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Published on : Jan 08, 2015
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Slide 1 - Acute Appendicitis Tintinalli Ch 84
Slide 2 - Pathophysiology Obstruction of appendiceal lumen Food matter, Adhesions, Lymphoid hyperplasia, Mucosal secretion Causes increased intraluminal pressure Vascular compromise Causes breakdown of epithelial mucosa and bacterial invasion Inflammatory response Eventually leads to arterial stasis and tissue infarction
Slide 3 - Innervation Luminal distention triggers visceral afferent fibers entering at T10 → Vague, poorly localized periumbilical or epigastric Inflammation of serosa localized to RLQ Anatomic Variability Retrocecal (26%) → Flank Pain Pregnant Women → RUQ Pain Retroileal → Testicular Pain Pelvic → Irritate bladder/rectum, suprapubic pain/pain with urination/defecation
Slide 4 - Symptoms Vague abdominal pain with localization -64% sensitive, 82% specific Anorexia - 68% sensitive, 36% specific N/V - 50% sensitive, 45% specific Rebound tenderness - 63% sensitive, 69% specific Guarding - 74% sensitive, 57% specific Rigidity - 27% sensitive, 83% specific Fever - 67% sensitive, 79% specific
Slide 5 - Physical Exam McBurney’s point May have rectal or flank tenderness if pelvic or retrocecal Rovsing sign - Palpation of LLQ produces RLQ pain Psoas sign - Patient in left lateral decubitus, Extend right leg at hip Obturator sign - Passive flexion of hip & knee with internal rotation of hip
Slide 6 - Diagnostics CBC 70-90% sensitive, low specificity Urinalysis - Abnormal in 19-40% Plain Radiographs - Limited diagnostic value Abnormal in 24-95% Look for appendiceal gas, fecalith, localized paralytic ileus, blurred right psoas muscle, free air
Slide 7 - Diagnostics Graded Compression Ultrasound – Test of choice in children and pregnant women 94.7% sensitive, 88.9% specific Inflamed appendix cannot be compressed Findings Diameter > 6mm Presence of appendicolith Periappendiceal abscess Doppler may show hyperemia Limitations Retrocecal Ruptured appendix = normal diameter
Slide 8 - Diagnostics CT – Contrast may not be necessary, depends on your radiologist Findings Pericecal inflammation Abscess Periappendiceal phlegmon Fluid collections Localized fat stranding
Slide 9 - Special Populations Very young, High misdiagnosis rate, High perforation rate, Communication difficulty Atypical symptoms Concurrent respiratory symptoms Gastroenteritis Lethargy, inactivity, hypothermia Elderly, Late presentation with an advanced course, Misdiagnosis can exceed 50%, Incidence of perforation 40-70%, Mortality rate in patients > 70 ~ 30% Pregnant Most common extrauterine surgical emergency Fetal mortality rate increases up to four times if complicated by perforation and peritonitis
Slide 10 - Management NPO IV fluids Preoperative antibiotics cover for anaerobes, enterococci, and gram-negative’s Zosyn or Unasyn Analgesics Surgical consult