Management of Appendicitis. Anita Chiu, MD Long Island College Hospital June 12, 2009

Transcription

1 Management of Appendicitis Anita Chiu, MD Long Island College Hospital June 12, 2009

2 Case Presentation ti xx-year-old male presenting with a x-day history of abdominal pain associated with nausea, vomiting, decreased appetite, fever and chills on mm/dd/yyyy Pain began in epigastrium and migrated to right lower quadrant Increased in intensity but improved 2 days prior to admission PMHx: none PSHx: none Birth History: none Immunizations: up to date Parents separated with joint custody

3 Case Presentation ti Vitals: Temp F BP 104/54 HR 108 RR 20 Physical Exam: Gen: thin male, anxious, in mild distress HEENT: NC/AT Lungs: CTA B/L CVS: RRR Abdomen: soft, RLQ tenderness (+Murphy s) with palpable 6cm mass, nondistended, +Rovsing s, +obturator, +rebound tenderness GU: normal scrotum, testes descended bilaterally, no inguinal hernias

4 Case Presentation ti Labs: %N/6%B/27%M /0.1 Amylase 35 Lipase 18 UA (-)

5 Case Presentation ti Diagnosis of perforated appendicitis with appendicolith and phlegmon made Resuscitation ti with IVF, antibiotics Taken to OR RLQ incision Unable to remove appendix or appendicolith Open drainage of pus Drain placed Skin left partially open with staples

6 Case Presentation ti Post-op course: POD#0: fever, WBC 13.6 POD#1: +N/V/D, fever POD#2: fever, diarrhea,distended abdomen POD#3: fever, abdomen tense, WBC 21 POD#4: fever, +flatus, bloody BMx1 POD#5: afebrile, abx changed based on C/S, increased abdominal distension POD#6: +diarrhea, C.diff+ -> started on flagyl, JP pulled POD#7: fever, WBC 22 -> repeat CT scan

7 Case Presentation ti

8 Case Presentation ti POD#8: fever, parenteral nutrition started, IR drainage of RLQ collection (30cc hematoma) with pigtail left in place POD#9: fever POD#10: WBC 24, staples d/c d with 10cc pus drained POD#11: diarrhea improving, wound draining purulent fluid POD#12: afebrile, WBC 12 POD#13: IR drain d/c d d, patient d/c d d home on po antibiotics

9 Appendicitis

10 History 1736: first appendectomy credited to Claudius Amyand (St. George s Hospital, London) on an 11 yo boy with scrotal hernia and fecal fistula 1824: Louyer-Villermay presented 2 autopsy cases in Paris emphasizing importance of appendicitis 1827: Francois Melier first to suggest antemortem t recogniton of condition but discounted 1839: Bright & Addision described symptoms and identified RLQ 1886: Fitz coined appendicitis in landmark paper

11 History Initial surgical therapy designed to drain RLQ abscesses that occurred secondary to perforation 1848: Hancock performed first surgical treatment for appendicitis with abscess (open drainage without appendectomy) 1883: first elective appendectomy in Canada 1886: Krönlein first published account of appendectomy for appendicitis 1889: McBurney landmark paper describing early laparotomy for treatment of appendicitis 1894: McBurney s paper describing his famous incision 1982: Semm first successful laparoscopic appendectomy

12 Incidence Lifetime rate of appendectomy 12% men, 25% women; approx. 7% of all people undergoing appendectomy for acute appendicitis Rate of appendectomy for appendicitis is constant t at 10 per 10,000 patients/year ts/yea Most frequently seen in patients in 2 nd through 4 th decades of life (mean age 31.3, median 22) M:F 1.2 to 1.3:1 Misdiagnosis rate 15.3%

13 Etiology Luminal obstruction, usually by a fecalith Proximal obstruction causes closed-loop picture Venous return impaired first, then arterial inflow disrupted Epigastric pain caused by initial distension of appendix -> visceral afferent stretch fibers Shift to RLQ pain occurs when inflammation ato serosa of appendix and parietal peritoneum

14 Bacteriology Normal appendix similar to that of normal colon Principal organisms Escherichia coli and Bacteroides fragilis Facultative, anaerobic and mycobacteria may be present

15 Antibiotics Nonperforated: 24 to 48 hours Perforated: 7 to 10 days IV antibiotics are usually given until: WBC normal Afebrile x 24 hours

16 Presentation ti Symptoms: Anorexia Abdominal pain Vomiting Obstipation Diarrhea (in children) Signs: Determined by anatomic position of inflamed appendix Vital signs minimally i changed unless complication has already occurred Supine with right thigh drawn up McBurney s sign anterior appendix Rebound tenderness Rovsing s sign, psoas sign, obturator sign

17 Diagnosisi CBC Mild leukocytosis (10,000 to 18,000 mm 3 ) with mild PMN s Graded compression sonography Blind ending, nonperistaltic bowel loop coming off cecum -> noncompressible appendix 6mm in AP dimension Sensitivity 55 to 96%, specificity 85 to 98% CT scan Inflamed, dilated appendix (>5mm), thickened wall, dirty fat, target sign target sign OR

18 Appendectomy RLQ (or midline) incision over point of maximal tenderness Extend incision to external oblique aponeurosis

19 Appendectomy

20 Appendectomy

21 Appendectomy

22 Appendectomy

23 Appendectomy

24 Appendectomy

25 Appendectomy

26 Appendectomy

27 Appendectomy Irrigate Layered closure Peritoneum + transversalis with running or interrupted absorbable Internal oblique interrupted External oblique interruped Skin, subcutaneous

28 Incisions i McBurney s oblique incision 1/3 distance from ASIS to umbilicus Adapt incision to point of maximal tenderness Parallel to fibers of external oblique Rocky-Davis straight transverse incision through the skin, muscle splitting

29 Laparoscopic Appendectomy 3 ports (umbilical, suprapubic, LLQ) Dissection at base of appendix to create window Mesentery and base are secured and divided separately

30 Appendicitis iti in Children <5 years: negative appendectomy rate 25% Perforation rate 45% Tsao et al (2008) suggest that diagnosis with CT scan vs H&P alone is more statistically accurate and may guide initial management Nurse, he said, it s an appendix!

31 Appendicitis iti in Pregnancy 1:2000 pregnancies More frequent in 1 st 2 ti trimesterst WBC 15-20

32 Appendiceal Rupture Rate of perforated appendicitis 25.8% <5 (45%), >65 (51%) T> 39 F (102 C) WBC > 18,000 mm 3 Ill-defined mass 2-6% Majority contained (localized rebound tenderness)

33 Phlegmon Pronunciation: \ fleg-,män\ Function: noun : a purulent inflammation and infiltration of connective tissue

34 Abscess Pronunciation: \ ab,ses\ Function: noun a localized collection of pus surrounded by inflamed tissue

35 Complicated Appendicitis in Children Roach et al (2007) retrospective review of all children undergoing appendectomy over 5 year period 1,106 children -> 360 had perforation -> 92 with abscess or phlegmon 60/92 underwent appendectomy 32/92 underwent drainage and/or abx with delayed appendectomy 2 nd group had longer prodrome, higher WBC, same LOS but lower complication rate requiring readmission (0% vs 10%) Conclude that in children presenting with prolonged symptoms and discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice

36 Nonoperative management vs immediate appendectomy in perforated appendicitis Multicenter case-control study (2007) 1998 to 2003 Data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain > 5 days

37 Perforated appendicitis iti in children Whyte et al (2008) sought early identifiers of failure of nonoperative management in perforated appendicitis to help in surgical decision making 58 patients had CT-proven perforated appendicitis -> treated nonoperatively 36/58 (62%) responded 22/58 (38%) failed Determined that 3 parameters identify patients who fail Persistence of fever after 24 hours of treatment Bandemia on admission Multisector involvement on CT scan

38 Failure of conservative management Aprahamian et al (2007) concluded that lack of an abscess and presence of an appendicolith predict failure of nonoperative management

39 Interval Appendectomy Ein (2005) demonstrated that the presence of an appendicolith was associated with a 72% rate of recurrent appendicitis (vs 26% with no appendicolith) N = 96 pediatric patients (16 months to 17 years), 1980 to 2003 All were treated t with IV triple antibiotics for 5 to 21 days for ruptured appendix with inflammatory mass or abscess Authors conclude that patients with appendicolith should have an interval appendectomy

40 Outpatient ti t interval appendectomy Whyte et al (2008) retrospective observational study (2/03 to 1/07) 37 children who had successful nonoperative treatment of CT-documented perforated appendicitis Interval appendectomy offered and recommended when fecalith involved 31/37 requested IA 24/31 underwent LIA 21/24 (88%) were discharged on DOA

41 References Jaffe Bernard M, Berger David H, "Chapter 29. The Appendix" (Chapter). Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, Schwartz SI: Schwartz's Principles of Surgery, 8th Edition: Whyte Christine, Tran Eric, et al, Outpatient interval appendectomy after perforated appendicitis, Journal of Pediatric Surgery (2008) 43, Whyte Christine, Levin Terry, et al, Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management, Journal of Pediatric Surgery (2008) 43, Keckler Scott, Tsao Kuojen, et al, Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated of appendicitis with abscess, Journal of Pediatric Surgery (2008) 43, Tsao K, et al, Management of pediatric i acute appendicitis iti in the computed tomographic era, J Surg Res Jun 15; 147 (2): Aprahamian C, et al, Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences, J Pediat Surg Jun; 42(6): Ein, S, et al, Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis, Journal of Pediatric Surgery (2005) 40, Roach Jonathan, et al, Complicated appendicitis in children: a clear role for drainage and delayed appendectomy, The American Journal of Surgery 194 (2007) Meeks Derek & Kao Lillian, Controversies in Appendicitis, Surgical Infections. Vol 9 No 6, 2008.

42 The End