Appendix Flashcards
Anatomy of appendix:
- Postero-medial wall of the caecum
- valave of gerlach is the appendicular orifice
- mesoappendix: is a peritoneum - lower surface of the mesentry of the terminal ileum
Appendicular artery is
Lower division of ileo-colic artery
Position of appendix could be :
Retrocecal Paracecal Subcecal Pelvic Promontoric (subileal) Postileal Preileal
Wallbridge anomaly types :
Type A : single cecum, and a partial duplication of the appendix with a single base
Type B1 : 2 completely separate appendices arise from a single cecum
Type B2: the 2nd appendix is usually found arising from the taenia coli of the wall of cecum
Type C: double cecum , each with its own appendix
Size of appendix:
2-20cm
Average : 11cm
Diameter : 7-8mm
Acute appendicitis:
Essentials of diagnosis :
1abd.pain (mc burneys point)
2anorexia, nausea , vomiting
3low grade fever
4leukocytosis
Predisposing factors for appendicitis:
Age: 20-30 yrs
Socio economic condition: high profile
Lymphoid hyperplasia of the appendix
Fibrosis of the appendix
Causes of appendicitis :
🔸obstructive causes - faecolith or stricture 🔸bacterial proliferation 🔸intestinal parasites 🔸tumor 🔸fibrotic stricture of the appendix
Composition of faecolith:
Bacteria Calcium phosphate Epithelial debris Inspissated fecal material Foreign bodies
Clinical findings of appendicitis:
Protean manifestation: may mimic a variety of conditions
Progression of symptoms is essential
▪️onset: vague abd. Discomfort
▪️followed: nausea , anorexia indigestion , vomiting , pain , mild , localized in the epigastrum
▪️pain: localized in RLQ+
Examination of appendicitis :
- tenderness on coughing , localized in RLQ
- localized tenderness on palpation
- slight muscular rigidity
- rebound tenderness referred to the same area
- rectal and pelvic examination NORMAL
- low fever <38
Retrocecal appendicitis examination:
Poorly localized pain
No discomfort on coughing , walking
Diarrhea
Urinary symptoms (hematuria, urinary frequency)
Pain in the flank (tenderness in one finger examination )
Pelvic appendicitis examination:
May simulate gastroenteritis
Nausea vomiting and diarrhea
Negative abd. examination
IMPORTANT= repeated pelvic (rectal) examination
Perforation of the appendix :
If the fever is >38.9
&
WBC>18,000
Perforation of the appendix lead to -> peritonitis:
Extreme of age Immunosuppression Diabetes mellitus Faecolith obstruction Pelvic appendix Previous abd. Surgery
Symptoms -inflamed appendix :
Pain - initially periumbilical region then pain shift to right iliac fossa
Anorexia
Nausea / vomiting
Clinical signs of appendicitis:
Pyrexia -low grade after 6 hrs
Tenderness ( in RIF)
Muscle guarding
Rebound tenderness “BLUMBERG’s SIGN”
Foul breath (bad smell)
Tachycardia : perforation, gangrene and peritonitis
**Rovsing’s sign ( palpation of LLQ causes pain in RLQ
** obturator sign( pain on passive internal rotation of the flexed thigh )
Tenderness of appendicitis will be localized in:
Mc Burney’s point
ALVARDO score :
SYMPTOMS/ SIGNS/ LAB TESTS
-From 1-10 , symptoms , sign , lab tests
▪️7-10= strongly predictive of appendicitis
▪️5-6= equivocal
▪️1-4= appendicitis can be ruled out
X ray findings of appendicitis :
Air- fluid levels or isolated ileus
Fecaliths
Free air in the peritoneum
Signs of peritonitis
Appendicitis in pregnancy:
Diagnosis:
Difficult due to =
- high position of the appendix
- all usual signs are present
- difficult to interpret leukocytosis
- appendectomy is mandatory and urgent
Complications if appendicitis:
- perforation
- peritonitis
- appendiceal abscess
- pylephlebitis (suppurative thrombophlebitis of portal vein)
Appendiceal abscess treatment :
ANTBX + diet low in residue
Drainage of abscess -/+ appendectomy
Treatment of acute appendicitis:
5
✅ absolute bed rest & NPO ✅ IV fluid supplement ✅analgesics (pethidine-opiod) ✅ANTBX( ofloxacine+ orinidazole) ✅appendectomy ( within 24 hrs ASAP)
Indications of appendectomy:
- acute appendicitis
- recurrent appendicitis
- mucocele of appendix ( dilation of the appendix lumen as a result of mucin accumulation)
- carcinoma confined to the mucosa
Incision in appendectomy:
🔸grid iron and lanz incision - muscle splitting incisions
🔸bikini incision- slightly lower than lanz incision
🔸rutherford morison-
Chronic appendicitis :
Chronic inflammation in the wall due to multiple acute attacks
-Chronic abd. Pain in the RLQ
-Possible recurrent attack of acute appendicitis
-other problems
-
Treatment of chronic appendicitis:
Appendectomy -debatable
Classifications of the appendix tumors:
▪️Benign: fibroma , leyomyoma, lypoma
▪️malignant : carcinoma
▪️borderline: carcinoid , mucocele
Treatment for carcinoid tumor of appendix:
✅Appendectomy ✅ R. Hemicolectomy is indicated when: -tumor is >2cm in size -involves the base of appendix -involves the caecal wall or mesoappendix -LNs are involved
Mucocele :
+ clinical examination
+treatment
*not true tumors: Chronic distention of the appendix plus continuous mucus secretion *clinical examination: RLQ discomfort Mass Rupture in peritoneum *treatment: Appendectomy
Appindicular lump gold standard treatment :
Ochsner -sherren regimen treatment
