APPENDICITIS presentation for preop.pptx

appendicitis

1. APPENDIX JOON CHESTER GUINA 1 ST YEAR RESIDENT

2. EMBRYOLOGY Develops from the midgut Visible at 8th weeks True diverticulum of the cecum Tip: Retrocecal – 64% Pelvic 32% Subcecal 2% Preileal 1% Postileal 0.5%

3. ANATOMY AND FUNCTION Length: 6-9 cm outer diameter: 3 - 8 mm luminal diameter: between 1 - 3 mm Landmark: convergence of 3 taenia coli A ppendicular branch of the ileocolic artery S uperior mesenteric plexus (T10-L1) and the vagus nerve Function: Immunologic: secretion of IgA Integral component of GALT

4. INCIDENCE

5. ETIOLOGY LUMINAL OBSTRUCTION Pediatric Lymphoid hyperplasia Adult Fecaliths Fibrosis Foreign bodies (food, parasites, calculi) Neoplasia

6. PATHOGENESIS

7. BACTERIOLOGY

8. Operational Definitions Uncomplicated Appendicitis Includes acutely inflamed, phlegmonous , suppurative, or mildly inflamed appendix with or without peritonitis Complicated Appendicitis Include gangrenous, perforated, localized purulent collection at operation, generalized peritonitis and periappendiceal abscess Equivocal Appendicitis Patient with RLQ abdominal pain who presents with atypical history and physical examination The surgeon cannot decide to discharge or operate on the patient Schwartz 11 th ed: Complicated appendicitis Perforated and gangrenous appendicitis and appendicitis with abscess or phlegmon formation

9. When should one suspect Appendicitis? Consider the diagnosis when a patient presents with RLQ abdominal pain

10. What clinical findings are most helpful in diagnosing acute appendicitis? Any patient especially male who presents with a high intensity of abdominal pain of at least 7-12 hours duration , with migration to the right lower quadrant and followed by vomiting . The diagnosis of acute appendicitis becomes more certain when the physical examination findings include right lower quadrant tenderness , guarding , rebound tenderness and other signs of peritoneal irritation .

11. HISTORY CLINICAL DIAGNOSIS

12. 1-4 – 30% 5-7 – 66% 8-10 – 93%

13. SIGNS Vital Signs: Fever Prefer to lie supine due to the peritoneal irritation Direct and rebound tenderness at McBurney’s point Rovsing’s sign Cutaneous Hyperesthesia : T10, T11, T12 Voluntary and involuntary muscle guarding Retrocecal: flank pain Pelvis: rectal exam, suprapubic pain Psoas sign – pain with the extension of the right leg indicates irritation in the proximity of the right psoas muscle. Obturator sign – stretching of the obturator internus by internal rotation of a flexed thigh

14. What diagnostic tests are helpful in the diagnosis of acute appendicitis? Primarily based on clinical findings White blood cell with differential count CT Scan Ultrasound (graded compression) Diagnostic Laparoscopy Statistically significant favorable effects Should be viewed as invasive procedure requiring anesthesia and having risk similar to appendectomy

15. LABORATORY FINDINGS Leukocytosis: WBC 10,000/mm3 - uncomplicated appendix WBC 1 7 ,000 /mm3 – gangrenous and perforated appendix CRP, bilirubin, Il6, Procalcitonin – helpful in predicting perforated appendicitis Pregnancy test – essential for in women of child of childbearing age Urinalysis: rule out nephrolithiasis and pyelonephritis

16. IMAGING Diagnosis of appendicitis is unclear , high risk from operative intervention and general anesthesia ( pregnant or patients with multiple comorbidities )

17. CT SCAN Adults (Equivocal) Sensitivity 97% Specificity 100% Preferred over ultrasonography because of its superior accuracy Enlarged lumen and double wall thickness >6mm Thickened wall >2mm Periappendiceal fat stranding Appendiceal wall thickening Appendicolith

18. Pediatrics Comparable accuracy with CT Scan S ensitivity 55-96 %; Specificity 85-98% Preferred due to lack of radiation, cost-effectiveness and availability U ser-dependent , has limited utility in obese patients and painful for patients with peritonitis anteroposterior diameter of the appendix An easily compressible appendix <5 mm in diameter generally rules out appendicitis a diameter of >6 mm , pain with compression, presence of an appendicolith , increased echogenicity of the fat, and periappendiceal fluid Ultrasound (graded compression)

19. DIFFERENTIAL DIAGNOSIS Acute Mesenteric Adenitis Cecal Diverticulitis Meckel’s Diverticulitis Acute Ileitis Crohn’s Disease Acute Pelvic Inflammatory Disease Torsion of Ovarian Cyst or Graafian follicle Acute Gastroenteritis Mittelschmerz

20. PREOPERATIVE INTERVENTION Fluid resuscitation Placement of IFC is optional but not necessary Antibiotic prophylaxis at least 30 to 60 minutes prior to skin incision Effective in prevention of surgical site infection and should be considered in routine use Antipyretic medication and external cooling

21. What antibiotics is/are recommended for prophylaxis in uncomplicated appendicitis? Cefoxitin 2g IV single dose (Adults) Cefoxitin 40mg/kg IV single dose (Children) Alternatives: Ampicillin-Sulbactam 1.5-3g IV single dose (Adults); 75mg/kg IV single dose (Children) Amoxicillin-Clavulanate 1.2-2.4g IV single dose (Adults); 45mg/kg IV single dose (Children) Allergies to beta lactam antibiotics: Gentamicin 80-120mg IV single dose plus Clindamycin 600mg IV single dose (Adults) Gentamicin 2.5mg/kg IV single dose plus Clindamycin 7.5-10 mg/kg IV single dose (Children)

22. What antibiotics is/are recommended for prophylaxis in complicated appendicitis? Adults Ertapenem 1g IV q24 hours (Adults) Tazobactam-Piperacillin 3.375g IV q6 or 4.5g IV q8 hours Children Ticarcillin-Clavulanic Acid 75mg/kg IV q6 hours Alternative: Imipenem- Cilastin 15-25mg/kg IV q6 hours Allergies to beta lactam antibiotics: Ciprofloxacin 400mg IV q12 hours plus Metronidazole 500mg IV q6 hours (Adults) Gentamicin 5mg/kg IV q24 hours plus Clindamycin 7.5-10mg/kg IV q6 hours ( Children)

23. What is the recommended approach to the surgical management of acute appendicitis? Open appendectomy is the recommended primary approach to the treatment of acute appendicitis in our setting. Timing of surgery Emergent surgery Urgent surgery (waiting <12 hours) – no significant difference; slightly longer hospital stay; acceptable in non perforated nongangrenous appendicitis

24. LAPAROSCOPIC APPENDECTOMY Provides direct observation of appendix Allows evaluation of all intraabdominal organs (esp. female pelvis) Preferably obese (longer open incision, manipulation and the resultant increase in surgical site infections) Female, reproductive years (tubal and ovarian pathology) Safe as open appendectomy in the first trimester of pregnancy Always risk to the fetus with any anesthesia or operation Less incisional pain after surgery, faster return to normal function or work, better cosmetic result

25. Perforated Appendicitis O peratively or nonoperatively Septic i mmediate surgery is necessary Associated with higher complications ( abscesses and enterocutaneous fistulae due to dense adhesions and inflammation) Long standing perforation Fluid resuscitation and treatment with IV antibiotics better treated with adequate percutaneous image-guided drainage (79% successful)

26. Perforated Appendicitis Operative intervention failed conservative management and in patients with free intraperitoneal perforation Interval Appendectomy 6-8 weeks 80% have resolution of their symptoms with drainage and antibiotics 7.4%-8.8% - R ecurrent appendicitis and the presence of appendiceal neoplasms (benign 0.7%, malignant 1.3%) high incidence of no future events after a median follow-up of 34 months in 91% of patients

27. How should localized peritonitis be managed? No necrotic tissue or purulent material should be left behind as much as possible General peritoneal lavage IS NOT RECOMMENDED for localized peritonitis Placement of surgical drains has not been proven to be beneficial in multiple clinical trials for either complicated or uncomplicated appendicitis

28. What is the optimal timing of surgery for patients with periappendiceal abscess? Should undergo surgery as soon as the diagnosis is made Patients undergoing non operative management have a lower risk of complications but are at risk of recurrent appendicitis Early Appendectomy Eliminate need for interval appendectomy with its associated risks decrease the total hospital stays and complications associated with conservative treatment avoid the high complication rate that results from a failure of the initial non operative approach

29. What is the appropriate method of wound closure in patients with complicated appendicitis? The incision may be closed primarily in patients with complicated appendicitis No difference in surgical site infection rates between primary and delayed primary closure

30. Should GS/CS be routinely done in acute appendicitis? GS/CS testing of intraoperative specimens (purulent peritoneal fluid or tissue) SHOULD NOT be routinely performed Except in High risk and immunocompromised patients

31. POSTOPERATIVE INTERVENTION Fluid balance maintained (Ringer’s Lactate) Sit up for eating on the day of operation Ambulate on post op Day 1 Adequate pain control Sips of water may be given as soon as nausea subsides Diet progression as tolerated Follow up after 1 week Persistent signs of sepsis (wound infection, pelvic/subphrenic abscess) Prolonged sepsis (CT Scan 7 days post operatively may reveal the causative site)

32. POSTOPERATIVE INTERVENTION Uncomplicated Appendicitis Postoperative antibiotics are usually not necessary Complicated Appendicitis Generally <4 days (STOP-IT TRIAL) Depends on the Clinician’s assessment after operation (5-7 days) The absence of fever for 24 hours (<38 o C) , the ability to tolerate oral intake and a normal WBC count with 3% or less bands forms are useful parameters for discontinuation of antibiotic therapy Gangrenous Appendicitis Treat as uncomplicated appendicitis

33. Carcinoid Adenocarcinoma Mucocele Pseudomyxoma Peritonei Lymphoma Firm, yellow, bulbar mass most common site of GI carcinoid majority are located in the tip Malignant potential = Size Rare 3 major histologic subtypes: mucinous adenocarcinoma colonic adenocarcinoma Adenocarcinoid significant risk for synchronous and metachronous neoplasms CM: Acute appendicitis, Ascites or a Palpable mass Caused by one of four processes: retention cysts, mucosal hyperplasia, cystadenomas, cystadenocarcinomas often it is an incidental finding at operation Rare M < F Appendix - site of origin for the majority of cases of pseudomyxoma CT scan – preferred imaging modality Extremely Uncommon 1% to 3% of gastrointestinal lymphomas CT findings: appendiceal diameter ≥2.5 cm / surrounding soft tissue thickening Tx: ≤1 cm = appendectomy >1 to 2 cm located at the base, involving the mesentery / lymph node metastases = Right hemicolectomy Tx: Right hemicolectomy 5 yr survival rate: 55% (varies stage and grade*) Tx: Appendectomy + Wide resection of the mesoappendix + all the appendiceal lymph nodes + collection and cytologic examination of all intraperitoneal mucus (+) margin at the base of the appendix or positive periappendiceal lymph nodes = Right hemicolectomy / ileocecectomy Tx: Dubulking – mainstay treatment All gross disease and the omentum is removed Appendectomy routinely performed Hysterectomy with bilateral salpingo-oophorectomy Tx: Appendectomy - confined to the appendix Right hemicolectomy – extends beyond appendix NEOPLASMS OF THE APPENDIX

34. REFERENCES Lawenko , M.M., Sta Clara, E.L. (2023). Laparoscopic Appendectomy. In: Lomanto , D., Chen, W.TL., Fuentes, M.B. (eds) Mastering Endo-Laparoscopic and Thoracoscopic Surgery. Springer, Singapore. https://doi.org/10.1007/978-981-19-3755-2_17