43 - APPENDICITIS.pdf

43. APPENDICITIS Harrison’s Harrison’s Chapter 356 (pp 1985-1989) 1985 -1989) Schwartz’s Schwartz’s Chapter  Chapter 30 (pp 1241-1256)

4) Inflammation soon involves the serosa and parietal peritoneum causing shift to RLQ pain 5) Vascular thrombosis and ischemic necrosis with PERFORATION of PERFORATION of distal appendix occurs DISTAL  poorest blood supply !  Patients who have had symptoms for >48 ! HOURS are HOURS are more likely to perforate Perforation near the base should raise ! concerns about another disease process Simple disease DOES NOT always progress ! to perforation Simple acute appendicitis may resolve spontaneously or with antibiotic therapy Recurrent disease is remotely possible 6) When perforation occurs, the resulting leak may be contained by the omentum or surrounding tissues to form an ABSCESS 7) FREE perforation typically causes severe PERITONITIS These patients may develop infective !  suppurative thrombosis of the portal vein along with intrahepatic abscess Prognosis is very poor with this complication !

Epidemiology -

Appendicitis remains to be the most common common emergency surgical disease affecting the abdomen 9% of men and 7% of women women will experience appendicitis in their lifetime Occur most commonly in 10- to 19-year olds PERFORATION  common cause of morbidity and mortality; increasing incidence 20% of all patients have evidence of perforation ! at presentation Risk of perforation is higher in 65 years >65 years !

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 Anatomy and Histology -

Arterial Supply: Appendicular Br. of Ileocolic Artery Innervation: Superior Mesenteric Plexus (T10-L1) and Vagus Nerves 3 Layers: Serosa, Muscularis, Submucosa/Mucosa Submucosa  LYMPHOID aggregates !  Function: secretion of immunoglobulins (IgA) IgA)

Differential Diagnosis

Pathophysiology -

Factors leading to appendicitis: Fecaliths ! Fecaliths are found in ~50% of patients with gangrenous appendicitis who perforate Rarely identified in simple disease Incompletely digested food residue ! Lymphoid hyperplasia ! Intraluminal scarring ! Tumors !  Bacteria and viruses ! The flora of the inflamed appendix DIFFERS from that of the normal appendix:   Anaerobes  E. coli   Bacteroides  gangrene and perforated   Fusobacterium Inflammatory bowel disease (IBD) ! 

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Steps in the Pathophysiology: 1) CLOSED-LOOP OBSTRUCTION of OBSTRUCTION of appendiceal lumen and continuous secretion 2) Obstruction leads to bacterial overgrowth and luminal distention Stimulates nerve endings of visceral afferent ! stretch fibers producing vague, dull, diffuse epigastric or periumbilical pain Reflex nausea and vomiting occurs as ! visceral pain increases 3) Increase in intraluminal pressure inhibits flow of lymph and blood Capillaries and venules are occluded but ! arterial inflow continues causing congestion

Clinical Manifestations “Appendicitis should be included in the differential diagnosis of abdominal pain for every patient in any age group unless it is certain that the organ has been previously removed.” -

The appendix’s anatomical location, which varies, directly influences the patient’s presentation RUQ – RUQ – Pregnancy  Pregnancy !  LUQ – LUQ – Midgut  Midgut Malrotation !  LLQ – LLQ – Situs  Situs Inversus ! 

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Classic History of Appendicitis

DUNPHY’S SIGN !

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1) Non-specific complaints occur first: Changes in bowel habits ! Malaise !  Vague, intermittent, crampy abdominal pain ! in epigastric or periumbilical region 2) Pain migrates to Right Lower Quadrant over 12 TO 24 HOURS  where it is sharper and can be definitely localized Transmural inflammation when appendix ! irritates the parietal peritoneum 3) Parietal peritoneal irritation may be associated with local muscle rigidity and stiffness 4) Nausea and vomiting, if present, follows the development of abdominal pain GASTROENTERITIS  nausea before pain !  Vomiting is mild and scant ! 5) ANOREXIA  is so common that the diagnosis of appendicitis should be questioned in its absence Presentation of PELVIC APPENDICITIS: Dysuria !  Urinary Frequency ! Diarrhea !  Tenesmus !  Pain in Suprapubic Region on rectal/pelvic exam !

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3)

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All patients should undergo a RECTAL EXAMINATION An inflamed appendix located behind the cecum ! or below the pelvic brim may prompt very little tenderness of the anterior abdominal wall A PELVIC EXAMINATION in women is mandatory to rule out urogynecologic conditions: Pelvic Inflammatory Disease ! Ectopic Pregnancy ! Ovarian Torsion ! Patients with simple appendicitis will normally only appear MILDLY ILL Pulse rate and temperature only slightly above ! normal If T > 38.3 C  and with presence of rigors, consider COMPLICATIONS: Perforation !  Phlegmon  –  matted loops of bowel adherent to !  the adjacent inflamed appendix Abscess Formation ! Classic Signs of Appendicitis: 1) DIRECT RLQ TENDERNESS The entire abdomen must be examined ! systematically starting in an area where the patient does not report discomfort !

MCBURNEY’S POINT  

Point of maximal tenderness in RLQ Located 1/3 of the way along a line originating from the ASIS, running to the umbilicus

ROVSING’S SIGN

INDIRECT REBOUND TENDERNESS Palpating in the LEFT LOWER QUADRANT ! causes pain in the RLQ Can be indirectly elicited by gentle abdominal ! percussion, jiggling the patient’s bed or mildly bumping the feet 4) OBTURATOR SIGN INTERNAL ROTATION  of the right hip ! causes pain Suggesting the possibility of PELVIC !  appendicits 5) ILIOPSOAS SIGN EXTENDING the right hip causes pain along ! the posterolateral back and hip Suggesting RETROCECAL appendicitis !  !

Clinical Scoring Systems -

Physical Examination -

Patient’s lie still to avoid peritoneal irritation caused by movement Report discomfort from a bumpy car ride, coughing, sneezing and other movements that replicate a Valsalva maneuver

Useful for ruling out appendicitis and selecting patients for further diagnostic work-up [INSERT: Alvarado Score / AIRS from Schwartz!]  Ancillary Diagnosis Laboratory Testing

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Laboratory testing DOES NOT identify patients with appendicitis but may help with differentials WBC  count is mildly to moderately elevated; leukocytosis 10,000-18,000 cells/uL; neutrophilic predominance or “LEFT SHIFT” Serum AMYLASE and LIPASE should be measured URINALYSIS  is indicated to exclude genitourinary conditions Inflamed appendix that abuts the ureter or urinary ! bladder may cause sterile pyuria or hematuria Every woman of childbearing age should have a PREGNANCY TEST Imaging

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Done when Hx/PE is suggestive but not convincing PLAIN FILMS are rarely helpful so are not routinely done; 6mm Wall thickening Lumen does NOT fill with enteric contrast Fatty tissue stranding Air surrounding the appendix Non-visualization of the appendix is a non! specific finding that SHOULD NOT be used to rule out the presence of appediceal or periappendiceal inflammation

Laparoscopic Appendectomy -

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Management -

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All patients should be prepared for SURGERY and have fluid and electrolyte abnormalities corrected Uncomplicated Appendicitis: OPEN or LAPAROSCOPIC APPENDECTOMY When the diagnosis in uncertain, observe the ! patient and repeat abdominal exam OVER 6-8 HOURS Phlegmon or Abscess: Broad-spectrum Antibiotics ! Drainage if abscess is >3 cm in diameter ! Parenteral fluids and bowel rest ! Appendix can be safely removed AFTER 6 TO 12 ! WEEKS when inflammation has diminished DISCHARGE: within 24 TO 40 HOURS of operation Most common POST-OP COMPLICATIONS: FEVER AND LEUKOCYTOSIS Persistence > 5 days should raise concern for ! INTRAABDOMINAL ABSCESS

Post-Operative Care -

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Performed under General Anesthesia Patient initially placed in supine position then placed in slight Trendelenburg with rotation of bed to the left once incision is made Types of Incisions: 1) NON-PERFORATED Appendicitis RLQ Incisions: a. MCBURNEY  OBLIQUE b. ROCKY-DAVIS  TRANSVERSE 2) PERFORATED Appendicitis MIDLINE Incisions: a. LOWER MIDLINE Laparotomy Pregnancy DOES NOT change the proportion of patients with the appendiceal base within 2 cm of McBurney’s point Identifying the Appendix: Locate the cecum ! Trace the TAENIA LIBERA (aka Anterior Taenia) ! Most visible of the 3 Taenia Coli Base of the appendix is identified distally !

Uncomplicated Appendectomy: Most patients can quickly be started on a diet and ! discharged home the following day Post-op ANTIBIOTICS are UNNECESSARY! ! Complicated Appendectomy: Patients should be continued on BROAD ! SPECTRUM ANTIBIOTICS for 4 TO 7 DAYS Post-op ILEUS  may occur so died should be !  started based on daily clinical evaluation Increased risk for SURGICAL SITE ! INFECTIONS  Tx: Open the incision and obtain culture STUMP APPENDICITIS ! Results from incomplete appendectomy Presents ~9 years after initial surgery   The remaining stump should be no longer than 0.5 cm   

Open Appendectomy -

Advantages: Less post-op pain ! Shorter hospital stay ! Faster recovery ! Fewer wound infections ! Facilitates exposure in the very obese ! Disadvantage HIGHER risk of intraabdominal abscess !  formation APPENDICEAL CRITICAL VIEW 10 o’clock  Appendix ! 3 o’clock  Taenia Coli ! 6 o’clock  Terminal Ileum !

 Appendicitis in Pediatric Patients -

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Establishment of diagnosis is more difficult PE Findings with Highest Sensitivity: Maximal tenderness in RLQ ! Inability to walk or walking with a limp ! Pain with percussion, coughing or hopping ! More rapid progression to rupture and the inability of the underdeveloped omentum to contain a rupture lead to significant morbidity in children  Appendicitis in Pregnancy

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Appendicitis is the most common surgical emergency during pregnancy Appendicitis could occur anytime during pregnancy but is RARE in the 3 rd Trimester Incidence of perforated or complex appendicitis is NOT increased in pregnant patients Laparoscopy was associated with 2.31 times increased risk of fetal loss compared to open Appendectomy is associated with 4% risk of fetal loss and 7-10% risk of early delivery  ALLIE 2018 