Pathophysiology of appendicitis
- obstruction due to fecolith/calculi/lymphoid tissue/tumor
- swelling over mucosal/submucosal tissue
- bacterial translocation leading to necrosis and perforation
Explain the mechanism behind traveling pain to RLQ
Visceral afferent nerves entering T8- T10 → vague abdominal pain
Further irritation of parietal peritoneum → localized RLQ pain
Anatomical locations of appendix
Retrocolic and retrocecal 75%
Subcaecal and pelvic 20%
Retroileal and pre-ileal 5%
Name the clinical signs of appendicitis
McBurney’s point of tenderness
Rovsing’s sign
Psaos stretch sign
Obturator sign
What is alvarado’s score?
Predictor of appendicitis
5-6 compatible
7-8 probable
9-10 very probable
Name some components of Alvarado’s score
MANTRELS
M- migration of pain to RIF
A-Anorexia
N- Nausea/vomiting
T-Tenderness in RIL
R-Rebound tenderenss
E-Elevated temperature
L- leucocytosis
S- shift of white cells to left
CT features for appendicitis
Appendiceal diameter >7mm
Thickened appendiceal wall > 3mm
Periappendiceal stranding/fluid
Presence of fecolith
CT accurancy for detection of appendicitis
90%
Sensitivity 95
Specificity 75-80%
Should interval appendiectomy be offered for patient’s with delayed presentation?
pros: risk of recurrence, risk of ca
cons: risk of IA
Inform patient of option of option and offer IA selectively (>40
Management for delayed presentation of appendicitis
- Control any component of sepsis
- course of antibiotics
- percutaneous drainage of any intraabdominal collection
- Offer elective colonoscopy for those > 40 in 6-8 weeks
- Discuss option of interval appendiectomy vs conservative management
Complications of appendectomy
Wound infection
Bleeding
Pelvic abscess
Fecal fistula
Iatrogenic bowel injury
Adhesive IO
Mortality < 0.5%
Name some appendiceal tumors of epithelial origin
Carcinoid: classical, tubular, globet cell
Adenoma: tubular, tubulovillous, serrated
Adenocarcinoma: intestinal, mucinous, signet ring
Name some appendiceal tumors of non-epithelial origin
GIST
lymphoma
leiomyoma
leiomyosarcoma
neurofibroma
ganglioneuroma
Kaposi sarcoma
Two patterns of appendiceal carcinoma
Mucinous
Intestinal
DDX for appendiceal mucocele
Non-neoplastic
-simple mucoceles /retention cysts
Neoplastic
- serrated + hyperplastic polyps
- LAMN
- HAMN
- Mucinous adenocarcinoma
LAMN
Low-grade appendiceal mucinous neoplasm
- true neoplasm with dysplastic epithelium
- produced abundant mucin
- exhibits an expansile growth with a ‘pushing’ border
- confined to muscular propria, not infiltrative
HAMN
High-grade appendiceal mucinous neoplasm
- high grade dysplastic changes
- distinguished from LAMN only by degree of epithelial dysplasia
Treatment of localized disease of appendiceal mucocele
Complete resection of lesion:
- standard appendectomy
- if base involved (partical cecectomy/ileocecetomy/right colectomy)
Appendiceal specimen information to determine subsequent management after initial appendectomy
Any perforation
Margins of resection
Cytology
Appendiceal lymph nodes
Treatment of ruptured lesions
- Appendectomy/Right Hemicolectomy
- Careful inspection of abdominal cavity with documentation
- Biopsy of any suspicious peritoneal lesions
- Thorough irrigation of abdomen and surgical wounds
- Referral of patients with gross peritoneal spread to specialized center
Treatment of disseminated peritoneal disease
- Completion right hemicolectomy with lymphadenoectomy
- Cytoreductive surgery (CRS) + heated intraperitoneal chemotherapy (HIPEC)
T4a LAMN/HAMN
acellular/cellular mucin on serosal surface of appendix/mesoappendix
M1 LAMN
mucin involvement of distant peritoneal sites
a: acellular mucin in peritoneal sites
b: metastases confined to peritnoeum
c: metastases outside of peritoneum
Recurrence rate of T4a LAMN
acellular: 3-7%
cellular: 33-78%
