Appendicitis

Commonest cause of acute abdomen

E.coli, Strept fecalis, Strept viridans → Lumen → Adult, Meat, Civilized
Types:
• None-Obstructive 1/3 → Constipation
• Obstructive 2/3 → Wall (Stricture, Tumor), Lumen (FB, Fecolith, Parasites), Outside (Mass,
Kink, Band)
Pathology
• Catarrhal stage
• Suppurative stage
• Gangrenous
Fate:
Rupture, Formation of appendicular mass and abscess.

Clinical picture: Triad of Pain, Vomiting, Constipation

• Pain: Shifting pain from umbilicus to right iliac fossa, Colicky, Stabbing, Stitching
• Vomiting: Usually with complicated cases.
• Constipation: Cause rather than symptom.
On Examination:
• Tenderness over right iliac fossa
• Crossed tenderness (Rovsing's sign) → Due to displacement of gases and fluids
• Rebound tenderness (On removal of hand and Cough)
• Crossed Rebound tenderness (Blumberg's sign) → Due to peritonitis
• Sherren triangle hypersthesia (ASIS, Ubmilicus, Symphysis pubis)
• Straight leg raising sign (Baldwing's sign) → Pain on raising right lower limb.
Atypical presentations
• Long retrocaecal → Ureteric colic, Psoas sign
• Pelvic → Tenesmus, Diarrhea, Frequency (UB, Rectum), Zachary coup sign (Painful internal
rotation of hip due to irritation of Obturator internus)
• Pre & Postileal → Portal pyaemia, Diarrhea, Subhepatic (Acute cholecystitis like)
Complications = Fate → Rupture (generalized peritonitis), Mass, Abscess, Portal pyaemia
• Mass = 2-3 days , Vomiting, Fever, Leucocytosis, Rigidity, Mass in right iliac fossa
• Abscess = 5 days, Vomiting, Hectic fever, Leucocytosis, Rigidity, Throbbing pain
• Portal pyaemia = Ascedning cholangitis (Pain, Fever, Rigor, Jaundice) = Charcot's triad
• Generalized septic peritonitis
Investigations:
CCUU (Clinical mainly → CBC, CT, Urine, US → Exclude gynecological causes)
Treatment:
EUA → If no mass → Appendicectomy (Grid iron incision over McBurney's point)
If mass is found → Oschner sherren (3 Tubes, 3 Drugs, Semisetting positiong, Observation, Mark mass
and follow size)
• If improvement occurred (Decrease fever, vomiting, mass size) → Interval appendicectomy after
3 months
• If no improvement (Hectic fever, Throbbing pain, Leucocytosis) → Abscess is formed →
Extraperitoneal drainage via Muscle cutting incision → Interval appendicectomy 6m

Children → Rapid perforation, Misdiagnosed as GE

Old → Cancer caecum must be excluded first
Pregnancy → High level of pain and tenderness, More perforation as omentum is elevated by uterus
Appendicectomy has no contraindications (Even Children, Old, Pregnancy)
Carcinoid tumor: Most common tumor of appendix (Other sites rectum, bronchus, ileum)
• Mic: Kulchitsky cells, Benign (< 1cm), Malignant (> 1cm)
• Clinical picture: Asymptomatic, Liver metastasis (Carcinoid syndrome → Diarrhea, Flushing,
Bronchospasm)
• Investigations: 5 HIAA in urine
• Treatment: Small and Confined to appendix → Appendicectomy, Large (Rt. Hemicolectomy)

Meckel's diverticulum (Disease of 2):

Persistent proximal part of Vitello-Intestinal duct
• Site & length: 2 inches, 2 feet away from iliocecal valve (60 cm)
• Age and Sex: 2 years, M > F (2:1)
• Incidence: 2% of people, 2% of them are complicated.
• Pathology: 2 ectopic mucosa (1 Gastric, Other is Pancreatic or Colonic)
Clinical picture (Gastric mucosa → PU → Bleeding, Inflammation, Foreign body reaction)
• Bleeding per-rectum (Most common cause of bleeding per-rectum in children)
• Intuscception (Inflammed base act as Foreign body), Volvulous (Persistent fibrous band)
• Acute Diverticulitis (As Appendicitis, Diagnosed intra-operative), Chronic pain (PU)
• Littre's hernia
Investigations: Tc99 (Ectopic gastric mucosa), Ba meal follow through, Intra-operative
Treatment: Excision of the segment carrying the diverticulum and Anastomosis
If asymptomatic → Excision (Young, Narrow base, Ectopic mucosa), Leave + Certificate (Old, Wide base,
No Ectopic mucosa)

Other vitello-intestinal duct anomalies

• All obliterated → Vitello-intestinal band
• All patent → Umbilical-fecal fistula
• Patent proximal part → Meckel's diverticulum
• Patent middle part → Vitelline cyst
• Patent distal part → Umbilical sinus (Rasberry tumor → Red mass at umbilicus)

Familial polyposis (Adenomatous polyposis coli)

Autosomal dominant disease = Adenomatous polyposis coli gene on short arm of Chromosome 5
Pathology: Start at 10 years, Full at 20 years, Must operate before 30 years or will develop Carcinoma
at 40 years
Site: Mainly rectum
Clinical picture (BCD) → 10 years old → Bleeding per-rectum, Colic, Diarrhea
OE: PR (Polypi)
Complicated: Anemia, Loss of weight
Investigations: BC → Barium enema (Multiple filling defects), Colonoscopy
Treatment:
• Total procto-colectomy + Terminal ileostomy
• Total colectomy + Ileo-rectal anastomosis + Microscopic fulgration of polypi + Follow up for life.
• Total colectomy + Rectal mucosectomy + Ileo-anal anastomosis
• Total colectomy + Ileo-anal anastomosis (J, S, W pouch of ileum using EEA stapler)
• All members of family should be followed up every 2 years from puberty till 20 years, then 5
years till 50 years.
Gardner's syndrome: FP + Osteomata (Skull, Mandible), Sebaceous cysts, Desmoid tumors
Turcot's syndrome: Gardners + Neurovascular tumors.