Appendix short note by S.

Wichien (SNG KKU)

Acute appendicitis Incidence -7% of popu--appendectomy -10:10,000 /yr -mean age 31.3 yr median age 22 yr -m:f = 1.2-1.3 : 1 -misdx/rupture rate--15.3% -neg appendec in repro female--23% obstruction of lumen -fecalith--most common -others--hypertrophy of lymphoid, Barium,tumor,vegetable,parasite Pathogenesis -Prox.obstr lumen--close loop obstr -continue normal secretion -rapidly distension (normal lumen capacity--0.1ml) -distent--+n.ending of viscer aff fiber :dull pain in mid abdomen :reflex n/v -inflam at parietal perito--shift pain -inc P--venous/capilla occlude -infarct develop in antimesentery -perforate--beyond point of obstr Bacteriology -child--no Porphyromonas Gingivalis -polymicrobial infection -perito c/s should in immunosup pt -ATB 24-48 hr in non-perforate 7-10 d in perforate Symptoms -Anorexia--always in appendicitis -Vomiting--neural stimulate/ileus -Abdo.pain 1.diffuse lower epigas/umbilical pain :usually 4-6 hr 2.localized pain to RLQ :some pt,pain begins in RLQ Pain by location -long appendix--LLQ -retrocecal--frank/back pain -pelvic type--suprapubic pain -retroileal--testicular pain Sequence -anorexia(1st)--abdo.pain--vomiting -if vomiting 1st--hould be questioned Signs -temp is rarely more than 1c -prefer to lie supine -tender at McBurney point -Rovsing sign--indirect tener -cutaneous hyperesthesia--T10,11,12 -volun/involuntary guarding -Psoas sign--retrocecal type -Obturator sign--pelvistype Lab -mild leukocytosis 10,000-18,000 ->18,000 = complicated appendicitis -UA--r/o UTI Appendiceal rupture -<5, >65 yr--highest rate suspected in -fever >39 -WBC >18,000 -illed define mass--phlegmon/abscess Imaging 1.Plain film -rarely helpful in dx -r/o other pathology -rare fecalith but if have--hi suggest 2.Barium enema -if appendix fills on barium enema, appendicitis is excluded 3.Graded compression sonography -blind ending tube -AP diameter -noncompress appendix >=6mm -thickening of appendiceal wall -periappendiceal fluid -sens 55-96% spec 85-98% False positive -Dilated follapian -obesity--non compress -periappendicitis False negative -retrocecal -perforate--compressible -confine appendicitis at tip -mark dilate--as smb 4.High resolution CT -dilated >=5 cm, thickened wall -dirty fat--thick mesoappendix -phlegmon -fecalith--not pathognomonic -arrowhead sign--thick cecum -should in Alvarado score 5-6

Appendix short note by S.Wichien (SNG KKU)

Alvarado scale Symptoms migrate pain 1 Anorexia 1 N/v 1 Signs RLQ tender 2 Rebound 1 Elevate temp 1 Lab Leukocytosis 2 Left shift 1 Scores 9-10 = almost certain dx 7-8 = hi likelihood of appendicitis 5-6 = compatible ,but not dx score 5-6 or some 7-8--CT score 7--should sx Differential dx 1.Acute mesenteric adenitis -confused c appendicitis in children -present c URI or subside -pain usually diffuse -tender not sharp localized -general lymphadenopathy -relative lymphocytosis -Yersinia enterocolitica/tuberculosis Samonella,campylobactor jejuni 2.Acute gastroenteritis -profuse watery diarrhea -n/v -hyperperistalsis abdo cramp -no localizing sign 3.Gyne disorder PID Rupture grafian follicle--mittelschmerz Euptured ectopic preg Twisted ovarian cyst 4.Male urogenitel system Torsion testis Acute epididymitis Seminal vesiculitis 5.Other intes dz Meckel diverticulitis -same c/p as appendicitis -require same tx Intussuception -appendicitis not common in <=2yr -bloody mucoid stool -sausage shaped mass may in RLQ Crohn`s enteritis -acute regional enteritis -fever,RLQ pain/tender,leukocytosis -often stimulate appendicitis Colonic lesion -diverticulitis -perforate ca of caecum Epiploic appendagitis -infarction of colonic appendage -2nd to torsion -continuous abdo pain in area of colon -lasting several day -appetite unaffected -rebound 6.urology UTI -acute pyelonephritis on rt side -mimic retroileal type UC -referr pain to labia,scrotum,penis -hematuria -absence of fever or leukocytosis 7.others Henoch-Schonlein Purpura -2-3wk after streptococcal infection -abdo pain,jt pain,purpura,nephritis FB perforate of bowel Closed loop intes obstruction Mesenteric vascular obstruction Pluritis RLL Acute cholecystitis Acute pancreatitis Hematoma of abdo wall

Appendix short note by S.Wichien (SNG KKU)

Open appendectomy Incision -McBurney (oblique) -Rocky Davis (transverse) -if abscess is suspected :laterally placed incision :to retroperitoneal drainage :avoid contaminate to perito cavity -if dx is in doubt ; lower midline Stump -simple ligation or purse string -nonabsorb suture Other -peritoneal cavity is irrigated -if perforate or gangrene :2nd closure in 4-5d :child : little subcu fat, can 1st closure -if not found appendicitis, look :cecum and mesentery :small bowel-extent at least 2 feet :a medial extension of incision (Fowler-Weir) if further evaluation of lower abdomen is indicated :if suspect upper abdo ,should closed incision then upper midline Laparoscopic appendectomy -under GA -NG tube, foley catheter -surgeon stand to left of pt -use 3 ports 1st trocar = umbilicus (10mm) 2nd trocar = suprapubic (10/12mm) 3rd trocar = LLQ,epigas,RUQ (5mm) -dissection at base of appendix -create a window between mesentery and base of appendix -benefit in obesed pt Compare c open appendectomy -higher of cost,duration of surgery -intra abdo abscess >3x -benefit :dec post op pain = 8/100 point (not sig) :less hospital stay = 1d Summary not been resolved whether LA is more effective than open appendectomy Chronic appendicitis -pain lasts longer -less intense than acute appendicitis -same location -less vomiting -leukocyte--normal -CT--nondiagnosis -laparoscopy can be effective -appendectomy is curative -symptom not cured or recur are diagnosed c crohn dz In the young -more rapid progresion to rupture -underdevelop greater omen -major c/p c appen rupture :wound infect/intra abdo abscess -Tx regimen for perforate appendix :immediate appendectomy :irrigation of peritoneal cavity -ATB 24-48hr in nonperforate ATB 7-10d in perforate In HIV -present similar of normal host -inc risk of rupture--delays in s+s -low CD4 count asso inc in rupture DDX CMV -anywhere in GI tract -vasculitis of bl vv in submuco -leading to thrombosis -mucosal ischemia -ulceration,gangrene bowel perforate Kaposi sarcoma/Lymphoma -RLQ pain c mass Tuberculosis Other cause of infectious colitis Spontaneous peritonitis -CMV,TB,cryptococcus,stronyloid Neutropenic enterocolitis -typhlitis

Appendix short note by S.Wichien (SNG KKU)

In pregnancy -1/766 birth -neg appendectomy--25% :anatomical change :inc abdo laxity Clinical -RUQ pain--74% classic pain--57% -physio leukocytosis 16,000 Ix Ultrasound /MRI Laparoscopy--equivocal case Tx Lap appen -inc preg related c/p -inc 2.3x fetal loss than open sx Overall fetal loss 4% Early delivery 7% Parasite Ascaris lumbricoides--most common E.vermicularis S.stercolaris Echinococcus E.histolytica Tumor -malignancy--rare -mostcarcinoid Carcinoid -firm,yellow,bulbar mass in appendix -appendix is most site of GI tract -carcinoid syndrome--in metas -located in tip -malignant potential is related to size -<1cm rarely in extension outside Tx 1.<1cm--appendectomy 2.>1 <2cm A.tip/mid appendix--appendectomy B.base/mesoappen/metas--rt colec 3.>2cm--rt colectomy Adenocarcinoma -mucinous adenocarcinoma colonic adenocarcinoma adenocarcinoid -present c appendicitis -may c ascitis or mass Tx rt hemicolectomy Pseudomyxoma peritoni -rare -progresss slow -female 2-3x than male -appendix--site of origin -neoplas mucus secreting cell in perito -mucinous ascites -diffuse collection of gelatinous fluid c mucinous on peritoneal and omentum -rt hemidiaphragm,rt retrohepatic, lt paracolic gutter,lig of Treitz,ovary -peritoneal surface of bowel--free -present c abdo pain,mass -rare LN metas,distant metas Tx -all gross should be removed -appendectomy is routine performed -hysterctomy c bilat SO in women -recurrent--additional sx Lymphoma -extremely uncommon -non Hodgkin Lymphoma -1-3% of GI tract -CT--appendiceal diameter >2.5 cm or surrounding soft tissue thickening Tx -appendectomy -rt hemicolectomy,if extension onto caecum or mesentery Mucocele -accum mucoid material -caused by 4 process 1.retention cyst 2.mucosal hyperplasia 3.cystadenoma 4.cystadenocarcinoma -incidental finding in appendicitis -should not rupture :if lap finding--convese to open Tx 1.appendectomy wide resection of mesoappendix cyto exam intraperitoneal mucous 2.rt hemicolectomy -if +ve margin at base -if +ve peiappen LN