GIS-K-25 ACUTE Appendiceal Mass / Abscess

Syahbuddin Harahap Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik Hospital INTRODUCTION

The is :

-Wormlike extension of the cecum (vermiform appendix).

-Length is 8-10 cm (ranging from 2-20 cm).

-Fifth month of gestation

-Several lymphoid follicles. Etiology: Obstruction of the lumen appendix followed by infection

Catarrhal appendicitis. -lymphoid hyperplasia (60% children) -Gastro enteritis -Virus -Acute respiratory infection -Mononucleosis

Obstructive appendicitis -fecalith 35% adults.

-foreign body / parasites (4%)

- tumors (1%) Pathophysiology

Wangensteen proposed 1. Closed loop obstruction 2. Increase in luminal pressure. 3. Exceeds capillary pressure causes mucosal ischemia 4. Luminal bacterial overgrowth and translocation bacteria across the appendiceal wall result : -Inflammation -Edema -Necrosis  perforation occur about 48 hours .

If the body successfully walls off the perforation Appendiceal Mass

If the perforation is not successfully walled off  Diffuse will develop. Problem:

Appendicitis can mimic several abdominal conditions.

Laboratory test Imaging investigation

Statistics report 1 of 5 cases is misdiagnosed

Normal appendix is found in 15-40% Emergency appendectomy.(Negative Appendectomy) Differential diagnosis of acute appendicitis

Surgical Urological • • Acute Intestinalobstruction Right ureteric colic • • Intussusception Right pyelonephritis • • Acute Urinary tract infection

• Perforated peptic ulcer • Right Acute epididymitis

• Mesenteric adenitis Gynaecological

• Acute Meckel's diverticulitis • Ectopic pregnancy • Acute Pancreatitis • Ruptured ovarian follicle

Medical • Torted ovarian cyst • Gastroenteritis • Basal Pneumonia dextra • Salpingitis/pelvicinflammatory disease • Terminal ileitis Differential diagnosis of appendicitis appendicitis can mimic several abdominal conditions. Lab Studies:

Complete blood cell count A mild elevation of WBCs (ie, >10,000/µL)

Urinalysis

Mild pyuria relationship of the appendix with the right ureter.

Severe pyuria in UTI.

For women of childbearing age , Ectopic pregnancy  test urin (beta-hCG) On

•Lying down

•Flexing their hips

•The most common symptom of appendicitis is : - Acute . - Epigastric or Periumbilical pain migrating to the right lower quadrant (RLQ) of the . - , , and anorexia - Afebrile or has a low-grade fever , 38 º C

•Higher fevers are associated with a perforated appendix Special maneuvers

McBurney sign

McBurney's point it is only the area of greatest tenderness



Rovsing’s Sign

Dunphy sign Cough Test





 Location appendix during pregnancy INDICATIONS

Consider an appendectomy for patients with a history of :

•Persistent abdominal pain •Fever •Clinical signs of localized or diffuse peritonitis •Especially if leukocytosis is present. Imaging Studies

Abdomen plain film: Fecalith within the appendix Urolithiasis right middle third 1986 MANTRELS SCORE Characteristic Score

M = Migration of pain to the RLQ 1

A = Anorexia 1

N = Nausea and vomiting 1

T = Tenderness in RLQ 2

R = Rebound pain 1

E = Elevated temperature 1

L = Leukocytosis 2

S = Shift of WBC to the left 1

Total 10

A score of 7 or more is strongly predictive of acute appendicitis. normal less than 6 mm Sonography

Advantages of sonography

1. Noninvasiveness, 2. Short acquisition time 3. Lack of radiation exposure 4. Potential for diagnosis of other causes of abdominal pain 5. Pediatric patients 6. Women of childbearing age. 7. Pregnant women CT scan more than 6 mm

-Oral contrast medium -Rectal Gastrografin enema

Reserved for patients -Uncertain diagnosis -Severe obesity. If the clinical picture is unclear

Short period (4-6 h) of watchful waiting

USG / CT scan -May improve diagnostic accuracy

Without a definite diagnosis - return for continued or recurrent symptoms - follow-up examination in 24 hours. Complications • Perforation • General Secondary Peritonitis • Appendiceal Mass • Appendiceal Abscess • Pylephlebitis is suppurative thrombophlebitis of the portal venous system • Hepatic absces • Chills • High fever • TREATMENT Medical therapy

Resuscitated adequately with fluids .

Preoperative prophylactic antibiotics -Acute Appendicitis single agent second-generation cephalosporin. -Perforated appendix triple antibiotic therapy Ampicillin , gentamycin , metronidazol

Antibiotic prophylaxis should be administered before every appendectomy.

Antibiotic treatment may be stopped. -Becomes afebrile -WBC count normalizes Two approaches to appendectomy

1. Open Emergency Appendicectomy ( Appendectomy)

2. Laparoscopic appendectomy

 If normal appendix removed need to look for :

- Meckel's diverticulum - Acute salpingitis - Crohn's disease If the body successfully walls off the localized perforation

Appendiceal Mass

RLQ mass The pain may actually improve. Symptoms do not completely resolve. Still have right lower quadrant pain Decreased appetite Change in bowel habits (eg, , ) Intermittent low-grade fever. Treatment of

Appendiceal Mass Nonoperative management Becomes walled off by omentum and ajacent viscera. Initially treated with intravenous broad-spectrum antibiotic

Appendiceal Abscess  USG or CT scan -Percutaneous aspiration -Drain placement Intravenous antibiotics are continued until the patient - afebrile for 24 hours - return of normal gastrointestinal function - normal WBC count with a normal differential. At this time, patients are switched to oral antibiotics for a total antibiotic course of 10-14 days.

Traditionally, interval appendectomy is performed 6-8 weeks later.

Acute Appendicitis Appendicitis Perforation