy
To late pregancy :early operation
Superior Incision
No drainage
Broadspectrum antibiotics
Parturient with perforation :
cesarean section and appendectomy

54. Appendictis in the elderly
Less well-defined symptoms and signs
Severe pathologic type
Error diagnosis easily
High rate of perforation
Pay attention to tumor

55. Chronic appendicitis Etiology and pathology
Clinic feature and diagnosis
right low quadrant pain
local tenderness
x-ray
Treat
appendectomy