MAP of the Surgical Pathology Course 4th year USMF Baher Ahmad Krayem Acute Appendicitis Anatomy and

and physiology: History Layers: Serosa, muscular, submucosa, mucosa. Innervations: superior mesenteric, vagus. Blood supply: appindiceal artery, accessory appindiceal. Location: Descending, lateral, medial, ascending, retrocecal. Role

Definition and incidence:

Epidemiology: age between 10-40 years, women 2-3 folds more.

Etiology and pathogenesis: 1. Microbial: enterogenic, Hematogenic 2. Mechanical: appendiceal fecalithsm bile stones, outside of the abdomen, retrocecal position. 3. Chemical: intestinal contents. 4. Neurogenic: cortical neuro-reflex disturbances.

Pathology: Luminal obstruction increase in mucus production bacterial overgrowth from stasis and luminal obstruction dilatation of the appendix and primary inflammation process lymphatic and venous flow are decreased further dilatation decrease in arterial blood flow vessel thrombosis with necrosis of wall --> full wall necrosis perforation of the appendix contents are released to the abdominal cavity. Classification:
1. Catarrhal: inflammation is located within mucosa and submucosa. 2. Flegmonous: inflammation occupies all layers.

3. Gangrenous: anaerobe infection and mesoappendix vessel thrombosis. 4. Perforated: contents are released.

History: 1. Abdominal pain: 1) 35% Migrating first epigastric and afer 4-6 hours right iliac fossa (Kochers sign). 2) Atypical: infants and children, Rt iliac fossa or diffuse periumbilical without any migration. 2. Single vomiting episode, nausea. 3. Dyspeptic signs: less common, alteration in bowel movement, abdominal distention, diarrhea. 4. Fever 37.5-38, tachycardia, loss of appetite.

Symptoms and signs: 1. Inspection: no movement of the right iliac fossa on respiration.
2. Palpation: pain, muscular resistance in the right iliac fossa.

3. Triad of Dielafoy: pain, tenderness and hyperesthesia at McBurneys point (at the line joining the umbilicus and ASIS).
4. Blumbergs sign: (rebound tenderness) pain on withdrawing hands from the right

iliac fossa.
5. Rovesings sign: pain on deep palpation of the left lower quadrant.

6. Sitkovskys sign: pain while patient is lying on the left side. 7. Bartomie-Mihelsons sign: pain while palpation on the Sitkovskys position. 8. Copes sign (psoas sign): pain during extension of the right hip, or internal rotation of the hip. Typical for retrocecal appendix.
9. Obraztsovs sign: similar with psoas sign , passive extension of the hip in

association with palpation in the right iliac fossa. 10. Sign of cough: increased pain while coughing. 11. Mandel-Razdolskys sign: pain on percussion of the right lower quadrant.

Diagnosis:

1. US: 1) wall thickening more than 8-10 mm, 2) lack of compressibility, 3) luminal distention. Advanced appendicitis: 1) asymmetric wall thickening, 2) abscess formation, 3) associated free intra-peritoneal fluid, 4) surrounding tissue edema. 2. CT 3. Laparoscopy: mainly to rule out appendicitis. Special clinical forms: 1. Acute appendicitis in children: uncommon in children younger than 3 years. Violent pain, high grade temp (39-40), persistent vomiting, diarrhea, hyperleukocytosis with shift to the left. Atypical pain (unlocalized diffuse periumbilical), abdominal distention. Decreased abdominal tenderness. Oliguria, anuria. Gangrene and perforation occurs faster. 2. Acute appendicitis in elderly: age >60 = 12%, clinical symptoms are less pronounced: less severe pain, less local tenderness, low grade temperature. Dull right lower quadrant pain. Pain on palpation + alteration of bowel movement. 50% from >70 have ruptured appendix on surgery. Colonoscopy, US and barium enema. 3 clinical forms: 1) like intestinal obstruction, 2) pseudo-tumorous form, 3) with peritonitis.
3. Acute appendicitis on pregnancy: alterations of presentation on 2nd and 3rd

trimesters. Abdominal pain, nausea, and vomiting similar to pregnancy symptoms. After 5th month of pregnancy the appindiceal position moves up pain is superior than the right iliac fossa. Less localized abdominal distention.

Fever, tachycardia, abdominal pain, tenderness. Possible symptoms: leukocytosis + 7 +8 +9. US for DD.
4. Retrocecal appendicitis: less pronounced symptoms. Pasternatskys sign: pain due

to percussion of the XII rib, Laure-Rozanovs sign: pain on palpation on Petits triangle, Gabais sign: rebound tenderness on Petits triangle. 8+9.
5. Pelvic appendicitis: early symptoms are the same, but then pain and tenderness

migrate to the brim of the pelvis. Epigastric pain dominate longer time. Kulencampf-Grassmanns sign: pain on rectal examination. 6. Medial appendicitis: behind iliac mesentry. Fewer symptoms, paraumbilical pain dominates. Kummels sign: pain on pressing in the point localized in 2 cm below and on the right of the umbilicus. Krasnobaevs sign: Right rectal tenderness below the umbilicus. Diarrhea. 7. High lying appendicitis: rare in adults. Maximal pain and muscle resistance in sub-hepatic region. Slight jaundice. Diagnosis is based on age and absence of liver disease history. 8. Acute appendicitis in hernia. 9. Left-side appendicitis: left iliac fossa, 3 cases: 1) situs inversus, 2) movable cecum, 3) long appendix. Deferential Diagnosis: 1. Perforated peptic ulcer 2. Acute pancreatitis 3. Acute cholecystitis 4. Acute salpingitis 5. Ruptured graafian follicle 6. Rupture of a tubal gestation 7. Crohns disease Complications:
1. Appendiceal infiltrate: 3-5 days after onset, dull pain in right lower quadrant. 3

stages: 1) infiltration, 2) abscess formation, 3) fistula formation. 1st abdominal mass, abdominal pain, low grade fever, moderate leukocytosis. Conservative

hospital treatment. Special diet and ABs. Surgery is 3 months later. Requires DD with cancer and crohns. Xray, US, CT, Laparoscopy. 2nd stage- increased pain, high fever, hyperleukocytosis. Urgent surgery + abscess drainage. 2. Postoperative abscesses 3. Phylephlebitis 4. Diffused peritonitis 5. Generalized sepsis Surgical treatment: Appendectomy. First 1-2 hours. Surgery is NOT indicated: 1) appendiceal infiltrate, 2) appendiceal colic. McBurneys or medial incision. Appendectomy after mobilization of the cecum into the wound, then legation of the mesoappendix from the distal tip to the base of appendix. Ligation of the base with sutures and then transaction. Then purse string suture is placed around the base.