Appendiceal Abscess Ef Fix

APPENDICEAL ABSCESS
Appendix
• a narrow, muscular tube containing a large amount of lymphoid tissue
• It varies in length from 3 to 5 in. (8 to 13 cm).
• The base is attached to the posteromedial surface of the cecum about
1 in. (2.5 cm)
• lies in the right iliac fossa, and in relation to the anterior abdominal
wall its base is situated one third of the way up the line joining the
right anterior superior iliac spine to the umbilicus (McBurney’s point).
Clinical anatomy by regions / Richard S. Snell. – 9th ed.

Common Positions of the Tip of the Appendix
Positions:
1. hanging down into the pelvis
against the right pelvic wall,
2. coiled up behind the cecum,
3. projecting upward along the
lateral side of the cecum,
4. in front of or behind the
terminal part of the ileum.
The first and second positions are
the most common sites.
Blood Supply
Arteries
The appendicular artery is a
branch of the posterior cecal
artery
Veins
The appendicular vein drains into
the posterior cecal vein.

Pathophysiology
• Obstruction of the lumen is believed to be the major cause of acute
appendicitis.
• This may be due to inspissated stool (fecalith or appendicolith),
lymphoid hyperplasia, vegetable matter or seeds, parasites, or a
neoplasm.
• The lumen of the appendix is small in relation to its length, and this
configuration may predispose to closed-loop obstruction.
• Obstruction of the appendiceal lumen contributes to bacterial
overgrowth, and continued secretion of mucus leads to intraluminal
distention and increased wall pressure
Townsend: Sabiston Textbook of Surgery, 18th ed.
Copyright © 2007 Saunders, An Imprint of Elsevier
• Luminal distention produces the visceral pain sensation experienced
by the patient as periumbilical pain.
• Subsequent impairment of lymphatic and venous drainage leads to
mucosal ischemia.
• These findings in combination promote a localized inflammatory
process that may progress to gangrene and perforation.
• Inflammation of the adjacent peritoneum gives rise to localized pain
in the right lower quadrant.
• Although there is considerable variability, perforation typically occurs
after at least 48 hours from the onset of symptoms and is
accompanied by an abscess cavity walled-off by the small intestine
and omentum Townsend: Sabiston Textbook of Surgery, 18th ed.
Clinical Presentation
Symptoms
• Appendicitis usually starts with periumbilical and diffuse pain that
eventually localizes to the right lower quadrant (sensitivity, 81%;
specificity, 53%)
• Gastrointestinal symptoms like nausea, vomiting, and anorexia
• Early in presentation, vital signs may be minimally altered. The body
temperature and pulse rate may be normal or slightly elevated
Schwartz’s Principles of surgery 10 th Ed

Signs
• Usually move slowly and prefer to lie supine due to the peritoneal
irritation. On abdominal palpation, there is tenderness with a maximum at
or near McBurney’s point
• On deep palpation, one can often feel a muscular resistance (guarding) in
the right iliac fossa, which may be more evident when compared to the left
side.
• When the pressure of the examining hand is quickly relieved, the patient
feels a sudden pain  rebound tenderness.
• Indirect tenderness (Rovsing’s sign) and indirect rebound tenderness (i.e.,
pain in the right lower quadrant when the left lower quadrant is palpated)
are strong indicators of peritoneal irritation

Laboratory finding
• Mild leukocytosis is often present in patients with acute,
uncomplicated appendicitis and is usually accompanied by a
polymorphonuclear prominence.
• It is unusual for the white blood cell count to be >18,000 cells/mm in
uncomplicated appendicitis.
• Counts above this level raise the possibility of a perforated appendix
with or without an abscess.
• An increased C-reactive protein (CRP) concentration is a strong
indicator of appendicitis, especially for complicated appendicitis

Imaging
• ultrasonography has a sensitivity of about 85% and a specificity of
more than 90% for the diagnosis of acute appendicitis.
• appendix of 7 mm or more in anteroposterior diameter, a thick-
walled, noncompressible luminal structure seen in cross section
referred to as a target lesion, or the presence of an appendicolith

• Computed tomography (CT) is commonly used in the evaluation of
adult patients with suspected acute appendicitis.
• Improved imaging techniques, including the use of 5-mm sections,
have resulted in increased accuracy of CT scanning, which has a
sensitivity of about 90% and a specificity of 80% to 90% for the
diagnosis of acute appendicitis among patients with abdominal pain.

Differential Diagnosis
School-aged children:
Preschool-aged children
Gastroenteritis,
Intususeption, Diverticulitis
Limphadenitis Mesenteric,
Meckel, acute
Inflammatory Bowel
Gastroenteritis.3
Disease, Constipation.3
Adults:
Pyelonephritis, Colitis, Elderly:
Diverticulitis, Diverticulitis, Intraabdominal malignancy,
PID (Pelvic Inflammatory Diverticulitis, cholecystitis.3
Disease), Ectopic pregnacy.3
3. Maa, J., Kirkwood, K.S. 2012. The Appendix in Sabiston Textbook of Surgery. 19th ed. Elsevier: Philadelphia.
Diagnostic Algorithm

Perforated Appendicitis
• Patients with perforation of the appendix may be very ill and require
several hours of fluid resuscitation before safe induction of general
anesthesia.
• Broad-spectrum antibiotics directed against gut aerobes and
anaerobes are initiated early in the evaluation and resuscitation
phase

Chronic or Recurrent Appendicitis
• A small number of patients report episodic bouts of right lower
abdominal pain in the absence of an acute febrile illness.
• Some are found to have appendicoliths on CT or sonographic
evidence of an enlarged appendiceal diameter;
• most of these will have both surgical and pathologic evidence of
chronic inflammation of the appendix and relief of symptoms after
appendectomy.

Appendiceal abscess (appendiceal mass)
• Localized perforation occurs when the periappendiceal infection becomes
walled off by omentum and adjacent viscera.
• Clinical presentation consist of the usual findings in appendicitis plus a right
lower quadrant mass
• Ultrasound and CT scan should be performed
• If an abscess is found, it is best treated by percutaneus ultrasound guide
aspiration
• Some surgeon prefer a regimen consisting of antibiotics and expectant
management followed by elective appendectomy 6 weeks later
• The purpose is to avoid spreading the localized infection, which usually
resolves in response to antibiotics.
Current Diagnosis & Treatment Ed17th
LANGE McGrawHill
Algorithm for the management of appendiceal abscess

Treatment
• Open appendectomy
• Laparoscopic appendectomy
Algorithm summarizing the treatment of acute appendicitis

Outcomes
• The mortality rate after appendectomy is less than 1%
• morbidity of perforated appendicitis is higher than that of
nonperforated cases and is related to increased rates of wound
infection, intra-abdominal abscess formation, increased hospital stay,
and delayed return to full activity.
• Surgical site infections are the most common complications seen after
appendectomy


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APPENDICEAL ABSCESS

Clinical anatomy by regions / Richard S. Snell. – 9th ed.

Clinical anatomy by regions / Richard S. Snell. – 9th ed.

Schwartz’s Principles of surgery 10 th Ed

Schwartz’s Principles of surgery 10 th Ed

Schwartz’s Principles of surgery 10 th Ed

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

Townsend: Sabiston Textbook of Surgery, 18th ed.

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