acute appendicitis and its carcinoma

7/30/2019 ACUTE APPENDICITIS AND ITS CARCINOMA

1/47

APPENDICITIS.

Mass Lesion of Appendix.

Carcinoid, Cancer .

Dr.Oko Chukwuemeka otutodilchukwu

4th

year , Group 42Lugansk state medical university, ukraine

15-05-2013


2/47

Objectives

To review the pathophysiology and

clinical presentation of acute

appendicitis and the lesions/cancer.To understand which patient groups are

at high risk of misdiagnosis

To discuss the use of laboratory andimaging studies in the diagnosis of

acute appendicitis


3/47

Appendicitis Incidence &Complications

6 % lifetime incidence

69 % are ages 10 to 30

Up to 30 % misdiagnosed initially

20 to 30 % ruptured at surgery

Mortality : 0.1 to 0.2 % unruptured, 3 to 5

% rupturedSignificant morbidity


4/47

Anatomic Aspects

Blind pouch off of cecum

Contains lymphoid tissue which peaks in

adolescence, atrophies with ageFunction still unclear

Appendix can be anywhere within

peritoneal cavity

One study showed 65 % retrocecal, 31 %

pelvic

Review of 70,000 cases showed 4 % in

RUQ, 0.06 % LUQ, 0.04 % LLQ


5/47


6/47


7/47

Pathophysiology of Appendicitis

Lymphoid hyperplasia leads to luminal

obstruction

Often follows viral illnessEpithelial cells secrete mucus

Appendix distends, bacteria multiply

Visceral pain begins an average of 17 hours after

obstruction

Increased pressure compromises blood supply

Somatic pain develops

Average time to perforation = 34 hrs.


8/47

Classic Presentation

Seen in 60 %

Anorexia

Periumbilical pain, nausea, vomiting

RLQ pain developing over 24 hrs.

Anorexia and pain are most frequent

Usually nausea, sometimes vomitingDiarrhea, esp. with pelvic location

Usually tender to palpation

Rebound is a later finding


9/47


10/47

Physical Exam

Tenderness at McBurney's point

Cutaneous hyperesthesia in T 10 to 12

dermatomesRovsing's sign

Psoas sign

Obturator sign


11/47

MANTRELS Score

Established in 1986

Migration of pain

AnorexiaNausea / vomiting

Tenderness RLQ

ReboundElevated temp.

Leukocytosis

Shift to left


12/47


13/47

MANTRELS Score, cont'd.

RLQ tenderness and leukocytosis = 2

points each ; all others 1 point

Score of 5 to 6 = possible appendicitisScore of 7 to 8 = probable appendicitis

Score of 9 to 10 = very probable

appendicitis


14/47

High Risk Patients

Ovulating women

PID, TOA, ovarian cyst rupture can mimic

appendicitisLook for cervical motion tenderness,

adnexal tenderness, history of STDs

Can have CMT with pelvic appendix


15/47

High Risk Patients, cont'd.

Pregnancy

Most common surgical emergency in

pregnancyMortality rate if missed = 2 % for mother,

up to 35 % for fetus

WBC elevated in pregnancy

Appendix changes location


16/47


Pediatrics

Most common surgical disorder in kids

Accounts for 5 % of abd. pain visitsUp to 50 % initially misdiagnosed

< 2 yrs. : perforation rate approaches 100 %

3 to 5 yrs. = 71 %

6 to 10 yrs. = 40 %Most common misdiagnosis is AGE

Sequence of pain and vomiting may be helpful

Localized tenderness not a feature of AGE


17/47


Elderly

Vital signs and exam may not reflect

severity> age 60 : only 5 to 10 % diagnosed

without delay

Perforation rate = 46 to 83 %

RLQ tenderness absent in 23 %

N/V, anorexia less common

Leukocytosis less pronounced

Only 20 % classic presentation


18/47


Immunocompromised

HIV, chronic steroids, sickle cell,

chemotherapy, DM, dialysisIncreased risk of complications and

misdiagnosis

Inflammatory response decreased


19/47

Appendix Mass

An appendix mass is an inflamed appendix with

an adherent covering of omentum and small

bowel. The history is similar to that ofappendicitis with a longer duration since onset.

Examination reveals a mass in the right iliac

fossa.


20/47


21/47


22/47


23/47

CANCER OF THE APPENDIX

An estimated 1% (0.9%1.4%) of all

appendectomy specimens contain a neoplasm.

The majority of appendiceal tumors arecarcinoids, while the remaining 10% to 20% are

mucinous cyst adenocarcinoma,

adenocarcinoma, lymphosarcoma,

paraganglioma, and granular-cell tumors. Asexpected, most present as acute appendicitis, and

in some 40% of cases, the diagnosis is made

after appendectomy


24/47

If a mass in the appendix is encountered incidentally

during the course of abdominal surgery, an

appendectomy is performed with frozen-sectionanalysis of the mass. Most masses prove to be benign

mucoceles or very small carcinoids. When carcinoid

tumors of the appendix are small (


25/47


26/47


27/47

Differential Diagnosis

Gastroenteritis

Mesenteric

lymphadenitisPID

Mittelschmertz

Crohn's diseaseDiverticulitis

Endometriosis

TOA

Ectopic pregnancy

UTIPyelonepritis

Other processes

involving appendix


28/47

" No single evaluation can

substitute for the diagnostic

accuracy of the experienced

physician."


29/47

Laboratory Studies

CBC

75 to 85 % have elevated WBC, but it is

nonspecificWBC normal in 80 % in the first 24 hrs.

Can see elevated ANC in up to 89 %

WBC usually 12 to 18,000 in appendicitis

Chemistry panel

May help with diagnosis of dehydration


30/47

Laboratory Studies, cont'd.

Urinalysis

Specific gravity, ketones

Can see WBCs, RBCs, bacteria ifinflamed appendix close to ureter

> 30 WBCs = probable UTI

HCG

Essential in women of child-bearing age

CRP

Acute phase reactant


31/47

Imaging Studies

Plain films

Low sensitivity and specificity

Appendicolith specific, but seen in only 2 %May see local air-fluid levels, psoas

obliteration, soft tissue mass, gas in

appendix : all nonspecific


32/47

Imaging Studies, cont'd.

Ultrasound

75 to 90 % sensitive, 86 to 100 % specific

Noninvasive, low cost, but operator-dependent

Good for diagnosing GYN disorders

3 criteria for diagnosis

Tender, noncompressible appendix

No peristalsis of appendix

Overall diameter > 6 mm


33/47


Ultrasound (US)

Appendix may not be seen, due to obesity,

guarding, bowel gas, perforation,retrocecal location

2.4 to 56 % of normal appendixes seen

One study of 736 pediatric patients

showed 36.6 % without preop US hadnegative appendectomy vs. 9.8 % who had

US


34/47


Ultrasound

Study from Australia showed total WBC

and neutrophil count were more accuratethan US. They recommended pts. with

unequivocal presentation go to OR. If

equivocal, obtain CBC. If WBC > 15,000,

go to OR. If < 11,000, obtain CT (US onlyin pregnancy).


35/47


CT

Early studies showed low yield, but helical

CT much more accurateSensitivity 97 to 100 %, specificity 95 %

(similar no matter what type or whether

contrast is used)

Often shows alternative diagnosis

More expensive, radiation exposure


36/47


CT

Criteria for appendicitis :

Diameter > 6 mm Failure to completely fill with contrast or

air

Appendicolith

Wall thickening or enhancement

Other contributory signs include fat

stranding, fluid, inflammatory mass,

adenopathy


37/47


CT

One study showed negative laparotomy

rates of 4 % in men, 8 % in ovulatingwomen with CT (typical is 20 % and 45 %

respectively), but no change in perforation

rate

Another study showed increase in CT useled to earlier diagnosis, less severe

pathologic findings, and decreased length

of stay


38/47


CT

Study from Dept. of Surgery, Stamford,

Connecticut : use of CT markedlyincreased from 1994 to 2000, without

change in rate of negative appendectomy.

They concluded use of CT by

nonsurgeons leads to increased E.D. LOSwithout improving accuracy. They

recommend mandatory surgical consult if

CT considered.


39/47

Do We Need Imaging Studies?

Literature conflicting

Pediatric Imaging -Evidence-Based

Guidelines

Imaging most useful in clinically equivocal

cases

Costs of imaging minor compared to cost

of unnecessary surgery or delayeddiagnosis

US and CT both specific enough to rule in

appendicitis, but only CT sensitive

enough to rule it out


40/47


Study from Austria

350 patients divided into low,

intermediate, and high probabilityAll had US

10 % of low prob., 24 % of intermediate

prob., and 65 % of high prob. had

appendicitisSpecificity and sensitivity of US = 98 %

Concluded imaging should be done even

in high probability patients


41/47


NEJM : Suspected Appendicitis Jan. 2003

Patients with classic presentation should go to

O.R. Diagnostic accuracy approaches 95 %If equivocal or suspect perforation : CT

US reserved for pregnant women or high

suspicion of GYN disease

If study indeterminate, observe with repeatedexams or laparoscopy


42/47

Analgesia

Sir Zachary Cope's 1921 textbook of

surgery and Dr.Emeka Oko said no way!

Prospective studies (both EM andSurgery literature) now show

appropriate use of IV narcotics does not

decrease diagnostic accuracy, and may

improve exam


43/47

Analgesia, cont'd.

Journal of American College of Surgeons : Jan.

2003

Prospective, randomized, double blind studyAdults with abd. pain got up to 15 mg morphine

vs. placebo

Increased pain relief, with no change in diagnostic

accuracy

Not all surgeons read their own literature, so

give them a chance to come in a reasonable

time frame or give the meds


44/47

Risk Management

Misdiagnosis of appendicitis = 5th

leading cause of successful litigation

against EPs

7 features of misdiagnosed cases :No nausea / vomiting

Lack of distress

No reboundNo guarding

No rectal exam (controversial)

Narcotic pain meds given

Diagnosis of acute gastroenteritis


45/47

Risk Management, cont'd.

When discharging, stress unclear

diagnosis, what to watch for

Follow up in 12 hours (PMD or E.D.)Can always observe if unsure

"When in doubt, don't send them out."


46/47

Summary

Appendicitis is a common surgical

emergency with a varied clinical

presentationSeveral patient groups are at high risk of

misdiagnosis

Lab and imaging studies are helpful, but

no single study is a substitute for good

clinical judgement


47/47

THANKS FOR Y OUR ATTENTION

acute appendicitis and its carcinoma

Documents