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Published on : Jan 08, 2015
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Slide 1 - Acute Appendicitis Tintinalli Chap. 78 Nicholas Cardinal, DO
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 Further increases intraluminal pressure 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 pain Inflammation of serosa and adjacent structures Triggers somatic pain fibers Localized to RLQ Anatomic Variability Retrocecal (26%) Flank pain RUQ Pregnant women Retroileal Testicular pain Pelvic May irritate bladder or rectum causing suprapubic pain, pain with urination, or feeling of a need to defecate
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 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 Appears to change management decisions and decrease unnecessary appendectomies in women Greater sensitivity (96%), accuracy (94%), and negative predictave value (95%) than ultrasound 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 AIDS Delayed dianosis Frequency of GI symptoms No leukocytosis Higher incidence of perforation
Slide 10 - Management NPO IV fluids Preoperative antibiotics Cover for anaerobes, enterococci, and gram-negative’s Zosyn 3.375 grams IV Unasyn 3 grams IV Analgesics Surgical consult
Slide 11 - Questions?