APPENDIX

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APPENDIX

• James Taclin C. Banez, MD, FPSGS,FPCS

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Anatomy / Function

• Location, position
• Function
• Immunologic organ
• Secrets IgA, component of the GUT associated
  lymphoid tissue (GALT)
• Not essential its removal ----gt (-) sepsis

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Appendiceal Conditions of Surgical Importance

• Appendicitis
• Inflammation of the appendix
• 1500 perityphlitis inflammation of the cecal
  region
• Most common acute surgical disease of the abdomen
• Peak ----gt puberty / early adulthood
• Male gt female (1.3 1)

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Appendicitis

• Pathogenesis
• Obstruction (dominant causal factor)
• Fecalith usual cause
• Hypertrophy of the lymphoid tissue
• Inspissated barium
• Vegetable and fruit seeds
• Intestinal worms (Ascaris)
• Tumor

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Appendicitis

• Pathogenesis
• Sequence of events in Luminal Obstruction
• Proximal occlusion ---gt Closed loop Obst.
  ---- ---gt rapid distention due to
• Continuing secretion of the mucosa
• Rapid multiplication of normal flora
• ---gt elevate pressure ---gt capillary/venous
  occlusion (CONGESTION 1st stage)
• S/Sx () visceral afferent pain fibers (vague,
  dull, diffuse pain in mid-abdomen or lower
  epigastrium. Increase peristalsis (crampy pain)
  N/V and anorexia

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Appendicitis

• Pathogenesis
• Inflammatory process involves the serosa of
  appendix and in turns parietal peritoneum in the
  region.
• Infiltration of PMN (SUPPURATIVE 2nd stage)
• Damage of the lining epithelium ---gt entrance of
  bacteria to the wall.
• Impairment of blood supply (inc. pressure than
  arterial pressure)---gt ellipsoidal infarct at
  antimesenteric border near the tip. (GANGRENOUS
  3rd stage) ---gt (PERFORATION 4th stage)
• This process is not inevitable. Some subside
  spontaneously

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Appendicitis

• Pathogens
• Anaerobes, aerobes
• Bacteroides fragilis, Escherichia coli,
  Peptostreptococcus, Pseudomonas, Bacteroides
  splanchnicus, Lactobacillus

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Appendicitis

• Clinical Manifestation
• Abdominal pain
• Classic pain sequence .
• Right lower quadrant pain
• Others
• Left lower quadrant pain (long appendix)
• Flank or back pain (retro-cecal)
• Supra-pubic (pelvic)
• Testicular pain (retro-ileal ----gt irritates the
  spermatic artery and ureter
• Anorexia nearly always present
• Vomiting 75
• Obstipation / diarrhea
• Usual sequence (95) ANOREXIA ---gt ABD. PAIN
  ---gt VOMITING

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Appendicitis

• Signs PE depends on the location of the
  appendix and presence of rupture
• Direct and rebound tenderness at Mc Burneys
  point. ROVSING sign ---gt indicate muscles
  peritoneal irritation.
• Involuntary muscle guarding (true reflex
  rigidity).
• Psoas / Obturator signs ---gt retrocecal appendix
• Para-rectal tenderness
• Stages I II uncomplicated
• Stages III IV complicated

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Appendicitis

• Laboratory Findings
• WBC leucocytosis
• simple 10,000 to 18,000/mm3
• perforated gt18,000/mm3
• Urinalysis
• Hematuria and pyuria due to irritation of the
  ureter and urinary bladder
• w/o bacteriuria
• FPA rarely helpful () fecalith rare,
• highly suggestive of the dx.

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Appendicitis

• Graded Compression sonogram
• 7896 sensitivity 8598 specificity
• () non-compressible appendix, 6mm or gt at AP
  view
• (-) easily compressible 5mm not visualized a
  (-) pericecal fluid or mass
• False (-)
• Appendicitis confined at the tip
• Retrocecal position
• Perforated appendix

• False ()
• Periappendicitis from surrounding inflammation
• Dilated fallopian tube
• Inspissated stool can mimic an appendicitis
• Obese pt., appendix not compressed

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Appendicitis

• CT scan
• Shd. not delay or substitute for prompt operative
  intervention when clinically indicated
• Used primarily for percutaneous drainage

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Appendicitis

• Laparoscopy
• Diagnostic /therapeutic
• Useful for female to diferrentiate gynecological
  pathology

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• Appendiceal Rupture
• Increase morbidity / mortality
• No accurate way to determine the occurrence of
  rupture
• Suspected
• Fever gt 39 C
• WBC of gt 18,000/mm3
• Localized rebound, involuntary muscle guarding
• Signs of genralized peritonitis
• Ill defined mass (PHLEGMON motted loops of
  bowel adherent to the inflamed appendix)

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• Differential Diagnosis
• Most common erroneous pre-op diagnosis
• Acute mesenteric lymphaditis
• No organic pathologic condition
• Acute pelvic pathologic condition
• Twisted ovarian cyst / ruptured graafian follicle
• Acute gastroenteritis
• Acute mesenteric adenitis
• w/ present or recent URTI
• Diffuse pain, tenderness not sharp, (-) rigidity
• Self limited -----gt observe

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Differential Diagnosis

• Acute gastroenteritis
• Childhood, viral gastroenteritis
• Chills, fever, profuse watery diarrhea, N/V
• Hyper-peristaltic abdominal cramps w/o localizing
  sign
• Disease of the male
• Torsion of the testes and acute epididymitis
• Diagnosed by palpating the enlarged tender
  seminal vesicle
• Meckels diverticulitis
• Same clinical picture w/ AP
• Associated w/ same complication of AP, hence
  needs prompt surgical intervention.

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Differential Diagnosis

• Intussusceptions
• Shd. Be differentiated pre-operatively due to
  different management.
• Char
• Common under 2 y/o
• Occur in well nourished infant who suddenly
  doubled up due to colicky pain. Hrs. later pass
  out bloody mucoid stool
• Sausage shape mass in the RLQ
• Regional enteritis (Crohns dse)
• s/sx is almost the same w/ AP this is dx. in
  celiotomy

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Differential Diagnosis

• UTI / Ureteral stone
• Referred pain to the labia, scroyum or penis
• Chills, fever () R costo-vertebral angle
  tenderness, hematuria, leucocytosis
• Dx -----gt pyelography
• Gynecological disorders
• Rate of erroneous diagnosis of AP is highest in
  young adult female
• Order of frequency
• PID -----gt ruptured grafian follicle ----gt twistd
  ovarian cyst or tumor -----gt endometriosis -----gt
  ruptured ectopic pregnancy

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TREATMENT

• Adequate hydration, correct electrolyte imbalance
• Manage other medical problems
• Pre-operative antibiotics
• Simple AP - hrs antibiotic
• Ruptured AP - antibiotic until fever
• Peritonitis - 10 days antibiotics
• Surgery
• Open appendectomy
• McBurney (oblique) Rocky Davis (transverse)
• right paramedian midline incision

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• Open Appendectomy

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TREATMENT

• Laparoscopy

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TREATMENT

• Phlegmon and small abscesses can be treated
  conservatively w/ IV antibiotic
• Well localized abscess ---gt percutaneous drainage
• Complex abscess ---gt surgical drainage
• Interval appendectomy 6 wks. Following an acute
  event treated either non-operatively or w/ simple
  drainage of an abscess.
• 0-37 recurrent appendicitis

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PROGNOSIS

• Mortality
• 9.9 -------gt 0.2
• Factors
• Ruptured prior to surgery
• Simple - 0.06
• Ruptured - 3
• Age of pt.
• Ruptured - 15
• Death due to
• Uncontrolled sepsis (peritonitis, intra-abdominal
  abscess, gm (-) septicemia.
• Cardiac / pulmonary insufficiency (elderly)
• Pulmonary embolism
• aspiration

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PROGNOSIS

• Morbidity
• Simple - 3 Ruptured - 47
• Early
• Septic
• Wound infection / abscess
• Intra-abdominal abscess (appendiceal fossa, pouch
  of Douglas, sub-hepatic space, multiple
  intestinal loops.
• Fecal fistula
• Wound dehiscence
• Intestinal obstruction due to locculated abscess
  exuberant adhesive formation

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PROGNOSIS

• Morbidity
• Late
• Adhesived bands
• Inguinal hernia (3x greater in pt. who had
  appendectomy)
• Incisional hernia (paramedian / midline incision)
  

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Appendicitis in the Young

• Difficult to establish diagnosis
• Inability of a child to give accurate history
• Diagnostic delays by both parents physicians
• Rapid progression to rupture
• Underdeveloped greater omentum ----gt higher
  morbidity
• lt 8y/o had a twofold increase rate of perforation
  as compared to older children

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Appendicitis during Pregnancy

• AP is the most frequent extra-uterine dse.
  requiring surgical Tx during pregnancy
• Most frequent during the 1st 2nd trimesters
• S/Sx
• Abdominal pain, tenderness
• Rebound tenderness and guarding less due to
  laxity of abdominal wall
• Increase WBC abdominal ultrasound
• Dx is difficult due to displacement of the
  appendix

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Appendicitis during Pregnancy

• Dx is difficult due to displacement of the
  appendix

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Appendicitis during Pregnancy

• Risk of surgery
• Premature labor - 10-15 both for negative
  laparotomy and appendectomy for uncomplicated AP
• Appendiceal perforation is significant factor
  associated w/ fetal and maternal death.
• Fetal mortality - 3-5 w/ early appendicitis
• 20 perforation
• Suspicion of appendicitis during pregnancy shd
  prompt rapid diagnosis and surgical intervention

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Tumors of the Appendix

• Appendiceal malignancy is rare
• Discovered during laparotomy or in association w/
  acute inflammation of the appendix
• CARCINOID
• Firm, yellow, bulbar mass in the appendix
• Located appendix ---gt small bowel ----gt rectum
• Carcinoid syndrome is rare in appendiceal
  carcinoid unless widespread metastases are
  present
• Malignant potential related to its SIZE ---gt gt
  2cm
• Treatment lt 2cm appendectomy
• gt 2cm right hemicolectomy

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Tumors of the Appendix

• ADENOCARCINOMA
• Rare
• Histologic type
• Mucinous adenocarcinoma
• Colonic adenocarcinoma
• Adenocarcinoid
• Manifestation
• Acute appendicitis
• RLQ mass
• Treatment right hemicolectomy
• Prognosis
• 55 ----gt 5yr. survival

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Tumors of the Appendix

• MUCOCELE
• Progressive enlargement of the appendix from the
  intraluminal accumulation of a mucoid substance
• Histologic type
• Retention cyst
• Mucosal hyperplasia
• Cystadenomas
• Cystadenocarcinoma
• Rarely occurs w/ gelatinous ascites (Pseudomyxoma
  Peritonei) usually associated w/ malignant
  ovarian or appendiceal mucinous CA. if present
  survival is decreased

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Tumors of the Appendix

• MUCOCELE
• Treatment
• Benign - appendectomy
• Malignant - right hemicolectomy for cystadenoCA
  of the appendix THABSO and appendectomy for
  ovarian cystadenoCA
• Adjuvant Tx
• Radiation, intraperitoneal and systemic
  chemotherapy recommended but its role is unclear
• 57 local recurrence at appendiceal primary site
• Death ensues due to progresive obstruction and
  renal failure

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THANK YOU