APPENDICITIS
Anatomy and physiology of
appendix
The appendix is a slender, worm-shaped
pouch, averaging 510cm in length, that
protrudes from the top of the colon in the
lower right abdomen
Location
McBurneys point:one-third of the
way from the anterior,superior iliac
spine to the umbilicus.
Pelvis and right ilac fossa appendix
Anterior or posterior ileum appendix
Retrocaceal appendix
Right lateral caceal appendix
Retrocaceal appendix
Supply & nerve
Appendix artery: a final artery ,from
ileocolic artery
Appendix vein :
portal vein
sympathetic nerve :celiac plexus and
lesser splanchnic nerve
T10,T11
Acute appendicitis
Appendicitis is a
common
cause of
abdominal
pain
life-threatening condition because of systemic
sepsis (systemic inflammatory response
syndrome/SIRS leading to multiple organ failure)
following rupture and abscess formation
Etiology
Obstruction:
anatomy :wormed-shaped
narrow
plenty of lymph glands
mechanical reason:
food residue, ascarid,
tumor,etc.
Etiology
Gastrointestial disease
Bacteria invasion:
all kinds of G- bacilus
Pathology
Four type:
Acute simple appendicitis
Acute purulent appendicitis
Perforation and gangrenous
Appendiceal abscess
Acute simple appendicitis
Acute purulent
appendicitis
Perforation and gangrenous
Gangrenous
Perforation
Appendiceal abscess
Results
Inflammation disappear
Inflammation localization
Inflammation diffusion
Clinical manifestation
symptoms :
abdominal pain :
Periumbilical or epigastric pain that
migrates to right lower quadrant
Pain becomes persistent and well
localized. It worsens with moving,
breathing deeply, coughing,
sneezing, walking, or being touched
Symptoms :
Gastrointestinal symptoms:
Anorexia, nausea, and vomiting
occur after the onset of pain
Constipation
Diarrhea
bladder and rectum stimulus
symptoms
Symptoms
General symptoms :
tired ,headach
fever
Rapid pulse
SIRS (systemic inflammatory
response syndrome)
Signs
Tenderness in the right lower
abdomen, usually about a third of
the distance from the navel to the
top of the hip bone
peritoneal irritation sign : muscular
rigidity
Blumberg sign
bowel sounds disappear
Others
Rovsings sign:pain in the right
lower quadrant upon palpation of
the left lower quadrant.
Psoas sign :pain on active
elevation of the legs
The obturator sign: pain on
internal and external rotation of
the hip
Rectal exam & vaginal exam
Lab test
Mild to moderately elevated WBC with
left shift is typical but rarely may be
normal, range of 11000-17000/mm 3
over 20000/ mm3
perforation
UA may show ketonuria or a few RBCs
or WBCs
pregnancy test (women only)
Lab test
B-us
X-ray
Diagnostic abdominal puncture
Diagnosis
Periumbilical or epigastric pain
that migrates to right lower
quadrant
Tenderness in the right lower
abdomen, usually about a third
of the distance from the navel
to the top of the hip bone
Differential diagnosis
Two type :
A:
B:
surgery
required surgery
not required
Differential diagnosis
Required surgery:
Perforation of gastointestinal tract
ulcer,tumor, diverticulitis
obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsion
Meckel diverticulitis
Tumor
Differential diagnosis
Not required surgery
Pelvic inflammation
Mesenteric adenitis:at exploration a
normal appendix and enlarged lymph
nodes in the mesentery
Viral & bacterial gastroenteritis
Pneumonia, pleurisy
MATERIALS AND METHODS
The Alvarado score
Symptoms
Score
migratory right iliac fossa pain
Signs nausea/vomiting
1
RIF tenderness
2
anorexia
1 fever >37.30C
1
Laboratory
test
rebound pain in RIF
1 leucocytosis (>10 X 109/L)
2
neutrophilic shift to the left >75%
Total score
1
10
CONCLUSION
Treatment
Early operation:
surgical removal(appendectomy)
Acute simple appendicitis:
appendectomy
Acute purulent and gangrenous
appendicitis:
appendectomy and/or drainage
Treatment
Appendiceal abscess:
if local in right low quadrant
antibiotic therapy and general treatment
if infection diffusion
incision and drainage
Treatment
Operation
Incision :
incision over the point of maximal
tenderness,generally at McBurny point
true McBurneys incision
tansvers skin incision
36cm long
Incision
McBurneys
incision
Incision
tansvers
skin
incision
Treatment
Operation
Process:
The taenia of
the colon are
followed to
the base of
the appendix
Treatment
Operation
Process:
Mesoappendix
is divided
between
clamps and
ligated
Treatment
Operation
Process:
The base of
appendix is divided
and ligated 0.5cm
from caceum and
inverted using a
purse-string
Treatment
Suspected case: not definite.
Admit the patient to hospital for
further observation 12-24hrs
Operation
exploration incision
Treatment
Antibiotic thearpy:
Acute simple appendicitis
Contraindication of operation
Appendiceal abscess
Treatment
Antibiotic thearpy
antibiotics: broadspectrum antibiotics
ampicillin-sulbactam
gentamycin
triad drugs
metronidazol
3rd generation cefotides
Treatment
New method :
laparoscopy appendectomy
Complication
Acute appendicitis:
Abdomen abscess
Inter or extra fistula
Phylephlebitis
Complication
Operation :
Incision infection
Peritonitis and abdomen abscess
Bleeding
Stool fistula
Stump infection
Adhesive intestinal obstruction
Appendicitis in neonate
Seldom
Non-specific clinical manifestation
Anorexia, nausea, and vomiting diarrhea
dehydration
Difficult in early diagnosis
High rate of perforation
High mortality
Appendicitis in neonate
Diagnosis &Treatment
Carefully physical exam
Early operation
Appendicitis in child
Quick onset and severe
high fever and vomiting present early
Non-typical tenderness at right low
quadrant
High rate of perforation
High mortality
More complication
Appendicitis in child
Treatment:
Early operation
Transfusion and correct dehydration
Broadspectrum antibiotics
Appendicitis in pregnancy
Uterus enlargement
appendix displaced
superiorly
Tenderness
site upper shift
elevation of
abdominal
wall
Inconspicuous of
tenderness
rebound tenderness
muscular rigidity
Without
adherent
blanket of
omentum
Peritonitis
diffusion
Appendicitis in pregnancy
Treatment :
Operation :appendectomy
To late pregancy :early operation
Superior Incision
No drainage
Broadspectrum antibiotics
Parturient with perforation :
cesarean section and appendectomy
Appendictis in the elderly
Less well-defined symptoms and
signs
Severe pathologic type
Error diagnosis easily
High rate of perforation
Pay attention to tumor
Chronic appendicitis
Etiology and pathology
Clinic feature and diagnosis
right low quadrant pain
local tenderness
x-ray
Treat
appendectomy
