Complications-of-Appendicitis.pdf when things go wrong

complications of appendicitis
when things go wrong
presented by dr. suhaib almaghariz
general surgery specialist

1. Complications of Appendicitis

2. • Death is rare
• Perforated appendix ~30% complication rate Peritonitis
• Wound infection +/-dehiscence
• Intra-abdominal abscess
• Fistulas
• Small bowel obstruction (adhesions) (esp after perf)
•Paralytic Ileus
• Infertility
•Sepsis
Complications

3. 3
Case:
A 37-year-old woman with no past medical
history went to ED complaining of vomiting
and periumbilical abdominal pain for 6 hours.
On physical examination, she was afebrile,
BP 110/70, HR 85. Abdomen was soft, with no
rebound or guarding. She was diagnosed with
gastroenteritis, discharged with antiemetics,
and told to return for persistent vomiting, pain,
or new fever.

4. Case (cont.) :
Patient went to OPD 2 days later with persistent
abdominal pain; vomiting had resolved. On physical
exam, patient was afebrile, with normal vital signs.
Abdomen was diffusely tender, with localization around
the umbilicus. Pelvic exam revealed no cervical motion
and mild adnexal tenderness. Diagnosis: Mittelschmerz
vs. ovarian cyst. Transvaginal ultrasound ordered for
following week. Patient told to take NSAIDS for pain.

5. Case (cont.):
The next day, the patient returned to the
ED with persistent pain. She was seen by
the same ED attending, who then asked a
colleague to evaluate the case. This second
ED attending performed a pelvic exam and
ordered a CT scan of the abdomen and
pelvis. CT revealed a perforated appendix.

6. Perforated Appendix

7. •The major reason for appendiceal perforation is
delay in diagnosis and treatment.
•In general, the longer the delay between diagnosis
and surgery, the more likely is perforation.
•The risk of perforation 36 hours after the onset of
symptoms is at least 15%.
• Therefore, once appendicitis is diagnosed, surgery
should be done without unnecessary delay.
Perforated Appendicitis

8. Perforated Appendicitis
•Patients very ill; may require several hours of fluid
resuscitation before induction of general anaesthesia
•Broad spectrum antibiotics directed against gut
aerobes and anaerobes are initiated early in the
evaluation and resuscitation phase
•A laparoscopic approach to perforated appendix
appears to reduce incidence of post operative wound
infection and ileus and shorter hospital stay

9. •Diagnostic laparoscopy and assess whether or
not to convert to an open appendectomy
•Any pus encountered is aspirated and sent for
Gram stain and culture
•Oozing from inflamed retroperitoneum is
easily controlled with argon beam
coagulation(if available)
•Surgical excision of appendix as described
Perforated Appendicitis…Management

10. Perforated appendicitis

11. Peritonitis
•It’s secondary type of peritonitis
•Life threatening if not treated quickly
•Patient presents with
–Immobile with shallow thoracic breathing
–Swelling and tenderness in the abdomen with pain ranging
from dull aches to severe, sharp pain
–Fever and chills
–Loss of appetite
–Thirst
–Nausea and vomiting
–Limited urine output
–Inability to pass gas or stool

12. Case (cont.): Missed Appendicitis
The patient was seen by general surgery
and it was decided not to take her to the
operating room immediately due to the
peritonitis. She was admitted and started
on IV antibiotics. Her hospital stay was
prolonged due to ileus. On hospital day
number #8, her WBC count began to rise.
A repeat CT scan was obtained.

13. Intra-abdominal Abscess

14. Case (cont.): Missed Appendicitis
CT revealed an intra-abdominal abscess
“the size of an orange.” The patient
underwent percutaneous drainage by
interventional radiology. On hospital day
#13, she was discharged home with a
plan to follow-up for elective
appendectomy.

15. Pelvic abscess
•Can occur irrespective of position of appendix
•Patient presents with spiking pyrexia several
days following appendicitis
•Pelvic pressure symptoms like loose stools or
tenesmus
•PR – Boggy mass in pelvis anterior to rectum
•Managed normally by or transrectal drainage
under GA

16. Case (cont.): Missed Appendicitis
Shortly after discharge, the abdominal pain
returned. The patient returned to the ED and
underwent a repeat CT scan, which revealed
a small bowel obstruction. The patient went
to the operating room the next day for lysis
of adhesions and appendectomy. Eight days
later, the patient was discharged home. She
has returned to her previous state of health.

17. Small bowel obstruction
•Blockage occurs when the inflammation
surrounding the appendix causes the intestinal
muscle to stop working, and this prevents the
intestinal contents from passing. If the intestine
above the blockage begins to fill with liquid and
gas, the abdomen distends and nausea and
vomiting may occur.

18. Fistulas
•Typically for perforated appendicitis
•Fistulas to the skin generally close after any
local infection is treated
•Fistulas to the bladder have been successfully
diagnosed and treated laparoscopically in
recent years

19. Infertility
•Many surgeons believe that girls and young women who suffer

perforation of the appendix are at risk of developing subsequent

tubal infertility

•This conviction presumably arose from the
clinical observation that
acute appendicitis complicated by
perforation sometimes caused
severe intra abdominal infection
•The resulting peritoneal adhesions were thought to obstruct
the
fallopian tubes, leading to tubal infertility
•Several previous
studies have found an association between
complicated appendicitis
and female infertility (1–4), whereas
others have not
detected a relation

20. Sepsis
•A feared complication of appendicitis is sepsis,
a condition in which infecting bacteria enter
the blood and travel to other parts of the
body.
•This is a very serious, even life-threatening
complication. Fortunately, it occurs
infrequently.

21. Chronic or Recurrent Appendicitis
•A small number of patients report episodic bouts
of RLA pain in absence of acute febrile illness
•Some are found to have appendicoliths on CT or
sonographic evidence of an enlarged
appendiceal diameter
•Most will have both surgical and pathologic
evidence of chronic inflammation(fibrosis)
•Dilemma is more difficult when report of pain is
not accompanied by other clinical or
radiographic findings

22. Appendicitis in pregnancy
Complications:
•More chances of perforations and peritonitis
– Incidence:
4 -19% - non pregnant patients
57% - pregnant women (Tracey & Fletcher,2000)
•Abortion , Fetal loss ~ 15% (1st trimester)
•Decreased birth weight
•Other surgical complication – wound infection, atelectasis
•No congenital malformation
•No stillborn infants

23. •Perforation – why more ???
Position change of appendix
No containment of infection by omentum
Inability of omentum to isolate infection
More generalized peritonitis

24. Complications of Appendicectomy

25. 1.Pre-operative
2.Intra-operative
3.Post-operative

26. Pre-operative complications
Risks for any anesthesia include the following:
Problems with breathing
Chest infection
Reactions to medications

27. Intra-operative complications
1.If gridiron incision used
–then ligation of arterial twig from Supf circum iliac
artery should be done to prevent excessive blood
loss
–Sparing of iliohypogastric nerve
2.Normal-appearing appendix
What to do?
Consensus is still lacking even after introduction of
laparoscopy
Recent practice is to remove the appendix and perform a
thorough search for other causes of patients’ symptoms
Check Small Intestine, Mesentery and Pelvis

28. 3.Absent appendix
Caecum should be mobilised and taenia coli
mobilised till confluence with caecum before
diagnosis of ‘absent appendix’ is made
4.Appendicular tumour
Small size( <2cm in diameter) appendicectomy
Larger size Right Hemicolectomy
5.Internal injuries

29. Post-operative complications
•Relatively uncommon
•Mainly reflect degree of peritonitis
1.Wound infection
–Most common; occurs in 5-10% patients
–Higher in those with perforation ; about 25%
–Present as pain and erythemia of wound on 4
th to 5
th day post-op
–Treated by wound drainage and antibiotics
–Most common organism Bacteriodes species and Anaerobic
streptococci

30. 2.Intra-abdominal abscess
–Rare because of pre-op antibiotics
–Spiking fever, malaise and anorexia developing 5-7days
post-op
–Sites Interloop, Paracolic, Pelvic and Subphrenic
–Use Abdominal USG and CT
–Drainage done mostly percutaneously
–Laparotomy only to those where site cannot be identified
by imaging
3.Ileus
–may last for some days especially after removal of
gangrenous appendix
–If lasts for more than 4-5days with accompanying fever,
one should suspect intra-abdominal sepsis

31. 4.Small bowel obstruction
–Occurs in less than 1% of patients operated for
uncomplicated appendicitis and in 3% cases with
perforation
–About half present within first year
5.Respiratory problems
–Rare complication
–Postoperative abdominal surgery patients require
analgesics to facilitate deep breathing, which minimizes
the risk of atelectasis
–Some also advocate physiotherapy in severe cases

32. 6.Stump Appendicitis
–Residual tissue left after an initial appendectomy risks the
development of stump appendicitis
–Typically, patients present with signs and symptoms
similar to acute appendicitis; however, due to prior
surgery, the diagnosis is difficult and the rate of
appendiceal stump perforation is extremely high
7.Portal pyaemia(Pylephlebitis)
–Rare but serious complication of gangrenous appendicitis
–Associated with high fever, jaundice and rigors
–Due to septicemia in portal system
–Development of intrahepatic abscesses
–Treated by systemic antibiotics and percutaneous
drainage

33. 8.Venous Thrombosis
–Rare
–Seen mainly in elderly and women on OCPs
–Therefore there’s need for prophylaxis
9.Faecal fistulae
–Occasionally seen following appendicectomy in Crohn’s
disease
10.Right inguinal Hernia
–Seen when Gridiron incision done and injury to
iliohypogastric nerve

34. Thank you