full APPENDICITIS lecture-ANDREW NJAMBA .pptx

everything to know about Appendicitis

1. Appendix and Appendicities REMEMBER TO BE PASSIONATE ALWAYS ‘Don’t waste time focusing on the past because you cannot change it. Don’t focus on the future because you cannot predict it, Focus on the Present because it’s a Gift from life to have it.”

2. Firstly we begin with the Anatomy Appendix  is a Latin word from appendere . It means to hang upon. It is a blind-ended muscular tube attached to the posteromedial wall of cecum, near the junction of ileum with cecum.

3. It is actually a part of cecum where the three taeniae coli merge to form outer longitudinal muscle layer .(tri radiate layer) It is an out pouching or pocketing from cecum.

4. Teniae coli The  teniae coli  (also  taeniae coli ) are three separate longitudinal ribbons of  smooth muscles on the outside of the ascending, transverse, descending and sigmoid  colons.

5. They are visible, and can be seen just below the  serosa or fibrosa. They are the Mesocolic , Libera or Free and  The Omentalis The teniae coli contract lengthwise to produce the haustrations, the bulges in the colon.

6. The teniae coli contract lengthwise to produce the haustrations, the bulges in the colon.

7. The bands converge at the root of the appendix. At the recto-sigmoid junction, the taeniae spread out and unite to form longitudinal muscle layer.

8. These bands correspond to the outer layer of the muscularis externa, in other portions of digestive tract.

9. The appendix is 9 cm (7 to 11cm) in length but can range from 2 to 20 cm. The diameter of the appendix is 1 to 7 mm . (other literatures like SRB will say 1 to 3 mm long) It is relatively longer in children and decreases after 40 years of age.

10. Following statements regarding appendix are true EXCEPT It is a blind-ended muscular tube attached to the anteromedial wall of cecum, near the junction of ileum with cecum. The appendix is located in the right lower quadrant of abdomen (right iliac fossa).  The mesoappendix extends the whole length of appendix. Appendicular artery runs at the margin of mesoappendix. Lymph drainage of appendix is to ileocolic lymph nodes.

11. Following statements regarding appendix are true EXCEPT It is a blind-ended muscular tube attached to the anteromedial wall of cecum, near the junction of ileum with cecum. C The appendix is located in the right lower quadrant of abdomen (right iliac fossa).  The mesoappendix extends the whole length of appendix. Appendicular artery runs at the margin of mesoappendix . Lymph drainage of appendix is to ileocolic lymph nodes.

12. Appendix is a blind-ended muscular tube attached to the posteromedial wall of cecum, near the junction of ileum with cecum.

13. Location of Appendix McBurney’s point The appendix is located in the right lower quadrant of abdomen (right iliac fossa).  Its position within the abdomen corresponds to a point on the surface known as McBurney’s point.

14. For appendicular base draw a line from anterior superior iliac supine to the umbilicus. The appendicular base is at the junction of the lateral and middle third of this line. This is McBurney’s point.

15. Clocks- a section worth talking about. While the base of the appendix is at a fairly constant location, 2 cm below the ileocecal valve, the location of the tip of the appendix can vary from being retrocecal (behind the cecum) to being in the pelvis.

16. In rare individuals with situs inversus , the appendix may be located on left side, in the lower left iliac fossa.

17. One of the followings is the least common position of appendix Retro-cecal. Appendix is posterior to cecum and lower part of ascending colon. Pelvic. Appendix is descending downward over the pelvic brim. Sub-cecal. The appendix is descending down below the cecum. Pre-ileal. Here the appendix is related to the anterior abdominal wall. It is anterior to the terminal part of ileum. Post-ileal or retro-ileal. Here the appendix is posterior to the terminal part of ileum.

18. One of the followings is the least common position of appendix Retro- cecal . Appendix is posterior to cecum and lower part of ascending colon. Pelvic. Appendix is descending downward over the pelvic brim. Sub- cecal . The appendix is descending down below the cecum. Pre- ileal . Here the appendix is related to the anterior abdominal wall. It is anterior to the terminal part of ileum. Post- ileal or retro- ileal . Here the appendix is posterior to the terminal part of ileum . C

19. Retro-cecal (70%). Appendix is posterior to cecum and lower part of ascending colon. Para-cecal or para-colic. Appendix runs along the lower border of cecum and if long enough, ascends along ascending colon. Pre-cecal. Appendix is anterior to cecum and lower part of colon. Sub-cecal. The appendix is descending down below the cecum.

20. Pelvic (20%). Appendix is descending downward over the pelvic brim. It is closely related to right fallopian tube and ovary. Promontoric . The appendix runs medially (left-ward) and horizontally, inferior and parallel to ileum from cecum to the promontory of sacrum.

21. Pre-ileal. Here the appendix is related to the anterior abdominal wall. It is anterior to the terminal part of ileum. Post-ileal or retro-ileal (0.2%). Here the appendix is posterior to the terminal part of ileum.

22. The mesoappendix (mesentery of appendix) is short, triangular and variable. It extends the whole length of appendix. It is connected to the inferior ileal mesentery.

23. Inferior ileocecal recess It is a recess inferior to the terminal ileum and opens infero -medially (down and left) It is formed by ileocecal fold, which extends from terminal ileum to mesoappendix. The fold and recess can be used to trace the base of the appendix.

24. The boundaries of inferior ileocecal recess are Above: terminal ileum Front: ileocecal fold Behind: mesoappendix Right: cecum

25. Ileocecal recess Latin: Plica ileocaecalis

26. Blood supply of the Appendix. Ileocolic artery The ileocolic artery is the lowest branch arising from the concavity of superior mesenteric artery.

27. It passes downward and to the right behind the peritoneum toward the right iliac fossa, where it divides into a superior and an inferior branch The superior branch anastomoses with right colic artery. The inferior branch anastomoses with the end of superior mesenteric artery Supplies the cecum, ileum, and appendix.

28. Branches Colic artery to ascending colon Anterior and posterior cecal arteries to cecum Ileal artery to terminal ileum Appendicular artery to appendix

29. Appendicular artery runs at the margin of mesoappendix. It is a branch of the inferior division of ileocolic artery which is a branch of superior mesenteric artery.

30. The appendicular artery runs behind the terminal ileum to enter the mesoappendix. Here it gives a recurrent branch which anastomoses at the base of the appendix with a branch of posterior cecal artery. The posterior cecal artery is also a branch of inferior division of ileocolic artery.

31. The terminal part of appendicular artery lies on the wall of the appendix and may be thrombosed in appendicitis, resulting in distal gangrene or necrosis.

32. Appendicular vein drains into ileocolic vein which is a tributary of superior mesenteric vein. Superior mesenteric vein drains into portal vein.

33. McBurney’s point to shade more light The junction of the lateral and middle thirds of the line that joins the right anterior superior iliac spine to the umbilicus is used as a surface marking for the base of the appendix.

34. The three teniae coli converge at the tip of the cecum to form the continuous longitudinal muscle layer of the appendix. The base of the appendix can be located by tracing the anterior taenia coli (taenia libera) to the tip of the cecum.

35. The ileocecal fold of peritoneum, which connects the terminal 2.5 cm of ileum to the cecum, can also be used to locate the base of the appendix. Ileocecal fold forms the anterior boundary of inferior ileocecal recess. This fold is also called “bloodless fold of Treves”

36. A short, triangular mesoappendix extends along the length of the appendix and connects it to the lower portion of the mesentery of the ileum.

37. McBurney’s point is at the junction of lateral two-third and medial on-third of the line that joins the right anterior superior iliac supine to the umbilicus at the junction of the lateral one-third and medial two-third of the line that joins the right anterior inferior iliac supine to the umbilicus at the junction of medial and middle third of the line that joins the right anterior superior iliac supine to the umbilicus at the junction of the lateral one-third and medial two-third of the line that joins the right anterior superior iliac supine to the umbilicus at the junction of the lateral one-third and medial two-third of the line that joins the left anterior superior iliac supine to the umbilicus

38. McBurney’s point is at the junction of lateral two-third and medial on-third of the line that joins the right anterior superior iliac supine to the umbilicus at the junction of the lateral one-third and medial two-third of the line that joins the right anterior inferior iliac supine to the umbilicus at the junction of medial and middle third of the line that joins the right anterior superior iliac supine to the umbilicus at the junction of the lateral one-third and medial two-third of the line that joins the right anterior superior iliac supine to the umbilicus C at the junction of the lateral one-third and medial two-third of the line that joins the left anterior superior iliac supine to the umbilicus

39. Deep tenderness at McBurney's point, known as  McBurney's sign , is a sign of acute appendicitis.

40. HISTOLOGY OF Appendix Identification points Lining epithelium is simple columnar with numerous goblet cells Crypts of Lieberkun or intestinal glands are numerous but not closely packed. They are lined by simple columnar epithelium with lot of goblet cells.

41. Lamina propria contains large amounts of lymphoid tissue, extending through muscularis mucosae into submucosa. Lymphoid nodules surround the lumen completely.

42. Muscular layer consist of inner circular and outer longitudinal layer . Out longitudinal muscle layer is a continuous layer and not arranged in three bands or teniae coli.

43. EMBRYOLOGY OF APPENDIX. INNERVATION OF APPENDIX . Parasympathetic – Vagus nerves on both sides Sympathetic- T10 via lesser thoracic splanchnic nerves, to the superior Mesenteric plexus .

44. Function OF APPENDIX.

45. DUPLICATION OF APPENDIX. ( Wallbridge classification ) Type A: Partial duplication in a single caecum. Type B: Two separate appendices in a single caecum. Type C: Double caecum with each one having one appendix

46. DEFINITION OF APPENDICITIES. Inflammation of the VERMIFORM appendix

47. Types OF APPENDICITIES.(CORS) 1) Catarrhal (Non obstructive) - Acute nonobstructive appendicitis (catarrhal) (mucosal appendicitis): the disease natural history may follow; Resolution→Ulceration→Fibrosis→Suppuration→Recurrent appendicitis→Gangrene (rare initially in non-obstructive type but later can occur) →Peritonitis. 2) Obstructive (Acute obstructive appendicitis) - pus collects in blocked lumen → oedematous → gangrenous, and rapidly progresses to perforation→then peritonitis→formation of appendicular abscess or pelvic abscess. Often, there is thrombosis of appendicular artery 3) Recurrent appendicitis : Repeated attacks of nonobstructive appendicitis leads to fibrosis, adhesions causing recurrent appendicitis. 4) Subacute appendicitis: is milder form of acute appendicitis.

48. EDIDEMIOLOGY OF APPENDICITIES.

49. RISK FACTORS OF APPENDICITIES. Common in young males of white races.  Less fibre diet & high refined carbohydrates increases risk  Common in May and Aug-seasonal variation-called epidemic appendicitis.  Viral infection may cause mucosal oedema and inflammation which later gets infected by bacteria causing appendicitis.  FH- relevant in 30% of children with appendicitis occurring in first degree relatives.

50. ETIOLOGY/CAUSES OF APPENDICITIES. FECOLITH AND NON FECOLITH 1.FECOLITH Obstruction of lumen of appendix causing obstructive appendicitis due to Faecoliths , N:B Faecolith referred to as an ‘ appendicolith is most common cause . 2. NON FECOLITH Obstruction of lumen of appendix causing obstructive appendicitis due to - Faecoliths , stricture, FB, round worm or threadworm. -Adhesions and kinking, Ca of caecum near base, ileocaecal Crohn’s dx. -Fibrotic stricture indicates previous appendicitis that resolved with no op. - Abuse of purgatives . -Viral infection may cause mucosal oedema and inflammation which later gets infected by bacteria causing appendicitis

51. CONT: EXAMPLES Of such bacteria Organisms (BEES):  E. coli (85%),  Enterococci, (30%),  Streptococci, Anaerobic streptococci, Cl. welchii , bacteroides .  Pseudoappendicitis is appendicitis due to acute ileitis following Yersinia infection. It is often due to Crohn’s disease.

52. PATHOGENESIS OF Appendicities :

53. PATHOGENESIS OF Appendicities CONT: In summary  Mucus and inflammatory fluid collects inside lumen ( Mucocele ) → increases intraluminal pressure → leads to blockage of lymphatic & venous drainage → resulting in increased oedema of mucosa&wall → causes mucosal ulceration& ischaemia → Bacterial translocation → bacterial spread through submucosa and muscularis propria → acute obstructive appendicitis.

54. CONT :  Thrombosis of appendicular artery→ ischaemic necrosis of appendix→ gangrene→ perforation at tip or base → peritonitis.  After perforation → localisation of infection by greater omentum and ileum dilation occurs → with suppuration and pus inside forming appendicular abscess or localisation can occur without pus inside → forming appendicular mass

55. SYMPTOMS OF APPENDICITIES : A. Migratory Pain – visceral pain starts around the umbilicus due to distension of appendix, later after few hours, somatic pain occurs in RIF due to irritation of parietal peritoneum due to inflamed appendix b) Anorexia- if good appetite not appendicitis c) Malaise d) Fever (low grade) e) Abdomen pain caused by coughing f) Nausea and reflex vomiting- due to reflex pylorospasm g) Other features: Foetor oris ,  constipation is usual feature but diarrhoae can occur if appendix is in postileal or pelvic postion and  urinary frequency: inflamed appendix may be in contact with bladder and cause bladder irritation LASTLY check below a must know for you.

56. SIGNS OF APPENDICITIES : a ) Tachycardia b) Abdominal tenderness- maximum at McBurney‘s point c) Pointing sign d) Psoas test - for retrocaecal appendix, hyperextension of right hip, causes pain in right iliac fossa- due to irritation of psoas muscle e) Obturator test – for pelvic appendix, internal rotation of right hip causes pain in RIF due to irritation of obturator internus muscle f) Rovsing sign – On pressing/palpating left iliac fossa, pain occur in RIF due to shift of bowel loops which irritate the peritoneum (parietal peritoneum) g) Blumberg sign – tenderness & rebound tenderness in right iliac fossa h) Baldwing test - + ve in retrocaecal appendix- when legs are lifted off the bed with knee extended, the pt complains of pain while pressing over the flanks

57. SIGNS OF APPENDICITIES CONT : i ) Bastede sign- an obsolete sign; in chronic appendicitis, pain& tenderness in RIF on inflation of colon with air j) Bed shaking Test: ( Bapat Test) If in doubt of early peritonitis presence, bed is shaken and the cause pain at site of inflammation k) Markle Sign, Markle Test or Heel Drop Jarring Test is elicited in pts with intraperitoneal inflammation by having a pt stand on his toes, suddenly dropping down on heels with an audible thump. If abdominal pain is localised as heels strike ground, sign is + ve l) Dunphy sign- characterized by increased abdominal pain with coughing. It may be an indicator of appendicitis. m) Deep tenderness at McBurney's point, known as McBurney's sign, is a sign of acute appendicitis. n) DRE shows tenderness in right side of the rectum. o) Hyperaesthesia in ‘ Sherren’s triangle’. This triangle is formed by anterosuperior iliac spine, umbilicus, and pubic symphysis.

58. SIGNS OF APPENDICITIES CONT :

59. SIGNS OF APPENDICITIES CONT ALVARADO SCORING :

60. SIGNS OF APPENDICITIES CONT :

61. SIGNS OF APPENDICITIES CONT :

62. TREATMENT OF APPENDICITIES

63. COMPLICATIONS OF APPENDICITIES Complications 1. Perforation ( peritonism ) – local or generalized peritonitis 2. RIF appendix Mass, (appendicitis + densely adherent caecum & omentum ) 3. RIF abscess 4. Pelvic abscess

64. DIFFERENTIAL DIAGNOSIS OF APPENDICITIES a) GIT i . Cholecystitis ii. Ruptured PUD (Peptic Ulcer Disease) iii. Pancreatitis iv. Intusucception v. Crohn‘s disease vi. Caecal tumors vii. Caecal diverticulitis viii. Meckel‘s diverticulitis ix. Sigmoid volvulus b) Other abdominal i . Ovarian cyst/ Torsion of ovarian cyst ii. Ovarian abscess iii. Ectopic pregnancy iv. Oophoritis vs. Salpingitis vi. Renal colic vii. Psoas abscess viii. Rectus sheath hematoma c) Extra-abdominal i . Lobar pneumonia ii. Herpes zoster

65. REFERRENCES: a.SRB b. BELLIE and LOVE c. Amboss d. Kaplan youtube REMEMBER TO BE PASSIONATE ALWAYS