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View Full Version : ACUTE APPENDICITIS (Etiology-Pathology-Clinical picture-Complications-Investigations-Treatment)



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04-28-2008, 11:38 AM
mIncidence: More in meat eating people than vegetarians.
mAetiology: 2 Predisposing factors:
1- Obstruction: by a) Faecolith. b) Forign body.
c) Stricture after previous inflammation
d) Rarely thread worms.
2- Infection:
The common orgainsms are; B coli, streptococcus faecalis, staph, strept and Cl. welchii. Usually mixed infection.
mPathology:


1- Obstructive type 80%:Obstruction ®intraluminal pressure® Ischaemia of the wall ® devitalization ® Invasion by organisms:
a- Suppurative appendicitis ® Empyema of the appendix.
b- Gangrenous appendicitis ®perforation.
The base is the site of obstruction and perforation.
2- Non obstructive 20%: Infection mainly through lymphatic or blood stream:
a) Catarrhal appendicitis; "Congestion & oedema".
b) Suppurative appendicitis; multiple abscesses in the wall. If obstruction occurred® Empyema of the appendix.

mClinical Picture:
Age: Commonly in young adult (teenagers).
Rare in children due to short appendix and wide base.
Rare in old age due to atrophy of lymphoid tissue.
Symptoms:
1- Pain:
· Site: at firstaround the umblicus ,(supplied by the l0th thoracic like the appendix), then localized to Rt. iliac fossa.
· Precipitated by: movement or palpation or distention.
· Relieved by: not relieved by antispasmodics.
· Character: Aching pain until abscess formation ® throbbing pain.
2- Vomiting:
Nausea is more than vomiting. Vomiting occurs once when obstruction occurs. Repeated vomiting occurs after peritonitis.
3- Fever:
Mild or moderate ­ in temp. but high pyrexia occurs if suppuration is established.
4- Other symptoms:
a) Constipation. "reflex to ¯ pain".
b) Tenesmus. "In pelvic appendix in contact with rectum".
c) Frequency and dysuria "In pelvic appendix in contact with bladder.
Signs:
· General examination:
* Tachycardia * Low grade fever 37.5-38.5 > 39 = suppuration.
· Local examination:
1- Mc Burney's sign:
Maximum tenderness at a point in the junction between medial 2/3 and lateral 1/3 of a line extending between A.S.I.S & umblicus.
2- Rebound tenderness = Spread of infection to peritoneal covering of the appendix.
3- Rovesing sign:
On pressure on Lt side of abdomen ®Occurrence of pain in Rt. side. due to either displacement of air in the colon or viscera to Rt. side.
4- Hyperasthesia "not constant sign" pinching of the skin in the triangle from umblicus to ends of inguinal lig. (Sherren's triangle). ®­ pain.
5- Rigidity in the Rt. iliac fossa.
6- Psoas sign:
on flexion of the hip against resistance ®­ pain ® relaxation immediately.
· Special signs due to various positions of appendix:

1- Retrocaecal appendix (commonset): Lies on psoas muscle causing its spasm with hip flexion and painful extention. Abdominal tenderness and rigidity are minimal due to deep seated appendix.
2- Pelvic appendix (tip directed downwards): It gives pelvic pain with absent tenderness at McBurney's point. If it touches bladder there is dysuria. If it touches rectum there is tenesmus. If it touches psoas, there is psoas spasm with hip flexion and painful extension. If it touches obturator internus® spasm of this muscle produces external rotation (internal rotation is painful). P.R. Reveals pelvic tenderness on rightside.
3- Pre or post-ileal appendix (splenic type, its tip directed towards spleen): Irritation of ileum causes diarrhea.
4- Subhepatic appendix: Due to maldescent of caecum. Symptoms and signs are in right hypochondrium.
5- Left sided appendix: Symptoms and signs in the left side
m Investigations:
1- Total leucocytic count: Mild ­but in suppurative cases it will be very high.
2- Plain x-ray: To exclude lower ureteric stone.
To detect gas under diaphragm in cases of perforated duodenal ulcer.

F N.B. Perforated appendix does not show gas under diaphragm in x-ray. "As it is always obstructed".

m Complications:
1- Appendicular mass:
· Formed of: Loops of intestine, Inflammed appendix and Caecum surrounded by Greater omentum. Adherent to each other by fibrinous layer.
· Time: 48 hs. after infection.
· Prognosis: It indicate good resistance.
2-Perforation: Usually at the base and may give:
a- Generalized peritonitis.
b- Localized peritonitis e.g;


· Appendicular abscess. · Pelvic abscess. · Subphrenic abscess.

3- Portal pyaemia: In post ileal appendix thrombophlebitis of ileo-colic vein ® multiple pyaemic abscesses in the liver ® High fever, rigors, mild jaundice prognosis was poor until production of recent antibiotics.
4- Chronic appendicitis: Recurrent non obstructive appendicitis healed by fibrosis ® whitish appendix.
m Differential Diagnosis of Acute appendicitis or Acute Abdomen (Pain in abdomen of sudden onset)
Differential diagnosis according to the site of origin:
1- Floor = Pelvic causes:
· Torsion ovarian cyst
· Tubo-ovarian abscess.
· Disturbed ectopic pregnancy.


2- 1st floor = Lower abdomen:
· Acute appendicitis (The commonest cause).
· Mickle diverticulitis
· Perforated typhoid ulcers.
· Intestinal obstruction.
· Regional enteritis.







3- 2nd floor = Upper abdomen:
· Perforated peptic ulcer.
· Acute gastritis
· Acute cholecystitis,
· Liver abscess
· Acute pancreatitis.

4- Roof = Chest:
· Fracture rib.
· Pleurisy.
· Pneumothorax.
· Pneumonia.
· Myocardial infarction.
· Heart failure with congested liver.



5- Electricity = Nervous system:
· Herpes Zoster.
· Pott's disease
· Tabes dorsalis.
6- Drainage = Urinary:
· Renal colic e.g; stone Rt. ureter.
· Pyelonephritis.

mTreatment of acute appendicitis:
I- Uncomplicated cases: = Within 48 hs.
Appendectomy is done to avoid complications.
The operation is urgently advised in the following vulnerable groups:
1- In children as omentum is short.
2- In senile patient with sclerotic vessels and ­ liability to develop gangrene.
3- Pregnant female: Gravid uterus raise the omentum.
4- Diabetics due to ¯ immunity and sclerotic vessels.
5-Patients under corticosteroid therapy due to low resistance & decrease of fibroblastic activity makes perforation more easier.
6- Patients took potent analgesics e.g. Morphine as it mask clinical picture of perforation à painless perforation.
II- Complicated cases:
A- Appendicular mass:
· Diagnosis: It can be palpated clinically preoperative or under anesthesia or after exploration.
· Treatment: Conservative treatment = Oschner Sherren technique.


1- Position: Semisitting "Fowler position".
2- Diet: I-V- fluid or fluid orally.
3- Antibiotics: Broad spectrum.
4- Antispasmodics.
5- Hot fomentation. Modified Fowler Position
6- Observation of: Pain tenderness & rigidity, Pulse, Temperature
(> 39 = pus), and size of the mass. 90% of cases regress & 10% progress. 3 months after resolution appendectomy is done:
B- Appendicular abscess= Extra-peritoneal drainage then 6 months later on we do appendectomy.
C- Portal pyaemia ® legation of iliocolic vein + antibiotic.
D- Generalized peritonitis: Appendecetomy + peritoneal lavage + drains.
E- Localized peritonitis ® drainage then after 6ms appendectomy.
F- Chronic appendicitis ® elective appendictomy.
Appendectomy
SOURCE: DR. AYMAN SALEM'S BOOK
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