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APPENDICITIS

Anatomy and physiology of


appendix

The appendix is a slender, worm-shaped


pouch, averaging 510cm in length, that
protrudes from the top of the colon in the
lower right abdomen

Location
McBurneys point:one-third of the

way from the anterior,superior iliac


spine to the umbilicus.
Pelvis and right ilac fossa appendix
Anterior or posterior ileum appendix
Retrocaceal appendix
Right lateral caceal appendix

Retrocaceal appendix

Supply & nerve


Appendix artery: a final artery ,from
ileocolic artery
Appendix vein :

portal vein

sympathetic nerve :celiac plexus and


lesser splanchnic nerve
T10,T11


Acute appendicitis
Appendicitis is a
common
cause of
abdominal
pain

life-threatening condition because of systemic


sepsis (systemic inflammatory response
syndrome/SIRS leading to multiple organ failure)
following rupture and abscess formation

Etiology
Obstruction:
anatomy :wormed-shaped
narrow
plenty of lymph glands
mechanical reason:
food residue, ascarid,
tumor,etc.

Etiology
Gastrointestial disease
Bacteria invasion:
all kinds of G- bacilus

Pathology
Four type:
Acute simple appendicitis
Acute purulent appendicitis
Perforation and gangrenous
Appendiceal abscess

Acute simple appendicitis

Acute purulent
appendicitis

Perforation and gangrenous

Gangrenous
Perforation

Appendiceal abscess

Results
Inflammation disappear
Inflammation localization
Inflammation diffusion

Clinical manifestation
symptoms :
abdominal pain :
Periumbilical or epigastric pain that
migrates to right lower quadrant
Pain becomes persistent and well
localized. It worsens with moving,
breathing deeply, coughing,
sneezing, walking, or being touched

Symptoms :
Gastrointestinal symptoms:
Anorexia, nausea, and vomiting
occur after the onset of pain
Constipation
Diarrhea
bladder and rectum stimulus
symptoms

Symptoms
General symptoms :
tired ,headach
fever
Rapid pulse
SIRS (systemic inflammatory
response syndrome)

Signs
Tenderness in the right lower

abdomen, usually about a third of


the distance from the navel to the
top of the hip bone
peritoneal irritation sign : muscular
rigidity
Blumberg sign
bowel sounds disappear

Others
Rovsings sign:pain in the right

lower quadrant upon palpation of


the left lower quadrant.
Psoas sign :pain on active
elevation of the legs
The obturator sign: pain on
internal and external rotation of
the hip
Rectal exam & vaginal exam

Lab test
Mild to moderately elevated WBC with

left shift is typical but rarely may be


normal, range of 11000-17000/mm 3
over 20000/ mm3
perforation
UA may show ketonuria or a few RBCs
or WBCs
pregnancy test (women only)

Lab test
B-us
X-ray
Diagnostic abdominal puncture

Diagnosis
Periumbilical or epigastric pain

that migrates to right lower


quadrant
Tenderness in the right lower
abdomen, usually about a third
of the distance from the navel
to the top of the hip bone

Differential diagnosis
Two type :
A:
B:
surgery

required surgery
not required

Differential diagnosis
Required surgery:

Perforation of gastointestinal tract


ulcer,tumor, diverticulitis
obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsion
Meckel diverticulitis
Tumor

Differential diagnosis
Not required surgery

Pelvic inflammation
Mesenteric adenitis:at exploration a

normal appendix and enlarged lymph


nodes in the mesentery
Viral & bacterial gastroenteritis
Pneumonia, pleurisy

MATERIALS AND METHODS

The Alvarado score


Symptoms
Score

migratory right iliac fossa pain

Signs nausea/vomiting

1
RIF tenderness
2
anorexia
1 fever >37.30C
1
Laboratory
test
rebound pain in RIF
1 leucocytosis (>10 X 109/L)
2
neutrophilic shift to the left >75%

Total score

1
10

CONCLUSION

Treatment
Early operation:
surgical removal(appendectomy)
Acute simple appendicitis:
appendectomy
Acute purulent and gangrenous
appendicitis:
appendectomy and/or drainage

Treatment
Appendiceal abscess:

if local in right low quadrant


antibiotic therapy and general treatment
if infection diffusion
incision and drainage

Treatment
Operation
Incision :
incision over the point of maximal
tenderness,generally at McBurny point
true McBurneys incision
tansvers skin incision
36cm long

Incision
McBurneys
incision

Incision
tansvers
skin
incision

Treatment
Operation

Process:
The taenia of
the colon are
followed to
the base of
the appendix

Treatment
Operation

Process:
Mesoappendix
is divided
between
clamps and
ligated

Treatment
Operation

Process:

The base of
appendix is divided
and ligated 0.5cm
from caceum and
inverted using a
purse-string

Treatment
Suspected case: not definite.
Admit the patient to hospital for
further observation 12-24hrs
Operation
exploration incision

Treatment
Antibiotic thearpy:
Acute simple appendicitis
Contraindication of operation
Appendiceal abscess

Treatment
Antibiotic thearpy
antibiotics: broadspectrum antibiotics
ampicillin-sulbactam
gentamycin
triad drugs
metronidazol
3rd generation cefotides

Treatment
New method :
laparoscopy appendectomy

Complication
Acute appendicitis:
Abdomen abscess
Inter or extra fistula
Phylephlebitis

Complication
Operation :
Incision infection
Peritonitis and abdomen abscess
Bleeding
Stool fistula
Stump infection
Adhesive intestinal obstruction

Appendicitis in neonate
Seldom
Non-specific clinical manifestation
Anorexia, nausea, and vomiting diarrhea
dehydration

Difficult in early diagnosis


High rate of perforation
High mortality

Appendicitis in neonate
Diagnosis &Treatment
Carefully physical exam

Early operation

Appendicitis in child
Quick onset and severe
high fever and vomiting present early
Non-typical tenderness at right low
quadrant
High rate of perforation
High mortality
More complication

Appendicitis in child
Treatment:
Early operation
Transfusion and correct dehydration

Broadspectrum antibiotics

Appendicitis in pregnancy
Uterus enlargement
appendix displaced
superiorly

Tenderness
site upper shift

elevation of
abdominal
wall

Inconspicuous of
tenderness
rebound tenderness
muscular rigidity

Without
adherent
blanket of
omentum

Peritonitis
diffusion

Appendicitis in pregnancy
Treatment :
Operation :appendectomy
To late pregancy :early operation
Superior Incision
No drainage
Broadspectrum antibiotics
Parturient with perforation :
cesarean section and appendectomy

Appendictis in the elderly


Less well-defined symptoms and
signs
Severe pathologic type
Error diagnosis easily
High rate of perforation
Pay attention to tumor

Chronic appendicitis
Etiology and pathology
Clinic feature and diagnosis
right low quadrant pain
local tenderness
x-ray
Treat
appendectomy

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