SPECIMENS

APPENDIX
Identifying points:
It is a tubular structure.

Two borders

- Medial border ( Convex border ) Probably

messoappendix was attached.
- Outer border which is concave covered with serous
layer
It has two ends

- One blind end

- One cut open end .
 Clour is variable. Some parts are dark coloured and some
parts are pale. There are marked dark coloured blood vessels
on the surface.
It is very much dilated may be due to obstructive type of

appendicitis.

Important points:
Average length of appendix is 7.5-10 cm.
Pathophysiology-

Non obstructive type- Acute inflammation of mucous membrane

with secondary infection. It may lead to resolution, fibrosis,
recurrent appendicitis and eventually obstructive appendicitis.
Why not the small gut
Lumen is narrow
wall is thickened
No messentery
Why not the large gut
No taeniacoli
No appendices epiploicae
Obstructive type : Luminal obstruction by-
Faecolith is the commonest
Lymphoid hyperplasia
Pinworm
Foreign body
Carcinoma of caecum
Chrones disease.
Obstruction continued mucous secretion, inflammatory
exudates- increase intraluminal pressure- blockage of
lymphatic and venous drainage- mucosal ulceration and
ischaemia- bacterial translocation to submucosa- thrombosis
of app. Artery-ischaemic necrosis of wall of appx- gangrene-
perforation-peritonitis.
 Exciting cause of obstructive appendicitis- Infection.
Predisposing factors-

Ulceration
Obstruction
Infection
Appendicular lump- Greater omentum,loops of small intesine

and terminal ileum become adherent to the inflammed

appendix walling off the spread of peritoneal contamination
resulting in a phlegmonous mass.
Appendicular abscess- Superadded infection and pus

formation will lead to abscess formation.

 Rarely appendiceal inflammation resolves leaving a distended
mucous filled organ termed as mucocele of appx. It occurs due to
blockage at the opening of lumen. When there is infection it will
form empyema.
Complications of appendicitis-
App lump

App abscess
Gangrene
Perforation
Localised or generalised peritonitis
Portal pyemia
Liver abscess
 Treatment-
Appendicectomy( within 24h of onset,no lump on
examination, diagnosis confirmed)
App lump- Ochsner-Sherren regimen
Contraindications of OS regimen:
Extremes of ages- children: less devt of omentum
elderly: chances of art thrombosis.
Diagnosis not confirmed
Immunocompromised patients.
 What is retrograde appendicectomy?
= Usually meso appendix is cut starting from the free end but here it is cut starting
from the base. It is done in case of-
Presence of adhesion in the free end
If free end is not clearly visible.
Why base of the Appendix is crushed?

= So that there will not be any chance of bleeding.

So that the ligature will not be slipped away.
Mucosa is crushed so no chance of mucosal fistule
Complications of surgery:
Bleeding

Injury to the colon, terminal ileum

Complications of anaesthesia.
GALLBLADDER
Identifying points:
This is a split open hollow viscous.

Two ends-

One end is blunt

Other end is ligated by a thread.
Two surfaces-

Mucosal surface
Serosal surface
 Why it is not a testis
Fibro fatty tissue is present, vas deferens is absent, surface is not
smooth.
Size/capacity of GB: 50ml, it can enlarge up to 10 times larger

than its normal capacity.

As it is easily distensible so perforation is rare.

Pericholecystic fluid: Small amount of bile leakage along the

point of entry of blood vessel because it is the weakest point.

Gallstones:
Cholesterol stone:
6% common. Often solitary.
Mixed stones:
90% common . Contains calcium salts of carbonate, phosphate,
palmitate, protein . These are multi faceted.
Pigment stones:
These are small and often sludge like
Black stones are common inGB. Usually Calcium bilirubinate,
phosphate,bicarbonates. Common in hemolytic diseases.
Brown stones: Contains Calcium palmitate, stearate. Formed in the biliary
tree as primary stone. Associated with infection by E. coli, bacteroids.
Complications of cholecystitis:
Acute cholecystitis :
Perforation at fundus or neck

Peritonitis

Pericholecystitic abscess

Empyema GB

Gangrenous GB

Cholangitis

Septicaemia
Chronic cholecystitis :
CBD stone

Cholangitis

Pancreatitis

Mirizzis syndrome
Complications of stone in the GB:
Acute/chronic cholecystitis.

Mucocele of GB

Empyema

Gangrene

Mirizzi syndrome

Perforation.

Signs of pathological GB:

Calculus

Fibrosis

Excessive fat infiltration in the wall

Adhesion to the surrounding structures

Cholecystoduodenal fistula

Thickening of wall.
Complications of stone in the CBD:
Obstructive jaundice

Acute suppurative cholangitis

Pancreatitis

Choledoco enteric fistula

Gram negative septicaemia

Perforation

Peritonitis

Hepatorenal Failure

Obstructive jaundice :
Causes: Non malignant & malignant
Non malignant causes-
Choledocolithiasis

Stricture in the CBD

Sclerosing cholangitis

Pancreatitis

Choledocal cyst

Rupture of hydatid cyst in billiary duct

Foreign body in the CBD.

Malignant causes-
Ca head of the pancreas/ Ca periampullary region.

Cholangiocarcinoma

Ca gallbladder

Secondary deposit in the porta hepatis.

Preoperative preparation of patient with obstructive jaundice:
Proper diagnosis and assessment

Adequate hydration : IV 5/10% dextrose

Multivitamins

Vitamin K IM 10 mg for 5 days

Antibiotics- 3rd generation cephalosporine

Mannitol 100-200 ml BD IV to prevent hepatorenal syndrome

Lactulose

Blood tranfusion if there is anaemia

IV Calcium chloride ?

Repeated monitoring of PT, electrolytes

Correction of hyponatraemia,coagulopathy.
Important points:
Mirizzi syndrome :
Gallstones impacts in the GB wall and compresses it
causing pressure necrosis and further get adherent to CBD
wall. It forms cholecystocholedochal fistula.It occurs either
from Hartmanns pouch or fundus of GB.
Surgical/White bile:
In prolong obstructive jaundice bile secretion from the
liver is reduced due to increased intraductal pressure, causing
secretion of mucous into the biliary canaliculi. This is called
white bile.
Hepatorenal syndrome:
Bile salts are nephrotoxic
Deposited in kidney
|
Endotoxaemia
|
Renal ischaemia
|
Release of pressure substance renin
|
Hypotension in the glomeruli
|
Renal failure
Mullberry stone: found in Acalculous cholecystitis
Adenosis, Aschoffs nodule ,mucosal polyp fall down from the
wall and cholesterol deposited over it. It causes a calculus
which is known as mullberry stone.