ACUTE APPENDICITIS
CHAIR OF FACULTY SURGERY # 2
FIRST MOSCOW STATE MEDICAL UNIVERSITY
NATROSHVILI A.G.
ANATOMY AND FUNCTION
• FIRST VISIBLE IN THE 8TH WEEK
OF LIFE
– PROTUBERANCE
OFF THE TERMINAL
ILEUM
• BASE OF THE APPENDIX ARISES FROM THE POSTEROMEDIAL ASPECT OF THE
CECUM
• TIP OF THE APPENDIX – RETROCECAL, PELVIC, SUBCECAL, PREILEAL,
PERICOLIC, RETROPERITONEAL, SUBHEPATIC
• 3 TAENIA COLI CONVERGE
AT JUNCTION OF CECOM WITH THE APPENDIX
• LENGTH – 6-9 CV
• FUNCTION – IMMUNOLOGIC ORGAN, SECRETES IG A
• LYMPHOID TISSUE FIRST APPEARS ABOUT 2 WEEKS AFTER BIRTH
• INCREASES THROUGHOUT PUBERTY
• AFTER 60 YO – NO LYMPHOID TISSUE REMAINS WITHIN THE APPENDIX AND
COMPLETE OBLITERATION OF THE LUMEN
ETHIOLOGY
• CAUSE OF APPENDICITIS – OBSTRUCTION OF THE LUMEN
• CAUSE OF OBSTRUCTION:
• LYMPHOID HYPERPLASIA (ASSOCIATED WITH A VARIETY OF INFLAMMATORY AND
INFECTIOUS DISORDERS)
• FECALITHS
• LESS COMMONLY – PARASITES, FOREIGN MATERIAL, TUBERCULOSIS, TUMORS
PATHOPHYSIOLOGY (1/2)
Obstruction of the lumen
Mucus accumulates in the lumen, intraluminal
pressure increases
Bacteria convert mucus into pus
Obstruction of the lymphatic drainage ensuesedema of the appendix, beginning diapedesis of
the bacteria and appearance of mucosal ulcers
Venous obstruction & further edema & ischemia
in the appendix
Symptoms:
o Poorly localized visceral pain –
periumbilical or epigastric
o Anorexia
o Nausea & vomiting
o (small bowel and appendix have
the same nerve supply)
PATHOPHYSIOLOGY (2/2)
Bacterial invasion spreads thru the wall of the appendix
Compromise of the arterial blood supply
Midportion of the antimesenteric border undergoes gangrene with the
appearance of the ellipsoidal infarcts
Excape of bacteria from the lumen of the appendix and contamination
of the peritoneal cavity
Cntinued high intraluminal pressure – perforation thru gangrenous
infarct, spilling accumulated pus lead to local and then generalized
peritonitis
Inflammatory site is bordered from abdominal cavity – appendiceal
phlegmon develops
Symptoms:
o Inflamed serosa of the appendix
contacts the parietal
peritoneum – somatic pain –
perceived as classic shift and
localization of pain in RLQ
o Fever
o Tachycardia
o Leukocytosis
o Muscle defence
o Positive Blumberg sign
CLINICAL MANIFESTATION
• CONSTANT MODERATE PERIUMBILICAL
PAIN WITH SHIFT IN
4-6 HOURS TO SHARP RLQ
• MILD TACHYCARDIA
• TEMPERATURE ELEVATION OF 1°C
• ANOREXIA
• ANTERIOR APPENDIX – MAXIMAL TENDERNESS, GUARDING AND REBOUND AT
MCBURNEY’S POINT (BLUMBERG SIGN POSITIVE)
• ROVSING’S
SIGN
• PSOAS SIGN (SLOWLY EXTENDING PATIENT’S RIGHT THIGH – NEARBY INFLAMMATION
WHEN STRETCHING THE ILIOPSOAS MUSCLE CAUSES PAIN)
• CBC – MILD LEUKOCYTOSIS
WITH MODERATE NEUTROPHIL PREDOMINANCE
• U/A: LEUCOCYTES ARE PRESENT WHEN THE INFLAMED APPENDIX LIES NEAR THE
URETER/BLADDER
CLINICAL MANIFESTATION
Typical clinical
manifestation in 5070% of patients
Possible diagnostic
pitfalls
Negative
appendectomy rate
up to 25-45%
IMAGING
• ABDOMINAL X-RAY – LOW SENSITIVITY, POSSIBLE
FECALITH IN THE RLQ
• BARIUM ENEMA – NONFILLING OF THE APPENDIX AND
MASS EFFECT ON THE MEDIAL&INFERIOR BORDERS OF
CECUM (RARELY USED)
• GRADED COMPRESSION ULTRASONOGRAPHY –
NONCOMPRESSIBLE APPENDIX 6 MM OR GREATER IN
DIAMETER, WALL THICKNESS MORE THEN 2 MM
• OPERATOR-DEPENDENCY (ACCURACY VARY FROM 50
TO 95%)
• LESS USEFUL IN PERFORATION – DECREASING DIAMETER
AND APPENDIX BECOMES COMPRESSIBLE
IMAGING
• ENHANCED CT
• ADVANTAGES
•
HIGH SENSITIVITY, SPECIFICITY AND ACCURACY (90-98%)
• DISADVANTAGES:
• RADIATION
• ALLERGIC REACTION
• COST
• CANNOT BE DONE IN SOME PATIENTS (PREGNANT WOMEN, CRITICALLY ILL ETC.)
LAST DIAGNOSTIC STEP – DIAGNOSTIC LAPAROSCOPY
• ADVANTAGES
•
HIGH SENSITIVITY, SPECIFICITY AND ACCURACY (95-99%)
•
CAN TRANSFORM TO LAPAROSCOPIC APPENDECTOMY
• DISADVANTAGES
•
INVASION
•
SURGICAL AND ANESTHESIOLOGICAL RISK
TREATMENT
• ONLY ONE FORM OF APPENDICITIS CAN BE TREATED WITH
ANTIBIOTICS AND NSAIDS – APPENDICEAL PHLEGMON
(HARD INFILTRATE), IN WHICH INFLAMED APPENDIX IS BORDERED
FROM ABDOMINAL CAVITY WITH SURROUNDING TISSUES AND
BOWELS.
•
PALPABLE MASS IN RLQ
•
PAIN FOR MORE THEN 5-7 DAYS
•
ABSENCE OF PERITONEAL SIGNS
• APPENDECTOMY
IN SUCH CIRCUMSTANCES WILL LEAD TO BOWEL
PERFORATION
• DYNAMIC EXAMINATION SHOULD BE PERFORMED FOR POSSIBLE
ABSCESS FORMATIOIN AND ADEQUATE DRAINAGE
• APPENDECTOMY
IS RECOMMENDED IN
4-6 MONTHS
TREATMENT
• OPEN APPENDECTOMY (INCISION)
TREATMENT
• OPEN APPENDECTOMY (ANTEGRADE)
TREATMENT
• OPEN APPENDECTOMY (RETROGRADE)
TREATMENT
• LAPAROSCOPIC APPENDECTOMY
[B.NAVEZ, C.SOLANO (WWW.WEBSURG.COM)]
OR
OR