APPENDIX

James Taclin C. Banez, MD, FPSGS,FPCS

Anatomy / Function

  Location, position Function:  Immunologic organ  Secrets IgA, component of the GUT associated lymphoid tissue (GALT)  Not essential; it’s removal ----> (-) sepsis

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 ----> puberty / early adulthood Male > female (1.3 : 1)

Appendicitis

Pathogenesis:



Obstruction

(dominant causal factor) 1.

Fecalith – usual cause 2.

3.

4.

5.

6.

Hypertrophy of the lymphoid tissue Inspissated barium Vegetable and fruit seeds Intestinal worms (Ascaris) Tumor

Appendicitis

Pathogenesis:

 Sequence of events in

Luminal Obstruction

Proximal occlusion ---> Closed loop Obst. ---- - -> rapid distention due to: a.

b.

Continuing secretion of the mucosa Rapid multiplication of normal flora ---> elevate pressure ---> capillary/venous occlusion (

CONGESTION

1 st 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

Appendicitis Pathogenesis

   Inflammatory process involves the serosa of appendix and in turns parietal peritoneum in the region.

Infiltration of PMN (

SUPPURATIVE

2 nd stage)  Damage of the lining epithelium ---> entrance of bacteria to the wall.

Impairment of blood supply (inc. pressure than arterial pressure)---> ellipsoidal infarct at antimesenteric border near the tip. (

GANGRENOUS

stage) 3 rd stage) ---> (

PERFORATION

4 th

This process is not inevitable. Some subside spontaneously



Appendicitis

Pathogens:

  Anaerobes, aerobes Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, Bacteroides splanchnicus, Lactobacillus

Appendicitis

Clinical Manifestation:

1.

2.

3.

4.

    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 ----> irritates the spermatic artery and ureter Anorexia: nearly always present Vomiting 75% Obstipation / diarrhea Usual sequence (95%) :

ANOREXIA ---> ABD. PAIN --> VOMITING

Appendicitis

Signs:

PE depends on the location of the appendix and presence of rupture 1.

Direct and rebound tenderness at Mc Burney’s point. ROVSING sign ---> indicate muscles peritoneal irritation.

2.

Involuntary muscle guarding (true reflex rigidity).

3.

4.

Psoas / Obturator signs ---> retrocecal appendix Para-rectal tenderness Stages I & II – uncomplicated Stages III & IV – complicated

Appendicitis

Laboratory Findings:

1.

2.

3.

WBC: leucocytosis simple = 10,000 to 18,000/mm3 Urinalysis :  Hematuria and pyuria due to irritation of the ureter and urinary bladder  perforated = >18,000/mm3 w/o bacteriuria FPA: rarely helpful; (+) fecalith – rare, highly suggestive of the dx.

Appendicitis

4.

   Graded Compression sonogram: 78–96% sensitivity; 85– 98% specificity (+) non-compressible appendix, 6mm or > at AP view (-) easily compressible 5mm; not visualized a & (-) pericecal fluid or mass a.

False (-): Appendicitis confined at the tip b.

c.

Retrocecal position Perforated appendix  False (+): a.

Periappendicitis from surrounding inflammation b.

c.

d.

Dilated fallopian tube Inspissated stool can mimic an appendicitis Obese pt., appendix not compressed

Appendicitis

5.

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

6.

Appendicitis

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

Appendiceal Rupture:

   Increase morbidity / mortality No accurate way to determine the occurrence of rupture 1.

Suspected: Fever > 39 C 2.

3.

4.

5.

WBC of > 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)



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 1.

 Acute mesenteric adenitis: w/ present or recent URTI   Diffuse pain, tenderness not sharp, (-) rigidity Self limited -----> observe

2.

3.

4.

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  Meckel’s diverticulitis: Same clinical picture w/ AP  Associated w/ same complication of AP, hence needs prompt surgical intervention.

5.

6.

Differential Diagnosis:

  Intussusceptions: Shd. Be differentiated pre-operatively due to different management.

Char: a.

b.

c.

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 (Crohn’s dse): s/sx is almost the same w/ AP this is dx. in celiotomy

7.

8.

Differential Diagnosis:

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

   

TREATMENT

Adequate hydration, correct electrolyte imbalance Manage other medical problems  Pre-operative antibiotics: Simple AP - hrs antibiotic   1.

Surgery: Open appendectomy:  Ruptured AP - antibiotic until fever Peritonitis - 10 days antibiotics McBurney (oblique); Rocky Davis (transverse); right paramedian; midline incision

Open Appendectomy:

2.

TREATMENT

Laparoscopy:

TREATMENT

    Phlegmon and small abscesses can be treated conservatively w/ IV antibiotic Well localized abscess ---> percutaneous drainage Complex abscess ---> 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

PROGNOSIS

Mortality:

  1.

2.

9.9% -------> 0.2% Factors: Ruptured prior to surgery   Simple - 0.06% Ruptured - 3% Age of pt.:  Ruptured - 15%  1.

2.

3.

4.

Death due to: Uncontrolled sepsis (peritonitis, intra-abdominal abscess, gm (-) septicemia.

Cardiac / pulmonary insufficiency (elderly) Pulmonary embolism aspiration

PROGNOSIS

Morbidity:

  Simple - 3% 1.

Early: Septic : 2.

3.

4.

Ruptured - 47% a.

Wound infection / abscess b.

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

PROGNOSIS

Morbidity:

 1.

Late: Adhesived bands 2.

3.

Inguinal hernia (3x greater in pt. who had appendectomy) Incisional hernia (paramedian / midline incision)

Appendicitis in the Young

  1.

Difficult to establish diagnosis: Inability of a child to give accurate history 2.

Diagnostic delays by both parents & physicians   Rapid progression to rupture: Underdeveloped greater omentum ----> higher morbidity < 8y/o had a twofold increase rate of perforation as compared to older children

Appendicitis during Pregnancy

     AP is the most frequent extra-uterine dse. requiring surgical Tx during pregnancy Most frequent during the 1 st & 2 nd 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

Appendicitis during Pregnancy

 Dx is difficult due to displacement of the appendix

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

 

Tumors of the Appendix

Appendiceal malignancy is rare Discovered during laparotomy or in association w/ acute inflammation of the appendix

1.



CARCINOID:

Firm, yellow, bulbar mass in the appendix     Located: appendix ---> small bowel ----> rectum Carcinoid syndrome is rare in appendiceal carcinoid unless widespread metastases are present Malignant potential related to it’s SIZE ---> > 2cm Treatment: < 2cm appendectomy > 2cm right hemicolectomy

2.

Tumors of the Appendix



ADENOCARCINOMA:

Rare     a.

Histologic type: Mucinous adenocarcinoma b.

c.

Colonic adenocarcinoma Adenocarcinoid a.

Manifestation: Acute appendicitis b.

RLQ mass Treatment: right hemicolectomy  Prognosis: 55% ----> 5yr. survival

3.

Tumors of the Appendix

 

MUCOCELE:

Progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance Histologic type:  a.

b.

c.

d.

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

3.

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 it’s role is unclear   57% local recurrence at appendiceal primary site Death ensues due to progresive obstruction and renal failure

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