‫בס"ד‬
Diseases of the
Appendix
‫יונתן אברהם דמה‬
Appendicitis
> Disease of the young
> Incidence
> Rare in very young children and elderly
> Overall mortality 0.25%
> Higher mortality in age extremes
Plan
1. Introduction
2. Diagnosis
3. Treatment preop, op and post op
4. Special consideration
5. Complication
6. Neoplasm
Introduction
> Embryology
> Normal anatomy
> Pathophysiology
> Bacteriology
Embryology
Embryology
Anatomy
Anatomy
Pathophysiology
Diagnosis
> Clinical
> History
> Physical examination
> Laboratory
> Imaging
> Plain abdominal film
> US
> CT
History
> 1889: Chester McBurney
> History 24-36 hours
> Abdominal pain:
(diffuse and periumbilical, localizing to the RLQ)
> Anorexia (almost always).
> Vomiting (75%).
> Low grade fever.
> If >38 suspect perforation
> Only 55% have classical features.
Physical exam
Peritoneal inflamation sign
> Dunphy's sign
> Rovsing's sign
> Guarding
> Rebound sign
> Obturator sign
> Psoas sign
Dunphy
Rovsing
Guarding
Rebound
Obturator
Psoas
Diffuse Peritonitis
‫כשהמצב מתקדם‬
Laboratory settings
> WBC
> Urinalysis
‫אבחנה של דלקת בתוספתן היא קודם‬
‫כל קלינית‬
Scoring
‫אבל עם אנחנו לא בטוחים‪....‬‬
Diagnosis - US
> Noninvasive
> Available
> Operator dependant
> Sensitivity 80%
> Specificity 90%
> Positive Findings
• Noncompressible
tubular structure
• >7 mm
• Fluid
• appendicolith
CT
>
>
>
>
>
Requires contrast - oral and IV
Radiation
Sensitivity 90-95%
Specificity 90%
Findings
> Nonfilling tubular structure (target)
> >7 mm
> Pericecal inflammation and Fluid
> appendicolith
Target
‫מ"מ ‪>7‬‬
Fecalith
DD
> Go by organ systems or by category
> Consider symptoms, Age and Sex
> Concomitant conditions
Differential diagnosis
Diagnostic laparoscopy
If you are not sure…
Treatment
> Medical
> Periappendicular abscess
> Surgical
Surgical Treatment
> Appendectomy : Laparoscopic versus open




Sex
Habitus
Diagnostic uncertain
NOTES, SILS, Lap assisted
Lap versus open appendectomy
After the surgery
Complication
In op:
> Lap converted to open
> Bowel resection
Post op:
> Wound infection
> Deep space infection/abcess
> Small bowel obstruction
> Infertility
> Enterocutaneous Fistula
Special issues
> Normal appearing appendix
> Meckels diverticulum
> Interval appendectomy
> Chronic or recurrent appendicitis
> Children
> Pregnancy
> Crohns dis
> FMF
Neoplasms
> Rare
> Mucocele
> benign, malignant, pseudomyxoma
> Treatment (Rt colectomy vs appendectomy)
> Survival rate 55% vs 20%
> Adenocarcinoma
> Carcinoid
> Treatment: size, location
> Survival
Laparoscopic Appendectomy
‫תודה‬