appendicitisinchildren-230410071737-e014af7f 2.pptx

This is for children

1. Acute appendicitis. Peritonitis in children STUDENT : ЕЛСАЙЕД МОХАМЕД ЯСЕР ГРУПП : 1903

2. APPENDICITIS IN CHILDREN

3. INTRODUCTION  Appendicitis : Inflammation of the appendix

4. Historical background  In 1886 DR.REGINALD FITZ coined the term appendicitis.  Morton is credited with performing the first deliberate appendectomy for a perforated appendix in the United States in 1887. In 1889 McBurney reported his treatment of appendicitis with appendectomy before rupture

5. Incidence  Most common acute surgical condition in children  Major cause of childhood morbidity  The lifetime risk 9% for male 7% for female  Peak incidence between age 11-18  Race – whites >black  Season – peak incidence in autumn and spring

6. Ana t omy  The appendix 1st becomes visible during the 8th week of gestation as a continuation of the inferior tip of the cecum.  The appendix rotates to its final position on the posteromedial aspect of the cecum, about 2 cm below the ileocecal valve, during late childhood.  The variability in this rotation leads to multiple possible final positions of the appendix.  The exact location varies widely

7. BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY

8. Retrocecal/retrocolic(64%) Subcaecal(32%) Pre-ileal(1%) Post-ileal(2%) Pelvic appendix

9.  The appendix averages 8 cm in length but can vary from 0.3 to 33 cm.  The diameter of the appendix ranges from 5 to 10 mm.   The mesoappendix arises from the lower surface of the mesentery or the terminal ileum.  Function is unknown. BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY

10. Its blood supply is the appendicular artery is a branch of the ileocolic artery , which passes behind the terminal ileum. It is an end artery

11. Et i ology  EXACT CAUSE – not completely understood  ASSOCIATED FACTORS:  Fecoliths  Decreased dietary fibre  Increased consumption of refined carbohydrates  Incompletely digested food particles  Lymphoid hyperplasia

12. INTRALUMINAL SCARRING blunt trauma •TUMORS OR MALIGNANCIES carcinoid tumors •MICROORGANISMS: a. BACTERIA – Yersinia Salmonella Shigella spp b.VIRUSES – Mumps CoxsackievirusB Adenovirus Infectious mononucleosis c. OTHERS - Ascaris lumbricoides

13. Pathophysiology

14. Clinical course  Simple  Acute appendicitis  Suppurative appendicitis  Complicated  Gangrenous appendicitis  Perforated appendicitis

15. Diagnosis:  Best made with careful history and physical examination  Laboratory investigations  Scoring systems

16. Clinical presentation  Children with appendicitis usually lie in bed with minimal movement.  Older children may limp or flex the trunk  Infants may flex ther right leg over the abdomen.

17. Classical features : Periumbillical colic Pain shifting to the right iliac fossa Anorexia Nausea Indigestion or subtle changes in bowel habits Diarrohea

18. Age dependent signs and symptoms

19. Atypical presentation

20. Physical examination  Presence of LOCALIZED ABDOMINAL TENDERNESS the SINGLE MOST reliable finding in the diagnosis of acute appendicitis

21. Mc B u r ney d escri b ed : “the seat of greatest pain . . . has been very exactly between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from the process to the umbilicus.” From then on, this location was known as the McBurney point

22. Physical sign:  Pyrexia  Localized tenderness in the right iliac fossa  Muscle guarding  Rebound tenderness Signs to elicit in appendicitis : Pointing sign Rovsing’s sign Psoas sign Obturator sign

23. ROVSING’S SIGN  Palpating in the left lower quadrant causes pain in the right lower quadrant

24. Obturator sign  Spasm of the obturator internus when the hip is flexed and internally rotated.  If inflamed appendix is in contact with the muscle, the maneuver causes pain in the hypogastrium

25. Psoas sign  Extending the right hip causes pain along posterolateral back and hip, suggesting retrocecal appendicitis

26. Digital rectal examination  If other signs point to appendicitis, the rectal examination is unnecessary.  Maybe helpful if pelvic appendix or abscess suspected  Tenderness in the rectovesical pouch or the pouch of douglas,especially on the right sight – indicates pelvic appendix

27. If appendicitis is allowed to progress  1.Diffuse peritonitis and shock – more common in infants  2.Formation of abscess – older children and teenagers are more likely to have

28. Differential diagnosis Appendix Cecum and colon Hepatobiliary Small i n tes t i n es Ap p en d icular tumor Carcinoid tumor Ap p en d iceal mucocele Diverticulitis Intestinal obstruction Crohn's disease Typhilitis Cecal carcinoma Cholecystitis Hepatitis cholangitis Adenitis Meckel’s di v ertic u litis Gastroenteritis Intestinal o b structi o n Intussusception TB Typhoid (ulcer perforation)

29. Urinary tract Uterus/ovary Others Hydronephrosis Wilm’s tumor Ureteral or renal calculus Ectopic pregnancy Salphingitis Ruptured ovarian cyst BAN GA BA Pancreatitis Parasitic infection Pleuritis Pneumonia Schonlein-Henoch purpura Porphyria Psoas abscess Kawasaki disease Burkitt lymphoma Omental torsion Rectus sheath hematoma Sickle cell disease CMV Torsion of appendix NDH e U pi S p H l E o IK ic H a MUJIB MEDICAL UNIVERSITY

30. Investigations  CBC  WBC – elevated leukocyte and neutrophil count  Urine analysis  Indicated to help exclude genitourinary conditions  May have some WBC or RBC

31. Other investigation:  Serum electrolytes  Liver function tests  C-reactive protein  Tumor markers  Tuberculin Test  Viral markers  Beta HCG

32. Imag i ng  Plain radiographs  Most helpful in evaluating complicated cases in which small bowel obstruction or free air is suspected  Findings:  Fecol i th  Sentinel loops of bowel and localized ileus  Scoliosis from psoas muscle spasm  Abnormal gas shadow in the RLQ  Calcified appendicolith

33. USG of whole abdomen  Highly operator dependent  Helpful in other diagnoses  Findings –  Wall thickness >6mm  Appendicolith  Luminal distension  Lack of compressibility  Complex mass in the RLQ

34. Barium enema contrast radiograph  Absent or incomplete filling of appendix  Irregularities of the appendiceal lumen  Extrinsic mass effect on cecum or terminal ileum

35. Computed tomography  Gold standard  Findings  Enlarged appendix >6mm  Appendiceal wall thickening >1mm  Periappendiceal fat stranding  Appendiceal wall enhancement

36. Clinical scoring system <3 – low likelihood 4-6 – needs further evaluation >7 – high likelihood The ALVARADO (MANTRELS) Score Symptoms Score M igratory RIF pain 1 A norexia 1 N ausea and vomiting 1 Signs T enderness(RIF) 2 R ebound tenderness 1 E levated temperature 1 Laboratory L eukocytosis 2 S hift to left(segmented neutrophils) 1 Total 10

37. Paediatric appendicitis scores Features Score Fever >38 o C 1 Anorexia 1 Nausea/Vomiting 1 Cough/percussion/hopping tenderness 2 Right lower quadrant tenderness 2 Migration of pain 1 Leukocytosis > 10,000/L 1 Polymorphonuclear neutrophilia>7500/L 1 Total 10 ≤2 low likelihood 3-7 needs further evaluation ≥8 high likelihood

38. Management Medical management :  Correction of dehydration  Correction of electrolytes  Management of pain  Antibiotic therapy  The use of antibiotic for treatment of appendicitis is clearly beneficial  For simple appendicitis  Single preoperative dose to 24 hours of post operative antibiotic therapy  Complicated appendicitis  A 10-day course of intravenous ampicillin, gentamicin,and clindamycin or metronidazole is the gold standard for the treatment of complicated appendicitis

39. Surgical management For uncomplicated appendicitis  Non-operative management : Used in an environment where surgery not available. Patient having spontaneous resolution. Surgery remains the gold standard. Bowel rest Intravenous antibiotics If tends to be complicated, Surgery is the choice of treatment. Criteria for stopping A rising pulse rate Increasing or spreading abdominal pain Increasing size of the mass

40. For complicated appendicitis  the majority of pediatric surgeons will perform appendectomy within 8 hours  Opinions range from nonoperative treatment to aggressive surgical resection with antibiotic irrigation, drainage of the peritoneal cavity, and delayed wound closure

41. Operative interventions include  Interval appendectomy –  Performing appendectomy following initial successful non-operative management in patients with no further symptoms  Majority of pediatric surgeons perform this routinely (6-8wk interval)

42. Open appendectomy BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY

43. Laparoscopic appendectomy

44. Problems encountered during appendectomy  A normal appendix is found  The appendix cannot be found  An appendicular tumour is found  An appendix abscess found  Pelvic abscess

45. Complications  Wound infection  Intraabdominal abscess  Ileus  Adhesive intestinal obstruction  Faecal fistula

46. Outcome  The mortality rate for complicated appendicitis has dropped to nearly  Antibiotics have markedly decreased the incidence of infectious complications.  The overall morbidity in children with complicated appendicitis is <10%

47. Summary  Appendicitis is a common cause of abdominal pain in children.  Repeated abdominal pain should not be overlooked.  A careful history and physical examination can reliably make diagnosis in majority of cases  Minimally invasive appendectomy is treatment of choice.  Post-operative management is determined by operative findings.