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Different anatomical positions of vermiform appendix. [TU 2064,68/5]
- The appendiceal tip may be found in a variety of locations, with the most common being retrocecal (but intraperitoneal) in approximately 60% of individuals, pelvic in 30%, and retroperitoneal in 7% to 10%.
Blood supply of appendix?
As a midgut organ, the blood supply of the appendix is derived from the superior mesenteric artery. The ileocolic artery, one of the major named branches of the superior mesenteric artery, gives rise to the appendiceal artery, which courses through the mesoappendix.
Explain why appendicitis is uncommon at two extremes of life. [TU 2064,68/5]
Pathophysiology of acute appendicitis?
- luminal obstruction - elevated pressure in the distal portion because of ongoing mucus secretion and production of gas by bacteria within the lumen - progressive distention of the appendix, the
- venous drainage becomes impaired, resulting in mucosal ischemia. With continued obstruction, full-thickness ischemia ensues, which ultimately leads to perforation.
- Causes of obstruction – fecolith, lymphoid hyperplasia, neoplasm, parasites like ascaris
Atypical presentation of acute appendicitis?
- Retroperitoneal appendix – flank or back pain
- Pelvic appendix – suprapubic pain
- Small bowel obstruction – due to appendicular perforation
Important signs in acute appendicitis?
- Rovsing sign - the presence of right lower quadrant pain on palpation of the left lower quadrant
- Obturator sign - right lower quadrant pain on internal rotation of the hip
- Psoas sign - pain with extension of the ipsilateral hip
CECT findings in acute appendicitis?
- Thickened, inflamed appendix with surrounding “stranding” indicative of inflammation.
- Appendix > 7 mm in diameter with a thickened, inflamed wall and mural enhancement or “target sign”
- Periappendiceal fluid or air is also highly suggestive of appendicitis and suggests perforation
Incisions in appendectomy?
- McArthur-McBurney - oblique muscle-splitting incision
- Rockey-Davis - a transverse incision
- Midline incision
Indications of interval appendectomy?
- Symptoms of recurrent appendicitis
- Presence of appendicolith
- Colonoscopy is recommended in all patients (>40 years) as a routine follow up after non operative management of complicated appendicitis
Normal appearing appendix intraoperatively, what next?
- Find out other causes
- Perforation of hollow viscus
- Meckles diverticulum
- Crohns disease
- Mesenteric lymphadenitis
- Tubo-ovarian or salpingeal diseases
- Gall bladder or duodenal perforation
Do we remove normal appendix?
Remove the normal appendix for following reasons.
1. appendectomy is advisable because it removes appendicitis from the differential diagnosis when the patient presents with recurrent right lower quadrant pain.
2. In addition, abnormalities of the appendix not apparent on gross inspection at the time of operation are sometimes identified on pathologic examination
What is incidental appendectomy?
- term applied when a grossly normal appendix is removed at the time of an unrelated procedure, such as a hysterectomy, cholecystectomy, or sigmoid colectomy.
- Do not remove appendix unless any abnormality is detected.
Appendicitis in elderly, Management?
- If peritonitis – emergency laparotomy
- If no peritonitis – CECT to confirm the diagnosis and to evaluate other pathology
- Lap appendectomy – procedure of choice
Management of carcinomid appendix?
- <1cm – are usually benign – appendectomy is sufficient
- >2cm with extension to base/mesoappendix – right hemicolectomy with regional lymphadenectomy
- Evidence of mucin spillage or mucinous ascites – appendectomy with peritoneal lavage with cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRC-HIPEC)
What is HIPEC?
Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery.
Positions of appendix
- Rigidity is often absent, and even application of deep pressuremay fail to elicit tenderness (silent appendix), the reason beingthat the caecum, distended with gas, prevents the pressure exerted by the hand from reaching the inflamed structure. However,deep tenderness is often present in the loin, and rigidity of thequadratus lumborum may be in evidence. Psoas spasm, due to theinflamed appendix being in contact with that muscle, may be sufficient to cause flexion of the hip joint.
- Occasionally, early diarrhoea results from an inflamed appendixbeing in contact with the rectum. When the appendix liesentirely within the pelvis, there is usually complete absence ofabdominal rigidity, and often tenderness over McBurney’s point is also lacking.
- In this case, the inflamed appendix lies behind the terminalileum. It presents the greatest difficulty in diagnosis because thepain may not shift, diarrhoea is a feature and marked retchingmay occur
Signs to elicit appendicitis
- ■ Pointing sign
- ■ Rovsing’s sign
- ■ Psoas sign
- ■ Obturator sign
Unusual presentations of acute appendicitis?
- When appendix is retrocecal or behind the ileum, it may be separated from the anterior abdominal peritoneum, and the abdominal localizing signs may be absent. Irritation of adjacant structures can cause diarrhoea, urinary frequency, pyuria or microscopic hematuria depending on location.
- When the appendix is located in pelvis, it may stimulate acute gastroenteritis, with diffuse pain, nausea, vomiting and diarrhoea.
- Rectal examination is most useful for atypical presentation suggestive of a pelvic or retrocecal appendix. There is localized tenderness or an inflammatory mass in the pararectal area.
Differential diagnosis of right lower quadrant pain
- 1. Gynecological disease
- - PID
- - Ectopic pregnancy
- - Ovarian cysts
- - Ovarian torsion
- 2. Urological diseases
- - Pyelonephritis
- - Ureteric colic
- 3. Other causes
- - Gastroenteritis - nausea and emesis before the onset of pain
- - Meckel diverticulitis
- - Peptic ulcer disease, diverticulitis and cholecystitis
- - Mesenteric lymphadenitis
- - Typhilitis - inflammation of wall of cecum
- Migration to the right iliac fossa,
- Tenderness in the right iliac fossa,
- Rebound pain,
- Elevated temperature (fever),
- Leukocytosis, and
- Shift of neutrophils to the left
- 2 points for T and L, one for all the others
- A score of 7 or more is strongly predictive of acute appendicitis.
What is Tzanakis Scoring?
- Tzanakis Scoring incorporates the presence 4 variables made up of specific signs and symptoms
- - Ultrasound - 6
- - Tenderness in RIF - 4
- - Right lower abdominal tenderness = 4points
- - Rebound tenderness - 3
- - Leukocytes > than 12,000 in the blood = 2
- A total score of 15 is the maximum that can be scored. Where a patient scores 8 or more points, there is greater than 96 percent chance that appendicitis exists.
Investigations for appendicitis
- 1. Complete blood count
- - WBC count elevation - infection
- - Left shift
- - Hematocrit - elevated in volume contraction, low in occult blood loss
- 2. Electrolyte profile
- - Hypokalemia, hypochloremic and metabolic alkalosis - prolonged vomiting
- - Low serum bicarbonate or metabolic acidosis - general tissue hypoperfusion, intestinal ischemia
- - Elevation of Urea, creatinine - volume depletion
- 3. Liver enzymes -
- - Mild elevation of transaminases (<2 times) - acute cholecystitis
- - Moderate elevation of transaminases (>3 times) CBD stones
- - Markedly elevation in transaminases - (>1000 IU/L) - acute hepatitis or ischemia
- 4. Pancreatic enzymes
- - Mild degree of hyperamylasemia - intestinal obstruction
- 5. Lactic acid level - indicator of tissue hypoxia
- - Mild lactic acidosis - arterial hypotension
- - Ongoing elevation inspite of resiscutitation - progression of tissue ischemia
- 6. Urinalysis to rule out UTI, hematuria due to nephrolithiasis and renal and urothelial cancer
- Appendicitis in pregnancy
- Nausea and vomiting can be incorrectly attibuted to the morning sickness
- Tachycardia is normal finding in pregnancy
- Fever, a common finding in appendicitis is often absent in pregnancy
- Leukocytosis is common in pregnancy. WBC count of 12000 is normal finding in pregnancy. However, a left shift is always abnormal and requires further investigations
- Appendicitis in children
What are the features of appendicitis in USG?
- - aperistaltic, noncompressible, dilated appendix (> 6mm outer diameter)
- - distinct appendiceal wall layers
- - target appearance (axial section)
- - appendicolith
- - periappendiceal fluid collection
What is target sign appearence in acute appendicitis?
Target sign appearance is caused by a fluid-filled centre (hypoechoic centre), surrounded by a hyperechoic ring (mucosa/submucosa) which is surrounded by a hypoechic muscularis layer giving a target sign on axial imaging.
Features of appendicular abscess
- It takes >72 hours for formation of appendicular abscess
- High grade fever with chills and rigor
- Toxic look, tachycardia
- Persistant vomiting because of pyloric spasm
Perforation is more common in children and in elderly, in children omentum is poorly developed and in elderly because of athersclerosis
What does grid iron mean?
- Gridiron means a frame of parallel bars or beams, typically in two sets arranged at right angles, in particular.
- In appendectomy, gridiron indicates the separation of internal oblique and transverse abdominis.
Incisions in appendectomy?
- The gridiron incision - is made at right angles to a line joining the anterior superior iliac spine to the umbilicus, its centre being along the line at McBurney’s point. (3cm up, 2 cm down , total 5 cm) If better access is required,it is possible to convert the gridiron to a Rutherford Morison incision
- A transverse skin crease (Lanz) incision has become more popular, as the exposure is better and extension,when needed, is easier. The incision, appropriate in length to the size and obesity of the patient, is made approximately 2 cm below the umbilicus centred on the mid-clavicular–midinguinal line. It is cosmetically better as it is along the line of langer.
- Rocky devis incision is like Lanz but Lanz is curved, and Rocky devis is straight
- Fowler Weir Incision
HPE in appendectomy
- - to confirm diagnosis
- - carcinoid syndrome
- - ileocecal TB
- • Temp, BP, Pulse chart.
- • Marking the mass to identify the progression/regression.
- • Antibiotics (Ampicillin, metronidazole, gentamycin,or other drugs given depending on severity and requirement).
- • IV fluids.
- • Analgesics.
- • NPO for bowel rest
- • Daily counts - normal count in appendicitis is about 11-16 thousands. Count >20,000 may indicate appendicular abscess.
- • Initial nasogastric aspiration.
- Patient usually shows response by 48 to 72 hours an