Appendicitis,General Surgery Department of 2nd hospital, CMUTian Zhong,A case History:At 23:00 hrs a 27 year old female arrived in the casualty department. She stated that early that morning she began to feel unwell. Soon after she developed a central abdominal pain in the region of her umbilicus. She vomited a little later and the pain moved to her right iliac fossa. The pain has been constant and has progressively worsened. Her last menstrual period had finished two weeks previously. She had some increased urinary frequency and some discomfort with micturition. Exam: The patient appeared to be in pain. Heart Rate 100/min BP 120/80 mmHg Tempt 38.2o C She had tenderness and guarding at McBurneys point. Rebound tenderness was also elicited. Bowel sounds were present. Rectal examination elicited some tenderness high on the right side. Lab test:blood routine: Hb 15.2 g/l WC 20.8X109,Now,Diagnosis Differential diagnosis Treatment,Anatomy and physiology of appendix,The appendix is a slender, worm-shaped pouch, averaging 510cm in length, that protrudes from the top of the colon in the lower right abdomen,Location,McBurneys point:one-third of the way from the anterior,superior iliac spine to the umbilicus. Pelvis and right ilac fossa appendix Anterior or posterior ileum appendix Retrocaceal appendix Right lateral caceal appendix,Retrocaceal appendix,Supply & nerve,Appendix artery: a final artery ,from ileocolic artery Appendix vein portalal veinsympathetic nerve :celiac plexus and lesser splanchnic nerve T10,T11,Acute appendicitis,Appendicitis is a common cause of abdominal pain,life-threatening condition because of systemic sepsis (systemic inflammatory response syndrome/SIRS leading to multiple organ failure) following rupture and abscess formation,Etiology,Obstruction: anatomy :wormed-shapednarrowplenty of lymph glands mechanical reason: food residue, ascarid, tumor,etc.,Etiology,Gastrointestial diseaseBacteria invasion:all kinds of G- bacilus,Pathology,Four type: Acute simple appendicitis Acute purulent appendicitis Perforation and gangrenous Appendiceal abscess,Acute simple appendicitis,Acute purulent appendicitis,Perforation and gangrenous,Gangrenous,Perforation,Appendiceal abscess,Results,Inflammation disappear Inflammation localization Inflammation diffusion,Clinical manifestation,symptoms : abdominal pain :Periumbilical or epigastric pain that migrates to right lower quadrantPain becomes persistent and well localized. It worsens with moving, breathing deeply, coughing, sneezing, walking, or being touched,Symptoms :,Gastrointestinal symptoms:Anorexia, nausea, and vomiting occur after the onset of painConstipationDiarrheabladder and rectum stimulus symptoms,Symptoms,General symptoms : tired ,headachfeverRapid pulse SIRS (systemic inflammatory response syndrome),Signs,Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone peritoneal irritation sign :muscular rigidityBlumberg signbowel sounds disappear,Others,Rovsings sign:pain in the right lower quadrant upon palpation of the left lower quadrant. Psoas sign :pain on active elevation of the legs The obturator sign: pain on internal and external rotation of the hip Rectal exam & vaginal exam,Lab test,Mild to moderately elevated WBC with left shift is typical but rarely may be normal, range of 11000-17000/mm3 over 20000/ mm3 perforation UA may show ketonuria or a few RBCs or WBCs pregnancy test (women only),Lab test,B-us X-ray Diagnostic abdominal puncture,Diagnosis,Periumbilical or epigastric pain that migrates to right lower quadrant Tenderness in the right lower abdomen, usually about a third of the distance from the navel to the top of the hip bone,Differential diagnosis,Two type :A: required surgeryB: not required surgery,Differential diagnosis,Required surgery: Perforation of gastointestinal tractulcer,tumor, diverticulitis obstetrics and gynecologic disease:ectopic pregancy,ovarion torsion Meckel diverticulitis Tumor,Differential diagnosis,Not required surgery Pelvic inflammation Mesenteric adenitis:at exploration a normal appendix and enlarged lymph nodes in the mesentery Viral & bacterial gastroenteritis Pneumonia, pleurisy,Treatment,Early operation:surgical removal(appendectomy) Acute simple appendicitis: appendectomy Acute purulent and gangrenous appendicitis:appendectomy and/or drainage,Treatment,Appendiceal abscess:if local in right low quadrantantibiotic therapy and general treatmentif infection diffusionincision and drainage,Treatment,Operation Incision :incision over the point of maximal tenderness,generally at McBurny pointtrue McBurneys incisiontansvers skin incision36cm long,Incision,McBurneys incision,Incision,tansvers skin incision,Treatment,Operation Process:The taenia of the colon are followed to the base of the appendix,Treatment,Operation Process: Mesoappendix is divided between clamps and ligated,