CHAPTER 1

Acute appendicitis (AA)

Latin - appendicitis acuta- this is an acute inflammatory disease of appendix, the causal organism of this disease, as a rule, is unspecific purulent infection. Patients with AA make 20-50% of all

sick persons in surgical departmentsAppendectomy makes 70-80% of all surgical interventions in patients with urgent pathology. The disease is more frequent met in the age of 10-40 years. Level of postoperative lethality is 0,2-0,3%Reasons of death at AA: -late resort for medical aid - doctors errors in diagnostics of AA (primary care physician make 55%, doctors of first-aid - 35%, surgeons - 10%)

Anatomy and physiology of the appendixThe ileocecal part of intestine includes: - terminal part of iliac intestine; - cecum; - Baouginiy’s valve; -appendix (Fig 1.1). Appendix joins to cecum on postero-medial wall, in a place, where three ribbons of longitudinal muscles of colon(tenia coli) meet and represents a cylinder, it’s length is 6-12 cm. and the diameter is 0,5 cm. Appendix is covered by peritoneum from all sides, it has its own mesentery - mesoappendix,

Fig.1.1 Blood supply :( Fig, 1.1)Vessels and nerves pass in mesoappendix. The wall of appendix consists of serous layer, muscular layer, and submucous layer, where the lymphatic follicles are located, and mucous layer the superior mesenteric artery gives the ileocolic artery, and this gives the appendicular artery.

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2 Veins - the vein of appendix runs into the ileocolic vein, and this runs into the superior mesenteric vein. The last with the inferior mesenteric and splenic veins form the portal vein. Innervation of ileocecal part of intestine is provided by solar plexus, by upper and lower mesenteric plexus.

Fig.1.2 Inflamed appendix

Variants of location of appendix in the abdominal cavity

1. Retrocecal (12 o'clock). 2. Pelvic in 20% of cases (4 o'clock). 3. Pre ileal and post ileal in about 70% patients (2 o'clock). 4. Subcecal (6 o'clock). 5. Paracecal. 6. Subhepatic appendix is associated with subhepatic caecum. It occurs due to malrotation of the gut.

Fig.1.3 Variants of location of appendix in the abdominal cavity

Physiology of appendix

- Secretory - mucus layer produces juice, which contains mucus, traces of enzymes such as amylase, lipase; - Retractive - the poorly expressed peristalsis provides evacuation of contents; - Hemopoietic, lymphopoietic, - Immune, thanks to accumulation of lymphoid tissue;

Etiology, pathogeny of AAThe microbes of purulent infection: - Aerobes, that inhabit large intestine (intestinal bacillus, staphylococcus, streptococcus, proteus and other enterobacteria); - Nonclostridial anaerobes that inhabit the colon (Peptococcus, Peptostreptococcus, fousobacterias, bacteroids and others). - Mixed aerobic-anaerobic infection;

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- Specific infection: tuberculosis, actinomycosis, abdominal typhus, salmonella, sometimes Crown’s illness, tumors of appendix.

Ways of penetration of infection:

• - Enterogenous way - from the lumen of appendix through mucus layer as a result of loss of barrier function;

• - Lymphogenous way is rare, - to lymphatic vessels from the nearby organs. It is possible in women on right-side adnexitis through the Clado’s ligament.

• -Hematogenous way in bacteriemia, when appendix with its lymphoid tissue becomes the target organ - is rare too.

Theories of pathogeny of AA

1. Infectious. Leading role in the development of disease the supporters of this theory give to the infection of appendix, its amount, virulence, which can be activated at favorable terms (stagnation, excrement stones, helminths, foreign body). 2. Neuro reflex (nervous-trophic). The reason of all is necrosis of mucus layer of appendix which is the result of its durable ischemia. The ischemia is caused by the long-standing spasms (appendiceal bauginio spasm), or spasms of vessels of this region.3. Allergic (immunological). The supporters of this theory consider that the reason of beginning of inflammation and of defeat of mucus layer is allergic reaction antigen-antibody. Allergization is caused by penetration of alimentary and microbic antigens into the immune components of mucus layer (lymphatic follicles).

Classification of AA by V.I.Colesov

(I). Acute appendicitis 1. Acute simple (superficial) appendicitis. 2. Acute destructive appendicitis: а) Phlegmonous, b) Gangrenous, c) Perforative,d) Empyema of appendix. 3. Complicated acute appendicitis:а) Appendicular infiltrate; b) Appendicular abscess;

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c) Peritonitis of appendiculars origin; d) Other complications (pylephlebitis, sepsis and others). (II). Chronic appendicitis

Primary chronic appendicitis. Residual chronic appendicitis.Recurrent chronic appendicitis.

Clinic’s of AA

General symptomatology: The attack of acute appendicitis begins, as a rule, from stomach-ache. In 20-40% of cases the pain arises up at first in epigastric region, then it moves to right iliac region (s-m of Volcovich-Koher), but can be localized from the beginning in right iliac region. For AA are characteristic gradual progression of pain and its permanent character, absence of irradiation, moderate intensity. 2-3 hours from the beginning of disease in 50% of patients nausea appears, vomit is more frequent single, Delay of defecation, gases is expressed. In children with toxic forms of AA diarrhea can appear. Temperature of body subfebrile is marked. At objective examination of patients tachycardia is determined. In clinical blood test moderate leukocytosis is marked (up to 10-12X10/l), neutrophilia, shift of neutrophils to the left are marked, too. Local symptomatology: The most informing from them are: 1. D'elofoua’s triad (classic triad of AA) - Spontaneous pain in the right iliac fosse; - Tension of muscles of right iliac region on palpation of abdomen; - Hyperesthesia of skin of right iliac region. 2. Rovsing’s Symptom - pain in right iliac fossa on impulse motion in the projection of descending part of large intestine with fixing of sigmoid intestine. 3. Obraztsov’s symptom - it is strengthening of pain at pressure in right iliac fosse during the bending of right leg in coxofemoral joint. 4. Voscresenskiy’s symptom 1 - it is strengthening of pain in right iliac fosse during the sliding palpation through the strained shirt from the epigastrium to the right iliac region (symptom of shirt). 5. Sitcovskit’s symptom - it is appearance of dragging pain in the right iliac fossa, when patient lies on the left side.

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6. Bartom'e-Mihelson’s symptom - pain on palpation in the right iliac fosse is more expressed, if a patient lies on the left side than on the back. 7. Yaoure-Rozanov’s symptom - it is appearance of pain at the palpation in the region of Petit’s triangle from the right side (at retrocecal AA). 8. Coup’s symptom 1 – it is appearance of pain in right iliac fossa at passive overextension of right leg in the coxofemoral joint.

Three phases of the AA by Rusanov A.A.

• Appendicular colic - functional phase of AA, when ischemia of mucus layer of appendix does not result in necrosis. In clinical picture there is only pain syndrome and there are no expressed signs of inflammatory process - increase of temperature of body, leucocytosis, and local peritoneal symptoms are absent. This phase is called by some authors an epi gastral phase, because the pains in this phase are more frequent localized in the epi gastral region.

• - Phase of local inflammatory or inflammatory-destructive changes. Pathomorphologically the process can look likes superficial, phlegmonous, or even gangrenous appendicitis, but the feature of it consists in that inflammatory process is limited to the right iliac fosse, it does not go outside of it. Clinically both general and local symptoms are expressed in this phase of appendicitis, including the local symptoms of irritation of peritoneum, but they are determined only in the right iliac fosse.

• Phase of spreading of inflammation on peritoneum. In this phase the symptoms of endogenous peritoneal intoxication are on the first plan, local and spread peritoneal symptoms in other departments of the abdomen take very important role, too.

Diagnostics of AA.

Diagnostics of AA is based on revealing of characteristic complaints about permanent pain in the right iliac fosse, or Volcovich-Koher’s symptom, nausea, increase of temperature of body, at objective examination –positive Rovsing’s, Voscresenskiy’s, Obraztsov’s, Sitcovskiy’s, Bartom'e-Mihelson’s symptoms. For the confirmation of diagnosis clinical blood test and analysis of urine are done. In the analysis of blood leucocytosis, neutrophilia, neutrophil shift to the left are determined.

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Additional examinations - Laparoscopy -Diagnostic laparotomy

Fig.1.4 Abdominal ultrasound examination showing features of acute appendicitis, disended edematous appendix (open arrows),longitudinal scan (left) & transverse scan (right).A fecalith is seen (closed arrow).

-Abdominal ultrasound (Fig.1.4)Fig.1.5 Abdominal contrast-enhanced CT scan showing a fecalith (open arrow) at the base of a distended (>0.6 cm) appendix with intramural gas (white arrows).

Fig.1.5 Abdominal contrast-enhanced CT scanClinical Features and peculiarities of AA and surgical tactic’s in children

AA in children of the first year of life meets very rarely. The diagnostics of AA in children of early age is very difficult because it is impossible to collect the anamnesis and to define pain symptoms which are used for adults.

The clinical picture and run of AA in children are caused by the anatomo physiological features of child's organism: not enough developed nervous and blood system, not enough developed lymphoid system and large omentum which achieves the right iliac fosse only in 7 years. That is why there are no cases of forming of appendicular infiltrate in children of early age, and AA is more frequent complicated by the perforation of appendix and peritonitis.

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The disease begins often with the high temperature of body (39-40°C),

With repeated vomits, quite often it is accompanied by diarrhea.

The examination of child is difficult because the palpation of abdomen results in crying and in active strain of muscles of the abdomen walls. It is necessary to carry out the palpation on mother’s hands. Quite often AA in children of the first year of life pain and strain of muscles of right iliac fosse are the single symptoms. A pain feeling on palpation of the right iliac fossa is determined by the symptom of "pushing away of hand" - a child pushes away the hand of surgeon, when he carries out the palpation of the right half of abdomen. Darter’s symptom - percussion of the right heel at peritonitis at child results in bringing child’s hands to the lower part of abdomen. AA at children is accompanied by high leucocytosis (up to 18-20*10/9) with the shift of neutrophils to the left.

Operation - appendectomy in children is carried out under general anesthesia and just ligation method is used due to fragile caecum.

Clinical Features and peculiarities of AA and surgical tactic’s in a pregnant women

Fig.1.6 (Peculiarities of female pelvis)Pregnancy of the first three months has no influence on clinic of AA, but by 4th- 5th month the increased uterus displaces upwards the cecum and appendix. For AA in pregnant the acute beginning of disease with the pain in lower part of right half of abdomen is characteristic.

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Tension of muscles of abdomen and also Shotcin-Bltomberg’s, Rovsing’s symptoms are rarely determined at objective examination. Appearance of pain, or the strengthening of pain in the right iliac fosse at pressure on the left rib of pregnant uterus (Brenda’s symptom); Strengthening of pain in the right half of abdomen, when the patient lies on the right side (Michelson symptom, or Sitcovskiy’s reverse symptom). In the blood test the amount of leucocytes can be normal, and more constant sign of AA is the neutrophil shift to the left. Early operation is the single method of treatment. Anesthesia – mainly local infiltration anesthesia, narcosis is used only in case of peritonitis. In the second half of pregnancy Volcovich-D'yaconov’s operational access is used, but it is displaced upwards the more, than the term of pregnancy is greater. Carefulness of manipulations in the area of uterus and appendages, prescribing of sufficient anesthetic and spasmolytic therapy in postoperative period are necessary for saving of pregnancy. In acute peritonitis of appendicular nature medical tactic does not differ from tactic in other case. Artificial breaking of pregnancy in such cases is the rough tactical error.

AA in old age

The temperature of body rises insignificantly, or it is normal, the special symptoms are poorly expressed, tension of muscles of abdomen is absent in 50% of cases, Shotcin-Blumberg’s symptom is poorly expressed. More frequent there is paresis of intestine. Leucocytosis is not always observed in the blood test because the reduction of reactivity of organism is present, but often the expressed neutrophil shift to the left in leukogram is determined.

Appendectomy is the single method of treatment of AA. Surgical tactic consists in all patients with AA, are exposed to immediate appendectomy.

Endotracheal narcosis is the main method of anaesthetization.

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There are different operating accesses

Fig.1.7 Fig.1.81. Volcovich-Dyaconov’s (Mac-Barney’s) access (Fig1.7) Cut in the right iliac fosse, it is parallel to the inguinal ligament, and the center of this cut is Mac-Barney’s point. 2. Lekser’s access - through the Mac-Barney’s point, as well as the previous, but avoiding traumas of muscles, - through the Spigeliy’s line. 3. Lenander’s access - right-side pararectal cut, it is carried out in case of doubt in the diagnosis (AA or cholecystitis, AA or urgent diseases of appendages of uterus). 4. Lower middle laparotomy – it is carried out in case of spread peritonitis of appendicular origin. 5. Laparoscopic Appendectomy (Fig.1.8) - Minimum invasive surgery carried out with the help of videolaparoscope creating pneumoperitoneum with the help of probes.

PYLEPHLEBITS (portal pyemia)

Pylephlebitis can be defined as a pus-producing inflammation of the wall of the portal vein that drains blood from the abdominal part of the gastrointestinal tract. The infection is often fatal. It usually occurs as a complication of abdominal or pelvic infections such as diverticulitis and appendicitis. Or septic inflammation and thrombosis of the hepatic portal vein. This is a rare result of spread of infection within the abdomen (as from appendicitis) this condition causes severe illness, like liver damage fever, abscesses, and ascitis.

Incidence2, 3 per 100,000

Etiology 88% of cases are associated with bacteremia, frequently polymicrobial

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Most common organism: B. fragilis; also aerobic gram negative bacteria are common Underlying causes can be appendicitis, diverticulitis and chronic cholecystitis Pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system.

PathogenesisPylephlebitis begins with thrombophlebitis of small veins draining an area of infection. Extension of the thrombophlebitis into larger veins leads to septic thrombophlebitis of the portal vein, which can extend further to involve the mesenteric veins. The superior mesenteric vein is involved in 34 percent of cases series. Mesenteric vein involvement can lead to bowel ischemia, infarction and death.

Clinical featuresChillsHigh FeverVomiting, (mild) nauseaEpigastric pain or pain in the upper abdominal quadrantTenderness in right hypochondrium due to hepatomegaly There may be unexplained sepsis with few early localizing signs, then rapid progression to gangrene and perforation of the gallbladder

Fig.1.9 Fig.1.10

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Medical history can be used as a basis for diagnosisCT scan (Fig.1.9) usually reveals signs of septic thrombophlebitis Ultrasound (Fig.1.10) shows increase in size of liver and changes in portal vein (e.g. Thrombosis) Blood cultures help to determine the causative agent.

Treatment

Conservative treatmenta. Antibiotic treatment:

Broad spectrum antibiotics that cover gram-negatives and anaerobes until definitive ID of organism is detected:

b. Anticoagulation therapy In cases of portal vein thrombosis Heparin initially 5000 to 10000units IV push, then adjust dose according to result and give 4000 to 5000units 4 hours.

Surgical Treatment

Surgical drainage of abscess and dead tissue removal, Ligation of inflamed vein, Removal of thrombosis.Treatment of underlying cause such as appendicitis, cholecystitis and diverticulitis.Complications Mortality (11%-32%)Portal hypertension

Fetal death in pregnant women

PERI-APPENDICULAR MASS (APPENDIX MASS/INFILTRATE)The mass is composed mainly of greater omentum, edematous cecal wall, edematous portions of small intestine, & in its middle is a perforated or otherwise inflamed vermiform appendix.

Clinical Features Symptoms

History of acute appendicitis, 3-4 days back.Signs

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(1) On 3rd day after the onset of acute appendicitis(a) A tender mass is felt in right iliac fossa (or in pelvis).(b) Some rigidity of overlying musculature.(2) By 4th or 5th day

Mass becomes more circumscribed, & as the rigidity passes off its periphery can be defined clearly.

(3) During 5th - 10th day(a) Swelling becomes larger, & an appendix abscess results, or(b) It becomes smaller, & subsides slowly as inflammation resolves.

NOTE: Diffrential diagnosis should be carried out making sure carcinoma caecum is outlined with the help of irrigography before starting conservative therapy.

TREATMENT

CONSERVATIVE TREATMENT

(A) Ochsner - Sherren regimen

If the condition of patient is satisfactory, then conservative treatment is performed as follows:

(1) Charting :(a) Pulse, every four hours (b) Temperature, every four hours

(c) Watch for vomiting; if excessive or recurrent, transnasal gastric aspiration is performed.

(2) Diet

(a) Water, 30 ml hourly, given by mouth.

(b) Desire for food, usually about 4th-5th days, is an indication that satisfactory progress is being made, & that oral feeding may be started.

(3) Intravenous fluids

Given according to fluid balance chart & daily assay of electrolytes.

(4) Drugs

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(5) Antibiotic therapy

(a) Parenteral ampicillin, gentamicin, & metronidazole.

(b) Oral antibiotics when oral feeding is resumed.

(6) Bowels

If bowels are not opened naturally by 4th or 5th day, a glycerin suppository is given.

(7) Antithromboembolic therapy

Prophylaxis against thrombosis of pelvic & leg veins should be given with compression stockings & subcutaneous low-dose heparin or fraxiparin.

OPERATIVE TREATMENT

(B) Operative treatment

Appendicectomy is indicated if in spite of conservative treatment there is:

(1) Increasing or spreading abdominal pain due to perforation.

(2) Abscess formation.

ATTN: There may be two ways of development/course of this condition.

(1) Firstly if the appendicular infiltrate responds well to the conservative treatment & regress or disappears completely within 2-3 weeks. The patient fells well & symptoms disappear. Patient should be discharged & called back after 2-3 months for conduction of planned appendectomy.(2) Secondly if the appendicular infiltrate does not respond to conservative treatment & the infiltrate convert to abscess. Patient feels unwell with increased temperature, pain & size of infiltrate-are signs of appendicular abscess formation. Extraabdominal drainage of appendicular abscess to be done by retroperitoneal approach & the incision is closed by secondary intention in 2-3 weeks depending on patient’s recovery.USG provides additional evidence/assessment of the condition of the appendicular infiltrate during the conservative treatment.Leucocyte count also helps to assess the condition of the patient.

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(3) Appendicular perforation is an indication of lower midline emergency laparotomy.

Primary appendiceal tumors

Table: Primary appendiceal malignancies Type of tumor Frequency (%)

Carcinoid 85Mucinous cystadenocarcinoma 8Adenocarcinoma 4Adeno carcinoid 2Others: sarcoma, paraganglioma,

And granular cell tumors 1Benign tumors

Benign tumors are also rare and comprise two groups: polyps and adenomas. Appendiceal polyps are similar to those in the rest of the colon and may therefore have varying degrees of malignant transformation. On pathologic examination, an adenoma of the appendix tends to be diffuse and villous, unlike its colorectal counterpart. Excessive production of mucus by an adenoma causes a large sausage-shaped cystic mass referred to as a cystadenoma.

Benign lesions of the appendix are usually asymptomatic and are usually found incidentally at exploration or pathologic examination. Cystadenomas may present with acute appendicitis or a palpable mass. Preoperative ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI) of patients with a cystadenoma should reveal a fluid-filled, variable-shaped, thin-walled structure in the right lower quadrant containing low density contents. Cystadenomas can occasionally rupture, but the mucus is usually contained in the right iliac fossa (localized pseudomyxoma peritonei).

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Benign tumors

Benign tumors are cured by appendectomy provided that the resection margin is negative. Localized pseudomyxoma peritonei usually resolves after appendectomy and excision of local mucin deposits. Similar to patients with colonic polyps, those with appendiceal polyps should undergo colonoscopy to rule out synchronous colorectal adenomas or carcinoma.

Malignant tumors

Carcinoid tumors

The most common tumor of the appendix is a carcinoid, occurring in up to 0.5 per cent of appendectomy specimens and accounting for 85 per cent of all appendiceal tumors. At least 50 per cent of all carcinoid tumors originate in the appendix. They are common in young women and are detected incidentally at abdominal exploration or present with signs of acute appendicitis.

Mucinous cystadenocarcinoma

Cystadenocarcinoma is the second most common appendiceal malignancy and one that many times can be diagnosed preoperatively. Patients usually present with symptoms of acute appendicitis or a right lower quadrant mass. A barium enema may show a non-filling appendix with a globular mass. CT demonstrates a mass near water density with calcium in its wall. About 50 per cent of these patients will have intra-abdominal metastases and pseudomyxoma peritonei.

Adenocarcinoma

Adenocarcinoma of the appendix is much less common than carcinoids and accounts for 0.1 per cent of all performed appendectomies. The mean age of presentation is 50 years and men are affected more than women.

Adeno carcinoid

Patients with adeno carcinoid tumors are usually symptomatic presenting with acute appendicitis, an abdominal mass, or an ovarian mass. Most patients are 40 to 50 years old.

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Mucocele

An appendiceal mucocele leads to progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance.

DIFFRENTIAL DIAGNOSIS

Perforated Peptic Ulcer

Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents gravitate down the right gutter to the cecal area and if the perforation spontaneously seals fairly soon, thus minimizing upper abdominal findings.

Urinary Tract Infection (right sided renal colic)

Acute pyelonephritis, on the right side particularly, may mimic a retroileal acute appendicitis. Chills, right costovertebral angle tenderness, pus cells, and particularly bacteria in the urine usually suffice to differentiate the two.

Ureteral Stone

If the calculus is lodged near the appendix, it may simulate retrocecal appendicitis. Pain referred to the labia, scrotum, or penis; hematuria; and/or absence of fever or leukocytosis suggest stone. Pyelography usually confirms the diagnosis.

CHRONIC APPENDICITIS

CHRONIC APPENDICITIS :Chronic appendicitis usually refers to a milder form of the illness and almost UN perceivable symptoms this may include inflammation of the vermiform appendix with recurring attacks of right-sided abdominal pain over an extended period of time or simply Recurring inflammation of the appendix.

Chronic appendicitis is classified as:

A. primary chronic appendicitis

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b. Residual chronic appendicitis

c. Recurrent chronic appendicitis

SIGNS AND SYMPTOMS

Chronic appendicitis is rare and not only that, it is slower in its progress and less intense, even significant signs and symptoms. Symptoms of chronic appendicitis include patient merely feeling exhausted and generally unwell. Apart from its normal symptoms, the pain is mild as the patient is quite accustomed with the abdominal pain. A partial obstruction of the appendix and milder bacterial infection are the main components in the chronic appendicitis making it important symptoms of chronic appendicitis. Other symptoms include:

Lethargy, nausea and fatigue, Change in bowel habit

DIAGNOSIS

Complete History and Physical Examination including pelvic and rectal examination

The history usually includes an acute illness at some time in the past, compatible with acute appendicitis, which was managed nonoperatively. On examination, the appendix is chronically inflamed or fibrotic. The symptoms resolve with appendectomy.

Barium x-rays are sometimes helpful, particularly in children. In many patients, the diagnosis is not obvious.

Blood tests:

Complete Blood Count with

Blood Biochemistry

Urine analysis, stool Analysis

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Diagnosis

Abdominal and Pelvic Ultrasound, CT scan Abdomen, Colonoscopy, Laproscopy

TREATMENT AND MANAGEMENT

Treatment of chronic appendicitis usually doesn't involve surgical removal of the appendix, despite such measures being common for the acute form of the disease.

Instead, doctors prescribe powerful antibiotics to help fight the infection. Yet, one dose of antibiotics won't do the trick, since chronic appendicitis can be somewhat tough to treat.

Sufferers of chronic appendicitis may have to take the drugs over time to help beat their disease. Of course, if there is a threat that the chronic appendicitis may actually make the appendix burst, doctors will probably opt for its removal

Rest, relaxation, and pain-killers are the usual steps involved in the recovery process following surgery.

Supportive Therapy, IV Fluids

Specific Therapy

Antibiotics ( Cefoxitin/ Ampicillin/Gentamicin/Metronidazole amoxicillin/clavulanate potassium 1 gram, 3 times a day, intra venous initially and then orally for one or two weeks because of relapsing nature a constant and long term antibiotic therapy is required.

Surgical Management

Laparoscopic Appendectomy

Management of Complications

Abscess Drainage

Perforation Laparotomy

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