Download MBBS Surgery Presentations 4 Appendicitis Lecture Notes

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PATHOLOGY AND PATHOGENESIS

Appendix lumen obstruction leads to congestion within the appendix

Inflammatory exudate and mucous increases luminal pressure

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Initial stage might resolve in some patients

Appendix may distend with mucus- mucocele
APPENDICITIS COMPLICATIONS

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Gangrenous Appendicitis:

Thrombosis of the appendiceal artery and veins

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Perforation:

complication rates 58 %

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perforation rate increased at both ends of the age spectrum

Peri-appendiceal abscess:

most frequent complication

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peri-appendiceal fibrinous adhesions

Peritonitis:

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Bacterial peritonitis in absence of fibrinous adhesions.

Escherichia coli

Bowel Obstruction

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Septic seeding of mesenteric vessels

infection along the mesenteric?portal venous system

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

Obstructing lymphatic drainage

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Edema+ M.Ulceration+ Bacterial Translocation to the submucosa

Venous obstruction( cos of further distension)

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Ischemia Bacterial Invasion Acute Appendicitis.

PERFORATION

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

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If Ischemia continue

Necrosis of the appendicular wall

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Gangrenous appendicitis

Perforation with free bacterial contamination of the peritoneal cavity

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PERFORATED APPENDIX

GANGRENOUS APPENDIX

Thrombosis of Appendicular artery

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(as it is an end artery)


PHLEGMONOUS MASS/ PARACAECAL ABSCESS

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

Wal ing off the spread of peritoneal contamination

Phlegmonous Mass / Paracaecal abscess

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DESTRUCTIVE PHLEGMONOUS APPENDICITIS
Appendicular inflammation resolves

Distended mucus filled organ

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Mucocele of appendix

SYMPTOMS

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Pain

Initially periumbilical region

Pain shift to right iliac fossa

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Parietal peritoneum irritated and inflamed

Anorexia

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Nausea/ vomiting
CLINICAL SIGN

Pyrexia: Low grade after 6 hours

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Tenderness (localized) in the RIF

Muscle guarding

Rebound Tenderness/ BLUMBERG'S Sign

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Tachycardia: Perforation, Gangrene & Peritonitis

SIGN TO ELICIT APPENDICITIS

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Rovsing's Sign

Psoas Sign

Obturator Sign

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

Mc Burney's Point -Tenderness

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INVESTIGATION

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

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If TLC >18000 (suspect perforation)

Abdominal X-Ray

Abdominal Ultra sonography

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CT Scan

ALVARADO SCORING SYSTEM SYMPTOMS SCORE

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Score

Inference

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7-10

Strongly predictive of appendicitis

5-6

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Equivocal

Radiological investigations

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1-4

Appendicitis ruled out
TREATMENT

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Absolute bed rest & NPO

IV Fluids Supplements

Analgesics

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Antibiotics

Appendectomy ( within 24 hours ASAP)

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INDICATIONS OF APPENDECTOMY

Acute Appendicitis

Recurrent Appendicitis

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Mucocele of Appendix

Carcinoma

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INCISIONS IN APPENDECTOMY

COMPLICATION OF APPENDECTOMY

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Wound Infection

Adhesive Intestinal

Intra-abdominal abscess

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Obstruction

Ileus

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Faecal Fistula

Respiratory complication like

Richter's Hernia

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pneumonia

DVT & Embolism

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Portal Pyaemia
APPENDICULAR LUMP

Appendix Edematous Caecum Terminal Ileum

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Loop of Intestine Omentum ( Greater Omentum)

Adjacent Peritoneum Ascending Colon

PRESENTATION OF APPENDICULAR LUMP

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Usually on 3rd day of attack of appendicitis.

Lump in Right iliac Fossa

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Guarding over the lump

Tenderness

Fever/ Increase pulse

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Appendicular Lump- Don't Operate (?)

Severe adhesion/ Difficult to separate the part

Bloody and dangerous to operate

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Risk of Faecal fistula

Risk of iatrogenic injury

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OCHSNER- SHERREN REGIMEN

Ist mark the size of the swel ing for further assessment

NPO & IV Fluid supplements

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Antibiotics, Analgesics

Temp, Pulse( 4 hourly) & Fluid record charting

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

If more vomiting- antiemetic &/+ PPI

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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.

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

CRITERIA FOR STOPPAGE OF CONSERVATIVE TREATMENT IN

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APPEDICULAR LUMP

Rising pulse rate

Rising temperature

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Increasing or spreading abdominal pain

Increasing size of mass

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Vomiting or copious gastric aspirate