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Appendix
1.
2. FACTS
Acute appendicitis is the most common
surgical emergency of the abdomen
Appendectomy is one of the most
frequently performed surgical procedures
3. FACTS
Mortality rate from perforated appendicitis:
near certain death a century ago
10-20 per cent 50 years ago
5 per cent during the 1960s
1 per cent or less from the 1970s to the present
4. FACTS
“Rates of unnecessary appendectomies and
perforation have remained relatively high
despite gaining a century of clinical experience
with acute appendicitis”
“The dramatic expansion of diagnostic testing
options and the introduction of innovative
surgical approaches during the last decade has
actually caused even more debate and
disagreement than resolution of issues.”
6. OPERATIONAL DEFINITIONS
Complicated Appendicitis:
Includes gangrenous appendicitis, perforated
appendicitis, localized purulent collection at
operation, generalized peritonitis and
periappendiceal abscess
7. OPERATIONAL DEFINITIONS
Equivocal Appendicitis:
A patient with right lower quadrant
abdominal pain who presents with an atypical
history and physical examination and the
surgeon cannot decide whether to discharge or
to operate on the patient
8.
9.
10.
11.
12. Adult size 9 cms length ; 1-3 mm lumen
Base constant = confluence of taenia coli
Blood supply – appendicular branch of
ileocolic artery
Lymphatics – follows the blood supply
13. HISTOLOGIC FEATURES
- Muscular layer not well defined
- Lymphoid aggregates in submucosa and
mucosa
- Mucosa is like colon, but irregular shaped
crypts
15. DISEASES OF THE VERMIFORM
APPENDIX
I. Acute appendicitis
Etiology & Pathogenesis:
A.Role of environmental: Diet and
Hygiene
Western Diet (Low fiber, High fat)
Change in motility, flora, lumen –
fecalith formation
16. B. Role of obstruction
- anatomical
- hyperplasia of lymphoid
- neoplasm/foreign body
17. Sequence of events:
Increase mucus & fluids inc intraluminal
pressure – obstructed outflow of blood (venules)
& lymph inc P appendiceal wall obstructs
arterial supply mucosal ischemia,
inflammation, stasis, necrosis of muscularis
PERFORATION
18. Observation:
Impacted fecalith – no local inflammation
(50%)
C. Role of colonic flora
- 60% Anaerobes – inflammed AP
- 25% Anaerobes – non-inflammed AP
Lumen – source of microorganism
(E.coli/Bacteroides)
Pieper et al – inc antibody titer to Bacteriodes
Gangrene & perforation
19. NATURAL HISTORY
Temple et al(1995) Prospective study Ann.
Surgery
- 20% perforation < 24 hrs after onset of
symptoms
- 1 patient <10 hrs
- average time to perforate 64h
25. Alvarado scale for the diagnosis of AP
Migration of pain(1),anorexia(1), N/V(1)
RLQ pain (2),rebound (1),fever (1)
Leukocytosis (2), left shift (1)
• 9-10 = almost certain/no labs
• 7-8 = high likelihood
• 5-6 =compatible with but not diagnostic
26. Acute appendicitis is essentially a clinical
diagnosis; there is no laboratory or
radiologic test yet devised that is 100%
diagnostic of this condition
27. EVALUATION
Hx and PE – serial PE, one examiner, rectal
exam, speculum, bimanual examination,
urinalysis, pregnancy test
MANAGEMENT:
a. preop – fluids/antibiotics (2nd
gen)
b. Operative – open/laparoscopy
c. Postop - antibiotics
29. Differential diagnosis:
Acute mesenteric adenitis, AGE, dse of male
urogenital system
Meckel’s diverticulitis, intessusception,
perforated peptic ulcer, colonic lesion,
epiploic appendagitis
UTI, gynecologic dse, Henoch-Schonlein
purpura
30. Special consideration:
Lifetime risk- 12%( males )
25%( females )
Mean age – 31.3 y/o
2nd
- 4th
decade of life
Rate of misdiagnosis- 15% (higher in females,
22.3 vs 9.3%)
Negative appendectomy women- 23.2%
31. Special consideration:
Advance age – 50-70% perforation
Use of imaging modalities like CT scan
Pregnancy – location of appendix base on AOG
- ultrasound