Seminar Presentation On Appendicitis (1).pptx

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1. APPENDICITIS SEMINAR PRESENTATION ON APPENDICITIS 1

2. OUTLINES Anatomy & Physiology of Appendix Introduction To Appendicitis Epidemiology Risk Factors Etiologies Types Of Appendicitis PP Of Appendicitis 2

3. OUTLINES… CXNS Of Appendicitis Assessment Of Acute Appendicitis Investigations Differential Diagnosis Management Of Appendicitis References/ Sources 3

4. ANATOMY   Appendix is a small, finger-like tube about 10 cm (4 in) long That is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum . Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction & 4

5. … Is particularly vulnerable to infection Position :- is variable, but it is usually retrocecal Arterial Supply :- Appendicular branch of iliocolic artery Innervation : - From sympathetic elements contributed by superior mesenteric plexus ( T10-L1) Afferents : - From parasympathetic elements via vagus nerves. 5

6. Physiology Is an immunologic organ Secretion of immunoglobulins ( igA ) May serve as a reservoir for beneficial gut bacteria I,e maintaining gut flora . 6

7. Appendix Figure 1.1 location of the appendix. 7

8. INTRODUCTION TO APPENDICITIS Def of Appendicitis Is a condition where the appendix becomes swollen, inflamed , and filled with pus . Is inflammation of the vermiform appendix. Is an inflammation of appendix that develops most commonly in adolescents and adults. Is acute inflammation of the appendix and is the most common cause for acute, severe abdominal pain. 8

9. … Is the most common reason for emergency abdominal surgery . Anyone can get it, but occurs most often between ages 10-30 The abdomen is most tender at McBurney’s point- 1/3 from the RASIS to the umbilicus This corresponds to the location of the base of the appendix. 9

10. EPIDEMIOLOGY World population-7%- 12%,Men - 9% & Women-7 % Appendicitis is more common in: Males (aged 21-30 years ) & Females( aged 11-20 years/10-30years) Ap. 20% of all patients have evidence of perforation at presentation , but the percentage risk is much higher in patients under 5 or over 65 years of age. 10

11. Risk Factors Infection-Stomach infection Age:20-30 years( peak incidence in early 20s) Socio-economic condition: High profile (Low fiber) Lymphoid hyperplasia of the appendix Fibrosis of the appendix cos of previous damage 11

12. … Extreme of age Previous abdominal surgery Position of Appendix ( Retrocecal 56.5% ) Sex- more in males than females Familial- people who have family history of appendicitis are at high risk of developing it. 12

13. Risk Factors For Perforation Of Appendicitis 1 ) Extremes of age 2) Immunosuppression 3) Diabetes mellitus 4) Pelvic appendix 5) Previous abdominal surgery 13

14. Etiologies Obstruction of the lumen with Faecolith Is the predominant etiologic factor in acute appendicitis Bacterial proliferation-streptococci & E. coli Worm infestations Neoplasms , ca caecum (elderly& middle age) Viral 14

15. … Low dietary fiber Foreign bodies King- King of appendix ( Twisting) Swelling of the bowel wall Inspissated barium Vegetable & fruit seeds 15

16. … Appendicitis is caused by a blockage of the hollow portion of the appendix. This is most commonly due to a calcified stone made of faeces. Inflamed lymphoid tissue from a viral infection, parasites, gallstone or tumors may also cause the blockage. Mechanism of luminal obstruction varies depending upon the pt's age & other factors. In the young- - lymphoid follicular hyperplasia due to infection is the main cause . 16

17. … In older patients more likely to be caused by Fibrosis F ecaliths or Neoplasia (carcinoid, adenocarcinoma or mucocele) In endemic areas— parasites can cause obstruction at any age & groups. Examples: Schistosomes species ,Pinworms, Strongyloide & Stercoralis 17

18. Types of Appendicitis 1) Acute Appendicitis Develops very fast Usually in a span of several days or hours Mostly it is diagnosed within 24 to 48 hours. It is easier to detect Requires prompt medical treatment, usually surgery. occurs when the vermiform appendix is completely obstructed , either because of a bacterial infection, feces or other types of blockage 18

19. 2) Chronic Appendicitis Is a Rare Condition Is an inflammation that can last for a long time . It only occurs in only 1.5% of recorded acute appendicitis cases. Appendiceal lumen is only partially obstructed , causing inflammation. The inflammation worsens over time, causing internal pressure to buildup. Until the infection get worsened the appendicitis undiagnosed for several weeks, months, or years . 19

20. Can also be of four types 1)Acute simple appendicitis Is defined as an inflamed appendix without any signs of gangrene or perforation. 2) Acute purulent appendicitis Purulent, usually already perforated, appendicitis is the most common and dangerous differential diagnosis for acute infectious enteritis, in children as well as in adults. 20

21. … 3) Perforation and gangrenous Is defined as an inflamed appendix with signs of grossly necrotic tissue but no frank perforation or abscess. 4) Appendiceal abscess Is a condition in which an abscess is formed around the appendix as a result of appendiceal perforation or extension of inflammation to the adjacent tissues due to aggravation of appendicitis. Occurs in 2-6% of patients with appendicitis. 21

22. PP OF APPENDICITIS Obstruction Build up of mucous Increased luminal pressure   Decreased blood flow   Decreased oxygen delivery ( hypoxia) Ulceration or lesion formation   Invasion by bacteria severe inflammation and swelling Appendicitis 22

23. If appendicitis not get treated / Etiology   Ischemia Necrosis   Gangrene   Perforation   Peritonitis 23

24. SIGNS OF PERFORATION If fever > 102*F WBC > 18,000 24

25. COMPLICATIONS OF APPENDICITIS 1) Gangrenous Appendicitis Thrombosis of the appendiceal artery and veins 2) Perforation Complication rates 58 % Perforation rate increases at both ends of the age spectrum 3) Peri-appendiceal abscess Most frequent complication Peri-appendiceal fibrinous adhesions 25

26. … 4) Peritonitis Bacterial peritonitis in absence of fibrinous adhesions usually E. coli 5) Bowel Obstruction 6) Septic seeding of mesenteric vessels Infection along the mesenteric–portal venous system Pylephlebitis , pylethrombosis , or hepatic abscess 26

27. Assessment Of Acute appendicitis Subjective Data Abdominal Pain 1st noticed in the peri-umblical area -then shifts to the RIF. Mechanism of pain--As the appendix becomes engorged, the visceral afferent nerve fibers entering the spinal cord at T8-T10 are stimulated, leading to vague central or periumbilical abdominal pain. Well-localized pain occurs later in the course when inflammation involves the adjacent parietal peritoneum 27

28. Associated with :- Anorexia Nausea & Vomiting May be the pt present with constipation & diarrhea Cough & sudden movement exacerbate the pain NB The symptoms of appendicitis vary depending upon the location of the tip of the appendix 28

29. Objective Data G/A – Acutely Sick Looking (in pain) V/S --Low grade fever Tachycardia Tachypnoea Abdomen Direct & rebound tenderness Mc Burney’s point…point of maximum tenderness 1/3 from anterior superior iliac spine ( ASIS ) & 2/3 from umbilicus 29

30. Rovsing’s sign Palpating in the left lower quadrant causes pain in the right lower quadrant Psoas sign RLQ pain with passive right hip extension Associated with a retrocecal appendix . Obturator sign Flexing the patient's right hip and knee followed by internal rotation of the right hip elicits RLQ Pain Associated with a pelvic appendex Dunphy’s sign:- Increased pain in the RLQ with coughing . 30

31. IVESTIGATIONSN 1) History collection 2) Physical examination 3) TLC- Raised: 10000 - 18000 ( Neutrophils >75%). If TLC >18000 (suspect perforation) 4) Urinalysis— To rule out Urinary Tract Infection 5) Abdominal X-Ray 6) Abdominal USG Are the most commonly used tests 7) CT Scan 31

32. … Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel. NB 8) Urine HCG :- should be done for all women of childbearing age to exclude pregnancy related causes of acute abdomen. 32

33. 9) Advanced Diagnosing Technology Is neutroSpec imaging Is a new technique to diagnose appendicitis Uses a technetium Labeled anti-CD15 monoclonal antibody That selectively binds to neutrophils When injected into the blood, neutroSpec binds to neutrophils present at the infection site 33

34. … Labeling these cells with technetium As a result, physicians can rapidly detect an infection using a gamma camera that records radioactivity Advantage over the current standard of care Is in vivo labeling of WBCs & Diagnosis in less than 1 hour 34

35. 10) The Alvarado scoring System Is a clinical scoring system used in the diagnosis of appendicitis This scoring system has 6 clinical items and 2 laboratory measurements with a total of 10 points . 35

36. The Alvarado Score SN Symptoms Score 01 Migratory RIF pain 1 02 Anorexia / Loss of appetite) or ketenes in the urine 1 03 Nausea / Vomiting 1 Signs 04 Tenderness in the RIF 2 05 Rebound tenderness in the RIF 1 06 Elevated temperature 1 Laboratory Findings 07 Leucocytosis / increased in no but immature) 2 08 Shift to the left of neutrophils 1 09 Total 10 36

37. Interpretation Of Alvarado Score Alvarado score Interpretation A score of 5 or 6 Compatible with dx of acute appendicitis A score of 7 or 8 Indicates a probable appendicitis A score of 9 or 10 Indicates a very probable acute appendicitis 37

38. Differential Diagnosis 1) Children Gastroenteritis Mesenteric adenitis Meckel’s diverticulitis Intussusception Purpura Lobar pneumonia 38

39. 2) Adults Regional enteritis Ureteric colic Perforated peptic ulcer Torsion of testis Pancreatitis Rectus sheath haematoma 39

40. 3) Adult Female Mittelschmerz PID Pyelonephritis Ectopic pregnancy Torsion / Rupture of ovarian cyst Endometriosis 40

41. 4) Elderly Diverticulitis Intestinal obstruction Ca colon Mesenteric infarction Torsion of appendix epiploicae Leaking aortic aneurysm 41

42. 5) Rare Tabetic crisis Spinal condition Porphyria Diabetes Typhilitis 42

43. MANAGEMENT A) MEDICAL MANAGEMENT 1. Absolute bed rest & NPO 2. IV Fluids Supplements To avoid dehydration & electrolyte imbalance 3. Analgesics can be administered after the diagnosis is made Morphine is a common & effective analgesics for this purpose 43

44. 4.Antibiotics Ruptured appendix Evidence of peritonitis or abscess Medication is given for 6 to 8 hours prior to appendectomy to prevent sepsis Examples Cefotan ( cefotetan) & cefotaxime (claforan, mefotoxin) help prevent wound infection after surgery. Levofloxacin ,Metronidazole or Ofloxacine + Orinidazole 44

45. B) SURGICAL MANAGEMENT APPENDECTOMY Is surgical removal of the appendix Is a surgery to remove the appendix which is usually found in the right lower side of the abdomen. Usually carried out on an emergency basis to treat appendicitis. This may occur as a result of an obstruction in part of the appendex. 45

46. … Another name for this operation is appendicectomy. Performed as soon as possible to decrease the risk of perforation. May be performed under general or spinal anesthesia 46

47. INDICATION OF APPENDECTOMY Acute , chronic, recurrent & Perforated appendicitis As interval appendectomy after drainage of abscess or appendicial mass Carcinoma confined to the mucosa Mucocele of the appendix Appendicular graft, ileal conduit On table colonic lavage 47

48. Types Of Appendectomy Laparoscopic appendectomy Open appendectomy /Traditional surgery Natural orifice surgery (no incision appendectomy) The choice of method is made by the surgeon on a case-by –case basis. General anesthesia is used in both procedures. 48

49. 1) Laparoscopic Appendectomy Also referred to as lap appendectomy Is a minimally invasive surgery to remove the appendix through several small incisions Recovery time from the  lap appendectomy  is short. Under GA, pt is in supine position Use three ports, 10-12 mm port at umbilicus & 5 mm port at suprapubic & in LLQ Appendix should be identified by tracking taeniae libera / coli Appendix is removed through infraumbilical trocar in a retrieval bag. 49

50. Laparoscopic Procedure is :- Lower risk for postoperative infection A smaller scar A shorter hospital stay More expensive Resource intensive Keyhole” surgery Lower complication rate Faster recovery time 50

51. 2) Open Appendectomy Is the traditional method and the standard treatment for appendicitis. Typically performed under general anesthesia pt is in supine position Abdomen is prepared & draped Incision is made at McBurney ‘s point If appendix is not easily identified , caecum should be located. Tracing the taenia libera , the most visible of three taeniae coli, distally, the base of the appendix can be identified. 51

52. Procedure For an Open Appendectomy 1) Antibiotics are given immediately if:- Sign of actual sepsis Reasonable suspicion that the appendix has ruptured On set of peritonitis Not quickly treated – suspected A single dose of prophylactic intravenous antibiotics is given immediately before surgery. 52

53. Antibiotics Prophylaxis in Surgery Usually a single dose is sufficient A second dose may be required in the following situations i ) In prolonged operations ii ) When there is contamination during surgery Giving more than 1 or 2 doses is generally not advised The practice of continuing prophylactic antibiotics until surgical drains have been removed is not recommended. Should be given 1hour prior to surgery preferably with induction of anesthesia, 30min ? 53

54. 2) General anesthesia Is induced with endotrachcheal intubation & full muscle relaxation The pt is placed in supine position 3) The abdomen is prepared and draped & is examined under anaesthesia . 4) The incision is made over Mc Burney’s point The most common position of the base of the appendix If mass is present, the incision is made over the mass 54

55. … 5) The various layers of the abdominal wall are opened. 6) On entering the peritoneum, the appendix is identified, mobilized, and then ligated and divided at its base. 7) The stump of the appendix is buried by surgeon by inverting it so it points into the caecum . 8) Each layer of the abdominal wall is then closed in turn. 9) The skin may be closed with staples or stitches 10) The wound is dressed 11) The patient is bought to the recovery room. 55

56. 3) Natural Orifice Surgery Is an experimental surgical technique whereby scarless abdominal operations can be performed With an endoscope passed through a natural orifice like mouth, urethra, anus & vagina Then through an internal incision in the stomach, vagina, bladder, or colon, thus avoiding any external incisions or scars. 56

57. … No incision appendectomy Use the natural orifices Anal canal endoscopically or Trans-vaginally Less pain No scar Less hospital stay Fewer complications Take about 50 minutes 57

58. COMPLICATION OF APPENDECTOMY Wound infection 5-10% ,4-5 th day Intra- abdominal abscess 8% Hemorrhage Paralysis ileus Generalized peritonitis Aspiration pneumonia Urinary tract infection Deep Vein Cut thrombosis & embolism Portal pyemia - Adhesion intestinal obstruction Fecal Fistula Ritcher’s hernia 58

59. C) NURSING MANAGEMENT Pre-op preparative Care Intra-operative Care Post-operative Care Pt Education 59

60. Pre-Op Preparative Care Assessment - History taking & physical examination Monitor vital signs BP, To ,PR & RR for baseline data NPO ( 6-8 hrs ) and IV Fluids should be started Investigations:- U/A, CT Scan, Ultrasound & CBC Analgesics-- to relieve pain as per prescribed 60

61. … Administer antibiotics as prescribed :-Second generation Cephalosporin with Metronidazole is given Naso -gastric aspiration Monitor for signs of ruptured appendix &peritonitis Position right-side lying or low to semi fowler position to promote comfort. Auscultate Bowel Sounds 61

62. … Preparation for surgery i.e. physically & psychologically Remove anxiety & fears Maintaining skin integrity Informed ( Written) consent form must be signed knowing that the pt understands the procedure , the potential risks , and that he /she receives certain medications Prepare and send the patient for surgery without delay OT clothes and pre medications to be given 45 minutes before operation 62

63. Intra-Operative Care Position the patient on the OR table Skin preparation Induction of anesthesia Procedure is performed aseptically Closing of the incision Dressing of the site 63

64. Post-Operative Care Following surgery, the patient is taken to the post anesthesia care unit ( PACU) until the anesthesia wears off. During this time, the nurse check the ff:- Temperature Heart rate & Breathing at frequent intervals 64

65. … When the anesthesia wears off & vital signs stabilize, the pt is transferred to their hospital room. Place the pt in a semi-fowler position . This position reduces the tension on the incision and abdominal organs, helping to reduce pain. Clear airway Proper breathing and adequate tissue perfusion by IVF Monitor vital signs for signs of infection and shock. Fever Hypotension Tachycardia 65

66. … Monitor input & output for signs of fluid imbalance, dehydration & shock. Naso-gastric suction to be done regularly to relieve tension on sutures Provide safety & effective care environment to the patient Care of all drainage tubes Care of surgical wounds. Watch for soapage 66

67. … Evaluate dressing and incision Nutritional status maintained by IV fluids Observe for return of bowel sounds Encourage early ambulation to prevent post operation complications. Turning, coughing , deep breathing and incentive spirometry are performed every two hours. Maintain NPO till bowel sounds return, then start clear fluids orally 67

68. … Assess abdomen for increased pain, distension, rigidity, and rebound tenderness b/c these may indicate post operative complications Monitor for nausea & vomiting Administer & analgesics as per prescribed Evaluate the passing of flatus or faeces. 68

69. Pt Education The pt should avoid heavy lifting for 4 to 6 wks The pt must report the ff symptoms if there are:- Anorexia Nausea Vomiting Fever Abdominal pain Redness around incision area & drainage 69

70. … If drains from incision, patient may be kept in the hospital for several days & Monitored carefully for signs of intestinal obstruction or 2 O hemorrhage Diet and how to take ordered medication Returning to health facility on appointment 70

71. NB 1. Avoid Laxatives and enemas as they increase peristalsis that may cause perforation of the appendix. 2. Apply Cold , this may decrease the flow of blood to RLQ and help reduce the inflammatory process. 3. Heat is never used because it may cause the appendix to rupture. 71

72. References / Sources Medical- surgical Nursing vol 1, 13 th edition Schwartz’s principles of Surgery 9 th edition Emergency Medicine Clinics of North America. Black M. JOYCE, Medical Surgical Nursing, published by Elsevier, 8 th edition volume 2 Brunner and Suddarth’s , Textbook of Medical Surgical Nursing ,published by Lippincott Williams and Wilkins , 11 th edition Smeltzer C. Suzane, Textbook of Medical Surgical Nursing ,published by Lippincott, 9 th edition. 72

73. References / Sources… 7) Schwartz’s principles of Surgery 10 th edition 8) Baley and Love’s Short Practice of Surgery, 26 th edition 9) Schwartz Book of General Surgery 10) Medical- surgical Nursing vol 2, 13 th edition 11) Medical- surgical Nursing 10 th edition 12) Wikipedia , Google 73

74. THANKS 74