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1. appendicitis Dr.Abd-Allatif Khader

2. Anatomy

3. Anatomy Mesoappendix is the mesentery that suspends the appendix rom the terminal ileum. It contains the appendicular artery, the blood supply to the appendix. The appendix is composed of the same layers as the colon wall. ■ Mucosa, submucosa , inner circular muscle, outer longitudinal muscle, serosa. ■ The three distinct bands of outer longitudinal muscle, the taeniae coli, converge on the appendix. ■ Although many have claimed that the appendix is merely a vestigial organ, it is actually an immunological organ and secretes IgA. However, it is not an essential organ and can be removed without immunological compromise. ■ The length can range rom 2 to 20 cm but averages 6–9 cm. ■ Luminal capacity is < 1 mL

4. Case study A 25-year-old male presents to the emergency department with a 1-day history of periumbilical abdominal pain which has now shifted to the right lower quadrant. He describes the pain as constant and a 7/10. After the onset of pain, he subsequently developed nausea and has vomited twice. He has not eaten for 24 hours due to a lack of appetite. Physical examination is significant for a temperature of 38 °C, absent bowel sounds, and marked tenderness to palpation at 1/3 the distance from the anterior superior iliac spine to the umbilicus. When palpating in the left lower quadrant (LLQ), he reports pain in the right lower quadrant (RLQ). Active flexion of his right hip and internal rotation of the right leg reproduce the pain. His skin in the RLQ is hypersensitive to touch. There is no rebound tenderness. Laboratory values are significant for a white blood cell (WBC) count of 13.5 × 103/ μL (normal 4.1–10.9 × 103/ μL ), with 15% bands. The urinalysis demonstrates 1+ WBCs without bac .

5. Deferential Diagnosis

6. Acute appendicitis One of the most common acute surgical diseases. ■ Highest in early adulthood, at the peak of lymphoid tissue growth. ■ Second peak in the incidence of appendicitis occurs in the elderly. ■ There is a higher incidence of appendicitis in males than females (1.3:1

7. Pathophysiology The probable sequence of events in acute appendicitis is: 1. Luminal obstruction . ■ In young patients, more commonly by lymphoid tissue hyperplasia. ■ In older patients, fecalith is an increasingly common cause of obstruction. 2. Distention and increased intraluminal pressure . ■ The appendiceal mucosa continues to secrete normally despite being obstructed. ■ The resident bacteria multiply rapidly, further increasing intraluminal pressure. 3. Venous congestion. ■ The intraluminal pressure eventually exceeds capillary and venues pressures. ■ Arteriolar blood continues to flow in, causing vascular congestion and engorgement . 4. Impaired blood supply renders the mucosa ischemic and susceptible to bacterial invasion. 5. Inflammation and ischemia progress to involve the serosal sur f ace of the appendix

8. What Is the Most Likely Diagnosis ? Given the history of initial periumbilical pain that is now localized to the RLQ and subsequently followed by nausea/ emesis and leukocytosis with increased bands, the most likely diagnosis is acute appendicitis. The initial dull, diffuse (visceral) pain that occurs at the onset of acute appendicitis is a result of the stimulation of visceral afferent stretch fibers . These nerve endings fire as a result of the sudden-onset distention, and the pain is commonly felt around the umbilicus (T10 distribution).

9. What Are Rovsing’s , Psoas, and Obturator Signs and McBurney’s Point Tenderness ? Appendicitis creates an inflammatory response in the adjacent retroperitoneum and parietal peritoneum. These are signs (. Table 23.4) of localized peritonitis in the RLQ due to inflammation . Rovsing's sign is right lower quadrant pain with palpation of the left lower quadrant. Compression in the LLQ stretches the abdominal wall triggering pain in the inflamed underlying RLQ parietal peritoneum. Appendicitis can also inflame the adjacent psoas or obturator muscles. Psoas sign is RLQ pain on passive extension of the right hip or active flexion of the right hip. Obturator sign is RLQ pain anterior superior iliac spine to the umbilicus and marks the incision site for open appendectomies. McBurney’s sign is maximal tenderness at McBurney’s point.

10. History and physical exam What Is Usually the First Symptom of Appendicitis and What Is the Classic Sequence of Symptoms? In >95% of cases of acute appendicitis, anorexia is the first symptom. The classic sequence of symptoms is anorexia, vague periumbilical abdominal pain, nausea, vomiting, and then a shift to localized RLQ pain. What Is the Significance of Absent Bowel Sounds? Absent bowel sounds indicate a paralytic ileus which is seen in association with inflamed/infected bowel (such as acute appendicitis). It would be less likely found with gastroenteritis. What Is a Hamburger Sign? The majority of patients with acute appendicitis will have anorexia. If the patient is hungry, acute appendicitis is less likely. Inquire about the patient’s favorite food (e.g., hamburger , pizza), and ask if the patient would like to eat it. Patients with true anorexia will decline their favorite food (positive hamburger sign). Children may not follow this sign.

11. History and physical exam

12. Can Appendicitis Present with No Abdominal Pain? Yes. In some cases, a retrocecal appendicitis may not cause any abdominal pain. If the appendix is completely separated from the anterior abdominal peritoneum, then the patient will not develop any localizing symptoms. However, irritation of adjacent structures can cause diarrhea, urinary frequency, CVA tenderness, pyuria , and microscopic hematuria, which may be the only clues. Why Is Hyperesthesia of the Skin a Sign of Acute Appendicitis? Parietal peritoneum is supplied by spinal nerves. With irritation of the parietal peritoneum, the area of skin supplied by the spinal nerves on the right at T10–12 can become very sensitive to touch, a phenomenon known as cutaneous hyperesthesia..

13. Investigations What Are the Critical Laboratory Values Utilized in the Workup of Acute Appendicitis? The most important is leukocytosis with a left shift. More recently, elevated C-reactive protein (CRP), a marker for inflammation, has been shown to be useful in the diagnosis of acute appendicitis. All women of childbearing age presenting with abdominal pain should receive a beta- hCG pregnancy test to rule out an ectopic pregnancy. What Further Imaging Is Needed? Given the classic presentation in an adult male, no further imaging is needed .

14. When Would Imaging Be Indicated? How Should the Use of Imaging Studies Differ Between Adults and Kids? Men and Women? In cases where the diagnosis is equivocal, ultrasonography or CT scan can be helpful. Ultrasound can identify a thickwalled , noncompressible tubular structure (dilated appendix) in the right lower quadrant. Peritoneal fluid and/or an abscess can sometimes be seen in advanced cases. Ultrasonography is particularly useful in women and children. In women, ultrasound is used to rule out gynecologic pathology such as ovarian torsion, tubo -ovarian abscess, or an ectopic pregnancy. Ultrasonography is used in children and pregnant women (MRI is another option in pregnancy), as the child and the fetus are more vulnerable to the effects of radiation. Also, because children have less periappendiceal fat, the appendix is not as readily visualized on CT scan. Thus, CT scan is utilized in adult men and nonpregnant women when the diagnosis is unclear. CT findings consistent with acute appendicitis include periappendiceal fat stranding and an enlarged appendiceal diameter >6 m

15. What Are the Radiographic Signs of Appendicitis? Plain abdominal X-ray is generally not helpful in the diagnosis of acute appendicitis as there are no consistent and reliable findings. However, on occasion, a calcified fecalith will be seen in the RLQ, which is highly suggestive of appendicitis .

16. Management What Is the Definitive Treatment for Appendicitis? Surgical removal of the appendix (appendectomy) with either a laparoscopic or open approach

17. Is Laparoscopic or Open Appendectomy the Superior Approach? Both laparoscopic and open appendectomy approaches are effective treatments for acute appendicitis. Studies have shown that laparoscopic appendectomy results in slightly , decreased postoperative pain, shorter length of stay, decreased wound infection rate, and a faster return to normal activity. However, the duration of surgery is longer, and costs are higher with laparoscopy. Interestingly, the rate of postoperative intra-abdominal abscess may be higher with laparoscopic appendectomy. The decision over which approach to use is based on surgeon preference, patient characteristics, and patient preference. Presently, laparoscopic appendectomy is the preferred approach at most institutions.

18. What Is the Role of Pre- and Postoperative Antibiotics for Acute Non-perforated Appendicitis? For Perforated Appendicitis? A single dose of preoperative antibiotics has been shown to reduce infectious complications and should be given to patients with both acute non-perforated and perforated appendicitis. In simple non-perforated appendicitis, antibiotics should not exceed 24 hours postoperatively. For perforated or gangrenous appendicitis, the duration of IV antibiotics is controversial, most recommend continuation until the patient’s fever and leukocytosis have resolved which typically takes 3–5 days