GIS-K-25

ACUTE APPENDICITIS

Appendiceal Mass / Abscess

Syahbuddin Harahap

Division of Digestive Surgery

Department of SurgeryDepartment of Surgery

Faculty of Medicine University of North Sumatera

Adam Malik Hospital

INTRODUCTION

The appendix is :

-Wormlike extension of the cecum (vermiform appendix).

-Length is 8-10 cm (ranging from 2-20 cm).

-Fifth month of gestation-Fifth month of gestation

-Several lymphoid follicles.

Etiology: Obstruction of the lumen appendix followed by infection

�Catarrhal appendicitis. -lymphoid hyperplasia (60% children)

-Gastro enteritis -Virus -Acute respiratory infection -Mononucleosis

�Obstructive appendicitis -fecalith 35% adults.

-foreign body / parasites (4%)

- tumors (1%)

Pathophysiology

�Wangensteen proposed1. Closed loop obstruction2. Increase in luminal pressure. 3. Exceeds capillary pressure causes mucosal ischemia4. Luminal bacterial overgrowth and translocation bacteria across the

appendiceal wall result :-Inflammation-Inflammation-Edema-Necrosis � perforation occur about 48 hours .

�If the body successfully walls off the perforation Appendiceal Mass

�If the perforation is not successfully walled off � Diffuse peritonitis will

develop.

Problem:

Appendicitis can mimic several abdominal conditions.

�Laboratory test�Imaging investigation

Statistics report�1 of 5 cases is misdiagnosed�1 of 5 cases is misdiagnosed

�Normal appendix is found in 15-40% Emergency appendectomy.(Negative Appendectomy)

Differential diagnosis of acute appendicitis

Surgical

• Acute Intestinal obstruction

• Intussusception

• Acute cholecystitis

• Perforated peptic ulcer

• Mesenteric adenitis

• Acute Meckel's diverticulitis

Urological

• Right ureteric colic

• Right pyelonephritis

• Urinary tract infection

• Right Acute epididymitis

Gynaecological

• Ectopic pregnancy• Acute Meckel's diverticulitis

• Acute Pancreatitis

Medical

• Gastroenteritis

• Basal Pneumonia dextra

• Terminal ileitis

• Ectopic pregnancy

• Ruptured ovarian follicle

• Torted ovarian cyst

• Salpingitis/pelvic inflammatory disease

Differential diagnosis of appendicitis appendicitis can mimic several abdominal conditions.

Lab Studies:

Complete blood cell countA mild elevation of WBCs (ie, >10,000/µL)

Urinalysis

�Mild pyuria �relationship of the appendix with the right �Mild pyuria �relationship of the appendix with the right

ureter.

�Severe pyuria �in UTI.

�For women of childbearing age,Ectopic pregnancy� test urin (beta-hCG)

On physical examination

•Lying down

•Flexing their hips

•The most common symptom of appendicitis is :- Acute abdominal pain.- Epigastric or Periumbilical pain migrating to the - Epigastric or Periumbilical pain migrating to the right lower quadrant (RLQ) of the abdomen.

- Vomiting, nausea, and anorexia- Afebrile or has a low-grade fever , 38 º C

•Higher fevers are associated with a perforated appendix

Special maneuvers

�McBurney sign

�McBurney's point

it is only the area

of greatest tenderness

�Blumberg sign

�Rovsing’s Sign

�Dunphy sign Cough Test

�Obturator sign

�Psoas sign

�Markle sign

Location appendix during pregnancy

INDICATIONS

Consider an appendectomy for patients with a history of :

•Persistent abdominal pain•Persistent abdominal pain•Fever•Clinical signs of localized or diffuse peritonitis•Especially if leukocytosis is present.

Imaging Studies

Abdomen plain film: Fecalith within the appendixUrolithiasis right middle third

MANTRELS SCORE

Characteristic Score

M = Migration of pain to the RLQ 1

A = Anorexia 1

N = Nausea and vomiting 1

T = Tenderness in RLQ 2

Alvarado score 1986

R = Rebound pain 1

E = Elevated temperature 1

L = Leukocytosis 2

S = Shift of WBC to the left 1

Total 10

A score of 7 or more is strongly predictive of acute appendicitis.

Sonography

Advantages of sonography

1. Noninvasiveness,2. Short acquisition time3. Lack of radiation exposure4. Potential for diagnosis of

normal less than 6 mm

4. Potential for diagnosis of other causes of abdominal pain

5. Pediatric patients6. Women of childbearing age. 7. Pregnant women

CT scan

-Oral contrast medium

-Rectal Gastrografin enema

�Reserved for patients -Uncertain diagnosis

more than 6 mm

-Uncertain diagnosis -Severe obesity.

If the clinical picture is unclear

�Short period (4-6 h) of watchful waiting

�USG / CT scan -May improve diagnostic accuracy

�Without a definite diagnosis - return for continued or recurrent symptoms - follow-up examination in 24 hours.

Complications

• Perforation

• General Secondary Peritonitis

• Appendiceal Mass

• Appendiceal Abscess

• Pylephlebitis is suppurative thrombophlebitis of the • Pylephlebitis is suppurative thrombophlebitis of the

portal venous system

• Hepatic absces

• Chills

• High fever

• Jaundice

TREATMENTMedical therapy

�Resuscitated adequately with fluids .

�Preoperative prophylactic antibiotics-Acute Appendicitis single agent second-generation cephalosporin.

-Perforated appendix triple antibiotic therapy -Perforated appendix triple antibiotic therapy Ampicillin , gentamycin , metronidazol

�Antibiotic prophylaxis should be administered before every appendectomy.

�Antibiotic treatment may be stopped. -Becomes afebrile -WBC count normalizes

Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)

2. Laparoscopic appendectomy

� If normal appendix removed need to look for:

Meckel's diverticulum-Meckel's diverticulum

- Acute salpingitis

- Crohn's disease

�If the body successfully walls off the localized perforation

Appendiceal Mass

�RLQ mass�The pain may actually improve. �Symptoms do not completely resolve. �Still have right lower quadrant pain�Still have right lower quadrant pain�Decreased appetite�Change in bowel habits (eg, diarrhea, constipation)�Intermittent low-grade fever.

Treatment of

�Appendiceal Mass Nonoperative management Becomes walled off by omentum and ajacent viscera.Initially treated with intravenous broad-spectrum antibiotic

�Appendiceal Abscess � USG or CT scan

-Percutaneous aspiration-Drain placement

Intravenous antibiotics are continued until the patient Intravenous antibiotics are continued until the patient - afebrile for 24 hours- return of normal gastrointestinal function- normal WBC count with a normal differential.

At this time, patients are switched to oral antibiotics for a total antibiotic course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weeks later.

Acute Appendicitis Appendicitis Perforation