Acute Appendicitis

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Acute AppendicitisAcute Appendicitis

Presented by :Presented by :

Seyed Morteza MahmoodiSeyed Morteza Mahmoodi

Anatomy project

Year 2005-06

Supervised by:

Dr. Aziz Aziz

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ContentsContents

Introduction Introduction History History Incidence Incidence Etiology and pathology Etiology and pathology Case Case Signs and symptomsSigns and symptomsClinical diagnosisClinical diagnosisDifferential diagnosisDifferential diagnosis

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IntroductionIntroduction Appendicitis can be tricky diagnosis, even for skilled Appendicitis can be tricky diagnosis, even for skilled

physician physician Acute appendicitis is the most common cause of Acute appendicitis is the most common cause of

intraabdominal infection intraabdominal infection Appendicectomy is the most common emergency Appendicectomy is the most common emergency

surgical operationsurgical operation.. Variations in the position of the appendix, age of the Variations in the position of the appendix, age of the

patient, and degree of inflammation make the clinical patient, and degree of inflammation make the clinical presentation of appendicitis notoriously inconsistentpresentation of appendicitis notoriously inconsistent. .

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History History Recognition as clinical entity Recognition as clinical entity

Reginald Fitz ‘perforating Reginald Fitz ‘perforating inflammation of the vermiform inflammation of the vermiform appendix’appendix’

Charles McBurney described Charles McBurney described the clinical manifestation the the clinical manifestation the point of max. tenderness in the point of max. tenderness in the right iliac fossa right iliac fossa

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IncidenceIncidence Relatively rare in infantsRelatively rare in infants Common in childhood and adult life Common in childhood and adult life 3-4/1000/year3-4/1000/year Peak incidence in teens and early 20sPeak incidence in teens and early 20s After middle age the risk is quit smallAfter middle age the risk is quit small Before puberty the incidence is equal amongst Before puberty the incidence is equal amongst

males and females males and females In teenagers and young adults the ratio of In teenagers and young adults the ratio of

male:female is 3:2 at the age of 25male:female is 3:2 at the age of 25 Thereafter the incidence in males declinesThereafter the incidence in males declines approximately 1 in 7 people will undergo an approximately 1 in 7 people will undergo an

appendicectomy during their lifetime appendicectomy during their lifetime

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EtiologyEtiology

No unifying hypothesis No unifying hypothesis Bacterial proliferationBacterial proliferation Initiating event is controversialInitiating event is controversialObstruction of appendix lumenObstruction of appendix lumenFaecolith or fibrotic strictureFaecolith or fibrotic strictureTumor Tumor Intestinal parasitesIntestinal parasitesNo luminal obstruction No luminal obstruction

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Pathological sequencePathological sequence

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Pathological sequencePathological sequence

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Pathological sequencePathological sequence

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PathologyPathology

Continued mucous secretion and inflammatory Continued mucous secretion and inflammatory exudation intraluminal pressure exudation intraluminal pressure obstructing lymphatic drainage. obstructing lymphatic drainage.

Edema and mucosal ulceration develop with Edema and mucosal ulceration develop with bacterial translocation to submucosa . bacterial translocation to submucosa .

Further distention may cause venous Further distention may cause venous obstruction and ischcemia of the appendix wall. obstruction and ischcemia of the appendix wall.

Bacterial invasion through muscularis externea Bacterial invasion through muscularis externea producing acute appendicitis. producing acute appendicitis.

Ischaemic necrosis of appendicular wall Ischaemic necrosis of appendicular wall gangrenous appendix bacterial contamination gangrenous appendix bacterial contamination of peritoneal cavity. of peritoneal cavity.

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Pathology cont.Pathology cont. Greater omentum becomes Greater omentum becomes

adherent to inflamed adherent to inflamed appendix paracaecal appendix paracaecal abscess abscess

Extremes of age Extremes of age Immunosuppression Immunosuppression Faecolith obstructionFaecolith obstruction Pelvic appendixPelvic appendix Previous abdominal Previous abdominal

surgery surgery

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Pathology cont.Pathology cont.

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Pathology cont.Pathology cont.

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Case reportCase reportColicky periumblical pain Colicky periumblical pain Migrated to the right lower quadrantMigrated to the right lower quadrant Initial nausea Initial nausea Increasing emesis and anorexiaIncreasing emesis and anorexiaAbdominal guarding and rebound Abdominal guarding and rebound

tendernesstendernessRigid anterior abdominal wall in RLQRigid anterior abdominal wall in RLQLow grade fever and rising WBC countLow grade fever and rising WBC count

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Clinical signsClinical signs

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Clinical signsClinical signs

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Abdominal painAbdominal pain

Visceral abdominal painVisceral abdominal pain Somatic abdominal painSomatic abdominal pain referred abdominalreferred abdominal

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Visceral abdominal painVisceral abdominal pain

Visceral abdominal pain, organs, visceral Visceral abdominal pain, organs, visceral peritoneum, mesentery peritoneum, mesentery

1-distention of a hollow viscus1-distention of a hollow viscus

2-ischemia to a viscus 2-ischemia to a viscus

3-inflammation 3-inflammation

Referred to midline embryological Referred to midline embryological developmentdevelopment

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Colicky painColicky pain Colicky pain form of visceral pain Colicky pain form of visceral pain

rhythmic pain resulting from smooth rhythmic pain resulting from smooth muscle spasm as a reaction to luminal muscle spasm as a reaction to luminal obstructionobstruction

intestinal obstruction, passage of intestinal obstruction, passage of gallstone in biliary ducts, ureteric colic gallstone in biliary ducts, ureteric colic

Often thought to be indigestion, Often thought to be indigestion, constipation and is frequently ignored. constipation and is frequently ignored.

Lasts for a variable period, usually few Lasts for a variable period, usually few hours / 2 or 3 days, rarely longerhours / 2 or 3 days, rarely longer

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Referred painReferred pain

The vague referred pain in the periumblicalThe vague referred pain in the periumblical stretching of the lumen or spasm. stretching of the lumen or spasm. The visceral innervation comes from the The visceral innervation comes from the

10th thoracic spinal segment. 10th thoracic spinal segment. Accompany the sympathetic nerves through Accompany the sympathetic nerves through

the superior mesenteric plexus and the the superior mesenteric plexus and the lesser splanchnic nerve lesser splanchnic nerve

If the visceral innervation is higher, then the If the visceral innervation is higher, then the mid-line pain will be higher. mid-line pain will be higher.

Testicular pain due to visceral referral of Testicular pain due to visceral referral of afferent nerve impulses to the same spinal afferent nerve impulses to the same spinal segmentsegment

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Somatic painSomatic painSkin, fascia, muscle and parietal Skin, fascia, muscle and parietal

peritoneumperitoneumSever and precisely localized Sever and precisely localized Inflamed parietal peritoneum cutaneous Inflamed parietal peritoneum cutaneous

hyperesthesia and tenderness hyperesthesia and tenderness The right iliac fossa pain is due to the The right iliac fossa pain is due to the

irritation of parietal peritoneumirritation of parietal peritoneumsomatic pain as opposed to earlier somatic pain as opposed to earlier

visceralvisceral..

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Guarding and rigidityGuarding and rigidityGuarding is the protective phenomenon Guarding is the protective phenomenon abdominal muscles increase in tone abdominal muscles increase in tone attempts to localize the inflammationattempts to localize the inflammationThere is tenderness causing the patient There is tenderness causing the patient

to constantly tense the abdominal wall to constantly tense the abdominal wall muscles in palpation muscles in palpation

Voluntary guarding /apparent guarding Voluntary guarding /apparent guarding Involuntary guarding /true guardingInvoluntary guarding /true guardingMuscular spasm rigidity Muscular spasm rigidity localized initially progressing to localized initially progressing to

generalized with perforation or generalized with perforation or increasing peritonitisincreasing peritonitis

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Tenderness Tenderness Tenderness: Tenderness:

localised over McBurney's point localised over McBurney's point not evident before later inflammation of not evident before later inflammation of

serosa and parietal peritoneum serosa and parietal peritoneum often masked in obese due to inability to often masked in obese due to inability to

displace viscusdisplace viscusBlumberg’s sign The pain is elicited with Blumberg’s sign The pain is elicited with

pressing the abdominal wall deeply with pressing the abdominal wall deeply with fingers and abruptly releasing it.fingers and abruptly releasing it.

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ReflexesReflexes

Visceral afferent fibers participate in reflex Visceral afferent fibers participate in reflex activities. Reflex sweating, salivation, activities. Reflex sweating, salivation, nausea, vomiting and tachycardia may nausea, vomiting and tachycardia may accompany visceral pain.accompany visceral pain.

Carried by autonomic nerve fibersCarried by autonomic nerve fibers

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SignsSigns

lying still, with shallow breaths and reluctant to lying still, with shallow breaths and reluctant to cough cough

fever 37.5-38.5C, worsening with perforation fever 37.5-38.5C, worsening with perforation Foetor oris - halitosis Foetor oris - halitosis Furred tongue Furred tongue FlushedFlushed infrequently, diarrhoea: infrequently, diarrhoea:

early and transient as a result of visceral pain early and transient as a result of visceral pain later if retroileal or pelvic involvement appendix; this is later if retroileal or pelvic involvement appendix; this is

typically prolonged and mucoidtypically prolonged and mucoid constipation - sometimes for a few days before constipation - sometimes for a few days before

the attack the attack

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Signs to elicit in appendicitisSigns to elicit in appendicitis

Pointing signPointing signRovsing’s signRovsing’s signPsoas signPsoas signObturator signObturator sign

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Pointing signPointing sign

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Psoas signPsoas sign

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Obturator signObturator sign

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Differential diagnosisDifferential diagnosis

ChildrenChildren GastroenteritisGastroenteritisMesenteric adenitisMesenteric adenitisMeckel’s diverticulitisMeckel’s diverticulitis IntussusceptionIntussusceptionHenoch_Shonlein purpuraHenoch_Shonlein purpuraLobar pneumoniaLobar pneumonia

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Differential diagnosisDifferential diagnosis

AdultsAdults Terminal ileitisTerminal ileitisUreteric colicUreteric colicPerforated peptic ulcerPerforated peptic ulcerTesticular torsionTesticular torsionAcute pancreatitisAcute pancreatitisRectus sheath haematomaRectus sheath haematoma

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Differential diagnosisDifferential diagnosis

Adult femalesAdult femalesSalpingitisSalpingitisMittelschmerzMittelschmerzTorsion/hemorrhage of an overian Torsion/hemorrhage of an overian

cystcystEctopic pregnancyEctopic pregnancyEndometritis Endometritis

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Differential diagnosisDifferential diagnosis

ElderlyElderly Sigmoid diverticulitisSigmoid diverticulitis Intestinal obstructionIntestinal obstructionCarcinoma of the ceacumCarcinoma of the ceacumAortic aneurismAortic aneurism

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InvestigationInvestigation

RoutineRoutine Full blood count Full blood count leukocytosis is generally leukocytosis is generally

present present

Urinalysis assessment of dehydrationUrinalysis assessment of dehydration

Selected casesSelected cases Pregnancy testPregnancy test Urea and electrolytes Urea and electrolytes serum amylase - if pancreatitis suspected serum amylase - if pancreatitis suspected

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Investigations Investigations

Supine abdominal X-raySupine abdominal X-rayUltrasound abdomen/pelvis Ultrasound abdomen/pelvis abdominal radiology - helpful to abdominal radiology - helpful to

distinguish: distinguish: intussusception intussusception renal stones (90%) renal stones (90%) gallstones (10%) gallstones (10%) localised ileuslocalised ileus

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X-ray signsX-ray signs Reported signs include:Reported signs include: increased soft tissue density in the right lower increased soft tissue density in the right lower

quadrant quadrant a faecolith in the right iliac fossa a faecolith in the right iliac fossa

the majority are radio-opaque the majority are radio-opaque occur in about 10% of those with appendicitis occur in about 10% of those with appendicitis often mistaken for ureteric calculus or gallstonesoften mistaken for ureteric calculus or gallstones

a gas-filled appendix a gas-filled appendix free intraperitoneal gasfree intraperitoneal gas

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X-raysX-rays

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CT-scan CT-scan

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UltrasoundUltrasound

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Color-flow UltrasoundColor-flow Ultrasound

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GastroenteritisGastroenteritis

Gastroenteritis, or Gastroenteritis, or inflammationinflammation of the of the gastrointestinal tractgastrointestinal tract, is an illness caused by , is an illness caused by an infectious an infectious virusvirus, , bacteriumbacterium or or parasiteparasite. .

lasting less than 10 days and self-limitinglasting less than 10 days and self-limiting Sometimes it is referred to simply as Sometimes it is referred to simply as

'gastro'.'gastro'. If the inflammation is limited to the stomach, If the inflammation is limited to the stomach,

the term the term gastritisgastritis is used, and if the small is used, and if the small bowel alone is affected it is enteritis.bowel alone is affected it is enteritis.

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IntussusceptionIntussusception

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IntussusceptionIntussusception

An intussusception prolapsing of part of An intussusception prolapsing of part of intestine into another section of intestine, intestine into another section of intestine, (collapsible telescope) (collapsible telescope)

intussusceptum (The part which prolapses intussusceptum (The part which prolapses into the other), into the other),

intussuscipiens (the part which receives it). intussuscipiens (the part which receives it). The most frequent type ileum enters the The most frequent type ileum enters the cecum. cecum.

Almost all intussusceptions occur with the Almost all intussusceptions occur with the intussusceptum having been located intussusceptum having been located proximally to the intussuscipiens. proximally to the intussuscipiens.

The reason for this is that peristaltic action of The reason for this is that peristaltic action of the intestine "pulls" the proximal segment into the intestine "pulls" the proximal segment into the distal segment.the distal segment.

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Meckel’s diverticulumMeckel’s diverticulum

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Henoch-Schonlein purpuraHenoch-Schonlein purpura

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DiverticulitisDiverticulitis

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DiverticulitisDiverticulitis

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DiverticulitisDiverticulitis Diverticula small, pouches develop in the Diverticula small, pouches develop in the

wall of the colon. (sigmoid colon). Many wall of the colon. (sigmoid colon). Many people develop diverticula (called people develop diverticula (called diverticulosis), after age 50, and in most diverticulosis), after age 50, and in most individuals they cause no problem.individuals they cause no problem.

Diverticulitis (diverticula infected or Diverticulitis (diverticula infected or inflamed) can cause pain, fever and inflamed) can cause pain, fever and nausea. In rare cases, a pouch can rupture, nausea. In rare cases, a pouch can rupture, spilling intestinal waste into abdomen. spilling intestinal waste into abdomen.

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BibliographyBibliography

Clinical anatomy Richard SnellClinical anatomy Richard SnellBaily and Loves surgery Baily and Loves surgery Schwasrts SurgerySchwasrts SurgeryHandbook of general surgeryHandbook of general surgeryWeb sourcesWeb sources