Published on March 11, 2014
03/11/1403/11/14 11 Acute AppendicitisAcute Appendicitis Presented by :Presented by : Seyed Morteza MahmoodiSeyed Morteza Mahmoodi Anatomy project Year 2005-06 Supervised by: Dr. Aziz Aziz
03/11/14 2 ContentsContents IntroductionIntroduction HistoryHistory IncidenceIncidence Etiology and pathologyEtiology and pathology CaseCase Signs and symptomsSigns and symptoms Clinical diagnosisClinical diagnosis Differential diagnosisDifferential diagnosis
03/11/14 3 IntroductionIntroduction Appendicitis can be tricky diagnosis, even forAppendicitis can be tricky diagnosis, even for skilled physicianskilled physician Acute appendicitis is the most common cause ofAcute appendicitis is the most common cause of intraabdominal infectionintraabdominal infection Appendicectomy is the most commonAppendicectomy is the most common emergency surgical operationemergency surgical operation.. Variations in the position of the appendix, ageVariations in the position of the appendix, age of the patient, and degree of inflammation makeof the patient, and degree of inflammation make the clinical presentation of appendicitisthe clinical presentation of appendicitis notoriously inconsistentnotoriously inconsistent..
03/11/14 4 HistoryHistory Recognition as clinical entityRecognition as clinical entity Reginald Fitz ‘perforatingReginald Fitz ‘perforating inflammation of the vermiforminflammation of the vermiform appendix’appendix’ Charles McBurney describedCharles McBurney described the clinical manifestation thethe clinical manifestation the point of max. tenderness in thepoint of max. tenderness in the right iliac fossaright iliac fossa
03/11/14 5 IncidenceIncidence Relatively rare in infantsRelatively rare in infants Common in childhood and adult lifeCommon in childhood and adult life 3-4/1000/year3-4/1000/year Peak incidence in teens and early 20sPeak incidence in teens and early 20s After middle age the risk is quit smallAfter middle age the risk is quit small Before puberty the incidence is equal amongstBefore puberty the incidence is equal amongst males and femalesmales and females In teenagers and young adults the ratio ofIn teenagers and young adults the ratio of male:female is 3:2 at the age of 25male:female is 3:2 at the age of 25 Thereafter the incidence in males declinesThereafter the incidence in males declines approximately 1 in 7 people will undergo anapproximately 1 in 7 people will undergo an appendicectomy during their lifetimeappendicectomy during their lifetime
03/11/14 6 EtiologyEtiology No unifying hypothesisNo unifying hypothesis Bacterial proliferationBacterial proliferation Initiating event is controversialInitiating event is controversial Obstruction of appendix lumenObstruction of appendix lumen Faecolith or fibrotic strictureFaecolith or fibrotic stricture TumorTumor Intestinal parasitesIntestinal parasites No luminal obstructionNo luminal obstruction
03/11/14 7 Pathological sequencePathological sequence
03/11/14 8 Pathological sequencePathological sequence
03/11/14 9 Pathological sequencePathological sequence
03/11/14 10 PathologyPathology Continued mucous secretion andContinued mucous secretion and inflammatory exudation intraluminalinflammatory exudation intraluminal pressure obstructing lymphatic drainage.pressure obstructing lymphatic drainage. Edema and mucosal ulceration develop withEdema and mucosal ulceration develop with bacterial translocation to submucosa .bacterial translocation to submucosa . Further distention may cause venousFurther distention may cause venous obstruction and ischcemia of the appendixobstruction and ischcemia of the appendix wall.wall. Bacterial invasion through muscularisBacterial invasion through muscularis externea producing acute appendicitis.externea producing acute appendicitis. Ischaemic necrosis of appendicular wallIschaemic necrosis of appendicular wall gangrenous appendix bacterial contaminationgangrenous appendix bacterial contamination of peritoneal cavity.of peritoneal cavity.
03/11/14 11 Pathology cont.Pathology cont. Greater omentum becomesGreater omentum becomes adherent to inflamedadherent to inflamed appendix paracaecalappendix paracaecal abscessabscess Extremes of ageExtremes of age ImmunosuppressionImmunosuppression Faecolith obstructionFaecolith obstruction Pelvic appendixPelvic appendix Previous abdominalPrevious abdominal surgerysurgery
03/11/14 12 Pathology cont.Pathology cont.
03/11/14 13 Pathology cont.Pathology cont.
03/11/14 14 Case reportCase report Colicky periumblical painColicky periumblical pain Migrated to the right lower quadrantMigrated to the right lower quadrant Initial nauseaInitial nausea Increasing emesis and anorexiaIncreasing emesis and anorexia Abdominal guarding and reboundAbdominal guarding and rebound tendernesstenderness Rigid anterior abdominal wall in RLQRigid anterior abdominal wall in RLQ Low grade fever and rising WBC countLow grade fever and rising WBC count
03/11/14 15 Clinical signsClinical signs
03/11/14 16 Clinical signsClinical signs
03/11/14 17 Abdominal painAbdominal pain Visceral abdominal painVisceral abdominal pain Somatic abdominal painSomatic abdominal pain referred abdominalreferred abdominal
03/11/14 18 Visceral abdominal painVisceral abdominal pain Visceral abdominal pain, organs, visceralVisceral abdominal pain, organs, visceral peritoneum, mesenteryperitoneum, mesentery 1-distention of a hollow viscus1-distention of a hollow viscus 2-ischemia to a viscus2-ischemia to a viscus 3-inflammation3-inflammation Referred to midline embryologicalReferred to midline embryological developmentdevelopment
03/11/14 19 Colicky painColicky pain Colicky pain form of visceral painColicky pain form of visceral pain rhythmic pain resulting from smoothrhythmic pain resulting from smooth muscle spasm as a reaction to luminalmuscle spasm as a reaction to luminal obstructionobstruction intestinal obstruction, passage ofintestinal obstruction, passage of gallstone in biliary ducts, ureteric colicgallstone in biliary ducts, ureteric colic Often thought to be indigestion,Often thought to be indigestion, constipation and is frequently ignored.constipation and is frequently ignored. Lasts for a variable period, usually fewLasts for a variable period, usually few hours / 2 or 3 days, rarely longerhours / 2 or 3 days, rarely longer
03/11/14 20 Referred painReferred pain The vague referred pain in the periumblicalThe vague referred pain in the periumblical stretching of the lumen or spasm.stretching of the lumen or spasm. The visceral innervation comes from theThe visceral innervation comes from the 10th thoracic spinal segment.10th thoracic spinal segment. Accompany the sympathetic nerves throughAccompany the sympathetic nerves through the superior mesenteric plexus and thethe superior mesenteric plexus and the lesser splanchnic nervelesser splanchnic nerve If the visceral innervation is higher, then theIf the visceral innervation is higher, then the mid-line pain will be higher.mid-line pain will be higher. Testicular pain due to visceral referral ofTesticular pain due to visceral referral of afferent nerve impulses to the same spinalafferent nerve impulses to the same spinal segmentsegment
03/11/14 21 Somatic painSomatic pain Skin, fascia, muscle and parietalSkin, fascia, muscle and parietal peritoneumperitoneum Sever and precisely localizedSever and precisely localized Inflamed parietal peritoneum cutaneousInflamed parietal peritoneum cutaneous hyperesthesia and tendernesshyperesthesia and tenderness The right iliac fossa pain is due to theThe right iliac fossa pain is due to the irritation of parietal peritoneumirritation of parietal peritoneum somatic pain as opposed to earliersomatic pain as opposed to earlier visceralvisceral..
03/11/14 22 Guarding and rigidityGuarding and rigidity Guarding is the protective phenomenonGuarding is the protective phenomenon abdominal muscles increase in toneabdominal muscles increase in tone attempts to localize the inflammationattempts to localize the inflammation There is tenderness causing the patientThere is tenderness causing the patient to constantly tense the abdominal wallto constantly tense the abdominal wall muscles in palpationmuscles in palpation Voluntary guarding /apparent guardingVoluntary guarding /apparent guarding Involuntary guarding /true guardingInvoluntary guarding /true guarding Muscular spasm rigidityMuscular spasm rigidity localized initially progressing tolocalized initially progressing to generalized with perforation orgeneralized with perforation or increasing peritonitisincreasing peritonitis
03/11/14 23 TendernessTenderness Tenderness:Tenderness: localised over McBurney's pointlocalised over McBurney's point not evident before later inflammation ofnot evident before later inflammation of serosa and parietal peritoneumserosa and parietal peritoneum often masked in obese due to inability tooften masked in obese due to inability to displace viscusdisplace viscus Blumberg’s sign The pain is elicited withBlumberg’s sign The pain is elicited with pressing the abdominal wall deeply withpressing the abdominal wall deeply with fingers and abruptly releasing it.fingers and abruptly releasing it.
03/11/14 24 ReflexesReflexes Visceral afferent fibers participate in reflexVisceral afferent fibers participate in reflex activities. Reflex sweating, salivation,activities. Reflex sweating, salivation, nausea, vomiting and tachycardia maynausea, vomiting and tachycardia may accompany visceral pain.accompany visceral pain. Carried by autonomic nerve fibersCarried by autonomic nerve fibers
03/11/14 25 SignsSigns lying still, with shallow breaths and reluctant tolying still, with shallow breaths and reluctant to coughcough fever 37.5-38.5C, worsening with perforationfever 37.5-38.5C, worsening with perforation Foetor oris - halitosisFoetor oris - halitosis Furred tongueFurred tongue FlushedFlushed infrequently, diarrhoea:infrequently, diarrhoea: early and transient as a result of visceral painearly and transient as a result of visceral pain later if retroileal or pelvic involvement appendix; this islater if retroileal or pelvic involvement appendix; this is typically prolonged and mucoidtypically prolonged and mucoid constipation - sometimes for a few days beforeconstipation - sometimes for a few days before the attackthe attack
03/11/14 26 Signs to elicit in appendicitisSigns to elicit in appendicitis Pointing signPointing sign Rovsing’s signRovsing’s sign Psoas signPsoas sign Obturator signObturator sign
03/11/14 27 Pointing signPointing sign
03/11/14 28 Psoas signPsoas sign
03/11/14 29 Obturator signObturator sign
03/11/14 30 Differential diagnosisDifferential diagnosis ChildrenChildren GastroenteritisGastroenteritis Mesenteric adenitisMesenteric adenitis Meckel’s diverticulitisMeckel’s diverticulitis IntussusceptionIntussusception Henoch_Shonlein purpuraHenoch_Shonlein purpura Lobar pneumoniaLobar pneumonia
03/11/14 31 Differential diagnosisDifferential diagnosis AdultsAdults Terminal ileitisTerminal ileitis Ureteric colicUreteric colic Perforated peptic ulcerPerforated peptic ulcer Testicular torsionTesticular torsion Acute pancreatitisAcute pancreatitis Rectus sheath haematomaRectus sheath haematoma
03/11/14 32 Differential diagnosisDifferential diagnosis Adult femalesAdult females SalpingitisSalpingitis MittelschmerzMittelschmerz Torsion/hemorrhage of an overianTorsion/hemorrhage of an overian cystcyst Ectopic pregnancyEctopic pregnancy EndometritisEndometritis
03/11/14 33 Differential diagnosisDifferential diagnosis ElderlyElderly Sigmoid diverticulitisSigmoid diverticulitis Intestinal obstructionIntestinal obstruction Carcinoma of the ceacumCarcinoma of the ceacum Aortic aneurismAortic aneurism
03/11/14 34 InvestigationInvestigation RoutineRoutine Full blood countFull blood count leukocytosis is generallyleukocytosis is generally presentpresent Urinalysis assessment of dehydrationUrinalysis assessment of dehydration Selected casesSelected cases Pregnancy testPregnancy test Urea and electrolytesUrea and electrolytes serum amylase - if pancreatitisserum amylase - if pancreatitis suspectedsuspected
03/11/14 35 InvestigationsInvestigations Supine abdominal X-raySupine abdominal X-ray Ultrasound abdomen/pelvisUltrasound abdomen/pelvis abdominal radiology - helpful toabdominal radiology - helpful to distinguish:distinguish: intussusceptionintussusception renal stones (90%)renal stones (90%) gallstones (10%)gallstones (10%) localised ileuslocalised ileus
03/11/14 36 X-ray signsX-ray signs Reported signs include:Reported signs include: increased soft tissue density in the right lowerincreased soft tissue density in the right lower quadrantquadrant a faecolith in the right iliac fossaa faecolith in the right iliac fossa the majority are radio-opaquethe majority are radio-opaque occur in about 10% of those with appendicitisoccur in about 10% of those with appendicitis often mistaken for ureteric calculus or gallstonesoften mistaken for ureteric calculus or gallstones a gas-filled appendixa gas-filled appendix free intraperitoneal gasfree intraperitoneal gas
03/11/14 37 X-raysX-rays
03/11/14 38 CT-scanCT-scan
03/11/14 39 UltrasoundUltrasound
03/11/14 40 Color-flow UltrasoundColor-flow Ultrasound
03/11/14 41 GastroenteritisGastroenteritis Gastroenteritis, orGastroenteritis, or inflammationinflammation of theof the gastrointestinal tractgastrointestinal tract, is an illness caused by, is an illness caused by an infectiousan infectious virusvirus,, bacteriumbacterium oror parasiteparasite.. lasting less than 10 days and self-limitinglasting less than 10 days and self-limiting Sometimes it is referred to simply asSometimes it is referred to simply as 'gastro'.'gastro'. If the inflammation is limited to the stomach,If the inflammation is limited to the stomach, the termthe term gastritisgastritis is used, and if the smallis used, and if the small bowel alone is affected it is enteritis.bowel alone is affected it is enteritis.
03/11/14 42 IntussusceptionIntussusception
03/11/14 43 IntussusceptionIntussusception An intussusception prolapsing of part ofAn intussusception prolapsing of part of intestine into another section of intestine,intestine into another section of intestine, (collapsible telescope)(collapsible telescope) intussusceptum (The part which prolapsesintussusceptum (The part which prolapses into the other),into the other), intussuscipiens (the part which receives it).intussuscipiens (the part which receives it). The most frequent type ileum enters theThe most frequent type ileum enters the cecum.cecum. Almost all intussusceptions occur with theAlmost all intussusceptions occur with the intussusceptum having been locatedintussusceptum having been located proximally to the intussuscipiens.proximally to the intussuscipiens. The reason for this is that peristaltic action ofThe reason for this is that peristaltic action of the intestine "pulls" the proximal segment intothe intestine "pulls" the proximal segment into the distal segment.the distal segment.
03/11/14 44 Meckel’s diverticulumMeckel’s diverticulum
03/11/14 45 Henoch-Schonlein purpuraHenoch-Schonlein purpura
03/11/14 46 DiverticulitisDiverticulitis
03/11/14 47 DiverticulitisDiverticulitis
03/11/14 48 DiverticulitisDiverticulitis Diverticula small, pouches develop inDiverticula small, pouches develop in the wall of the colon. (sigmoid colon).the wall of the colon. (sigmoid colon). Many people develop diverticulaMany people develop diverticula (called diverticulosis), after age 50,(called diverticulosis), after age 50, and in most individuals they cause noand in most individuals they cause no problem.problem. Diverticulitis (diverticula infected orDiverticulitis (diverticula infected or inflamed) can cause pain, fever andinflamed) can cause pain, fever and nausea. In rare cases, a pouch cannausea. In rare cases, a pouch can rupture, spilling intestinal waste intorupture, spilling intestinal waste into abdomen.
03/11/14 49 BibliographyBibliography Clinical anatomy Richard SnellClinical anatomy Richard Snell Baily and Loves surgeryBaily and Loves surgery Schwasrts SurgerySchwasrts Surgery Handbook of general surgeryHandbook of general surgery Web sourcesWeb sources
Calcification Inhibitors in CKD and Dialysis Patients
The presentation of acute appendicitis includes abdominal pain, nausea, vomiting, and fever. As the appendix becomes more swollen and inflamed, it begins ...
Abdominal pain is the primary presenting complaint of patients with acute appendicitis. The diagnostic sequence of colicky central abdominal pain followed ...
Acute appendicitis is the most common reason for emergency abdominal surgery. Appendectomy carries a complication rate of 4-15%, as well as ...
Acute appendicitis is inflammation of the appendix, an organ of the digestive system. Here's what you need to know about its symptoms, causes, prevention ...
Acute Appendicitis information including symptoms, diagnosis, misdiagnosis, treatment, causes, patient stories, videos, forums, prevention, and prognosis.
Acute Appendicitis Information Including Symptoms, Diagnosis, Treatment, Causes, Videos, Forums, and Local Community Support.
Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical ...
Appendicitis — Comprehensive overview covers signs, symptoms, causes, treatment of this painful appendix inflammation.
Acute appendicitis is sudden inflammation of the appendix and happens most commonly in children. Get information about symptoms and other complications.
Evidence reviews Antibiotic therapy compared to appendectomy in the treatment of acute appendicitis. Acute appendicitis is one of the most common surgical ...