APPENDICITIS clinical sign symptoms and Management.ppt

Appendicitis and it's management

1. Appendicitis

2. Introduction
1889 Mac Burney described location,
the clinical features of appendicitis
and the importance of operative
intervention and muscle-splitting
incision.

3. Surgical Anatomy
Surface anatomy
Development: It is develop from
midgut and appears as diverticulum of
ceacum appearing in the 8
th
week of
life
Positions: constant base enters in to
caecum at below and behind the ileo
caecal junction,tip positions are varies
(retroceacal, pelvic, subcaecal,
preileal, pericolic)

4. Arterial supply –appendix is supplied
by appendicular artery (branch of ileo
colic artery ) lies in meso appendix.

7. ACUTE APPENDICITIS
Inflammation of appendix
Incidence 0.1-0.2%
Appendectomy for appendicitis is the
most common performed emergency
operation in the world.
Disease of young with 40 % of cases
being between 10-30 Yrs of age group.

8. ETIOLOGY &
PATHOGENESIS
OBSTRUCTIVE CAUSES
◦Obstruction of lumen caused by
Fecolith
Lymphoid tissue hypertrophy
Tumors
Parasites ( pinworms)
NON OBSTRCTIVE CAUSES
◦Haematogeneous spread of infection
◦Vascular occlusion
◦Trauma
◦Diet lack of fibers

9. EITIOLOGY AND PATHOGENESIS
Due to etiological factors => Obstruction
of lumen of appendix => Increased
intraluminal pressure => ischemic injury
Bacterial Proliferation ( tissues infected
by bacteria in digestive tract)=>
mucosal oedema => decresed blood
flow in appendix => ischemia =>
rupture of appendix => peritonitis (
Localised / Generalised)

10. Fecalith

11. BACTERIOLOGY
Bacteria cultured in cases of
appendicitis are similar to those seen in
other colonic infection.
The principal organisms seen are E.
coli and Bacteroid fragilis.

12. Histology
Histological terms used:
Catarrhal appendicitis
Inflamed
Suppurative
Necrotic
Gangrenous
Perforated
Appendicularmass

13. CLINICAL FEATURES
SYMPTOMS:
Pain-severe colicky pain initially felt at
periumbilical region and right iliac
fossa region
Vomiting
Anorexia
Fever
Diarrhoea/Constipation

14. SIGNS
PSOA’s Sign
OBTURATOR’S sign
ROVSING’S sign
Bloomberg’s sign( Rebound
Tenderness)
Mc burney’s sign

19. Gaurding and rigidity in right iliac
fossa.
Per rectal examinations
◦Tenderness in right side of rectal wall

20. STAGES OF APPENDICITIS
Early stage–in early stage due to
obstruction of appendicular lumen =>
mucosal oedema , bacterial
overgrowth, inflammation of
apendicular wall, distension of
appendix due to fluid accumulation
and increasing intralumial pressure.

21. Suppurative appendicitis
◦Increasing intraluminal pressure
eventually exceed capillary perfusion
pressure
◦Leads to transmural spread of bacteria =>
suppurative appendicitis
Gangreneous appendicitis
◦Intramural venous and arterial thrombosis
leads to gangreneous appendicitis

22. Perforation of appendix/
appendicular Lump
◦Suppurative /gangreneous appendicitis
ruptures => localised peritonitis =>
omentum is get adhered to limit the
spread of peritonitis and phlegmon /Lump
formation occur.

23. DIAGNOSTIC MEASURES
History and clinical examinations
WBC count –elevated
C reactive protein –Elevated
Complete blood count
Urinalysis
Ultrasound abdomen
CT Scan abdomen

24. ALVARADO SCALE
9-10: almost certain appendicitis requiring surgery .
7-8: high likelihood of appendicitis, imaging study to
confirm diagnosis.
5-6: possible diagnosis of acute appendicitis.
0-4: unlikely to be acute appendicitis.

25. Differential Diagnosis
In male
◦Right ureteric colic
◦Right acute pyelonephritis
◦Testicular torsion
◦Perforated peptic ulcer
◦Acute pancreatitis
In female
◦Salpingitis
◦Ovarion torsion
◦Ectopic pregnancy

26. MANAGEMENT
Medical management
Surgical management

27. MEDICAL MANAGEMENT
Goal-
◦to treat infection
◦To prevent further complications
◦Medical management –antibiotics , anti
inflammatory drugs , analgesics and fluid
therapy
◦Conservative management for
appendicular lump –according to Ochsner
sherren regime.

28. Ochsner–SherrenRegime
Medical Management for appendicular
Lump (Mass)
Nil by mouth
Ryle’s tube aspiration
Antibiotics
Recording of size of mass daily
Recording of TPR chart 4 hourly
Input & output chart

29. Management of appendicular
mass
Interval appendisectomy if mass
resolves after 6-8 weeks
Early laparotomy if appendicular
abscess develops.
Or
Percutaneous US or CT guided
catheter drainage of abscess followed
by elective appendisectomy after 8-12
weeks.

30. SURGICAL MANAGEMENT
Open appendectomy
McBurney (oblique) (Muscle spilting );
Rutherford morison (Muscle Cutting );
Rocky Davis (transverse) (Lanz);
right paramedian;
midline incision
Laparoscopic appendisectomy

31. Open appendectomy

32. Open Appendectomy:

42. Operation field

43. acute appendicitis

44. 2.Laparoscopy:

45. Laparoscopy

46. Laparoscopic Appendectomy

47. Appendix
Site :
Retroperitonum
Subhepatic
Pelvic
Gross Pathology
The presence of parasites in the
appendix
Fixed cecum

48. Appendix.
Gross Pathology
Perforated
Very long
Short
Appendicular Mass
Chronic Appendicitis
Appendicular abscess
Tumors of The Appendix

49. Perforated appendicitis

50. Very long appendicitis

51. Appendicularabscess

52. Tumors of The Appendix
Carcinoid
Adenocarcinoma
Lymphoma.
Mucocele
Pseudomyxoma Peritonei

53. Carcinoid

54. Complications of Appendicitis
Perforation
Postoperative wound infection
Intra abdominal and pelvic abscess
Enterocutaneous fistula
Small bowel obstruction

55. summary
Acute appendicitis is the common
cause of acute abdomen.
Open, Laparoscopic Appendectomy is
the treatment of choice.

56. THANK YOU