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1. Appendix Malvina Asbah Aseel Sartawi Dr.Abdellatif Khader

2. Anatomy

3. Anatomy and emberyology The appendix is a midgut organ and is first identified at 8 weeks of gestation as a small outpouching of the cecum. As gestation progresses, the appendix becomes more elongated and tubular as the cecum rotates medially and becomes fixed in the right lower quadrant of the abdomen. The appendiceal mucosa is of the colonic type, with columnar epithelium, neuroendocrine cells, and mucin-producing goblet cells lining its tubular structure. Lymphoid tissue is found in the submucosa of the appendix – immune function As a midgut organ, the blood supply of the appendix is derived from the superior mesenteric artery. The ileocolic artery, one of the major named branches of the superior mesenteric artery, gives rise to the appendiceal artery, which courses through the meso- appendix . The mesoappendix also contains lymphatics of the appendix, which drain to the ileocecal nodes, along with the blood supply from the superior mesenteric artery.

4. The appendix is of variable size (5–35 cm in length) but averages 8 to 9 cm in length in adults. Its base can be reliably identified by defining the area of convergence of the taeniae at the tip of the cecum and then elevating the appendiceal base to define the course and position of the tip of the appendix, which is variable in location. The appendiceal tip may be found in a variety of locations, with the most common being retrocecal (but intraperitoneal) in approximately 60% of individuals, pelvic in 30%, and retroperitoneal in 7% to 10%. For example, patients with a retroperitoneal appendix may present with back or flank pain, just as patients with the appendiceal tip in the midline pelvis may present with suprapubic pain.

5. Case presentation 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. There is 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 neutrophil shift of 92%.

6. Acute appendicitis One of the most common acute surgical diseases. Highest in early adulthood 20-30, 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.

8. 4. Impaired blood supply renders the mucosa ischemic and susceptible to bacterial invasion. 5. Inflammation and ischemia progress to involve the serosal surface of the appendix.

9. Signs and symptoms 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). Within 6 -10 hours the pain shifts to right iliac fossa: - Due to irritation of parietal peritoneum. - Becomes sharper (Somatic pain). - Aggravated by movement or cough.

10. AIR scoring S ystem

11. AIR score interpretation 0-4 low – outpatient follow up 5-8 intermediate – observation with serial exam , imaging , diagnostic lap according to local pratice 9-12 high – surgical exploration

12. Investigations Labs 1- CBC: WBC moderate leukocytosis usually between 10,000-16,000. Normal leucocyte count does not exclude appendicitis. Neutrophil count – shift 2- CRP 3- urine analysis: UTI, renal stones. 4- pregnancy test for all female child bearing age

13. Radiology: Ultrasonography May diagnose appendicitis (dilated lumen, thick walled appendix), fat stranding , free fluid, abscess collection sensitivity 75%, specificity 95% Exclude other diseases (Ureteric stones, Gynecological problems, etc.) CT scan Patients older than 40 years CT scan is the modality of choice. Ct scan should be done to rule out malignancy.

14. Complications

15. Treatment either open or laparoscopic approach

16. Complicated appendix 1. Appendicular mass – conservative, follow up labs and imaging. Colonoscopy later on to r/o malignancy. 2. Appendicular Abscess drainage besides if appendectomy was possible or not. 3- Peritonitis – need surgical exploration and drains need to be applied

17. 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

18. Appendiceal tumors 1- Carcinoids: The appendix is the most common site of gastrointestinal carcinoid, followed by the small bowel and rectum. Carcinoid syndrome is rarely associated with appendiceal carcinoid unless widespread metastases are present, which occur in 2.9% of cases. The majority of carcinoids are located in the tip of the appendix. Malignant potential is related to size, with tumors < 1 cm rarely resulting in extension outside of the appendix or adjacent to the mass. The mean tumor size for carcinoids is 2.5 cm. Carcinoid tumors usually present with localized disease (64%). Treatment for tumors ≤1 cm is appendectomy. For tumors larger than 1 to 2 cm located at the base, involving the mesentery, or with lymph node metastases, right hemicolectomy is indicated.

19. 2. Adenocarcinoma Primary adenocarcinoma of the appendix is a rare neoplasm with three major histologic subtypes: mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid . The most common mode of presentation for appendiceal carcinoma is that of acute appendicitis. Patients also may present with ascites or a palpable mass, or the neoplasm may be discovered during an operative procedure for an unrelated cause. The recommended treatment for all patients with adenocarcinoma of the appendix is a formal right hemicolectomy. Patients with appendiceal adenocarcinoma are at significant risk for both synchronous and metachronous neoplasms, approximately half of which will originate from the gastrointestinal tract.

20. 3. Mucocele A mucocele of the appendix is an obstructive dilatation by intraluminal accumulation of mucoid material. The presence of a mucocele of the appendix does not mandate performance of a right hemicolectomy. The principles of surgery include resection of the appendix, wide resec-tion of the mesoappendix to include all the appendiceal lymph nodes, collection and cytologic examination of all intraperitoneal mucus, and careful inspection of the base of the appendix. Right hemicolectomy or, preferably, ileocecectomy is reserved for patients with a positive margin at the base of the appendix or positive peri-appendiceal lymph nodes.

21. Take home message Acute appendicitis is a clinical diagnosis. It is the most common cause of acute abdomen and should always be in mind in our differential diagnosis. Leukocytosis and neutrophil shift is usually seen but normal WBC does not rule out appendicitis. In age above 40 years, CT scan should be done to r/o malignancy. Treatment is either open or laparoscopic appendectomy.

22. Thank you