Appendicitis and its complications asdpptx

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1. Appendicitis and its complications

2. Contents

3. Anatomy Located at the terminal end of the caecum. Size: 5 to 10 cm Diameter: 3-8 mm Mesoappendix: Extention of the mesentery containing appendicular artery, branch of ileocolic artery. Positions of appendix: Retrocaecal (74%) – most common Pelvic Paracaecal Preileal Subcaecal Post ileal (0.5%) – least common

4. Appendicitis Appendicitis is an inflammation of the appendix that develops most common in adolescents. It refers to the acute inflammation of the appendix, and is the most common cause for acute severe abdominal pain The abdomen is most tender at McBurny’s point – 1/3 rd of the distance from R ASIS to umbilicus, corresponds to the location of the appendix

5. Risk Factors Faecolith – most common cause Infection White races Lack of fibre rich diet Family history: 30% Obstuction Extremes of age Previous abdominal surgery

6. Causes Organism: E.Coli (85%) enterococci, (30%), streptococci, Anaerobic streptococci, Cl. welchii , bacteroides

7. Pathogenesis Acute inflammation of the mucus membrane with secondary infection without obstruction causes acute nonobstructive appendicitis. Luminal obstruction by faecolith , lymphoid hyperplasia, pinworm ( oxyuris vermicularis), other worms, foreign body, carcinoma/Crohn‘s disease

8. Types Acute nonobstructive appendicitis (catarrhal) (mucosal appendicitis) Acute obstructive appendicitis. Recurrent appendicitis. Subacute appendicitis. Stump appendicitis

9. Clinical Features Pain: earliest symptom. Visceral pain starts around the umbilicus -> right iliac fossa Vomiting: due to reflex pylorospasm . Murphy’s triad Pain Vomiting Febrile Constipation is the usual feature but diarrhoea can occur Fever, tachycardia. Urinary frequency: bladder irritation. Tenderness and rebound tenderness at McBurney’s point. Rovsing’s sign: On pressing left iliac fossa, pain occurs in right iliac fossa Baldwing’s test is positive in retrocaecal appendix.

10. Alvarado Score Several clinical and laboratory-based scoring systems have been devised to assist diagnosis. The most widely used is the Alvarado score. A score of 7 or more is strongly predictive of acute appendicitis. In patients with an equivocal score (5 or 6), abdominal ultrasonography or contrast-enhanced CT examination is recommended.

11. Differential Diagnosis for Acute Appendicitis Perforated duodenal ulcer. Acute cholecystitis Acute pancreatitis Right ureteric calculi Acute typhlitis Bacterial enterocloltis PID Testicular torsion

12. Investigations USG: Noncompressible appendix of size > 6 mm AP diameter, hyperechoic thickened appendix wall > 2 mm—target sign. Appendicolith. Interruption of submucosal continuity. Periappendicular fluid. CBC (WBC) to correlate clinically. CECT: usually in old people MRI: useful in pregnancy

13. Surgery Open appendectomy- Grid iron incision, Lans incision, Rutherford Morrison’s incision Appendix identified and the base of mesoappendix clamped, divided and ligated. Base of the appendix is ligated close to the base, and amputated between artery forceps and the ligature. Appendicualr vessels are then ligated.

14. Open appendectomy

15. Laparoscopic appendicectomy: Penumoperitoenum established using infra umbilical approach. Umbilical port + 2 working ports. The appendix is found using caecel taeniae. Appendix elevated and mesoappendix is displayed and is dissected. Appendicular vessels are ligated. Appendix is free at its base and is ligated. The specimen is removed through one of the operating ports.

16. Laparoscopic appendectomy

17. Complications

18. APPENDICULAR MASS It is the localisation of infection occurring 3 to 5 days after an attack of acute appendicitis. Inflamed appendix, greater omentum , oedematous caecum, parietal peritoneum and dilated ileum (ileus) forms a mass in the right iliac fossa. Investigations TC is increased. Ultrasound confirms the mass. Treatment - Ochsner- Sherren Regimen

19. Contraindications for Ochsner- Sherren regimen 1. When diagnosis is in doubt. 2. In acute appendicitis in children and elderly. 3. In burst, gangrenous appendicitis. 4. In patients in whom diffuse peritonitis sets in.

20. APPENDICULAR ABSCESS Suppuration in an acute appendicitis or suppuration in an already formed appendicular mass. commonly occurs in retrocaecal region Clinical features High fever, tender abdomen, smooth, dull (to percuss), soft swelling in right iliac fossa. Investigations: Ultrasound confirms the diagnosis. Treatment Antibiotics are started. CT-guided aspiration or catheter drainage is done often as initial Drainage of abscess.

21. Treatment Surgery: Open appendicectomy Laparoscopic appendicectomy

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