I.

3a Appendix (Lecture)
Dr. Bibera June 18, 2013
ANATOMY AND FUNCTION Appendix 1st become visible in the 8th week of development as a protuberance of the terminal part of the cecum During development, the growth rate of cecum exceeds that of appendix, displacing the appendix medially toward the ileocecal valve The base arises from the posteromedial aspect of the cecum, where three taeniae coli meet The relationship of the base of the appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal or right pericolic position Lymphoid tissue appears in the appendix 2 weeks after birth increases throughout puberty and remains steady for the next decade steadily decreases with age 60 years and , virtually no lymphoid tissue remains within the appendix complete obliteration of the appendiceal lumen in the elderly is common Secretory immunoglobulins (IgA) are produced as part of gut-associated lymphoid tissues to protect the milieu interior The appendix is useful but not indispensable Congenital defects are rare and clinically insignificant Appendectomy does not predispose to bowel cancer or alter the immune system Three taenia coli converge at the junction of the cecum with the appendix and can be a useful landmark to identify the appendix Appendiceal artery, a branch of the ileocolic artery, supplies the appendix. Normal/usual location of the appendix is retrocecal but within the peritoneal cavity constant (15.3%), as has the rate of appendiceal rupture. Percentage of misdiagnosed cases is significantly higher in women than in men (22.2 vs. 9.3%) The negative appendectomy rate is 30-35% ETIOLOGY Results from obstruction of the lumen followed by infection (dominant etiology) Others: Fecalith (most common cause of luminal obstruction, 40% of cases[acute appendicitis]) 65% gangrenous; 90% gangrenous with perforation Fever before pain = NOT appendicitis hyperplasia of lymphoid tissue (*hypertrophy in Schwartz) inspissated barium from previous x-ray studies Strictures tumors (most common is carcinoid 80%) Vegetable and fruit seeds (tomatoes) Intestinal parasites (ascaris, schistosomiasis) PATHOGENESIS Proximal obstruction of the appendiceal lumen produces a closed-loop obstruction, and continuing(mucus) secretion by the appendiceal mucosa produces distention. Distention( intraluminal pressure)of the appendix stimulates nerve endings of visceral afferent stretch fibers (T8-T10), producing vague, dull, diffuse(visceral) pain in the mid-abdomen or lower epigastrium. Peristalsis is also stimulated by the sudden distention, so that some cramping may be superimposed on the visceral pain early in the course of appendicitis. Distention continues from continued mucosal secretion and from multiplication of the resident bacteria of the appendix. nausea and vomiting and severity of diffuse visceral pain (Organ pressure > capillary pressure) As pressure in the organ increases, venous pressure is exceeded. Capillaries and venules are occluded, but arteriolar inflow continues, resulting in (venous)engorgement and vascular congestion. The inflammatory process of surrounding tissuesoon involves the serosa of the appendix and in turn parietal peritoneum in the region, producing the characteristic shift in pain to the right lower quadrant. Serosa & peritoneum classic location of symptoms The mucosa of the appendix is susceptible to impairment of blood supply, thus its integrity is compromised early in the process, allowing bacterial invasion. As progressive distention encroaches on first the venous return and subsequently the arteriolar inflow, the area with the poorest blood supply suffers most. As distention, bacterial invasion, compromise of vascular supply, and infarction progress, perforation occurs, usually through one of the infracted areas on the antimesenteric border Persistent distension perforation of wall BACTERIOLOGY Same colonic flora except Porphyromonas gingivalis (adult) Routine cultures are questionable

Figure 1. Various anatomic positions of the vermiform appendix. LENGTH: Varies from < 1 cm to 30 cm (most are 6 -9 cm) An immunologic organ that actively participates in the secretion of immunoglobulins, specially IgA An integral part of gut-associated lymphoid tissue but it is NOT ESSENTIAL so appendectomy is not associated with any predisposition to sepsis or immune compromise APPENDICITIS One of the most common causes of abdominal emergencies Accounts for 1% of all surgical operations Rare in infants and elderly (narrow lumen in infants; dilated in the elderly obstruction) Nothing can obstruct in the elderly 2nd-4th decade, slight M:F predominance: 1.2-1.3:1 Lifetime rate of appendectomy is 12% for men and 25% for women, with ~ 7% of all people undergoing appendectomy for acute appendicitis Despite use of UTZ, CT scan, and laparascopy, rate of misdiagnosis (negative appendectomy)remains

ROBZ, Pat, Suzie, Dale, Lenard, Morrice, Charlie, GEMMY(Italicized texts are from Doc Biberas side lecture notes and notes not found in the upper batchs trans)

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Table 1. Common bacteria found in appendicitis

CLINICAL MANIFESTATIONS SYMPTOMS Pain Movement causes pain over RLQ Initially diffusely centered in lower epigastrium or periumbilical area, moderately severe, and steady, sometimes with intermittent cramping superimposed. KOCHERS SIGN periumbilical pain that localizes at the RLQ after 4 6 hours (Schwartz: this period varies from 1-12 hours but is usually within 4-6 hours) 45% fail to follow the visceral to somatic pattern (common in elderly)depending on the POSITION of the appendix Variable position of the tip of the appendix or malrotation allows for variability in pain location Most common is retrocecal area (hindi si sure si Doc hehe) Determined by the position of the appendix and whether it is ruptured Cutaneous hyperesthesia may present early in the area supplied by right spinal nerves T10, T11 and T12 Anorexia Present in almost all patients Nearly always accompanies acute appendicitis Nausea and vomiting Vomiting fewer than 75% occurring after onset of pain Constipation or obstipation and diarrhea subsequent episodes of emesis may occur with obstipation or diarrhea appendix is near the ileum can stimulate the bowel pain relieved by moving the bowel Fever vital signs show mild tachycardia or temperature elevation >1C Murphys Triad pain, vomiting, fever DICTUM: Anorexia Pain Vomiting = ACUTE APPENDICITIS SIGNS Signs of peritoneal irritation in anteriorly positioned appendix Fever elevation >1C Movement causes pain over the RLQ Mc Burneys Sign localized and maximum tenderness over RLQ (McBurneys point) Blumbergs sign rebound tenderness on the RLQ Dunphys sign cough elicits pain in 85% Rovsings sign contralateral tenderness in the RLQ with palpation in the LLQ Psoas/ Obrastova sign

stretching the iliopsoas muscle by extending the thigh while lying cause pain Obturators sign passive internal rotation of the flexed right thigh with patient supine, indicates irritation near the Obturator internus Retrocecal appendicitis may present with flank or back pain Pelvic appendicitis principally suprapubic pain may give pain on rectal examination with pressure on the cul-de-sac of Douglas Retroileal appendicitis testicular pain Muscle guarding Rectal Exam Abdominal mass usually in complicated cases: Abscess Omentum Loops of intestines

LABORATORY FINDINGS Complete Blood Count Mild leukocytosis of 10,00018,000/mm3 is usually present in patients with acute, uncomplicated appendicitis and is often accompanied by moderate polymorphonuclear predominance WBC (shift to the LEFT); 90% neutrophils, 10% the rest CRP determination Not really necessary according to Doc Urinalysis Pyuria is present when the inflamed appendix lies near the ureter or bladder Bacteriuria indicates urinary tract infection IMAGING STUDIES When used, you are 85-90% right Plain Films of the Abdomen Rarely helpful in diagnosing appendicitis, although plain radiographs may be of significant benefit when ruling out other pathology such as cholecystitis, perforated PUD, perforated viscus, or pyelonephritis Chest radiography rules out right lower lung field disease, which may stimulate right lower quadrant pain by irritating T10, T11 and T12 nerves Gentle Barium Enema Shows nonfilling of the appendix and mass effect on the medial and inferior borders of the cecum; complete filling of the appendix rules out appendicitis. Helpful in female if diagnosis is questionable Extrinsic procedure defect in the cecum (inverted 3 sign) Ultrasound Over 90% accurate Findings of non-compressible appendix over 6mm in diameter Complex mass Sonographically, the appendix is identified as a blind-ending, nonperistaltic bowel loop originating from the cecum with maximal compression, the diameter of the appendix is measured in the anteroposterior dimension A scan is considered positive if a noncompressible appendix 6 mm or greater in the anteroposterior direction is demonstrated The presence of an appendicolith establishes the diagnosis The presence of thickening of the appendiceal wall and periappendiceal fluid is highly suggestive. May differentiate from perforation and abscess formation

I.3a Appendix (Lecture)

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 CT Scan Computed tomographic (CT) scan is useful especially with suspected abscess 90% accurate Finding of edema, fluid, appendolith and diameter of over 6mm In cases of suspected appendicitis may be used when diagnosis is not certain Laparoscopy can be diagnostic and therapeutic, especially in females to rule out gynecologic pathology
Table 2 Alvarados Scoring for Acute Appendicitis

somatic pain due to irritation of the parietal peritoneum whitish purulent 3. GANGRENE APPENDICITIS venous and arterial thrombosis wall infarct occurs bacterial escape and peritoneal cavity contamination 4. PERFORATIVE APPENDICITIS abscess formation peritonitis (if the omentum is not well developed) ngumingiti na yung appendix? ACUTE APPENDICITIS IN SPECIFIC POPULATIONS ACUTE APPENDICITIS IN THE YOUNG More difficult than in the adult (inability of young children to give an accurate history, diagnostic delays by both parents and physicians, and the frequency of gastrointestinal upset in children). More rapid progression to rupture and the inability of the underdeveloped greater omentum to contain a rupture lead to significant morbidity rates in children. Children younger than 5 years of age have a negative appendectomy rate of 25% and an appendiceal perforation rate of 45%. The incidence of major complications after appendectomy in children is correlated with appendiceal rupture. The incidence of intra-abdominal abscess is also higher after the treatment of perforated appendicitis as compared to nonperforated cases (6% vs. 3%). The treatment regimen for perforated appendicitis generally includes immediate appendectomy and irrigation of the peritoneal cavity. Laparoscopic appendectomy has been shown to be safe and effective for the treatment of appendicitis in children.

ALVARADOS SCALE FOR ACUTE APPENDICITIS DIAGNOSIS Symptoms Migration of pain to RLQ 1 Anorexia 1 Nausea and/or vomiting 1 Signs RLQ tenderness 2 Rebound tenderness 1 Elevated temperature 1 Lab values Leukocytosis 2 Left shift in leukocyte count* 1* TOTAL 10 Interpretation: 9 to 10 are almost certain to have appendicitis(positive) 7 to 8 have a high likelihood of appendicitis(likelihood) 5 and 6 compatible, and a case can be built for imaging those with scores of 7 and 8 0 to 4 make it extremely unlikely (but not impossible)(unlikely so just observe the patient for a while) Tzanaki Scale may also be utilized as an alternative *(MAS) Modified Alvarado Scoring detects shift to the left Not used in the Philippines because yung ibang labs daw kasi hindi naman ginagawa or hindi marunong maginterpret yung doctors? DECISION MAKING ALGORITHM

ACUTE APPENDICITIS IN THE ELDERLY Incidence of appendicitis in the elderly is lower than in younger patients However, the postop morbidity and mortality are significantly increased in this patient population. Delays in diagnosis, a more rapid progression to perforation, and comorbid disease are all contributing factors. The diagnosis of appendicitis may be subtler and less typical than in younger individuals, and a high index of suspicion should be maintained. In patients older than age 80 years, perforation rates of 49% and mortality rates of 21% have been reported. Possible DDx in ill older px: diverticulitis, perforated PU, cholecystitis, pancreatitis, ruptured aortic aneurysm Diverticulitis mostly in sigmoid colon left-sided perforation ACUTE APPENDICITIS DURING PREGNANCY Frequently encountered extrauterine disease requiring surgical treatment during pregnancy (1 in 2000 pregnancies). Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy. More frequent during the first two trimesters. At 3rd trimester, pain is more cephalad and over the flank Symptoms same as non-pregnant Perforation leads usually to generalised peritonitis due to lack of omentum As fetal gestation progresses, the diagnosis of appendicitis becomes more difficult as the appendix is displaced laterally and superiorly. Performance of any operation during pregnancy carries a risk of premature labor (10 to 15%); risk is similar for both negative laparotomy and appendectomy for simple appendicitis. Appendiceal perforation is a significant factor associated with both fetal and maternal death

Figure 2. Clinical algorithm for suspected cases of acute appendicitis. If gynecologic disease is suspected, a pelvic and endovaginal ultrasound examination is indicated. STAGES/TYPES OF APPENDICITIS 1. ACUTE APPENDICITIS increase pressure within the lumen increase mucus secretions edema and diapedesis of bacteria production of purulent material infection localized to the appendix clinically felt as visceral pain

2. ACUTE SUPPURATIVE APPENDICITIS increase pressure causes venous obstruction and ischemia bacteria invades the wall of the appendix
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 Fetal mortality increases from 3 to 5% in early appendicitis to 20% with perforation.

acute mesenteric lymphadenitis, no organic pathologic condition, acute pelvic inflammatory disease, twisted ovarian cyst or ruptured graafian follicle, and acute gastroenteritis Older patients Diverticulitis(sigmoid colon; LEFT-sided appendicitis; pag sumakit na, perforated agad [agad-agad talaga?!] di lang inflammed), perforated peptic ulcer, cholecystitis, pancreatitis, ruptured aortic aneurysm TREATMENT Treatment is always operative because the obstructed lumen will not resolve with antibiotics alone acute appendicitis without rupture is treated with immediate appendectomy after the medical evaluation is complete General objectives: Fluid replacement Prophylactic antibiotics Examination under anesthesia UNCOMPLICATED CASES OF APPENDICITIS Open appendectomy utilizing Rockey-Davis or McBurneys incision(transverse) Handling of the stump: Simple ligation or drop method Inversion Ligation and inversion often leads to abscess and mucocele or cecal tumor LAPARASCOPIC APPENDECTOMY (MIS) Minimally Invasive Surgery (MIS) Usually 3 butas lang Both diagnostic and therapeutic Reduces perforation Negative appendectomy rate < 10% COMPLICATED APPENDICITIS

Figure 3. Location of the appendix during pregnancy ACUTE APPENDICITIS IN PATIENTS WITH AIDS OR HIV INFECTION There appears to be an increased risk of appendiceal rupture in HIV-infected patients. HIV-infected patients do not manifest an absolute leukocytosis; however, if a baseline leukocyte count is available, nearly all HIV-infected patients with appendicitis demonstrate a relative leukocytosis In the HIV-infected patient with classic signs and symptoms of appendicitis, immediate appendectomy is indicated. APPENDICEAL RUPTURE Immediate appendectomy Overall rate is 25% Children have 45% (dahil daw late magconsult; baka nag aarti-artihan lang haha) while 51% for patients >65 (dahil daw matigas ang ulo ayaw pa pa-check up) No accurate way of determining when and if an appendix will rupture prior to resolution of the inflammatory process (accdg to Doc: increase incidence of rupture occurs within 36 hours) Studies in selected cases, observation and antibiotic therapy alone may be an appropriate treatment for acute appendicitis Pero sabi ni Doc these studies naman didnt include the mortality after such modality Remember, perforation causes very high fever, usually >38C CLINICAL MANIFESTATIONS Temp > 39oC WBC> 18,000/mm3 (majority) localized rebound tenderness generalized peritonitis will be present if the walling-off process is ineffective in containing the rupture (in 2-6% cases) an ill-defined mass (Phlegmon) is detected on PE (RLQ) consists of matted loops of bowel adherent to the adjacent inflamed appendix, or a periappendiceal abscess symptoms are longer in duration, developing over 5 to 7 days DIAGNOSIS AND TREATMENT CT Scan Antibiotics in cases of small abscess Peritoneal abdominal drainage Surgical drainage and interval appendectomy in 6-10 weeks

DIFFERENTIAL DIAGNOSIS Almost all causes of abdominal pain Rule: Never place appendicitis lower than acute abdomen Accuracy of diagnosis is 85% If accuracy is less, unnecessary appendectomy are being performed If high, bona fide patients, unnecessarily observed when they should be receiving prompt surgical intervention Common errors (in descending order of frequency):
I.3a Appendix (Lecture)

Figure 4. Algorithm summarizing the treatment of acute appendicitis. Ruptured Peritonitis with abscess Small bowel obstruction OTHER DISEASES OF THE APPENDIX TUMORS OF THE APPENDIX Benign Mucinous cystadenoma Malignant Tumors
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 Mucinous cystadenocarcinoma Argentafinoma or carcinoid tumor Adenocarcinoma TREATMENT Appendectomy In-situ or tumor confined to mucosa Carcinoid< 1cm Right hemicolectomy INTRA-ABDOMINAL ABSCESSES Secondary to peritoneal contamination from gangrenous or perforated appendicitis Incidence has decreased markedly since the introduction of potent antibiotics Sites of predilection for abscesses are the appendiceal fossa, pouch of Douglas, subhepatic space, and between loops of intestine Transrectal drainage is preferred for an abscess that bulges into the rectum. CHRONIC APPENDICITIS Pain lasts longer and is less intense than that of acute appendicitis, but is in the same location Lower incidence of vomiting, but anorexia and occasionally nausea, pain with motion, and malaise are characteristic. Leukocyte counts are predictably normal and CT scans are generally nondiagnostic. Laparoscopy can be effectively used in the management of this clinical entity. Appendectomy is curative. APPENDICEAL PARASITES Ascaris lumbricoides is the most common, a wide spectrum of helminths have been implicated, including Enterobius vermicularis, Strongyloides stercoralis, and Echinococcus granulosis. Live parasites occlude the appendiceal lumen, causing obstruction. Once appendectomy has been performed and the patient recovered, therapy with helminthicide is necessary to clear the remainder of the gastrointestinal tract. Amebiasis can also cause appendicitis. Invasion of the mucosa by trophozoites of Entamoeba histolytica incites a marked inflammatory process. Appendectomy must be followed by appropriate antibiotic therapy (metronidazole). MISCELLANEOUS TREATMENT INTERVAL APPENDECTOMY Provides much lower morbidity and mortality rates than immediate appendectomy. 50% of patients treated conservatively never develop manifestations of appendicitis, and those who do, can generally be treated nonoperatively. INCIDENTAL APPENDECTOMY Appendectomy that are done incidentally upon laparotomy

Throwback Tuesday Presents Two years ago

I.3a Appendix (Lecture)

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