Welcome. In this talk, we're going to cover appendicitis.
Literally, inflammation of the appendix.
The lifetime risk is about 10%
which is a fairly substantial portion of the population
who will eventually have appendicitis.
The peak incidence is in the young adult,
late teen's period of time.
Males develop this more frequently than females
for reasons that I don't entirely understand myself.
It is the most common acute surgical problem
in the pediatric population.
So, in children and young adults,
there is associated with a variety of GI
and even extraintestinal inflammation.
Follicular lymphoid hyperplasia that occurs throughout the GI tract
but can also prominently involve the appendix.
As those lymphoid follicles expand,
they can compromise luminal outflow from the appendix
and that can lead to the appendicitis.
They may also locally have increased cellular turnover
and that turnover may lead to the production of uric acid
that can cause an innate immune response
that's been somewhat likened to gout.
In older adults, the more common ideology
is not this follicular lymphoid hyperplasia,
but rather, faecalis which is what it sounds like.
It's little rocks of hard stool that get impacted
in the proximal portion of the appendix.
You can have calculi that are occurring
because of mucus, brine.
You can have fibrosis that occurs because of local inflammation
and if that occurs at the tip of the appendix, no problem,
but if it occurs more proximally, potential problem
is that limits movement of material out of the appendix.
And rarely, tumors or parasites can be a cause of appendicitis.
So, exactly what is happening here?
Highlighted in green is our appendix sitting
at the base of the cecum.
And normally, this is a tubular structure that drains
epithelial sloughing and mucus into the cecum.
So, it is another part of the GI tract.
Focal inflammation can cause distal dilation, not too surprising.
If you have focal inflammation more proximally,
in the early time, first 24 hours,
you'll have referred pain that is associated with an inflammation
and the way that the viscera have their neural connections,
it will - the pain will be referred to the umbilicus.
It's the stimulation of the TA to T10 afferent nerves.
In a significant number of cases, about a fifth overall, the symptoms
will spontaneously resolve in less than 24 hours.
The inflammation is reduced, the edema is reduced.
There's normal movement of material out of the appendix.
You're good to go. However, if you are not able
to resolve that proximal occlusion,
then, there will be bacterial overgrowth more distally.
There's going to be further dilation of the distal appendix
because we're sloughing epithelium, we're sloughing mucus,
and the bacteria are happily growing.
And in those cases, symptoms will last longer than a couple days.
And it gets localized now to right over the appendix.
So, it starts at the umbilicus and then, moves
to the right lower quadrant at McBurney's point.
Finally, if we don't get resolution
of this proximal inflammation and obstruction,
we will get so much pressure within the lumen
of the appendix that we compromise
our arterial blood supply into the appendix
and we'll get ischemic necrosis
in up to 50 - in up to 20% of cases, a fifth,
we can actually get frank perforation
which will lead to peritonitis.
How do these patients present?
So, again, the initial pain is periumbilical that later migrates to the right
lower quadrant and the point there is called McBurney's point.
It's about 2/3rds of the way from the umbilicus to the
anterior superior iliac spine, abbreviated there as ASIS.
So, you will have anorexia, nausea, vomiting, fever,
indigestion, diarrhea, generalized malaise,
a whole variety of symptoms that are non-specific.
Just because you have these
doesn't mean you have appendicitis
but those are the common findings
and you'll want to listen to the appropriate history.
Also shown on this image is Rovsing's sign.
And Rovsing was a surgeon and he discovered
that if he pressed on the contralateral side,
he could elicit pain over the appendix
and that's kind of a - because of edema and traction,
you're able to get an indirect pain sign.
Neither McBurney's point sign, periumbilical sign,
or Rovsing's sign are absolutely
pathopneumonic for appendicitis
but if you find them, you can feel more
confident in your diagnosis.
So, how do we formally make the diagnosis
and really prove the point?
Well, it's a combination of things.
And in fact, as we'll see, we want the surgeons
to air on the side of not missing appendicitis.
So, they may take out normal appendices
with a certain degree of regularity and that's okay.
That is not malpractice.
So, with appendicitis, we typically
would expect a low-grade fever.
If there's a high-grade fever, we may actually
suspect that there's been perforation.
There will be rebound tenderness and abdominal guarding
particularly over the area of the appendix
and then, we will see on laboratory findings increased
white cells, increased C-reactive protein,
increased erythrocyte sedimentation rate,
We will want to exclude other causes.
Clearly, if there's a urinary tract infection
or a urinary stone or pregnancy, going in and removing
the appendix is not going to be all that helpful.
So, you do want to be relatively certain that you're dealing
with an inflammation of the appendix.
An ultrasound is shown here of where we're seeing
prominent edema and dilation of the appendicle wall
that's between the two X's is a way to say,
"Oh, yes, this is definitely appendicitis."
And then, the management. So, you would want to
for your patient, give them pain control, nausea control.
If you are worried about the possibility of infection or impending
perforation, you would give intravenous antibiotics.
And then, you call your friendly neighborhood surgeon
who would take them for an appendectomy.
This makes the point that a negative appendectomy, meaning,
surgery without appendicitis actually being present is present,
should be present in about 10 to 15%
of appendices that are taken out.
That's an acceptable fault negative rate that we want the surgeons
to air on the side of taking out an okay appendix
and not missing the appendix that's going to rupture.
And with that, we've covered appendicitis.