Вы находитесь на странице: 1из 7

APPENDIX

Dr. Rene PSA Mendoza, MD, MBAH


th
Schwartz 10 ed | lecture notes

HISTORY____________________________________________________  In patients with MIDGUT MALROTATION and SITUS INVERSUS, the


 Most common emergency procedures performed in contemporary Cecum (and thus the appendix) will not reside in the usual right lower
medicine quadrant location. With MIDGUT MALROTATION, the midgut
 Leonardo da Vinci depicted the appendix in his anatomic drawing but incompletely rotates or fails to rotate around the axis of the SMA
th
these were not published until the 18 century during fetal development, so in this situation, the appendix will
 Jean Fernel was credited for first describing appendiceal disease in a remain in the LEFT UPPER QUADRANT of the abdomen. SITUS
paper published in 1544 where a 7 yeard old died because of INVERSUS is a rare autosomal recessive congenital defect
obstructed appendiceal lumen bringing about to necroses and characterized by transposition of the abdominal and/or thoracic
perforation organs, in this situation the appendix is found in the LEFT LOWER
 Lorenz Heister provided first description of classic appendicitis in 1711 QUADRANT of the abdomen
 Claudius Amyand in London performed the first appendectomy in
1736

EMBRYOLOGY, ANATOMY AND PHYSIOLOGY______________________


th
 In the 6 week of human embryonic development, the appendix and
cecum appear as outpouchings from the caudal limb of the midgut
th
 Begins to elongate at about 5 month to achieve a vermiform
appearance and it maintains its position at the tip of the cecum
throughout development
 The subsequent unequal growth of the lateral wall of the cecum
causes the appendix to finds it s ADULT POSITION on the posterior
medial wall, just below the ileocecal valve.
 THE BASE OF THE APPENDIX can be located by following the
longitudinally oriented TAENIAE COLI to their confluence to the cecum  In the adult, the average length of the appendix is 6-9cm, however it
(to differentiate cecum w/ intestine in cecum you have the presence can vary in length from <1 to >30 cm
of haustrations)  The appendix receives it blood supply from the appendicular branch of
 THE TIP of the appendix can be located anywhere in the RLQ of the the ileocolic artery
Abdomen, Pelvis or Retroperitoneum
 THE TIP of the Appendix is the POINT OF MAXIMAL TENDERNESS

SURGERY 3A: APPENDIX| Lonski|2015 1


 Innervations is derived from Sympathetic elements contributed by
Superior Mesenteric Plexus (t10-L1) and afferents from the
parasympathetic elements via the vagus nerve

 Retrocecal Variation is the most common, it usually presents as flank


pain
 Promontory presents as low back pain
 Pelvic Variation differential diagnosis: Think of Testicular Torsion,
Hernia, PID and Ectopic pregnancy in women

 Diagnosis: ACUTE ABDOMEN to consider acute appendicitis

___________________________________________________________
___________________ACUTE APPENDICITIS_______________________
nd rd
 Lifetime risk: M>F, with the highest incidence in the 2 or 3 decades
 {lecture} not common 5 years and below; there are only few cases of
appendicitis in the elderly (appendix in the elderly already atrophied)
 {lecture} most common acute surgical disease in the abdomen,
frequent in pubertal age

A. ETIOLOGY AND PATHOGENESIS


 Proposed as the main etiologic factor in acute appendicitis is
obstruction of the lumen due to fecaliths or hypertrophy of
lymphoid tissue
 Predictable sequence of events leading to eventual appendiceal
rupture:
1. Proximal obstruction of the appendiceal lumen produces a closed
 {Lecture} The appendix is usually peritoneal, covered by peritoneum loop obstruction
 {lecture} Mesoappendix derived from left side of the mesentery 2. Continuing normal secretion by the appendiceal mucosa radpidly
proper produces distention
 {lecture} The Anti-Mesenteric Border of the Mesoappendix is the most 3. Distention stimulates the nerve ending of visceral afferent stretch
common site of perforation fibers, producing vague, dull, diffuse pain in the mid abdomen or
 For many years, the appendix was erroneously believed to be a lower epigastrium
vestigial organ with no known function. It is now well recognized that 4. Distention increases from continuous secretion and rapid
the appendix is an immunologic organ that actively participates in the multiplication of resident bacteria, which causes reflex nausea,
secretion of immunoglobulins, particularly IgA vomiting and the visceral pain increases
 {lecture} Part of GALT, produces lymphoid tissue 5. Pressure in the organ increases, venous pressure is exceeded
resulting into engorgement and vascular congestion
 NOTES FROM LECTURE 6. These inflammation process soon involves the serosa of the
 ACUTE ABDOMEN: can be surgical or medical (AGE/PUD); it is the appendix and in turn parietal peritoneum that produces the
occurrence of abdominal pain within 24-48 hours characteristic shift in pain to the RLQ
 There are 2 types of PAIN: VISCERAL (contained in the serosa of the 7. Compromise vascular supply and infarction progresses
intestines) and SOMATIC (localize type of pain; parietal epithelium) 8. Perforation occurs usually in the anti-mesenteric border just
 Rigidity is described as Board like tenderness; slight pressure will beyond the point of obstruction
release some pain  These sequence is not inevitable, however, and some episodes of
acute appendicitis may resolve spontaneously
 {lecture} Pathogenesis: Obstruction of the lumen by: Fecalith (most
common), hypertrophy of the lymphoid tissue, inspissated barium
from previous x-ray studies (barium enema), vegetable or fruit
seeds (kamatis/sili) and intestinal worms (ascariasis)

SURGERY 3A: APPENDIX| Lonski|2015 2


{LECTURE NOTES}
Fecalith

4 stages of Acute Appendicitis


1. Congestion
2. Suppuration
3. Gangrenous
4. Perforation
***you can consider distention as the first process actually B. MICROBIOLOGY
 The flora of the inflamed appendix differs from that of the normal
appendix.
 Tissue specimens of the inflamed appendix wall (not luminal
aspirates) virtually all grow Escherichia coli and Bacteroides species
in culture

C. NATURAL HISTORY
 Circumstantial evidence suggests that not all patients with
appendicitis will progress to perforation and that resolution may be
a common event

D. CLINICAL PRESENTATION
 The inflammatory process in the appendix presents as pain, which
initially is of a diffuse visceral type and later becomes more
localized as the peritoneal lining gets irritated

SYMPTOMS_______________________________________________
 Appendicitis usually starts with periumbilical (visceral) and diffuse
pain that eventually localizes to the right lower quadrant (somatic)
 RLQ pain is one of the most sensitive signs of appendicitis, but pain
in atypical locations will sometimes be the initial presentation
 Appendicitis is also associated with GI symptoms like Nausea,
vomiting, and anorexia. GI symptoms that develop before the onset
of pain suggests a different etiology such as gastroenteritis
 Many patients complain of a sensation of obstipation prior to the
onset of pain and feel that defecation will relieve their abdominal
pain. Diarrhea may occur in association with perforation, especially
children
 {Lecture} Location of somatic pain depends on the location of the
appendix (TIP OF THE APPENDIX)
o RETROCECAL –Flank or back pain
o PELVIC – suprapubic pain
o RETROILEAL – testicular pain

SIGNS____________________________________________________
 Physical findings are determined by the presence of peritoneal
irritation and are influenced by whether the organ has already
ruptured when the patient is first examined. Patients with
appendicitis usually move slowly and prefer to lie supine due to the
peritoneal irritation.
 On Abdominal Paplation, there is tenderness with a maximum or
near McBurney’s Point (pic below)
 On deep Palpation, one can often feel a muscular resistance
(guarding) in the right illac fossa, which may be more evident when
compared to the left side.

SURGERY 3A: APPENDIX| Lonski|2015 3


IMAGING STUDIES__________________________________________
 Plain films of the abdomen can show the presence of a fecalith and
fecal loading in the cecum associated with appendicitis but are
rarely helpful in diagnosing acute appendicitis
 Ultrasound and Computed Tomography scan are the most
commonly used imaging tests in patients with abdominal pain,
particularly in evaluation of possible appendicitis.

 McBurney’s point: point of maximal tenderness; ½ to 2 inches


inside the right Anterior Spinous Process of the ileum on a line
drawn to the umbilicus
 When the pressure of the examining hand is quicly relieved, the
patient feels a sudden pain, the so-called REBOUND TENDERNESS
 Indirect tenderness (ROVSING’S SIGN) and Indirect rebound
tenderness (i.e., pain in the RLQ when the LLQ is palpated) are
strong indicators of peritoneal irritation
 Pain with Extension of the Right Leg (PSOAS SIGN) indicates a focus
or irritation in the proximity of the right psoas muscle. Similarly,
Stretching of the Obturator internus through internal rotation of
flexed thigh (OBTURATOR SIGN) suggests inflammation near the
muscle

LABORATORY FINDINGS_____________________________________
 Appendicitis is associated with an inflammatory response that is
strongly related to the severity of the disease. Laboratory
examinations are therefore an important part of the diagnosis.
 MILD LEUKOCYTOSIS is often present in patients with acute
uncomplicated appendicitis. Predominance of PMN
o 10,000 – 18,000 cells
o >18,000 cells suggests perforation
 INCREASED CRP is a strong indicator of appendicitis especially for
complicated appendicitis ULTRASONOGRAPHY
FALSE + FALSE -
- - - - - - - - - - - - - - - - - - {NOTES FROM LECTURE}- - - - - - - - - - - - - - - - - -
Presence of peri-appendicitis Appendicitis confined to
Anal Verge -> Anal Canal is 2-4 cm
from surrounding inflammation appendiceal tip
CUTANEOUS HYPERESTHESIA (T10-T12 Spinal Nerves)
Dilated fallopian tube mistaken Retrocecal location
RUPTURE OF APPENDICITIS from inflamed appendix
-Occurs distal to the point of obstruction Inspissated stool mimics Markedly enlarged appendix
-Anti-mesenteric border appendicolith mistaken for small bowel
-SUSPECTED IF Obese patients, overlying fat Perforated appendix showing
- Temp >39 C obscures compressibility of compressibility
- WBC >18k appendix
- Localized tenderness if rupture is contained
- Generalized peritonitis if rupture is not contained

PHLEGMON
- Ill defined mass of matted loops of bowel and abscesses
- “when your ruptured appendix is enveloped by your omentum”
- TX: IV Antibiotics, Percutaneous drainage, Interval appendectomy,
surgery
- OMENTUM (avoids spreading of infection)

CLINICAL SCORING SYSTEM___________________________________


 ALVARADO SCORE is the most widespread scoring system

SURGERY 3A: APPENDIX| Lonski|2015 4


 CT SCAN: Fat Stranding/Mesenteric Fat stranding – Infectious MECKELS DIVERTICULITIS
process  Clinical picture similar as that of appendicitis (pertaining to
symptomatology)
 Preoperative differentiation is academic and not necessary
 Treatment:
o Diverticulotomy
o Wedge resection – take out the whole diverticulum
o Segmental ileal resection
 RULE OF 2 (extensive info in my Small Intestine Handout)
 Presents with bleeding

INTUSSUCEPTION
 Patients are usually less than 2 years old
 Bloody mucoid stool after abdominal pain
 Sausage shaped mass
 Treatment
o Segmental Resection if with peritonitis
o Reduction by barium enema if with no signs of
E. DIFFERENTIAL DIAGNOSIS peritonitis
o SAFEST: Explore Lap and Reduction
 The differential diagnosis of acute appendicitis is essentially the
diagnosis of acute abdomen.
GYNECOLOGIC DISORDER
 The most common findings in the case of an erroneous
 PID
preoperative diagnosis of appendicitis are in descending order of
 RUPTURED GRAAFIAN FOLLICLE
frequency
 TWISTED OVARIAN CYST or TUMOR
1. Acute Mesenteric Adenitis
 ENDOMETRIOSIS
2. No organic pathologic condition
 ECTOPIC PREGNANCY
3. Acute pelvic inflammatory disease
o Bilateral inguinal pain
DISEASES OF THE MALE
4. Twisted ovarian cyst
 TORSION OF THE TESTES
o Easily diagnosed by UTZ
o Severe inguinal pain
5. Ruptured graafian follicle
o Violaceous color of scrotum
6. Acute gastroenteritis
 ACUTE EPIDIDYMITIS
o Ask and see companions if they also bear the
o Inflammation of the epididymis
symptoms; then ask what food taken
o Counterpart of PID
 The diagnosis of acute appendicitis depends on four major factors:
1. the anatomic location of the inflamed appendix;
URETERAL STONE
2. the STAGE of the process (uncomplicated or complicated)
 May simulate retrocecal appendicitis
3. patients AGE
4. and the patients GENDER  Pain is reffered to the labia majora, scrotum or penis
 Hematuria
1. ACUTE MESENTERIC ADENITIS  Fever may be present
 inflammation of the mesenteric lymph node  Leukocytosis
 is the disease most often confused with acute appendicitis in  Increased RBC, cast in urine
CHILDREN  DX by UTZ or Pyelography or CT sonogram
 Recent or Present URTI
 Diffuse abdominal pain with occasional voluntary guarding URINARY TRACT INFECTION
 (-) boardlike rigidity  May present as hypogastric or flank pain
 (+) Lymphocytosis  Fever may be present
 Self-limited  Increased urine in WBC
 Close observation
APPENDICITIS IN PREGNANCY
 Surgery if complications set in st
 More frequent in 1 2 trimester but can occur anytime
st
6. ACUTE GASTROENTERITIS  1 trimester – teratogenic effects of MEDs –
 VIRAL or BACTERIAL developmental/congenital defects
 Viral Causes  Location of appendix may change as the uterus enlarges
o Watery diarrhea, nausea, vomiting, crampy abdominal pain  Surgery during pregnancy
o Absent Tenderness o RISK OF PREMATURE LABOR 10-15%
o Laboratory exams are usually low  Perforation is associated with 20% risk of fetal and maternal
 SALMONELLA GASTROENTERITIS death
o Intense abdominal pain, chills and fever  UTZ may be utilized if diagnosis is doubtful
o Tenderness present
o Prostration, maculopapular rash, leucopenia PEDIATRIC APPENDICITIS
o Canned goods!!! –source  Voluntary guarding is sometimes present, but true rigidity is rare
 Acute Mesenteric adenitis is most often confused with
appendicitis in children

SURGERY 3A: APPENDIX| Lonski|2015 5


 Children less than 8 years old have two fold increase in the rate  If PERFORATED APPENDICITIS is suspected or the DIAGNOSIS is in
of perforation doubt, a lower midline Laparotomy can be considered.
 Increase Morbidity  Following entry into the abdomen, the patient should be placed in
o Rapid progression of rupture slight tendelenburg position with rotation of the bed to the patient’s
o Underdeveloped omentum not able to contain left. If the appendix is not easily identified, the cecum should be
inflammatory process = icreases the risk of located. Tracing the TAENIA LIBERIA (Anterior Taenia), the MOST
perforation VISIBLE of the three taenia coli, distally, the base of the appendix can
be identified.
IMMUNOSUPPRESED PATIENTS  The appendix will often have attachement to the lateral wall or pelvis
 The incidence of acute appendicitis in patients infected with that can be dissected free. Dividing the mesentery of the appendix
HIV is reported to be 0.5%, higher than the 0.1%-0.2% first will often allow imporved exposure of the base of the appendix.
incidence for the general population The appendiceal stump can be managed by simple ligation of by
 The risk of appendiceal rupture appears to be increased in HIV- Ligation and inversion. As long as the stump is clearly visible and the
Infected patients. base of the cecum is not involved with the inflammatory process, the
 Studies have shown that a LOW CD4 is also associated with an stump can be safely ligated.
increased risk of incidence of appendiceal rupture  The skin can also be closed primarily and patients with perforated
appendicitis
F. MANAGEMENT
Outline is SCHWARTZ ________________LAPAROSCOPIC APPENDECTOMY_______________
UNCOMPLICATED  The first reported laparoscopic appendectomy was performed in 1983
Operative vs Nonoperative by Semm.
Urgent vs Emergent appendectomy  Laparoscopic approach is performed under general anesthesisa.
COMPLICATED  The appendix should be identified similarly as in open surgery by
Operative vs Nonoperative tracking the Taenia Libera/Coli to the appendiceal base. Through the
Interval Appendectomy following Nonoperative Management suprapubic port, the appendix should be grasped securely and
elevated to the 10 o’clock position. An “Appendiceal critical view”
In LECTURE should be obtained where the taenia liberia is at the 3 o’clock
position, the terminal ileum at the 6 o’clock position, and th retracted
appendix at the 10 o’clock position to allow proper identification of
the base of the appendix

 Important procedure is to check for fluid status (check urine


ouput) to accurately measure insert indwelling foley catheter

G. OPERATIVE INTERVENTIONS FOR THE APPENDIX

___________________OPEN APPENDECTOMY_____________________
 Typically performed with a patient under general anesthesis, the
patient is placed in supine position. The entire abdomen should be
prepped and draped in case larger incision is needed.
 For NONPERFORATED APPENDICITIS, a Right Lower Quadrant Incision
rd
at McBurney’s Point (1/3 of the distance from the ASIS to the
umbilicus) is Commonly Used
 A McBURNEY (OBLIQUE) or ROCKY DAVIS (Transverse) RLQ muscle
splitting incision is made.

SURGERY 3A: APPENDIX| Lonski|2015 6


Pic above is the appendiceal critical view B. ADENOCARCINOMA________________________________________
 Rare neoplasm with Three major histologic subtypes
_____NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY _____  Histological types
 NOTES o Mucinous
 A new surgical procedure using flexible endoscopes in the abdominal o Colonic
cavity. o Adenocarcinoid
 In this procedure, access is gained by way of organs that are reached  Presentation
through a natural, already-existing external orifice o Appendicitis (most common mode of presentation)
 CURRENTLY: 113 NOTES appendectomies is Human Patients have o Ascites
been reported in the medical literature, 87 were performed o Palpable Mass
transvaginally, and 26 were performed transgastrically. Majority of o Or may be discovered during an operative procedure
these cases are hybrid procedures (NOTES + Lap assist port) with only  Have a propensity to perforate early
14 cases of PURE NOTES appendectomies  Treatment: Right Hemicolectomy
 Much work remains to demonstrate whether NOTES is able to provide  Overall 5 eyar survival: 55%
the theoretical benefits purported
C. MUCOCELE________________________________________________
H. COMPLICATIONS  Progressive enlargement of appendix due to intraluminal
EARLY COMPLICATIONS accumulation of mucoid substance
 Early Complications Mortality: 0.2% per 100,000  Obstructive dilatation by intraluminal accumulation of mucoid
 Factors which decrease Mortality material
 Better diagnosis and treatment  Mucoceles may be cause by one of four processes:
 New antibiotic agents o Retention cysts
 New iv fluids o Mucosal hyperplasia
 Factors which increases mortality o Cystadenoma
 Rupture prior to surgery o Cystadenocarcinoma
 Age (elderly associated with 11% mortality  The clinical presentation of mucocele is nonspecific, and often it Is
 Causes of Death an incidental finding at operation for acute appendicitis
 Uncontrolled sepsis  An intact mucocele presents with no future risk, but opposite when
 Pulmonary embolism ruptured, so when it is visualized in laparoscopy, conversion to
 Aspiration open laparotomy is recommended
 Morbidity  Treatment: appendectomy
 Sepsis
 Wound infection D. PSEUDOMYXOMA PERITONEI________________________________
 Intra-abdominal abscess  Rare condition in which diffuse collections of gelatinous fluid are
 Wound dehiscence associated with mucinous implants on peritoneal surfaces and
 Enterocutaneous fistula omentum
 Intestinal obstruction  2-3x more common in females than males
 Ileus  Recent studies suggests that the appendix is the site of origin for
the overwhelming majority of pseudomyxomas
LATE COMPLICATIONS  Presents with
 Adhesive band obstruction  Abdominal pain
 Inguinal hernia  Distention
 Incisional hernia  Or mass
o Fascia is the strongest layer in the abdominal wall  DOES NOT CAUSE abdominal organ dysfunction
 Treatment: CT SCAN (preffered modality before surgery); Surgical
___________________________________________________________ debulking is the main stay of treatment: all gross disease and the
__________________APPENDICEAL NEOPLASMS___________________ omentum should be removed (hysterectomy with Bilateral salpingo-
1. CARCINOID oophorectomy is performed in women)
2. ADENOCARCINOMA
3. MUCOCELE E. LYMPHOMA_______________________________________________
4. PSEUDOMYXOMA PERITONEI  Extremely uncommon
5. LYMPHOMA
 GIT is the most frequently involved extranodal site for non-
Hodgkin’s lymphoma
A. CARCINOID________________________________________________
 Other types of appendiceal lymphoma such as Burkitt’s, as well as
 Firm, Yellow bulbar mass
leukemia have also been reported
 The appendix is the most common site of gastrointestinal carcinoid,
 Adjuvant therapy is not indicated for lymphoma confined to the
followed by the small bowel and rectum
appendix
 Carcinoid syndrome rarely presents in appendiceal carcinoid unless
if with metastasis
 Malignant potential is related to size (>2cm)
 Treatment:
o <1cm = appendectomy
o 1-2cm (LOCATED AT TIP or MID APPENDIX) = appendectomy
o 1-2cm (LOCATED AT BASE; Mesoappendiceal) = Right
Hemicolectomy
o >2cm = Right Hemicolectomy

SURGERY 3A: APPENDIX| Lonski|2015 7

Вам также может понравиться