Acute appendicitis

An introduction to acute appendicitis

1. Acute Appendicitis Made easy

2. a Case A 13 years old boy developed sore throat with painful swallowing and low grade fever , the tonsils were diffusely red and enlarged but no white patches or exudations seen .. Few days passed when he complained from vague abdominal pain of gradual onset and loss of appetite and some bouts of vomiting , the pain then became more localized to the right lower part of abdomen . There was + ve F x .

3. 13 years boy

4. Time to take a guess What the sore throat has to do with abdominal pain ? What are the cases in which we can link the two conditions ? What's the differential diagnosis in such a case ? QUESTION 1

5. Going through the sea of DDX Mesenteric lymphadenitis Acute appendicitis Henoch S chonlein purpura lobar pneumonia Meckel's diverticulitis Intussusception Ureteric stone Enterocolitis Familial Mediterranean fever

6. Tonsillitis and abdominal pain Mesenteric lymphadenitis Acute appendicitis Henoch Schonlein purpura lobar pneumonia Meckel's diverticulitis Intussusception Ureteric stone Enterocolitis Familial Mediterranean fever

7. On Exam The patient is conscious , alert ,looks unwell , lying in pain , right hip flexed . PR: 100 bpm RR:22 cycle /min . BP:120/85 mmHg . Temp: 38.1 °C . On palpation , marked tenderness in RIF , Rebound tenderness , Rovsing's + ve . Bowel sounds + ve Normal skin appearance , Resonant chest ,Good air entery , vesicular .

8. Clinical exam blames the appendix WBC , CRP were high Imaging : ultrasound and CT Normal appendix

9. Inflamed appendix on U/S

10. Inflamed appendix

11. On CT

12. Whats the appendix anyway ?! it’s the under-developed distal cecum blind muscular tube 7 – 10 cm mucosa , submucosa , muscle serosa appendicular artery (branch from ileocolic artery) , in meso -appendix many lymphoid follicles

13. ANATOMY

14. Anatomy

15. Ancient Egyptians called it : worm of intestine looks like a worm no specific site for it

16. Sites

17. How to find it ? Which of the following techniques could you use to precisely locate the appendix ? locate a region devoid of haustra trace the right colic artery trace the ileocolic artery trace the tenia coli on the cecum examine the pelvic cavity QUESTION 2

18. Leonardo da Vinci T he first drawing of an appendix a valve for the cecum H e was wrong ! it’s a vestigial structure

19. Acute appendicitis ( the angry worm) The most common cause of acute abdomen in young adults relatively rare in infants common in children and young adults Peak incidence around 20 years then declines WHY IS THAT ?!

20. Incidence of appendicitis according to the age

21. Causes Obstruction by fecolith , Stricture, foreign body Dietary factors ( low fibers , high refined CHO) Bacterial proliferation (aerobes & anaerobes) Obstruction by tumor ( CA cecum ) Infective trigger and seasonal variation ?!

22. Pathological types catarrhal appendicitis obstructed appendicitis perforated appendicitis gangrenous appendicitis malignant appendicitis

23. The classical history

24. The classical history Anorexia Nausea

25. Further notes on history family history is imp. 1/3 of children have first degree relative with similar history what happens when a pelvic appendix gets inflamed ? Suprapubic pain , tenesmus . highly located appendix may give right upper quadrant pain left located appendix may give left iliac fossa pain

26. Differential diagnosis in children Gastroenteritis Mesenteric lymphadenitis Meckels diverticulitis Intussusception Henoch Schonlein purpura Lobar pneumonia

27. Differential diagnosis in adult male Regional enteritis Ureteric colic Perforated peptic ulcer Testicular torsion Pancreatitis Rectus sheath hematoma

28. Differential diagnosis in adult female Mittelschmerz ( midcycle ovarian cyst rupture) PID Pyelonephritis Ectopic pregnancy Torsion / hemorrage of ovarian cyst Endometriosis

29. Differential diagnosis in elderly Diverticulitis Intestinal obstruction Colonic Ca Torsion of appendix epiplocae Mesenteric infarction

30. Signs pyrexia ( low grade , usually less than 38.5 °C ) localized tenderness muscle guarding rebound tenderness

31. “Localized tenderness” “ I believe that in every case , the seat of every pain – determined by the pressure of one finger - has been very exactly between an inch and a half and two inches from the anterior spinous process of ileum on a straight line drawn from that process to the umbilicus “ Sir Charles McBurney (1854 – 1913 )

32. Signs to elicit pointing sign Rovsings sign psoas sign obturator sign

33. Rovsings sign

34. Psoas sign

35. Obturator sign

36. Alvarado score (MANTRELS) M igratory pain 1 A norexia 1 N ausea and vomiting 1 T enderness (RIF) 2 R ebound tenderness 1 E levated temperature 1 L eukocytosis 2 S hift to left 1

37. MANTRELS 7 POINTS or more is strongly predictive of acute appendicitis Between 5 and 6 are equivocal , we need U/S or CT to confirm .

38. We had our green light Treatment Is surgical appendectomy but we have to prepare : Full blood count . U/S . CT . ….. Urinalysis IV fluids antibiotics (3 rd cephalosporin or gentamicin and metronidazole flagyn  )

39. Don’t operate in : Patient having peritonitis Presence of an appendicular mass Case the attack is resolved , nothing is emergent , one can treat by elective surgery later

40. Options Open / traditional surgery Laparoscopic Natural orifice surgery (no incision appendectomy )

41. Open / traditional if incision is perpendicular to the line : Grid iron incision Why called grid iron ? if better access is needed , one can change gridiron to Rutherford Morrison's incision Lanz incision (transverse skin crease incision , 2cm below umbilicus at mid-clavicular line)

42. Gridiron vs. Lanz

43. layers

44. Almost done

45. Then put drain if you find dirty iliac fossa , otherwise : suture .

46. Laparoscopic access

47. Natural orifice surgery No incision appendectomy Using the natural orifices like anal canal endoscopically or trans-vaginally . Less pain No scar Less hospital stay Fewer complications It takes about 50 minutes

48. Post appendectomy complications wound infection (commonest one) intra-abdominal abscess ileus Fecal fistula DVT Adhesive intestinal obstruction Hernia (?)

49. So , checklist Examine the wound and abdomen for abscess Consider pelvic abscess / DRE Examine the lungs for collapse Examine the legs /DVT

50. Appendicular mass conservative . OCHSNER- SHERREN regimen . record pt condition . exam and re-exam . give antibiotic . mark the skin for improvement . resolution in 48 hours .

51. Criteria for stopping conservative treatment in appendicular mass Rising pulse rate Increasing or spreading abdominal pain Increasing size of the mass

52. Summary the worm took a long way from the mummification to the natural orifice surgery its malnourished distal cecum appendicular artery is an end artery It could be in diverse locations the classical history ( or NOT ! ) signs are just helpful ultrasound Alvarado score

53. THANK YOU FOR YOUR KIND PATIENCE