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Detailed explanation about appendicitis

1. APPENDICITIS By Dr brima m sesay

2. Outline Introduction Relevant Anatomy Pathophysiology Clinical features Investigation Management Complications Conclusion

3. Introduction Inflammation of the vermiform appendix. Common in the 2 nd and 3 rd decade of life Accounts for 2-5% of acute abdominal pain 5-10% of cases occur in the elderly Appendicitis accounts for 30% of surgical emergencies in Accra Overall mortality is about 0.8%

4. Relevant Anatomy

5. Relevant Anatomy 8 th week of intrauterine life Derivative of the mid-gut along with the ileum and ascending colon Located at the confluence of the caecal taenia 7.5-10cm long

6. Pathophysiology Luminal obstruction by faecolith or lymphoid hyperplasia. Overgrowth of bacteria and continuous mucoid secretion Distension + increased intraluminal pressure Lymphatic & venous obstruction leading to edema and acute inflammatory response Necrosis of appendiceal wall and bacterial translocation occurs

7. Pathophysiology Perforation occurs with spillage of appendiceal contents into the peritoneal cavity. Localised / generalised peritonitis occurs Abscess when pus is walled off by omentum Appendix mass when inflammed appendix is walled off by omentum and loops of bowel

8. Stages of Appendicitis Early stage Suppurative Gangrenous Perforated Abscess Spontaneously resolving appendicitis Recurrent appendicitis Chronic appendicitis

9. Clinical features (History) Anorexia Periumbilical pain Nausea Right lower quadrant pain Vomiting The classic history occurs only in about 50% of cases. Most common is the migrating abd pain which has a sensitivity and specificity of 80%.

10. Clinical features (history) Duration of symptoms is usually <48hrs Longer duration common in the elderly and those with perforations GIT, Genitourinary history should be taken Complete gynaecological history in females

11. Clinical features (examination) Tenderness, guarding and re-bound tenderness in the right lower quadrant Re-bound tenderness is the most specific sign Tenderness is present in 96% of patients, but it’s a non-specific sign. General and systemic examination should be conducted.

12. Accessory signs ROVSING sign ( press ure & pain at d mac burney poin t ) OBTURATOR sign ( pt lies dwn n hip n keens flex , pain occur ) PSOAS sign ( rht knee flex backwa rds n elici t pain ) MUNPHY sign ( pt taks in breath n palpate d RLQ n pain is felt at d subcoastal area ) MARKLE sign

13. Investigations FBC – leucocytosis Abd USG CT scan – gold standard Diagnosis of appendicitis is essentially clinical, further investigation is required when the diagnosis is in doubt.

14. Differential diagnosis Renal colic Merkel’s diverticulum PID/ tubo -ovarian abscess UTI Cholecystitis Mesenteric adenitis Crohn’s dx Diverticular dx Testicular torsion

15. Principles of management of Appendicitis Resuscitation Establish diagnosis Control infection - Antibiotics Adequate pain relief Remove source of infection – Appendicectomy (open/laparoscopic)

16. Conclusion Appendicitis affects the younger population Diagnosis is clinical Imaging is required when the diagnosis is equivocal Requires prompt treatment to avoid complications