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Appendix

Huang,Shuo
Specialist Surgeon
Section of General Surgery
Department of Surgery
Jiamusi university hospital

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• Appendicitis

• History
• Although appendicitis has been a
common problem for centuries, it was
not until the early 19th century that the
appendix was recognized as an organ
capable of causing disease.
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• In 1827, Melier described several autopsy
cases of appendicitis and clearly stated the
opinion that the appendix was the likely cause,
including the presumed pathophysiology that
is accepted today.
• By 1880, both Matterstock in Germany and
with in Norway published papers that clearly
suggest the appendix as a significant cause of
iliac fossa inflammation.

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• In 1886, Reginald Fitz of Boston made a
landmark contribution by discussing the
appendix as the primary cause of right
lower quadrant inflammation.
• He coined the term appendicitis and,
importantly, recommended early surgical
treatment of the disease.

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• In 1889, Chester McBurney described the migratory pain as
well as the finger point localization of pain between 1.5 and 2
inches from the anterior iliac spine on an oblique line to the
umbilicus.
• He incorrectly stated that this was an almost constant finding in
patients with appendicitis.
• McBurney in New York and McArthur in Chicago described a
right lower quadrant muscle splitting incision for surgical
treatment in 1894.
• It is interesting to note that McBurney kept his patients on bed
rest for at least 4 weeks after surgery.
• In 1905, Murphy clearly described the appropriate sequence of
symptoms of pain followed by nauseas and vomiting with fever
and exaggerated local tenderness in the position occupied by
the appendix.
• Currently, the mortality rate is 0.25% if all ages are considered

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• Pathophysiology
• It is widely accepted that the inciting event in
most instances of appendicitis is obstruction
of the appendiceal lumen.
• Given the correlation with the incidence of
appendicitis by age and the size and
distribution of the lymphoid tissue, it is likely
that lymphoid obstruction or partial obstruction
of the lumen is a common cause.

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• Necrosis of the appendiceal wall subsequently
occurs along with translocation of bacteria through
the ischemic wall.
• This is gangrenous appendicitis.
• Without intervention, the gangrenous appendix will
perforate, with spillage of the appendiceal contents
into the peritoneal cavity.
• If this sequence of events occurs slowly, the
appendix is contained by the inflammatory response
and the omentum, leading to localized peritonitis and
eventually an appendiceal abscess.
• If the body does not wall off the process, the patient
may develop diffuse peritonitis.
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• Clinical
• history
• physical findings, laboratory and radiographic
examinations.
• Vomiting
• anorexia and nausea.
• The pain
• in the epigastrium and gradually moves towards
the umbilicus, finally localizing in the right lower
quadrant.

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• diminished bowel sounds
• direct tenderness
• muscle spasm
• rebound tenderness.
• The temperature
• The appendix is often situated at or around
McBurney’s point.

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Rovsing’s sign

The psoas sign


.
• The obturator sign

• Rectal examination

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• Radiographic

• flat and upright abdominal radiograph

• useful in patients with atypical symptoms and


physical signs.

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• Ultrasound

• the initial diagnostic imaging

• Noninvasive
• rapidly available
• avoids radiation exposure.
• Sensitivity more than 85%

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• Computed tomography
• atypical for appendicitis
• appears as a thin tubular structure in the
right lower quadrant
• Abnormal (distended or thickened)
• Sensitive
• 48-72 hours

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• Nuclear medicine
• Noninvasive
• not promptly available.
• Accuracy (unknown)

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• Laboratory

• complete blood count


• left shift
• C-reactive protein
• Urinalysis

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• Diagnoses
• a thorough history
• physical examination
• laboratory tests.

• Diagnostic laparoscopy
• Female,15 and 45

• whether to remove a normal appearing


appendix at laparoscopy.
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• Differential diagnoses

• Preschool children
• Intussusception
• Meckel’s diverticulitis
• Acute gastroenteritis

• School-age children
• Gastroenteritis
• Functional pain

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• Adolescent boys and young adult men

• Crohn’s disease
• ulcerative colitis
• epidihymitis.

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• Adolescent girls and young adult women

• gynaecologic conditions.

• Pelvic inflammatory disease

• Ovarian cysts (ruptured cyst, ovarian torsion)

• Urinary tract infections

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• Elderly age group
• gastrointestinal tract

• reproductive system.
• Diverticulitis
• perforated ulcers
• cholecystitis.

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• Types of treatment

• fluid resuscitation before surgery.

• nonperforated disease
• perforated appendicitis.

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• acute, nonperforated appendicitis

• antibiotic therapy alone for appendicitis.


• rare situations such as with sailors on
long submarine tours

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• Incision

• transverse right lower quadrant skin incision


• oblique version
• paramedian incision

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• Handle removal of the appendix.
• suture ligate
• purse string
• Z-stitch

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• Laparoscopy

• superior to an open approach?

• adult,
• operative costs are higher
• longer procedure
• more equipment
• Pain less
• return to work sooner.

• To children?
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• Perforated appendicitis

• require several hours or more of fluid resuscitation before


operative intervention.

• Management of appendiceal mass

• Percutaneous drainage

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• Appendicitis during pregnancy

• the location of point tenderness varies during gestation.

• The white blood cell count

• Common symptoms

• Ultrasound

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• Crohn’s disease

• Meckel’s diverticulum

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• Postoperative complications
• Infection
• Bowel obstruction
• Infertility
• Miscellaneous

• Urinary tract infections, pneumonia, and other


complications of hospitalization

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During an appendectomy for acute appendicitis, a
4 cm mass is found in the midportion of the
appendix. Frozen section reveals this lesion to be
a carcinoid tumor. Which of the following
statements is true?

A Ni further surgery is indicated


B A right hemicolectomy should be performed
C There is about a 50% chance that this patient
will develop the carcinoid syndrome
D Carcinoid tumors arise from islet cells
E Carcinoid syndrome can occur only in the
presence of liver metastases

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