Acute appendicitis notes, Study Guides, Projects, Research of Medical Sciences

Download Acute appendicitis notes and more Study Guides, Projects, Research Medical Sciences in PDF only on Docsity! Acute appendicitis ACUTE APENDICITIS lleocolic artery Ileal branch Superior mesenteric artery Appendicular artery Superior ileocecal recess Terminal part of ileum lleocecal fold (bloodless fold of Treves) Inferior ileocecal recess Mesoappendix Appendicular artery Vermiform appendix Appendix in different tL Le LE Age groups Child Adult Old [Type text] Page 1 Appendix Inflamed appendix Normal appendix [Type text] Page 2 Appendix 2.Suppurative inflammation — formation of multiple abscesses in the wall of the appendix and pus in the lumen — empyaema of the appendix. If the condition is untreated , the condition usually progress to the followings 3.Gangrenous inflammation: Gangrene uaually occurs at the tip of the appendix ( where appendicular vessels are close to the wall of the appendix ) or the site of obstruction (pressure necrosis ). * Non-obstructive * Obstructive. B) Acute Non-obstructive Appendicitis :(Less common,1/3 of cases ) e Produce mild slowly progressive inflammation e Usually catarrhal inflammation rarely progress to suppuration or gangrene . [Type text] Page 5 Appendix * Fate & Complications: 1) In non-obstructive type only , acute inflammation may resolve spontaneously and becomes subacute appendicitis but usually recurrent acute attacks occurs . 2) Appendicular Mass: # Mechanism: In non obstructive type — gives time for the greater omemtum , caecum , loops of intestine and adhesions to surround the inflamed appendix on the 3" day after the onset of the condition. * Fate of Appendicular Mass: 1. Usually it resolves within few weeks. 2.Perforation inside the mass > appendicular abscess. 3) Perforation. # More common in young below 5 years (thin wall) and elderly ( atherosclerosis) . # Sudden perforation with poor general resistance — generalized peritonitis which is more common in the obstructive type. * Gradual perforation inside an appendicular mass — appendicular abscess (localized peritonitis). = Fate of Appendicular Abscess: The abscess may point on the abdominal wall, rectum, vagina or brust into the generalized peritoneal cavity — generalized peritonitis. [Type text] Page 6 Appendix # Subphrenic abscess may occur especially in subhepatic appendix . 4) Local spread of infection with irritation of the uterus , uterine tube , ovaries, bladder, ureter, rectum , ileum , psoas major & obturator internus muscles etc ..... Transversus abdominis muscle sree Right psoas Aomieninal major muscle nerve Wise crest: Right gonadal vessels liacus muscle Lateral cutaneous nerve of the thigh Femoral nerve Right genitofemoral nerve [Type text] Page 7 Appendix 4.Nausea nearly always present and appears after pain . 5.Vomiting in 75% of patients ,occurs once or twice only & if persistant , it indicates complications. = Vomiting always occur after pain . « If vomiting precedes pain , one should think of another diagnosis . 6. Constipation is common but diarrhea may be present . B. Examination: a. General Examination: 1. Temperature rises gradually to 38°C, a higher temperature indicates complications or other diagnosis . = Appendicitis never start by rigor or temperature higher than 40°C . 2. Tachycardia is slight. Marked tachycardia indicates complications or other diagnosis . Oral tost of body temperature ADAM. b. Abdominal Examination: 1. Localized tenderness & rebound tenderness in the McBurney’s point ( which is the commonest site for the base of the appendix . It is the junction between medial 2/3 & lateral 1/3 of a line between umbilicus & right ASIS) or elsewhere, as determined by the position of the appendix. [Type text] Page 10 Appendix 2. Cough tenderness: on coughing, pain becomes sharp & localized to the site of appendix. 3. Rigidity , guarding & \imitation of abdominal wall movements with respiration over the position of the appendix occurs in advanced stage with perforation & peritonitis . = 1, 2 & 3, indicate involvement of the overlying parietal peritoneum [Type text] Page 11 Appendix 4. Rovsing’s sign. pressure on the left iliac fossa causes pain in the right iliac fossa due to displacement of gases from the pelvic colon to the appendix. i | } Rovsing’s Sign a, | : . —s 7 \} Palpate here (LLO) ‘ Pain elicited in RLO AN Suggestive of acute appendicitis 5. Hyperaesthesia in the sheren’s triangle (between the m " umbilicus, right A.S.1I.S. & symphysis pubis), rarely present in early cases due to strectch of the serous coat. (irritation of spinal segment supplying both areas). 4) Umbilicus Sherren's — triangle Antero-—4C superior iliac spine Pubic symphysis. 6. P-R or P-V exam. to exclude gynaecological causes of acute abdomen & show tenderness or mass in the right side , in pelvic appendicitis. [Type text] Page 12 Appendix 2. Pelvic Appendix: (20%) = Painmay be felt in the pelvis. = Deep tenderness can be elicited on P-R & P-V examination = Irritation of the surrounding structures. 1. Right obturator internus muscle — spasm — lateral rotation of the hip with abdominal pain on its medial rotation (obturator sign). 2. Bladder — frequency of micturation . 3. Uterus , uterine tube & ovaries — vaginal discharge. 4. Rectum — tenesmus . Appendix 3. Paracaecal Appendix: (1%), tenderness & rigidity in the flank. 4. Post-ileal appendix: (1/2 %), irritation of ileum — diarrhea with early vomiting. 5. Subhepatic appendix: (rare, due to failure of descent of caecum). Pain, tenderness and rigidity may be located in the right hypocondrium, simulating acute cholecystitis. 6. Appendicitis with pregnancy: [Type text] Pain is displaced upwards as pregnancy progress. Localization by the omentum is less efficient. The condition is usually misdiagnosed as pyelitis If perforation occurs, there is a high chance of abortion or premature labour. McBumey’s point 8mo 7 mo ! gma 50 y A\..2 Prepregnancy ( as & x f - =. Page 16 7. Appendix Appendicitis in infants & young children is more serious as perforation occurs in 80% of cases because difficult examination of children , thin wall , greater omentum is not well developed & the case may be misdiagnosed as gastroenteritis. 8. Appendicitis in elderly: perforation is common due to weak immunity & atherosclerosis — early thrombosis & gangrene. * Picture of complications: a. Appendicular Mass: « History suggests acute appendicitis since 2-3 days. « High temperature above 38°C. « Firm tender mass in the right iliac fossa ,with overlying muscle guarding therefore it is usually diagnosed only by exam. under anaethesia in the operating theater before the operation . b. Appendicular abscess: History suggests acute appendicitis since 5-10 days. Progressive fever, hectic fever & tachycardia. Tense cystic tender swelling in the right iliac fossa. Pain increases and becomes throbbing with persistent vomiting. Ultrasound confirm diagnosis by presence of fluid inside the mass. c. Peritonitis: History suggests acute appendicitis. High temperature above 38°C. [Type text] Page 17 Appendix "It is diagnostic & therapeutic by laparoscopic appendicectomy or laparoscopic surgery for gynaecological problems. *Scoring of Acute Appendicitis [ Alvarado Score | == MANTRELS = Fes Migratory right Iliac Fossa pain Anorexia Nausea/v omiting a Tenderness Right Lower Quadrant Rebound tenderness 1 Elevation of temperature 1 LABORATORY Liens: Osis 2 Q) Shift to the Left of Neutrophils 1 Total Score 10 e A popular mnemonic used to remember the Alvarado score factors is MANTRELS . e 0-3 : in 95% , there is no appendicitis — discharge . e 4-6 : in 35%, there is appendicitis — imaging . [Type text] Page 20 Appendix e 7 or more : in 75%, there is appendicitis + appendicectomy. *D.D.: causes of acute abdomen (mention). The most important are: I) Other causes of pain in the right iliac fossa : 1-Right tubo-ovarian causes : = Mid-cycle ovulation pain , rupture ectopic pregnancy , rupture or twisted ovarian cyst , pelvic inflammatory diseases ( salpingitis , pyosalpinx & tubo-ovarian abscess ) and degeneration in fibroid « U/S is usually diagnostic . 2-Non-specific mesenteric lymphadenitis : = The patient is usually child with attacks of pain & tenderness shifts with changing position . 3- Stone right ureter 4- Meckel’s diverticulitis : = The same manifestations of appendicitis but above and medial to McBurney’s point . = It is usually diagnosed at exploration . 5- Gastroenteritis . 6- Acute regional ileitis : " History of repeated attacks of pain in the right iliac fossa , diarrhea and bleeding per rectum are suggestive . = Vague mass is felt in right iliac fossa . 7- Right iliac lymphadenitis : " Manifestations of the cause . = Pain & tenderness is lower than McBurney’s point near the iliac vessels . II) Other causes of mass in the right iliac fossa : [Type text] Page 21 Appendix 1- Appendicular mass is the commonest mass in the right iliac fossa . 2- Apendicular abscess 3- Cancer caecum : « There is chronic irregular ill-defined hard not tender mass in the right iliac fossa . "The condition is usually associated with anaemia , weakness , dyspepsia and manifestation of metastases . 4- Chronic regional ileitis 5- Right iliac lymphadenitis 6- Hypertrophic ileocaecal TB. CONTENTS; “Appendix *Caecum *Mesoappendix *Terminal ileum s * Retro peritoneal 1 * iliac nodes iliac arteries Psoas major m Testicular a. Ascending colon A, Gonitotemoraln./ * Treatment: A) Urgent appendicectomy: (or also called appendectomy ) e Appendicectomy should not be delayed, especially in children, elderly, pregnant female & D.M., unless contraindicated . [Type text] Page 22