Download MBBS Surgery Presentations 4 Appendicitis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 4 Appendicitis PPT-Powerpoint Presentations and lecture notes

ACUTE APPENDICITIS:

COMPLICATIONS & TREATMENT

PATHOLOGY AND PATHOGENESIS

Appendix lumen obstruction leads to congestion within the appendix

Inflammatory exudate and mucous increases luminal pressure

Initial stage might resolve in some patients

Appendix may distend with mucus- mucocele
APPENDICITIS COMPLICATIONS

Gangrenous Appendicitis:

Thrombosis of the appendiceal artery and veins


Perforation:

complication rates 58 %

perforation rate increased at both ends of the age spectrum

Peri-appendiceal abscess:

most frequent complication

peri-appendiceal fibrinous adhesions

Peritonitis:

Bacterial peritonitis in absence of fibrinous adhesions.

Escherichia coli

Bowel Obstruction

Septic seeding of mesenteric vessels

infection along the mesenteric?portal venous system

pylephlebitis, pylethrombosis, or hepatic abscess
OBSTRUCTION
Mucus + Inflammatory exudation Increases intraluminal Pressure

Obstructing lymphatic drainage

Edema+ M.Ulceration+ Bacterial Translocation to the submucosa

Venous obstruction( cos of further distension)

Ischemia Bacterial Invasion Acute Appendicitis.

PERFORATION

If Fever > 102*F & WBC> 18,000

If Ischemia continue

Necrosis of the appendicular wall

Gangrenous appendicitis

Perforation with free bacterial contamination of the peritoneal cavity


PERFORATED APPENDIX

GANGRENOUS APPENDIX

Thrombosis of Appendicular artery
(as it is an end artery)


PHLEGMONOUS MASS/ PARACAECAL ABSCESS

Greater omentum & loops of smal bowel become adherent to the inflamed appendix

Wal ing off the spread of peritoneal contamination

Phlegmonous Mass / Paracaecal abscess

DESTRUCTIVE PHLEGMONOUS APPENDICITIS
Appendicular inflammation resolves

Distended mucus filled organ

Mucocele of appendix

SYMPTOMS

Pain

Initially periumbilical region

Pain shift to right iliac fossa

Parietal peritoneum irritated and inflamed

Anorexia

Nausea/ vomiting
CLINICAL SIGN

Pyrexia: Low grade after 6 hours

Tenderness (localized) in the RIF

Muscle guarding

Rebound Tenderness/ BLUMBERG'S Sign

Tachycardia: Perforation, Gangrene & Peritonitis

SIGN TO ELICIT APPENDICITIS

Rovsing's Sign

Psoas Sign

Obturator Sign

Dunphy's Sign: Any movement ( Coughing) causes Pain.

Mc Burney's Point -Tenderness


INVESTIGATION

TLC- Raised: 10000 to 18000 ( Neutrophils >75%).

If TLC >18000 (suspect perforation)

Abdominal X-Ray

Abdominal Ultra sonography

CT Scan

ALVARADO SCORING SYSTEM SYMPTOMS SCORE


Score

Inference

7-10

Strongly predictive of appendicitis

5-6

Equivocal

Radiological investigations

1-4

Appendicitis ruled out
TREATMENT

Absolute bed rest & NPO

IV Fluids Supplements

Analgesics

Antibiotics

Appendectomy ( within 24 hours ASAP)

INDICATIONS OF APPENDECTOMY

Acute Appendicitis

Recurrent Appendicitis

Mucocele of Appendix

Carcinoma


INCISIONS IN APPENDECTOMY

COMPLICATION OF APPENDECTOMY

Wound Infection

Adhesive Intestinal

Intra-abdominal abscess

Obstruction

Ileus

Faecal Fistula

Respiratory complication like

Richter's Hernia

pneumonia

DVT & Embolism

Portal Pyaemia
APPENDICULAR LUMP

Appendix Edematous Caecum Terminal Ileum

Loop of Intestine Omentum ( Greater Omentum)

Adjacent Peritoneum Ascending Colon

PRESENTATION OF APPENDICULAR LUMP

Usually on 3rd day of attack of appendicitis.

Lump in Right iliac Fossa

Guarding over the lump

Tenderness

Fever/ Increase pulse
Appendicular Lump- Don't Operate (??)

Severe adhesion/ Difficult to separate the part

Bloody and dangerous to operate

Risk of Faecal fistula

Risk of iatrogenic injury

OCHSNER- SHERREN REGIMEN

Ist mark the size of the swel ing for further assessment

NPO & IV Fluid supplements

Antibiotics, Analgesics

Temp, Pulse( 4 hourly) & Fluid record charting

Al ow oral liquid on subsequent days.
OCHSNER- SHERREN REGIMEN

If more vomiting- antiemetic &/+ PPI

If size of the lump decreases ? continue the same.

After 6-8 weeks = Interval Appendectomy (current literature does not support this view)

Prognosis: 90% success rate for this regimen.

Failure to this regimen: suspect Crohn's & or Carcinoma

CRITERIA FOR STOPPAGE OF CONSERVATIVE TREATMENT IN

APPEDICULAR LUMP

Rising pulse rate

Rising temperature

Increasing or spreading abdominal pain

Increasing size of mass

Vomiting or copious gastric aspirate