surgery_1.3 appendix (lecture).docx

8/14/2019 SURGERY_1.3 Appendix (Lecture).docx

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ROBZ , Pat, Suzie, Dale, Lenard, Morrice, Charlie, GEMMY(Italicized texts are from Doc Biberas side lecture notes and notes not found in the upper batchs trans)

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I.3a Appendix (Lecture)Dr. Bibera

June 18, 2013ANATOMY AND FUNCTION

Appendix 1st become visible in the 8th week ofdevelopment as a protuberance of the terminal part ofthe cecum

During development, the growth rate of cecum exceedsthat of appendix, displacing the appendix mediallytoward the ileocecal valve

The base arises from the posteromedial aspect of thececum, where three taeniae coli meet

The relationship of the base of the appendix to thececum remains constant, whereas the tip can be foundin a retrocecal, pelvic, subcecal, preileal or rightpericolic position

Lymphoid tissue appears in the appendix 2 weeks afterbirth increases throughout puberty and remainssteady for the next decade steadily decreases withage

60 years and , virtually no lymphoid tissue remainswithin the appendix complete obliteration of theappendiceal lumen in the elderly is common

Secretory immunoglobulins (IgA) are produced as partof gut-associated lymphoid tissues to protect the milieuinterior

The appendix is useful but not indispensable Congenital defects are rare and clinically insignificant Appendectomy does not predispose to bowel cancer oralter the immune system

Three taenia coli converge at the junction of the cecumwith the appendix and can be a useful landmark toidentify the appendix

Appendiceal artery, a branch of the ileocolic artery,supplies the appendix.

Normal/usual location of the appendix is retroc ecalbut within the peritoneal cavity

Figure 1 . Various anatomic positions of the vermiformappendix.

LENGTH: Varies from < 1 cm to 30 cm (most are 6 -9cm)

An immunologic organ that actively participates in thesecretion of immunoglobulins, specially IgA

An integral part of gut-associated lymphoid tissue but itis NOT ESSENTIAL so appendectomy is not associatedwith any predisposition to sepsis or immunecompromise

APPENDICITIS One of the most common causes of abdominalemergencies

Accounts for 1% of all surgical operations Rare in infants and elderly (narrow lumen in infants;dilated in the elderly obstruction)

Nothing can obstruct in the elderly 2nd-4th decade, slight M:F predominance: 1.2-1.3:1 Lifetime rate of appendectomy is 12% for men and25% for women, with ~ 7% of all people undergoingappendectomy for acute appendicitis

Despite use of UTZ, CT scan, and laparascopy, rate ofmisdiagnosis (negative appendectomy) remains

constant (15.3%), as has the rate of appendicealrupture.

Percentage of misdiagnosed cases is significantly higherin women than in men (22.2 vs. 9.3%)

The negative appendectomy rate is 30-35%

ETIOLOGY Results from obstruction of the lumen followed byinfection (dominant etiology)

Others: Fecalith (most common cause of luminal obstruction,

40% of cases [acute appendicitis] ) 65% gangrenous; 90% gangrenous with perforation

Fever before pain = NOT appendicitis hyperplasia of lymphoid tissue (*hypertrophy in

Schwartz) inspissated barium from previous x-ray studies Strictures tumors (most common is carcinoid 80%) Vegetable and fruit seeds (tomatoes) Intestinal parasites (ascaris, schistosomiasis)

PATHOGENESIS Proximal obstruction of the appendiceal lumen producesa closed-loop obstruction, and continuing (mucus) secretion by the appendiceal mucosa producesdistention.

Distention ( intraluminal pressure) of the appendixstimulates nerve endings of visceral afferent stretchfibers (T8-T10), producing vague, dull, diffuse (visceral) pain in the mid-abdomen or lower epigastrium.

Peristalsis is also stimulated by the sudden distention,so that some cramping may be superimposed on thevisceral pain early in the course of appendicitis.

Distention continues from continued mucosal secretionand from multiplication of the resident bacteria of theappendix. nausea and vomiting and severity ofdiffuse visceral pain

(Organ pressure > capillary pressure) As pressure inthe organ increases, venous pressure is exceeded.Capillaries and venules are occluded, but arteriolarinflow continues, resulting in (venous) engorgement andvascular congestion. The inflammatory process ofsurrounding tissue soon involves the serosa of theappendix and in turn parietal peritoneum in theregion, producing the characteristic shift in pain to theright lower quadrant.

Serosa & peritoneum classic location of symptoms The mucosa of the appendix is susceptible toimpairment of blood supply, thus its integrity iscompromised early in the process, allowing bacterialinvasion.

As progressive distention encroaches on first thevenous return and subsequently the arteriolar inflow,the area with the poorest blood supply suffers most.

As distention, bacterial invasion, compromise ofvascular supply, and infarction progress, perforationoccurs, usually through one of the infracted areas onthe antimesenteric border

Persistent distension perforation of wall

BACTERIOLOGYSame colonic flora except Porphyromonas gingivalis(adult)Routine cultures are questionable


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I.3a Appendix (Lecture)Page 2 of 5

Table 1. Common bacteria found in appendicitis

CLINICAL MANIFESTATIONSSYMPTOMS

Pain Movement causes pain over RLQ Initially diffusely centered in lower epigastrium or

periumbilical area, moderately severe, and steady,sometimes with intermittent cramping

superimposed. KOCHERS SIGN periumbilical pain that localizesat the RLQ after 4 6 hours (Schwartz: this periodvaries from 1-12 hours but is usually within 4-6hours)

45% fail to follow the visceral to somatic pattern(common in elderly) depending on the POSITION ofthe appendix

Variable position of the tip of the appendix ormalrotation allows for variability in pain location

Most common is retrocecal area (hindi si sure siDoc hehe)

Determined by the position of the appendix andwhether it is ruptured

Cutaneous hyperesthesia may present early in thearea supplied by right spinal nerves T10, T11 andT12

Anorexia Present in almost all patients Nearly always accompanies acute appendicitis

Nausea and vomiting Vomiting fewer than 75% occurring after onset of

pain Constipation or obstipation and diarrhea

subsequent episodes of emesis may occur withobstipation or diarrhea

appendix is near the ileum can stimulate thebowel

pain relieved by moving the bowel Fever vital signs show mild tachycardia or temperature

elevation >1C Murphys Triad

pain, vomiting, feverDICTUM: Anorexia Pain Vomiting = ACUTE

APPENDICITIS

SIGNS Signs of peritoneal irritation in anteriorly positionedappendix

Fever elevation >1C Movement causes pain over the RLQ Mc Burneys Sign

localized and maximum tenderness over RLQ(McBurneys point)

Blumbergs sign rebound tenderness on the RLQ

Dunphys sign cough elicits pain in 85%

Rovsings sign contralateral tenderness in the RLQ with palpation in

the LLQ Psoas/ Obrastova sign

stretching the iliopsoas muscle by extending thethigh while lying cause pain

Obturat ors sign passive internal rotation of the flexed right thigh

with patient supine, indicates irritation near theObturator internus

Retrocecal appendicitis may present with flank or back pain

Pelvic appendicitis principally suprapubic pain

may give pain on rectal examination with pressureon the cul-de-sac of Douglas Retroileal appendicitis

testicular pain Muscle guarding Rectal Exam Abdominal mass usually in complicated cases:

Abscess Omentum Loops of intestines

LABORATORY FINDINGS Complete Blood Count

Mild leukocytosis of 10,000 18,000/mm3 is usually

present in patients with acute, uncomplicatedappendicitis and is often accompanied by moderatepolymorphonuclear predominance

WBC (shift to the LEFT); 90% neutrophils, 10%the rest

CRP determination Not really necessary according to Doc

Urinalysis Pyuria is present when the inflamed appendix lies near the ureter or bladder Bacteriuria indicates urinary tract infection

IMAGING STUDIES When used, you are 85-90% right Plain Films of the Abdomen

Rarely helpful in diagnosing appendicitis, althoughplain radiographs may be of significant benefit whenruling out other pathology such as cholecystitis,perforated PUD, perforated viscus, or pyelonephritis

Chest radiography rules out right lower lung fielddisease, which may stimulate right lower quadrantpain by irritating T10, T11 and T12 nerves

Gentle Barium Enema Shows nonfilling of the appendix and mass effect on

the medial and inferior borders of the cecum;complete filling of the appendix rules outappendicitis.

Helpful in female if diagnosis is questionable Extrinsic procedure defect in the cecum (inverted 3

sign)

Ultrasound Over 90% accurate Findings of non-compressible appendix over 6mm in

diameter Complex mass Sonographically, the appendix is identified as a

blind-ending, nonperistaltic bowel loop originatingfrom the cecum

with maximal compression, the diameter of theappendix is measured in the anteroposteriordimension

A scan is considered positive if a noncompressibleappendix 6 mm or greater in the anteroposteriordirection is demonstrated

The presence of an appendicolith establishes thediagnosis

The presence of thickening of the appendiceal walland periappendiceal fluid is highly suggestive.

May differentiate from perforation and abscessformation


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CT Scan Computed tomographic (CT) scan is useful especially

with suspected abscess 90% accurate Finding of edema, fluid, appendolith and diameter of

over 6mm In cases of suspected appendicitis may be used

when diagnosis is not certain

Laparoscopy

can be diagnostic and therapeutic, especially infemales to rule out gynecologic pathology

Table 2 Alvarados Scoring for Acute AppendicitisALVARADOS SCALE FOR ACUTE APPENDICITIS

DIAGNOSISSymptoms Migration of pain to RLQ 1

Anorexia 1Nausea and/or vomiting 1

Signs RLQ tenderness 2Rebound tenderness 1Elevated temperature 1

Lab values Leukocytosis 2Left shift in leukocyte count* 1*

TOTAL 10

Interpretation: 9 to 10 are almost certain to haveappendicitis (positive)

7 to 8 have a high likelihood ofappendicitis (likelihood)

5 and 6 compatible, and a case can be built forimaging those with scores of 7 and 8

0 to 4 make it extremely unlikely (but notimpossible) (unlikely so just observe the patient for awhile)

Tzanaki Scale may also be utilized as an alternative *(MAS) Modified Alvarado Scoring detects shift tothe left

Not used in the Philippines because yung ibang labsdaw kasi hindi naman ginagawa or hindi marunongmaginterpret yung doctors?

DECISION MAKING ALGORITHM

Figure 2. Clinical algorithm for suspected cases of acuteappendicitis. If gynecologic disease is suspected, a pelvic

and endovaginal ultrasound examination is indicated.

STAGES/TYPES OF APPENDICITIS

1. ACUTE APPENDICITIS increase pressure within the lumen increase mucus secretions edema and diapedesis of bacteria production of purulent material infection localized to the appendix clinically felt as visceral pain

2. ACUTE SUPPURATIVE APPENDICITIS increase pressure causes venous obstruction andischemia

bacteria invades the wall of the appendix

somatic pain due to irritation of the parietal peritoneum whitish purulent

3. GANGRENE APPENDICITIS venous and arterial thrombosis wall infarct occurs bacterial escape and peritoneal cavity contamination

4. PERFORATIVE APPENDICITIS abscess formation peritonitis (if the omentum is not well developed) ngumingiti na yung appendix?

ACUTE APPENDICITIS IN SPECIFICPOPULATIONS

ACUTE APPENDICITIS IN THE YOUNG More difficult than in the adult (inability of youngchildren to give an accurate history, diagnostic delaysby both parents and physicians, and the frequency ofgastrointestinal upset in children).

More rapid progression to rupture and the inability ofthe underdeveloped greater omentum to contain arupture lead to significant morbidity rates in children.

Children younger than 5 years of age have a negativeappendectomy rate of 25% and an appendicealperforation rate of 45%.

The incidence of major complications afterappendectomy in children is correlated withappendiceal rupture.

The incidence of intra-abdominal abscess is also higherafter the treatment of perforated appendicitis ascompared to nonperforated cases (6% vs. 3%).

The treatment regimen for perforated appendicitisgenerally includes immediate appendectomy andirrigation of the peritoneal cavity.

Laparoscopic appendectomy has been shown to be safeand effective for the treatment of appendicitis inchildren.

ACUTE APPENDICITIS IN THE ELDERLY Incidence of appendicitis in the elderly is lower than inyounger patients

However, the postop morbidity and mortality aresignificantly increased in this patient population.

Delays in diagnosis, a more rapid progression toperforation, and comorbid disease are all contributingfactors. The diagnosis of appendicitis may be subtlerand less typical than in younger individuals, and a highindex of suspicion should be maintained.

In patients older than age 80 years, perforation rates of49% and mortality rates of 21% have been reported.

Possible DDx in ill older px: diverticulitis, perforated PU,cholecystitis, pancreatitis, ruptured aortic aneurysm

Diverticulitis mostly in sigmoid colon left-sided perforation

ACUTE APPENDICITIS DURING PREGNANCY Frequently encountered extrauterine disease requiringsurgical treatment during pregnancy ( 1 in 2000 pregnancies).

Appendectomy for presumed appendicitis is the mostcommon surgical emergency during pregnancy.

More frequent during the first two trimesters. At 3 rd trimester, pain is more cephalad and over theflank

Symptoms same as non-pregnant Perforation leads usually to generalised peritonitis dueto lack of omentum

As fetal gestation progresses, the diagnosis ofappendicitis becomes more difficult as the appendix isdisplaced laterally and superiorly.

Performance of any operation during pregnancy carriesa risk of premature labor (10 to 15%); risk is similarfor both negative laparotomy and appendectomy forsimple appendicitis.

Appendiceal perforation is a significant factorassociated with both fetal and maternal death


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Fetal mortality increases from 3 to 5% in earlyappendicitis to 20% with perforation.

Figure 3 . Location of the appendix during pregnancy

ACUTE APPENDICITIS IN PATIENTS WITH AIDS ORHIV INFECTION

There appears to be an increased risk of appendicealrupture in HIV-infected patients.

HIV-infected patients do not manifest an absoluteleukocytosis; however, if a baseline leukocyte count isavailable, nearly all HIV-infected patients withappendicitis demonstrate a relative leukocytosis

In the HIV-infected patient with classic signs andsymptoms of appendicitis, immediate appendectomy isindicated.

APPENDICEAL RUPTURE Immediate appendectomy Overall rate is 25% Children have 45% (dahil daw late magconsult; bakanag aarti-artihan lang haha) while 51% for patients>65 (dahil daw matigas ang ulo ayaw pa pa-check up)

No accurate way of determining when and if anappendix will rupture prior to resolution of theinflammatory process (accdg to Doc: increase incidenceof rupture occurs within 36 hours)

Studies in selected cases, observation and antibiotictherapy alone may be an appropriate treatment foracute appendicitis

Pero sabi ni Doc these studies naman didnt includethe mortality after such modality

Remember, perforation causes very high fever, usually>38C

CLINICAL MANIFESTATIONS Temp > 39 oC WBC> 18,000/mm3 (majority) localized rebound tenderness generalized peritonitis will be present if the walling-offprocess is ineffective in containing the rupture

(in 2-6% cases) an ill-defined mass (Phlegmon) isdetected on PE (RLQ)

consists of matted loops of bowel adherent to theadjacent inflamed appendix, or a periappendicealabscess

symptoms are longer in duration, developing over 5to 7 days

DIAGNOSIS AND TREATMENT CT Scan Antibiotics in cases of small abscess Peritoneal abdominal drainage Surgical drainage and interval appendectomy in 6-10weeks

DIFFERENTIAL DIAGNOSIS Almost all causes of abdominal pain Rule: Never place appendicitis lower than acuteabdomen

Accuracy of diagnosis is 85% If accuracy is less, unnecessary appendectomy are

being performed If high, bona fide patients, unnecessarily observed

when they should be receiving prompt surgicalintervention

Common errors (in descending order of frequency):

acute mesenteric lymphadenitis, no organicpathologic condition, acute pelvic inflammatorydisease, twisted ovarian cyst or ruptured graafianfollicle, and acute gastroenteritis

Older patients Diverticulitis (sigmoid colon; LEFT-sided appendicitis; pag sumakit na, perforated agad [agad-agadtalaga?!] di lang inflammed) , perforated pepticulcer, cholecystitis, pancreatitis, ruptured aorticaneurysm

TREATMENT Treatment is always operative because theobstructed lumen will not resolve with antibiotics alone

acute appendicitis without rupture is treated withimmediate appendectomy after the medical evaluationis complete

General objectives: Fluid replacement Prophylactic antibiotics Examination under anesthesia

UNCOMPLICATED CASES OF APPENDICITIS

Open appendectomy utilizing Rockey-Davis orMcBurneys incision (transverse)

Handling of the stump: Simple ligation or drop method Inversion Ligation and inversion often leads to abscess and

mucocele or cecal tumor

LAPARASCOPIC APPENDECTOMY (MIS) Minimally Invasive Surgery (MIS) Usually 3 butas lang Both diagnostic and therapeutic Reduces perforation Negative appendectomy rate < 10%

COMPLICATED APPENDICITIS

Figure 4 . Algorithm summarizing the treatment of acuteappendicitis.

Ruptured Peritonitis with abscess Small bowel obstruction

OTHER DISEASES OF THE APPENDIXTUMORS OF THE APPENDIX

Benign Mucinous cystadenoma

Malignant Tumors


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Mucinous cystadenocarcinoma Argentafinoma or carcinoid tumor Adenocarcinoma

TREATMENT Appendectomy

In-situ or tumor confined to mucosa Carcinoid< 1cm

Right hemicolectomy

INTRA-ABDOMINAL ABSCESSES Secondary to peritoneal contamination fromgangrenous or perforated appendicitis

Incidence has decreased markedly since theintroduction of potent antibiotics

Sites of predilection for abscesses are the appendicealfossa, pouch of Douglas, subhepatic space, andbetween loops of intestine

Transrectal drainage is preferred for an abscess thatbulges into the rectum.

CHRONIC APPENDICITIS Pain lasts longer and is less intense than that of acuteappendicitis, but is in the same location

Lower incidence of vomiting, but anorexia andoccasionally nausea, pain with motion, and malaise arecharacteristic.

Leukocyte counts are predictably normal and CT scansare generally nondiagnostic.

Laparoscopy can be effectively used in themanagement of this clinical entity.

Appendectomy is curative.

APPENDICEAL PARASITES Ascaris lumbricoides is the most common, a widespectrum of helminths have been implicated, includingEnterobius vermicularis, Strongyloides stercoralis, andEchinococcus granulosis.

Live parasites occlude the appendiceal lumen, causingobstruction.

Once appendectomy has been performed and thepatient recovered, therapy with helminthicide isnecessary to clear the remainder of the gastrointestinaltract.

Amebiasis can also cause appendicitis. Invasion of themucosa by trophozoites of Entamoeba histolytica incitesa marked inflammatory process.

Appendectomy must be followed by appropriateantibiotic therapy (metronidazole).

MISCELLANEOUS TREATMENTINTERVAL APPENDECTOMY

Provides much lower morbidity and mortality rates thanimmediate appendectomy.

50% of patients treated conservatively never developmanifestations of appendicitis, and those who do, cangenerally be treated nonoperatively.

INCIDENTAL APPENDECTOMY Appendectomy that are done incidentally uponlaparotomy

Throwback Tuesday Presents

Two years ago

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