Acute Appendictis diagnosis and management

Acute appendicitis

1. Acute Appendicitis Dr. Sarmendra Mishra Resident General surgery KISTMCTH

2. CONTENTS Introduction Embryology and anatomy History Pathophysiology Clinical diagnosis Laboratory and imaging studies Management References

3. INTRODUCTION It is the most common urgent or emergent general surgical operation performed in the United States and is responsible for as many as 3,00,000 hospitalizations annually I ncidence is 8.6% in men and 6.7% in women R are in infants Peaks in the second decade of life

4. Embryology and Anatomy Midgut organ and is first identified at 8 weeks of gestation as a small outpouching of the cecum A true diverticulum of the cecum as it contains all the histological layers of the colon

5. Embryology and Anatomy During childhood, continued growth of the caecum commonly rotates the appendix into a retrocaecal In approximately 25% of cases, rotation of the appendix does not occur, resulting in a pelvic, subcaecal or paracaecal position Bailey and love textbook of surgery, 27th edition

6. Embryology and Anatomy A verage length is between 7.5 and 10 cm The blood supply of the appendix is appendiceal artery, branch of ileocolic artery, branch of the superior mesenteric artery which courses through the mesoappendix Lymphatic drainage into ileocaecal lymph nodes Bailey and love textbook of surgery, 27th edition

7. History I n 1735, The first appendectomy was reported by a French surgeon, Claudius Amyand May 1880, The first surgeon to perform deliberate appendectomy for acute appendicitis was Lawson Tait In 1886, First formal description of the disease process, was by Reginald Heber Fitz of Harvard University. I n 1887, Thomas Morton was the first to diagnose appendicitis, Charles McBurney described the clinical manifestations of acute appendicitis including the point of maximum tenderness in the right iliac fossa

8. History In 1889 publication, Charles McBurney advocated for early appendectomy In 1894, classic muscle-splitting incision and technique for removal of the appendix In 1982, First laparoscopic appendectomy by Kurt Semm

9. Pathophysiology Appendicitis is caused by luminal obstruction I n pediatric populations, occurs as a result of lymphoid hyperplasia; I n adults, it may be due to fecaliths, fibrosis, foreign bodies (food, parasites, calculi), or neoplasia Intestinal parasites, particularly Oxyuris vermicularis (pinworm) Infections associated with appendicitis is polymicrobial Common isolates include Escherichia coli, Bacteroides fragilis , enterococci, Pseudomonas aeruginosa , Klebsiella Pneumoniae

10. Pathophysiology Risk factors for perforation of the appendix Extremes of age Immunosuppression Diabetes mellitus Faecolith obstruction Pelvic appendix Previous abdominal surgery

11. Clinical diagnosis (symptoms) Periumbilical colic Pain shifting to the right iliac fossa Anorexia Nausea

12. Symptoms The classic visceral–somatic sequence of pain is present in only about half of those patients subsequently proven to have acute appendicitis. Atypical pain is more common in the elderly Pelvis appendix causes suprapubic discomfort and tenesmus, may be elicited only on rectal examination During the first 6 hours, there is rarely any alteration in temperature or pulse rate. After that time, slight pyrexia (37.2–37.7ºC) with a corresponding increase in the pulse rate to 80 or 90 is usual. However, in 20% of patients there is no pyrexia or tachycardia in the early stages.

13. Signs of acute appendicitis Pyrexia Localised tenderness in the right iliac fossa Muscle guarding Rebound tenderness

14. Signs to elicit in appendicitis Rovsing sign: the presence of right lower quadrant pain on palpation of the left lower quadrant (normal position) O bturator sign: right lower quadrant pain on internal rotation of the hip (pelvic appendix) P soas sign: pain with extension of the ipsilateral hip Dunphy’s sign: pain with coughing (retrocecal appendix)

15. Special features, according to age Infant: rare, perforation Children: rare to find without vomiting, complete aversion to food Elderly: gangrene and perforation common Obese: diminishes all local signs Pregnancy: m/c extrauterine acute abdomen Frequency 1: 1500-2000 Diagnosis complicated by delayed presentation Fetal loss 3-5%, 20% if perforation at operation

16. Laboratory studies Routine Full blood count: leukocytosis with left shift is present in 90% of the cases higher leukocytosis associated with gangrenous and perforated appendicitis (∼17,000 cells/mm3) Urinalysis- to rule out nephrolithiasis Pregnancy test- mandatory in child bearing age Urea and electrolytes C-reactive protein

17. Imaging studies Imaging studies in patients suspected to have acute appendicitis can reduce the negative appendectomy rate, which can be as high as 15% Plain radiographs U ltrasound (US) C omputed tomography (CT) scanning M agnetic resonance imaging (MRI)

18. USG Ultrasonography has a sensitivity of 0.85 (95% CI 0.79–0.90) and a specificity of 0.90 (95% CI 0.83–0.95) 1 An easily compressible appendix <6 mm in diameter generally rules out appendicitis. Features on an ultrasound that suggest appendicitis include D iameter of greater than 6 mm P ain with compression, P resence of an appendicolith I ncreased echogenicity of the fat, P eriappendiceal fluid

19. CT-scan A contrast-enhanced CT scan has a sensitivity of 0.96 (95% confidence interval [CI] 0.95–0.97) and specificity of 0.96 (95% CI 0.93–0.97) Features on a CT scan that suggest appendicitis include Enlarged lumen and double wall thickness Wall thickening (greater than 2 mm) P eriappendiceal fat stranding A ppendiceal wall thickening and/or A n appendicolith

20. Sabiston’s textbook of surgery-21 st Edition

21. MRI MRI is typically reserved for use in the pregnant patient; the study is performed without contrast agents. Criteria for MRI diagnosis include A ppendiceal enlargement (>7 mm), T hickening (>2 mm), and T he presence of inflammation. S ensitivity of MRI to be 97% with a specificity of 95%

22. Migratory RIF pain 1 Anorexia 1 Nausea and vomiting 1 Tenderness (RIF) 2 Rebound tenderness 1 Elevated temperature 1 Leukocytosis 2 MODIFIED ALVARADO SCORE score of 7 or more: strongly predictive of acute appendicitis. (5–6): equivocal score

23. Modified Alvarado score The sensitivity and specificity of the Alvarado Score and the modified Alvarado Score have been reported to be 53–88% and 75–80% respectively Baidya N, Rodrigues G, Rao A, et al. Evaluation of Alvarado score in acute appendicitis: a prospective study.  Int J Surg.  2007 

24. Management of appendicitis Non-operative management Operative management

25. Non-operative management P atients with uncomplicated (absence of appendicolith, perforation or abscess) appendicitis. Bowel rest and intravenous antibiotics, often metronidazole and 3rd generation cephalosporin. The available data indicate initial successful outcomes in more than 90% of patients with CT confirmed appendicitis H owever, approximately one-quarter of patients initially treated conservatively will require surgery within 1 year for recurrent appendicitis

26. Operative management For open appendectomy, the patient is placed in the supine position. The choice of incision is a matter of the surgeon’s preference, whether it is an O blique muscle-splitting incision (McArthur-McBurney) T ransverse incision ( Rockey -Davis) or C onservative midline incision

27. Bailey and love textbook of surgery, 27th edition

28.   Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP ) database (2005-2008)

29. CONCLUSION T he investigators observed that laparoscopic appendectomy was associated with lower risk of wound complications and deep surgical site infection in uncomplicated appendicitis. In complicated appendicitis, laparoscopic appendectomy was associated with fewer wound complications but a slightly higher incidence of Intraabdominal abscess.

30. Management of appendix mass S tandard treatment is the conservative Ochsner – Sherren regimen Criteria for stopping conservative treatment of an appendix mass A rising pulse rate Increasing or spreading abdominal pain Increasing size of the mass Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn’s disease. Using this regime, approximately 90% of cases resolves.

31. Post operative complications Wound infection is the most common postoperative complication, occurring in 5–10% of all patients. I ntra-abdominal abscess: Approximately 8% of patients Ileus: A period of adynamic ileus is to be expected after appendicectomy , and this may last a number of days following removal of a gangrenous appendix. Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is indicative of continuing intra-abdominal sepsis and should prompt further investigation

32. REFERENCES Keyzer C, Zalcman M et al, Comparison of US and unenhanced multi-detector row CT in patients suspected of having acute appendicitis. Radiology. 2005 Aug;236(2):527-34. doi : 10.1148/radiol.2362040984. PMID : 16040910 . Bailey and love textbook of surgery, 27th edition Sabiston’s textbook of surgery-21 st Edition Schwartz textbook of surgery, 11th edition .

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