| How is appendix anatomy? | blind tube with mucosal, submucosal, muscular and serosal layers
at birth, appendix is short and broad at its junction with cecum
Final typical tubular shape by about the age of 2 years
Length between 1 and 30 cm (average 6 to 9 cm) |
| How is appendix blood supply? | Arterial supply of the appendix is by means of the appendicular artery, inf branch of the ileocecal artery of the sup mesenteric trunk
The appendicular vein, branch of the ileocecal vein, drains appendicecal venous network into the sup mesenteric vein and eventually into the portal circulation |
| Where is location of appendix base and tip? | 3 taenia coli converge at junction of cecum to form its base
Position of the Base is constant: arises from the posteromedial aspect of the cecum
Tip can have variable position within the abdomen: retrocecal, pelvic, subcecal, preileal, postileal |
| What is appendicitis? | Acute inflammation of the appendix One of the most surgical emergencies 1% of surgical operations Highest incidence in the second decade
(10 to 20 yrs) Appendicitis occurs in 7 % of the population
Etiology: blockage of the appendix lumen by:
Fecalith: stone made by feces Submucous lymphoid tissue hyperplasia
Parasites (oxyuris, pinworm ……) Gallstone Tumors
Foreign body |
| How is pathophysiology of appendicitis? | acute appendicitis is thought to begin with obstruction of the lumen
Obstruction can result from food matter, lymphoid hyperplasia……
Mucosal secretions continue to increase intra luminal pressure
Eventually: the intraluminal pressure exceeds capillary perfusion pressure
So: venous and lymphatic drainage are obstructed
Epithelial mucosa breaks down and bacterial invasion by bowel flora occurs
Increased pressure leads to arterial stasis and tissue infarction, end result is perforation abscess and peritonitis |
| What are clinical features of appendicitis? | main symptom is abdominal pain:
Initially peri-umbilical Later migrates to the right iliac fossa Other possible symptoms:
Vomiting (typically after the pain, not preceding it) Anorexia Nausea
Diarrhea, or constipation
Patient may be: tachycardic, tachypnoeic, and pyrexial On examination: Mc Burney’s sign Rovsing’s sign Blumberg’s sign Psoas’s sign Obturator’s sign Cri de Douglas Dunphy’s sign (coughing) |
| Why do patients feel pain periumbilical? | Normal visceral innervation of the appendix comes from the 10th thoracic spinal nerve
Obstruction then distention of the appendix stimulates visceral afferent pain fibers
Abdominal dermatome
Initial periumbilical pain - Referred pain |
| Why does pain shift to right iliac fossa? | When the inflamed serosa of the appendix touches the parietal peritoneum
Somatic pain – perceived as classic shift
Patient feels pain in the right iliac fossa |
| What is Mcburney sign? | Tenderness on deep compression at Mc Burney’s point which is the junction of lateral 1/3 rd and medial 2/3rd in the Spino Umbilical line |
| What is Rovsing sign? | Continuous deep palpation starting from the
left iliac fossa upwards may cause pain in the right iliac fossa by pushing bowel contents towards the ileo-cecal valve and thus increasing pressure around the appendix |
| ًWhat is Bomberg signs and Psoas sign? and obturator? And other signs | Also referred as rebound tenderness: Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes severe pain on the site indicating positive Blumberg’s sign and peritonitis
While patient is lying left lateral with knee extended: straightening out (hyperextension) the right hip causes the pain in the RLQ because it stretches the inflamed PSOAS muscle and the peritoneum overlying it.
Flexing the hip into the fetal position
relieves the pain
In the supine position Pain on passive internal rotation of the flexed thigh
Cri de Douglas: severe pain on rectal or vaginal exam indicating peritonitis Dunphy’s sign: increased abdominal pain with coughing |
| What are investigations done for appendicitis? | Labs (CBC [leukocytosis, left shift], CRP, urine exam, pregnancy)
Radio (US, CT very very imp, MRI) |
| How is abdominopelvic US? | Test of choice in children and pregnant women 95% sensitive & 90% specific Findings:
Diameter more than 6mm Presence of appendicolith Periappendiceal abscess Doppler may show hyperemia
Limitations:
Skills Highly Operator dependent Retrocecal Ruptured appendix = normal diameter |
| How is abdominopelvic CT? | Highly sensitive 98% and specific 97% Dilated appendix with diameter >6mm Thickened and enhancing wall Stranding of the adjacent fat Inflammatory phlegmon Abscess formation Appendicolith
Gold STD to confirm appendicitis |
| How is delay of dx and complications of appendicitis? | Delay of diagnosis: Perforation Abscesses Peritonitis Sepsis Bowel obstruction Decreased female fertility |
| How is MRI use in appendicitis? | Children and pregnant women Combined US & MRI is comparable to CT alone |
| How is tx of acute appendicitis? | Antibiotic alone: conservative treatment majority of patients required appendectomy in the following year
Antibiotic then late appendectomy (6 to 8 weeks later): phlegmon Appendectomy:
Open
Laparoscopic: gold stander |
| What are advatages of laparoscopic appendectomy? | Reduced postoperative pain Decreased postoperative wound infection rate Shorter hospital stay Rapid return to normal activities increased cosmetic satisfaction |
