alphalee, rpm, md

TOPIC 9: APPENDIX - Cefoxitin, ampicillin/sulbactam, cefazolin plus metronidazole – uncomplicated

By: Roselyn C. Baculi, RN, MSN, MD, DPBS - Piperacillin Tazobactam, cephalosporin plus metronidazole – complicated
HISTORY → discontinue less tham 4days after source control (STOP-IT trial)
• Signs/Symptoms: Anorexia, nausea, vomiting, and fever OPEN APPENDECTOMY VS LAPAROSCOPIC APPENDECTOMY
• Rule out: Ileus, Diarrhea, SBO and Hematuria
• Rule out: Menstruation
PHYSICAL EXAMINATION
• Warm to touch
• Focal tenderness with guarding, McBurney’s point
• Location of the appendix:
- Rovsing’s sign: Normal position
→ palpation at the LLQ, tenderness at the RUQ = malposition of the appendix
- Dunphy’s sign: Retrocecal
- Obturator sign: Pelvic • OPEN: Rocky Davies
- Iliopsoas sign: Retrocecal
→ these maneuvers will just give idea where is the tip of appendix
LABORATORY FINDINGS
• WBC: 10,000 – complicated appendicitis (17, 000)
• C reactive protein
• Urinalysis with PT
IMAGING
• ULTRASOUND
- r/o: easily compressible appendix <5 mm in diameter
- features:
o diameter >6 mm,
o pain with compression,
o presence of an appendicolith → surgical management
o increased echogenicity of the fat, and
o periappendiceal fluid
• CT SCAN
- Enlarged lumen and double wall thickness (>6 mm)
- Wall thickening (>2 mm)
• Negative exploration
- Periappendiceal wall thickening
- A normal appendix is often removed to reduce future diagnostic dilemma
- And/or appendicolith
• Incidental appendectomy
• MRI
- To prevent the future risk of appendicitis
- For pregnant or pedriatric patients
- Compromised hosts with unclear PE, patients with Crohn’s disease with a
- Advantage – no exposure to radiation
normal cecum, patients travelling to remote places with no urgent care, and in
DIFFERENTIAL DIAGNOSIS
patients undergoing cytoreductive operations for ovarian malignancies
• Acute mesenteric adenitis, Cecal diverticulitis, Meckel;’s diverticulitis, Acute Ileitis,
→ if normal cecum and normal appendix: remove
Crohn’s disease, Acute PID, Torsion of ovarian cyst or grafian follicle, and Acute
Gastroenteritis
- Most common: AGE, PID, Ectopic Pregnancy, Acute Ileitis
• Detailed menstrual history can distinguish mittelschmerz (no fever or leukocytosis,
mid-menstrual cycle pain) and ectopic pregnancy
TREATMENT
• Uncomplicated Appendicitis
- Conservative management
• Complicated Appendicitis
- Perforated and gangrenous appendicitis and appendicitis with abscess or
phlegmon formation
• Interval Appendectomy
- 6-8 weeks after onset of inflammation
- Shared decision-making
- Indication:
 For complicated appendicitis
 High risk of iatrogenic injuries
 Wait until inflammation subsides
PREOPERATIVE PREPARATION
• Fluid resuscitation
• IFC – optional
• Meckel’s diverticulitis: segmental resection and primary anastomosis
→ in pediatrics: IFC insertion carry high risk of iatrogenic injury to the bladder
• Prophylactic antibiotics 30-60 mins prior to skin incision
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 alphalee, rpm, md
SPECIAL CIRCUMSTANCES • Appendiceal mucocele
• Appendicitis in children - Describes a mucus-filled appendix that could be secondary to neoplastic or
- Infants and young children are most likely to present with perforated disease non-neoplastic pathologies (mucosal hyperplasia, simple or retention cysts,
(51-100%) mucinous cystadenomas, mucinous cystadenocarcinoma)
- School-age children have lower rates of perforation - Most common form of presentation is incidental
- Score of 7 or greater indicated that the patient has a high chance of having - Surgical excision without capsular disruption is undertaken
appendicitis (78-69%) • Pseudomyxoma peritonei syndrome
- Treatment: ExLap – mas mabilis mag perforate for children - Patients with appendiceal mucinous neoplasms develop peritoneal
- Exclude relevant differential diagnoses: dissemination leading to pseudomyxoma peritonei (PMP) syndrome
 Intussusception (currant jelly stools, abdominal mass) - Gastric, ovarian, pancreatic and colorectal primary tumors as well
 Gastroenteritis (often no leukocytosis) - Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)
 Malrotation (pain out of proportion)
 Pregnancy (ectopic)
 Mesenteric adenitis
 Torsion of the omentum
 Ovarian or testicular torsion
• Appendicitis in older adults
- Diminished inflammation and thus present with perforation or abscess more
frequent
• Appendicitis in pregnancy
- The point of maximum tenderness is usually displaced on PE
- US is the preferred imaging modality, although nonvisualization can occur
- MRI: alternative imaging modality
- CT can be performed in pregnancy, the risk of feral irradiation leads many
practitioners to avoid it unless other modalities are inconclusive
- Risk of fetal loss is up to 36% if appendiceal perforation occurs
→ complicated appendicitis
→ offer open or laparoscopic appendectomy
- Lower intra-abdominal pressures (10-12 mmHg) during insufflation in
laparoscopic technique
• Chronic or recurrent appendicitis
- Patients with recurrent RLQ abdominal pain not associated with a febrile illness
with imaging findings suggestive of an appendicolith or dilated appendix
- Patients often report resolution of symptoms with an appendectomy
- In the absence of imaging abnormalities, prophylactic appendectomy is not
encouraged
OUTCOME AND POST OPERATIVE COURSE
• Low mortality rate (<1 %)
• Uncomplicated appendicitis do not require further antibiotics
• Complicated appendicitis: 3-7 days of antibiotics (4days from STOP-IT trial)
→ supportive, noncomplicated: clean contaminated wound – no need for take home
antibiotics
STUMP APPENDICITIS
• An uncommon complication after surgery is the development of appendicitis in an
incompletely excised appendiceal stump (>0.5 cm stump length)
• Management: re-excision of the appendiceal base, but diagnosis can be difficult
and requires careful assessment of the patient’s history, physical exam, and
imaging studies
APPENDICEAL NEOPLASMS
• 1% of all appendectomy specimen
• MC: GEP-NET or carcinoids
- Submucosal rubbery masses
- <1 cm (95% of all lesions: negative margin appendectomy is adequate
- 2cm or larger: right hemicolectomy
• Usually incidental findings
• Goblet Cell Carcinomas
• Lymphomas
• Adenocarcinoma
- Mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid
- Most common mode of presentation for appediceal carcinoma is acute
appendicitis

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