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Appendicitis





Appendicitis


Appendicitis

Appendicitis

1. Epidemiology:

  • Appendicitis (AA) is rare in children under 3 years old, the incidence increases gradually, peaking in adolescents and decreasing with age. However, AA is not uncommon in the elderly.
  • The male to female ratio of AA is 2/3, in the elderly this ratio is 1/1.

2. Diagnosis of AA:

  • Diagnosis is mainly based on clinical presentation (CP). Paraclinal examinations (PE) are only for reference.

3. Location of the appendix (AP):

  • The AP is located in the cecum, where the three longitudinal muscle bands converge, 2-3 cm below the ileocecal valve.
  • The base of the AP is always fixed relative to the cecum, the tip of the AP varies from person to person but most are located in the right iliac fossa (RIF).
  • About 5% of APs are located outside the RIF, behind the cecum (CE).
  • If the gut rotates excessively during development, the CE and AP may be misplaced from the splenic flexure to the right iliac fossa (RIF).
  • Situs inversus: AP is located in the left iliac fossa (LIF).

4. Appendix size:

  • The AP is about 8-10 cm long.
  • AA: Ultrasound (US) shows AP diameter > 7 mm.

5. Appendix histology:

  • Serosa: The outermost layer.
  • Muscularis:
  • Longitudinal muscle layer (from the three longitudinal muscle bands of the CE becoming thinner).
  • Circular muscle layer (continuous with the CE muscle).
  • The convergence of the three longitudinal muscle bands determines the base of the AP.
  • Submucosa: Contains lymph nodes (LN):
  • Very few at birth.
  • Gradually increase from 12-20 years old.
  • Atrophy and disappear after 60 years old.
  • These LN enlarge after infection (INF)/ bowel inflammation (BI).
  • Mucosa: Lined by colonic epithelial cells.

6. Appendix artery:

  • Originating from the ileocolic branch, a branch of the superior mesenteric artery (SMA), it passes behind the terminal ileal loop, located in the mesentery, supplying blood to the AP.

7. Appendicitis occurs when:

  • Infection in the lumen of the obstructed AP.
  • When obstructed:
  • Secretions are stagnant.
  • Increased pressure in the AP lumen.
  • Stagnant circulation.
  • Create favorable conditions for bacteria to grow.

8. Causes of AP obstruction:

  • Main cause: Lymphoid tissue hyperplasia in the AP wall.
  • Other causes: Fecaliths, parasites (PAR) (roundworms entering), foreign bodies (fruit seeds).

9. Process of appendicitis:

  • Consists of 4 stages:
  • Congestive AA:
  • AP swells, becomes opaque, blood vessels dilate.
  • When incised, there is clear, sterile secretion.
  • Rapid recovery (RR).
  • Suppurative AA:
  • AP is swollen, has a pseudomembrane around it, no pus in the lumen.
  • When incised, the abdomen contains turbid fluid.
  • Gangrenous AA:
  • AP has areas of necrosis, or the AP is greenish, friable.
  • Perforated AA:
  • Pus and feces leak into the abdomen.
  • If localized by the umbilicus, omentum, RIF wall, it will form an appendiceal abscess.
  • If not localized, it will cause peritonitis (PT).
  • Newly inflamed, unperforated, but localized AP will become an appendiceal mass.

10. Functional symptoms:

  • Dull RIF pain, initially may be above/around the umbilicus —> gradually localizes to the RIF.
  • Nausea/vomiting.
  • Digestive disorders (DD): Anorexia, constipation, diarrhea.

11. Systemic symptoms:

  • Fatigue.
  • Low-grade fever 37.5- 38* (–> higher fever suggests considering other causes).
  • Signs of infection: Hollow cheeks, dry lips, dirty tongue.

12. Physical signs:

  • Abdominal wall tenderness.
  • RIF abdominal wall rigidity: Late stage of inflammation (When the AP has perforated).
  • Increased skin sensation in the RIF.
  • Pain points: Mc Burney, Lanz, Clado, point above the right iliac crest.
  • Signs: Blumberg, Rovsing.
  • Rectal/vaginal examination: Pain in the right wall of the rectum/vagina.

13. Pain points:

  • Mc Burney’s point: 1/3 of the outer line connecting the anterior superior iliac spine to the umbilicus.
  • Lanz’s point: The point between 1/3 right and 2/3 left of the line connecting the anterior superior iliac spines (ASIS).
  • Clado’s point: Where the ASIS line intersects the outer edge of the right rectus abdominis muscle.
  • Pain point above the right iliac crest: Occurs in AA behind the CE.

14. Signs:

  • Blumberg’s sign: Pain when suddenly releasing the hand pressing on the RIF.
  • Rovsing’s sign: Pain on the right when air is forced from the left into the colon by pressing on the LIF.

15. PE:

  • Blood count (BC): WBC > 10,000, mainly neutrophils (NE) (>75%). But BC does not increase in parallel with the degree of damage (especially in the elderly, it can be normal) –> Unincreased BC does not rule out AA.
  • Plain abdominal X-ray: Nothing special, late AA in infants has images of multiple air-fluid levels of the small bowel loops concentrated in the RIF.
  • US: Enlarged AP (diameter > 7mm), fluid around the AP.
  • Computed tomography (CT): Inflamed AP, fluid around the AP.
  • Diagnostic laparoscopy: Especially in young women to differentiate from gynecological diseases (ruptured Degraff follicle, PID, ovarian cyst).

16. Clinical types:

  • By age.
  • By progression.
  • By location.

17. By age:

  • Children.
  • Young pregnant women (YP).
  • Elderly.

18. AA in children:

  • Infants:
  • Very rare, difficult to diagnose, often late when already PT.
  • Plain abdominal X-ray: Multiple air-fluid levels in the RIF.
  • Children 2-5 years old:
  • Fever, diarrhea vomiting, restlessness.
  • Flexing the right leg toward the abdomen, distended abdomen.
  • Rectal examination: Pain in the right wall of the rectum.

19. AA in YP:

  • First 6 months: Symptoms similar to normal.
  • Last 3 months:
  • Enlarged uterus pushes the CE up and rotates outwards –> the pain point is pushed up and displaced behind the back –> near the kidney, loin –> Symptoms similar to acute pyelonephritis.
  • Due to water retention, reducing abdominal wall sensitivity, making diagnosis difficult.
  • Examination:
  • Tilt left to examine RIF.
  • Supine: Pushing into the uterus from the left will cause RIF pain.
  • Progression in YP is very rapid, necrosis –> surgery should be performed early.

20. AA in the elderly:

  • Atypical clinical presentation, may not have fever.
  • RIF pain localizes slowly.
  • Often have abdominal distention.
  • Discreet abdominal wall tenderness (due to flaccid abdominal wall muscles).
  • Special clinical types: AA with tumor appearance and AA with bowel obstruction.
  • Tumor appearance: Due to late inflammation, surrounding tissue encapsulates, creating a pseudo-tumor appearance –> easy to mistake for a CE tumor.
  • Bowel obstruction: Due to late inflammation, INF spreads to cause functional bowel paralysis.
  • Abdominal X-ray: Signs of bowel obstruction: dilated bowel loops, air-fluid levels in RIF (due to late stage –> INF spreads to PT causing functional bowel paralysis).

21. By progression:

  • Toxic AA.
  • Bowel obstruction AA.
  • PAR AA.
  • TB AA.

22. Toxic AA:

  • Occurs in children or strong adults, athletes.
  • Physical signs are very vague, while systemic symptoms are very severe:
  • Septic shock – toxic condition.
  • Poor abdominal examination signs.
  • Rectal examination does not show clear pain on the right side.
  • Surgery has little purulent fluid in the RIF, AP necrosis in one or all areas.
  • Treatment: Early surgery + high dose antibiotics + aggressive resuscitation.

23. Bowel obstruction AA:

  • Occurs in the elderly.
  • Slow progression, colicky pain with fever.
  • X-ray shows dilated bowel loops, air-fluid levels in RIF or pelvis.

24. PAR AA:

  • In children: due to roundworms (usually after insufficient deworming).
  • Severe abdominal pain.
  • No fever/ low-grade fever.
  • RIF examination shows pain, mild tenderness.
  • Surgery shows AP wriggling, hard when palpated externally, worms protruding from the tip of the necrotic AP.

25. TB AA:

  • In patients undergoing TB treatment.
  • Slow progression, unclear RIF pain and tenderness.
  • Surgery shows enlarged AP, scattered white granules on the peritoneum and PT, mesenteric LN.
  • There is yellow fluid in the abdomen.
  • Stage of positive reaction (SPR): Specific TB agglutination reaction.
  • Need aggressive TB treatment because of a high risk of leakage and rupture of the AP tip.

26. By location:

  • AA behind the CE.
  • Pelvic AA.
  • AA in the mesentery.
  • Subhepatic AA.
  • Left-sided AA.
  • AA within a hernia sac.

27. AA behind the CE:

  • Pain radiates to the back, examination shows unclear RIF pain –> need to differentiate from lumbar spine.
  • Sometimes the right leg is contracted due to irritation of the lumbar pelvic muscle –> need to differentiate from lumbar-pelvic myositis.
  • Pressing the point above the iliac crest causes excruciating pain (have the patient lie on their left side).

28. Pelvic AA:

  • Urinary symptoms: dysuria, urinary frequency.
  • Rectal symptoms only when an abscess has formed in the pelvis.
  • Pain point is lower in the RIF.
  • Rectal/vaginal examination is very important.

29. AA in the mesentery:

  • AP is located in the middle of the abdomen, surrounded by bowel loops –> When inflamed, it will cause bowel paralysis –> functional bowel obstruction + fever –> Surgery to confirm the diagnosis.

30. Subhepatic AA:

  • Pain, tenderness localizes under the right rib cage.
  • Easy to mistake for acute cholecystitis.
  • US, abdominal X-ray to differentiate.
  • If still in doubt, surgery because both have surgical indications.

31. Left-sided AA:

  • In people with situs inversus.
  • Fever + LIF pain –> thorough physical examination to detect situs inversus.

32. AA within a hernia sac:

  • Differentiate from incarcerated hernia.

33. Progression within 48h:

  • PT.
  • AP abscess.
  • Appendiceal mass.

34. PT from AA:

  • After 48 hours without treatment, it will rupture, causing PT.
  • Symptoms of PT, asking the patient carefully will reveal initial signs originating from the RIF.
  • PT due to AA in the elderly often presents with bowel obstruction, 3-5 days after the onset of pain: generalized peritoneal rigidity (GPR) throughout the abdomen + Mechanical bowel obstruction due to pseudomembrane adhesions to the bowel loops causing it.
  • PT is then 2: After 24-48 hours, the symptoms decrease (less pain, no fever), but then suddenly severe RIF pain again, rapid deterioration, PT.

35. AP abscess:

  • Due to ruptured AP, pus is localized by surrounding tissue, can rupture causing generalized PT.
  • Because the AP can be in many locations in the abdomen –> There are many forms of abscess.
  • AP abscess in the RIF:
  • Increased RIF pain, high fever fluctuating.
  • Examination shows a tense mass, excruciatingly painful on palpation, continuous with the iliac crest, sometimes the skin in this area is reddened due to the abscess being about to rupture externally.
  • AP abscess in the abdomen: (AP located in the mesentery becomes inflamed and ruptured, surrounded by the surrounding tissue, forming an abscess in the abdomen, not adherent to the abdominal wall, causing functional bowel obstruction)
  • Effusion syndrome (ES) + Septic shock syndrome (SSS).
  • Painful, mobile mass, located away from the iliac crest, displaced inward, near the umbilicus.
  • AP abscess in the pelvis: (AP located in the pelvis –> rupture creates an abscess in the pouch of Douglas)
  • Urinary symptoms.
  • Symptoms of rectal irritation.
  • Most important sign: Examination of the anus and rectum shows enlarged anal opening, relaxed anal sphincter, swollen rectal mucosa, palpation reveals a tense, very painful mass in the pouch of Douglas.
  • Aspiration of the pouch of Douglas reveals purulent discharge.
  • Without treatment, the abscess will rupture into the rectum/vagina, rarely into the free abdomen.

36. Appendiceal mass:

  • AP in the inflammatory stage, not ruptured, localized by surrounding tissue.
  • Usually on the 4th-5th day after RIF pain symptoms.
  • SSS + low-grade fever 37.5-38.
  • RIF has a firm mass, indistinct boundaries, tender on palpation.
  • The only case where surgery is not performed immediately, but antibiotics (AB) and treatment (TD) are used –> can spontaneously regress or localize again into an AP abscess.

37. Need to differentiate from:

  • Other causes in the abdomen.
  • Urinary tract diseases.
  • Internal medicine diseases.

38. Other causes in the abdomen:

  • Perforated peptic ulcer: Pain starts above the umbilicus, surgery shows unclear inflammation of the AP, mucous and food debris in the RIF.
  • Acute cholecystitis: Easy to mistake for subhepatic AA, US is a valuable method.
  • Acute pancreatitis.
  • In children: Acute intussusception, Meckel’s diverticulitis, mesenteric adenitis, enteritis.
  • Women: PID, ovarian cyst, ruptured Degraff follicle, ovarian torsion –> Diagnostic laparoscopy, treatment.
  • Elderly: Bowel obstruction, CE tumor (causing subocclusive syndrome).
  • Diverticulitis, necrotizing enterocolitis, superior mesenteric artery occlusion, ruptured abdominal aortic aneurysm.

39. Urinary tract diseases:

  • UTI or pyelonephritis: Easy to mistake for AA behind the CE.
  • Has urinary symptoms: dysuria, urinary frequency, cloudy/bloody urine.
  • Urine culture, urinary system imaging, urinary cell examination.

40. Infectious diseases:

  • Right lower lobe pneumonia.
  • Viral rash fever can cause RIF pain (especially in children) before the rash appears.
  • Viral hepatitis: Right upper quadrant/RIF pain + low-grade fever before jaundice.

41. Treatment of AA early <24h, not ruptured:

  • Laparoscopic surgery/ Open surgery through the Mc Burney incision to remove the AP, the abdominal wall is closed in layers, similar to (similar to) close (close).
  • Can be sutured/ not sutured the base of the AP:
  • If the CE base is inflamed, thick, stiff: Do not suture the base of the AP.
  • If the CE base is friable, suturing has a risk of rupture, then open the CE.

42. Treatment of PT from AA:

  • Incision through the right pararectal line or midline incision below the umbilicus, clean, check the abdomen. Close the abdominal wall in one layer, leave the skin open.
  • Can be laparoscopic surgery, but must ensure thorough abdominal cleaning.

43. Treatment of AP abscess:

  • When the abscess has formed: drain the abscess, surgically remove the AP after 3-6 months.
  • Abscess with adherent wall to the abdominal wall: Drain the abscess externally in the RIF.
  • Abscess in the RIF: Incision parallel to the inguinal crease, 1 cm within the ASIS.
  • Abscess behind the CE: Incision above the iliac crest and 2 cm within the ASIS.
  • Abscess in the pouch of Douglas: Draining through the anterior rectal wall.
  • AP abscess in the abdomen, between the mesenteric folds, not adherent to the abdominal wall: Abdominal surgery to remove the abscess, remove the AP immediately.

44. Treatment of Appendiceal mass:

  • Only for appendiceal mass, no surgery, but aggressive treatment (AB) and TD:
  • If it progresses into an AP abscess –> treat as an abscess.
  • If the mass gradually decreases and disappears, surgically remove the AP after 3-4 months.

45. Postoperative complications:

  • Postoperative bleeding.
  • Abdominal wall abscess.
  • Postoperative PT.
  • CE fistula.
  • Bowel obstruction on the 5th day after surgery.
  • Postoperative bowel obstruction.

46. Postoperative bleeding:

  • Bleeding in the abdomen: Due to slipping suture tying the SMA of the AP.
  • Abdominal wall bleeding: Due to damage to the abdominal wall blood vessels.

47. Abdominal wall abscess:

  • The most common complication.

48. Postoperative PT:

  • Due to rupture of the AP tip due to INF from the AP spreading to the CE base –> therefore open the CE when the CE base and AP base are friable.
  • Can be localized PT.

49. CE fistula:

  • After surgery, there is drainage and feces leaking through the incision or through the drainage tube.
  • Fistulography to diagnose.
  • Usually heals spontaneously, if it does not heal spontaneously, need to perform a barium enema and colonoscopy to check for tumors. If it does not heal spontaneously, surgery is required.

50. Bowel obstruction on the 5th day after surgery:

  • Fever, pain, and mild RIF tenderness usually appear on the 5th day after surgery.
  • Plain abdominal X-ray: dilated small bowel loops due to reflex ileus.
  • Cause: PT from the appendix stump, even if the stump does not rupture.
  • Early re-operation is recommended because it is easily complicated by PT.

51. Postoperative bowel obstruction:

  • Can occur early/ many years after surgery.
  • Early bowel obstruction: Related to INF in the abdomen.
  • Late postoperative bowel obstruction: Due to adhesions or bowel kinking formed after surgery.

52. Peritonitis type 1:

C. Ruptured appendix causing generalized peritonitis (after 48-72 h)

53. Peritonitis type 2:

E. A and B (Appendiceal mass + Ruptured appendiceal abscess causing peritonitis)

54. Peritonitis type 3:

D. Appendiceal mass with abscess formation


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