APPENDICITIS 4) Inflammation soon involves the serosa and
Harrison’s Chapter 356 (pp 1985-1989) parietal peritoneum causing shift to RLQ pain Schwartz’s Chapter 30 (pp 1241-1256) 5) Vascular thrombosis and ischemic necrosis with PERFORATION of distal appendix occurs Epidemiology o DISTAL poorest blood supply - Appendicitis remains to be the most common o Patients who have had symptoms for >48 emergency surgical disease affecting the abdomen HOURS are more likely to perforate - 9% of men and 7% of women will experience o Perforation near the base should raise appendicitis in their lifetime concerns about another disease process - Occur most commonly in 10- to 19-year olds o Simple disease DOES NOT always progress - PERFORATION common cause of morbidity and to perforation mortality; increasing incidence Simple acute appendicitis may resolve o 20% of all patients have evidence of perforation spontaneously or with antibiotic therapy at presentation Recurrent disease is remotely possible o Risk of perforation is higher in <5 and >65 years 6) When perforation occurs, the resulting leak may be contained by the omentum or surrounding Anatomy and Histology tissues to form an ABSCESS 7) FREE perforation typically causes severe - Arterial Supply: Appendicular Br. of Ileocolic Artery PERITONITIS - Innervation: Superior Mesenteric Plexus (T10-L1) o These patients may develop infective and Vagus Nerves suppurative thrombosis of the portal vein - 3 Layers: Serosa, Muscularis, Submucosa/Mucosa along with intrahepatic abscess o Submucosa LYMPHOID aggregates o Prognosis is very poor with this complication - Function: secretion of immunoglobulins (IgA) Differential Diagnosis Pathophysiology
- Factors leading to appendicitis:
o Fecaliths Fecaliths are found in ~50% of patients with gangrenous appendicitis who perforate Rarely identified in simple disease o Incompletely digested food residue o Lymphoid hyperplasia o Intraluminal scarring o Tumors o Bacteria and viruses The flora of the inflamed appendix DIFFERS from that of the normal appendix: Anaerobes Clinical Manifestations E. coli Bacteroides gangrene and perforated “Appendicitis should be included in the differential Fusobacterium diagnosis of abdominal pain for every patient in any age o Inflammatory bowel disease (IBD) group unless it is certain that the organ has been previously removed.” - Steps in the Pathophysiology: 1) CLOSED-LOOP OBSTRUCTION of appendiceal - The appendix’s anatomical location, which varies, lumen and continuous secretion directly influences the patient’s presentation 2) Obstruction leads to bacterial overgrowth and o RUQ – Pregnancy luminal distention o LUQ – Midgut Malrotation o Stimulates nerve endings of visceral afferent o LLQ – Situs Inversus stretch fibers producing vague, dull, diffuse epigastric or periumbilical pain o Reflex nausea and vomiting occurs as visceral pain increases 3) Increase in intraluminal pressure inhibits flow of lymph and blood o Capillaries and venules are occluded but arterial inflow continues causing congestion Classic History of Appendicitis 2) DUNPHY’S SIGN o Patient’s lie still to avoid peritoneal irritation 1) Non-specific complaints occur first: caused by movement o Changes in bowel habits o Report discomfort from a bumpy car ride, o Malaise coughing, sneezing and other movements o Vague, intermittent, crampy abdominal pain that replicate a Valsalva maneuver in epigastric or periumbilical region 3) ROVSING’S SIGN 2) Pain migrates to Right Lower Quadrant over 12 o INDIRECT REBOUND TENDERNESS TO 24 HOURS where it is sharper and can be o Palpating in the LEFT LOWER QUADRANT definitely localized causes pain in the RLQ o Transmural inflammation when appendix o Can be indirectly elicited by gentle abdominal irritates the parietal peritoneum percussion, jiggling the patient’s bed or mildly 3) Parietal peritoneal irritation may be associated bumping the feet with local muscle rigidity and stiffness 4) OBTURATOR SIGN 4) Nausea and vomiting, if present, follows the o INTERNAL ROTATION of the right hip development of abdominal pain causes pain o GASTROENTERITIS nausea before pain o Suggesting the possibility of PELVIC o Vomiting is mild and scant appendicits 5) ANOREXIA is so common that the diagnosis of 5) ILIOPSOAS SIGN appendicitis should be questioned in its absence o EXTENDING the right hip causes pain along - Presentation of PELVIC APPENDICITIS: the posterolateral back and hip o Dysuria o Suggesting RETROCECAL appendicitis o Urinary Frequency o Diarrhea Clinical Scoring Systems o Tenesmus o Pain in Suprapubic Region on rectal/pelvic exam - Useful for ruling out appendicitis and selecting patients for further diagnostic work-up Physical Examination [INSERT: Alvarado Score / AIRS from Schwartz!] - All patients should undergo a RECTAL EXAMINATION Ancillary Diagnosis o An inflamed appendix located behind the cecum Laboratory Testing or below the pelvic brim may prompt very little tenderness of the anterior abdominal wall - Laboratory testing DOES NOT identify patients with - A PELVIC EXAMINATION in women is mandatory to appendicitis but may help with differentials rule out urogynecologic conditions: - WBC count is mildly to moderately elevated; o Pelvic Inflammatory Disease leukocytosis 10,000-18,000 cells/uL; neutrophilic o Ectopic Pregnancy predominance or “LEFT SHIFT” o Ovarian Torsion - Serum AMYLASE and LIPASE should be measured - Patients with simple appendicitis will normally only - URINALYSIS is indicated to exclude genitourinary appear MILDLY ILL conditions o Pulse rate and temperature only slightly above o Inflamed appendix that abuts the ureter or urinary normal bladder may cause sterile pyuria or hematuria - If T > 38.3 C and with presence of rigors, consider - Every woman of childbearing age should have a COMPLICATIONS: PREGNANCY TEST o Perforation Imaging o Phlegmon – matted loops of bowel adherent to the adjacent inflamed appendix - Done when Hx/PE is suggestive but not convincing o Abscess Formation - PLAIN FILMS are rarely helpful so are not routinely - Classic Signs of Appendicitis: done; <5% will have opaque fecalith in RLQ 1) DIRECT RLQ TENDERNESS o The entire abdomen must be examined - ULTRASOUND systematically starting in an area where the o Highly operator dependent patient does not report discomfort o Suggestive Findings: o MCBURNEY’S POINT Wall thickening Point of maximal tenderness in RLQ Increased appendiceal diameter Located 1/3 of the way along a line Presence of free fluid originating from the ASIS, running to the umbilicus - CT SCAN Laparoscopic Appendectomy o High negative predictive value o Suggestive Findings: - Advantages: o Less post-op pain Dilatation >6mm o Shorter hospital stay Wall thickening o Faster recovery Lumen does NOT fill with enteric contrast o Fewer wound infections Fatty tissue stranding o Facilitates exposure in the very obese Air surrounding the appendix - Disadvantage o Non-visualization of the appendix is a non- o HIGHER risk of intraabdominal abscess specific finding that SHOULD NOT be used to formation rule out the presence of appediceal or - APPENDICEAL CRITICAL VIEW periappendiceal inflammation o 10 o’clock Appendix o 3 o’clock Taenia Coli Management o 6 o’clock Terminal Ileum
- All patients should be prepared for SURGERY and Post-Operative Care
have fluid and electrolyte abnormalities corrected - Uncomplicated Appendectomy: - Uncomplicated Appendicitis: OPEN or o Most patients can quickly be started on a diet and LAPAROSCOPIC APPENDECTOMY discharged home the following day o When the diagnosis in uncertain, observe the o Post-op ANTIBIOTICS are UNNECESSARY! patient and repeat abdominal exam OVER 6-8 - Complicated Appendectomy: HOURS o Patients should be continued on BROAD - Phlegmon or Abscess: SPECTRUM ANTIBIOTICS for 4 TO 7 DAYS o Broad-spectrum Antibiotics o Post-op ILEUS may occur so died should be o Drainage if abscess is >3 cm in diameter started based on daily clinical evaluation o Parenteral fluids and bowel rest o Increased risk for SURGICAL SITE o Appendix can be safely removed AFTER 6 TO 12 INFECTIONS WEEKS when inflammation has diminished Tx: Open the incision and obtain culture - DISCHARGE: within 24 TO 40 HOURS of operation o STUMP APPENDICITIS - Most common POST-OP COMPLICATIONS: FEVER AND LEUKOCYTOSIS Results from incomplete appendectomy o Persistence > 5 days should raise concern for Presents ~9 years after initial surgery INTRAABDOMINAL ABSCESS The remaining stump should be no longer than 0.5 cm Open Appendectomy Appendicitis in Pediatric Patients - Performed under General Anesthesia - Patient initially placed in supine position then placed - Establishment of diagnosis is more difficult in slight Trendelenburg with rotation of bed to the left - PE Findings with Highest Sensitivity: once incision is made o Maximal tenderness in RLQ - Types of Incisions: o Inability to walk or walking with a limp 1) NON-PERFORATED Appendicitis RLQ Incisions: o Pain with percussion, coughing or hopping a. MCBURNEY OBLIQUE - More rapid progression to rupture and the inability of b. ROCKY-DAVIS TRANSVERSE the underdeveloped omentum to contain a rupture 2) PERFORATED Appendicitis MIDLINE Incisions: lead to significant morbidity in children a. LOWER MIDLINE Laparotomy Appendicitis in Pregnancy - Pregnancy DOES NOT change the proportion of patients with the appendiceal base within 2 cm of - Appendicitis is the most common surgical McBurney’s point emergency during pregnancy - Identifying the Appendix: - Appendicitis could occur anytime during pregnancy o Locate the cecum but is RARE in the 3rd Trimester o Trace the TAENIA LIBERA (aka Anterior Taenia) - Incidence of perforated or complex appendicitis is Most visible of the 3 Taenia Coli NOT increased in pregnant patients o Base of the appendix is identified distally - Laparoscopy was associated with 2.31 times increased risk of fetal loss compared to open - Appendectomy is associated with 4% risk of fetal loss and 7-10% risk of early delivery ALLIE 2018