SURGERY 2 - G.I.

Module § Pain localizes to the RLQ within 4 to 6 hours

o Anorexia nearly always accompanies appendicitis
§ Appendicitis should be questioned with no anorexia
ACUTE APPENDICITIS
o Vomiting – 75% of patients
2013
§ Neither prominent or prolonged
APPENDIX ANATOMY § Vomits only once or twice
§ Due to both neural stimulation and presence of
ileus
o Obstipation
o Sequence – Anorexia, abdominal pain, vomiting.
§ Appendicitis questioned if vomiting precedes pain
o Temp elevation rarely >1%
o Pulse rate normal or slightly elevated
o Patients prefer to lie supin with thighs drawn up
o Referred or rebound RLQ pain – maximal in
mcburney’s point DUNPHYS SIGN Cough sign
o Rovsing Sign – pain in the RLQ when palpatory
pressure is exerted in the LLQ
o Psoas Sign – having patient lie on the left side as the
examiner slwly extends the patient’s right thigh
§ Positive if pain is present
§ Localized muscle irritation
o Obturator sign – passive internal rotation of the flexed
right thigh with the patient supin
§ Positive if pain is present
• Diagnosis
o Laboratory findings
§ Mild leukocytosis (10,000 to 18,000 cells/mm^3)
o Imaging Studies
• Appendix position of base remains constant in the cecum § Plain Film
• Tip can be found in the retrocecal, pelvic, subcecal, • Rarely helpful
preileal or right pericolic position • To rule out other pathology
• 3 taenia coli converge at the junction of the cecum with § Graded compression sonography
appendix • 55 yo 96% sn, 85 to 98% sp.
o can be a useful landmark to find the appendix
• Accurate way to establish appendicitis
• Length varies from <1cm to >30cm – Most are 6 to 9 cm
• With maximal compression, the diameter of the
long
appendix is measured in the anteroposterior
• Earlier viewed as vestigial with no known function dimension
• Now well recognized that the appendix is an immunologic • Noncompressible appendix >6mm in the
organ anteroposterior direction as positive test
o Secretes immunoglobulin, particularly IgA § High resolution Helical CT
• Lymphoid tissue first appears 2 weeks after birth • 92 to 97% sn, 85 to 94% sp
o Increases throughout puberty
• Dilated appendix with wall thickening
o Decrease after the first 10 decades after puberty
• “dirty fat”, thickened mesoappendix and
o Virtually no lymphoid tissue after the age of 60
phelgmon
ACUTE APPENDICITIS • Arrowhead sign – thickening of the cecum,
• Incidence funneling contrast agent toward the orifice of
o Lifetime rate of appendectomy inflamed appendix FECALITH - better sign for acute appendicitis
§ 12% for men and 25% for women, 7% of all people o Alvarado Scale for the Diagnosis of Appendicitis
undergoing appendectomy for acute appendicitis Alvarado Scale for the Diagnosis of Appendicitis
CBC scoring
th
o most commonly seen in patients in the 4 decade of
life Manifestations Value
o M:F – 1.2:1 to 1.3:1
Symptoms Migration of pain 1
• Etiology
o Obstruction of the lumen
Anorexia 1
§ Most dominant etiologic factor in Acute appendicitis
§ Fecaliths are most common cause – 40% of cases Nausea and/or 1
of simple appendicitis and 65% of gangrenous Vomiting
appendicitis without rupture and 90% in gangrenous Signs RLQ tenderness 2
appendicitis with rupture
§ Hypertrophy of lymphoid tissue, inspissated barium, Rebound 1
tumors, vegetable and fruit seed and intestinal
parasites as less common causes Elevated Temp 1
o Principal organisms seen in normal, acute appendicitis
and acute appendicitis – E. coli and B. fragilis Laboratory Leukocytosis 2
• Signs and Symptoms values
o Abdominal pain as prime symptom Left Shift in leukocyte 1
§ Initially diffusely centered in the lower epigastrium count
or umbilical area, moderately severe and steady Total Points: 10
Score of 4 - acute appendicitis 7 or more : appendicitis
sometimes with intermittent cramping

    MANTRELL

                 G  
   
Percusipsion tenderness - soft to harder
 CT scan > Ultrasound

• Treatment
o Open Appendectomy
§ McBurney (Oblique) or Rocky-Davis (Transverse)
RLQ muscle-splitting incision
o Laparoscopic Appendectomy
§ No evidence yet if laparoscopic procedure is more
effective that open procedure
o Natural Orifice Transluminal Endoscopic Surgery
(NOTES)
o Fluids and Antibiotics

APPENDECEAL RUPTURE
• 25.8% overall rate of perforated appendicitis
• <5 and >65 with highest rate of rupture
• Delays in presentation may be responsible for majority of
perforated appendicitis
• No accurate way to determine risk of rupture
• Occurs most frequently distal to the point of luminal
obstruction along the antimesenteric border of the
appendix
• Should be suspected if
o Temp >39C
o WBC >18,000 cells/mm^3
• Phlegmons in 2 to 6% of patients
o Consists of matted loops of bowel adherent to the
adjacent inflamed appendix or may represent a
periappendiceal abscess
• CT Scan beneficial in guiding treatment because treatment
differs in rupture and appendicitis
• Treatment
o Phlegmons and small abscesses
§ IV antibiotics
§ Percutaneous drainage for well-localized abscess
§ Surgical drainage for complicated abscess
o Interval Appendectomy Patients are operated on without symptoms

§ At least 6 weeks after acute event Inflammation should resolve

§ Classically been recommended for all patients
treated either nonoperatively or with simple
drainage of abscess

th
Source: Schwartz’s 9 ed

SGD NOTES
Consider appendectomy
- fever
- acute abdomen -> tender ; generalized tenderness

*development of infection - operate right away

Carbapenem -> not as good as imipenem (has for anaerobes)

- rupture : E.coli

   
                 G