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ACUTE APPENDICITIS
►LEARNING OBJECTIVES
• Acute appendicitis
• What is it?
• How is it diagnosed?
►INTRODUCTION
BACKGROUND
Appendicitis is a common and urgent surgical
illness with protean manifestations.
Appendicitis, Acute
►INTRODUCTION
BACKGROUND
SEX
The incidence of appendicitis is
approximately 1.4 times greater in men than
in women.
Anatomy recall: lateral anterior wall of
abdomen, and vermiform appendix
RIGHT LOWER QUADRANT
• CECUM
• APPENDIX
• RIGHT OVARY AND TUBE
• RIGHT URETER
WHAT’S APPENDIX
• Located in the RLQ . Out pouching • Narrow tube • Rises from the
cecum. 2.5 cm below the ileocecal junction • worm shaped • Generally
6-10 cm long, 1.5 cm wide • The taeniae coli converge at the base
of the appendix • Wall contained lymphatic follicles
APPENDICITIS, ACUTE
• ►PATHOPHYSIOLOGY
• Appendicitis:
• What is it?
• Appendicitis means inflammation of the
appendix
• What is inflammation?
A basic way in which the body reacts to infection,
irritation or other injury, the key feature being redness,
warmth, swelling and pain.
How is appendicitis happened?
• Obstruction of the appendiceal lumen is the primary
cause of appendicitis.
• *Obstruction of the lumen leads to distension of the
appendix due to accumulated intraluminal fluid.
• * Ineffective lymphatic and venous drainage allows
bacterial invasion of the appendiceal wall. perforation
and spillage of pus into the peritoneal cavity.
APPENDICITIS, ACUTE
• ►PATHOPHYSIOLOGY
• ► Causes:
• The blockage (obstruction) may be due:
1) to thick mucus within the vermiform appendix.
• ►PATHOPHYSIOLOGY
• ► Causes:
• ► Parasites: e.g. :Schistosomes species,
Strongyloides species
• ► Diseases: Tuberculosis, and Tumors
APPENDICITIS, ACUTE
► CLINICAL DIAGNOSIS
• HISTORY:
• When vomiting occurs, it nearly always follows the onset pain.
• ► CLINICAL DIAGNOSIS
• HISTORY:
• ► CLINICAL DIAGNOSIS
• HISTORY:
• ► CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► General Appearance;
► Patient’s well built or not
• INSPECTION
• Rarely, left lower quadrant (LLQ) tenderness has been the major
manifestation in patients with situs inversus or in patients with a lengthy
appendix that extends into the LLQ.
APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Palpation
• The most specific physical findings are:
► Rebound tenderness
► Pain on percussion
► Guarding (tensing of the abdominal wall muscles)
APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Other confirmatory peritoneal signs
• The Rovsing sign
• ► RLQ pain with palpation of the LLQ
Other confirmatory peritoneal signs
• ► Percussion:
• Point tenderness (RUQ)
• ► Auscultation
• Not helpful in making diagnosis
► Rectal examination
Is helpful in making clinical diagnosis of localized and
generalized peritonitis.
APPENDICITIS, ACUTE
• ► Differential Diagnosis
• The differential diagnosis of appendicitis is broad
• Gastrointestinal, Gynecologic, Pulmonary,
Genitourinary, Systemic and other diseases can
mimic appendicitis.
• ► Gynecologic: e.g.
• Entopic pregnancy, Endometriosis, Ovarian torsion,
Pelvic inflammatory disease, Ruptured ovarian cyst and
etc…
► Systemic e.g.:
Diabetic, ketoacidosis, Porphyria ,Sickle cell disease
etc..
• ► Differential Diagnosis
• ► Genitourinary e.g.: Kidney stone , Prostatitis
Pyelonephritis, Testicular torsion, Urinary tract infection
etc..
• ► Other e.g.: Parasitic infection, Psoas abscess
Rectus sheath hematoma
APPENDICITIS, ACUTE
• Complications
• Diagnosis
• An ill-defined mass may be felt in the right lower
quadrant.
► BIBLIOGRAPHY
• Garcia Pena BM, Mandl KD, Kraus SJ, et al. Ultrasonography and
limited computed tomography in the diagnosis and management of
appendicitis in children. JAMA. Sep 15 1999;282(11):1041-
6. Medline
• Malone AJ. Diagnosis of acute appendicitis: Value of un-enhanced
CT. Am J Roentgenol. 1993;160:763-766.
• Mullins ME, Kircher MF, Ryan DP, et al. Evaluation of suspected
appendicitis in children using limited helical CT and colonic contrast
material. AJR Am J Roentgenol. Jan 2001;176(1):37-41. [Medline].
• Mun S, Ernst RD, Chen K, et al. Rapid CT diagnosis of acute
appendicitis with IV contrast material. Emerg
Radiol. Mar 2006;12(3):99-102. [Medline].
APPENDICITIS, ACUTE
• ► BIBLIOGRAPHY
• Abou-Nukta F, Bakhos C, Arroyo K, et al. Effects of
delaying appendectomy for acute appendicitis for 12 to
24 hours. Arch Surg. May 2006;141(5):504-6;
discussioin 506-7. [Medline].
• Albu E, Miller BM, Choi Y, et al. Diagnostic value of C-
reactive protein in acute appendicitis. Dis Colon
Rectum. Jan 1994;37(1):49-51. [Medline].
Peptic ulcer
• Learning objective
• What is it ?
• What cause peptic ulcer?
• What are the symptoms of peptic ulcer?
• What is it diagnosed?
• How is it treated?
Peptic ulcer
• Background
• Peptic ulcer disease is the cause for dyspepsia in about
10% of patients
• Background
• Frequency
• Ulcers of the small intestine are known as duodenal
ulcers.
• Duodenal ulcers affect about one in 10 people at some
point in their lives
• Background
• Sex
• The prevalence is probably equal in men and women.
• Age
• Stomach and duodenal ulcers increases with age.
2) Chief cells
in fundus + body
Produced pepsinogen: that on contact with the
acid of the gastric juice, convert to proteolytic
enzyme - pepsin
• Stomach cell types
3) G-cells
in antrum
Produce mucus
coats and lubricates the gastric surface, and serves an
important role in protecting the epithelium from acid and
other chemical insults.
• Anatomy recall
• Duodenum
The first part of the small intestine
It is shortest and Widest
Most fixed part of the small intestine.
About 20-25cm long.
It begin at the level pylorus and ends at the junction Duodeno-jejunal flexure.
• Anatomy recall
• Duodenum
• It is divide into four parts
• Superior Part (first part): 3 cm long, and most movable of
the four parts.
• Descending Part (second part); 8-10 cm long.
• Horizontal Part (third part): 10 cm long
• Ascending Part (fourth part), 2-5 cm
Peptic ulcer
• Anatomy recall
• Duodenum
• Duodenal wall has four layers:
• Serosa
• Muscularis
• Submucosa
• Mucosal
• Anatomy recall
• Duodenum
• Type cells
• S cells: secretin
• D cells: somatostatin
• Enterochromatin cells: GIP
• N cells: Neurotensin
Peptic ulcer
• Physiopathology
• A peptic ulcer occurs when an alteration occurs in the
aggressive and/or protective factors such that the
balance is in favor of gastric acid and pepsin
• Any process
• that increases gastric acidity (e.g.., stress, fast)
• What is it?
• A peptic ulcer is a sore in the lining of the stomach or
duodenum, the first part of your small intestine.
• Peptic ulcer
• Clinical
• History
• Clinical
• History
• Classic gastric ulcer pain is described as pain occurring
shortly after meals, for which antacids provide minimal relief.
• Clinical
• History
• Pain can be sharp, dull, burning, or penetrating.
• Clinical
• History
• Clinical
• History
• Patients with bleeding gastric/duodenal ulcers may give a
history of hematemesis, melena (coffee-ground), or
episodes of presyncope.
• Clinical
• History
• Physical
• Physical examination usually is not helpful.
• H pylori bacteria
• NSAID consumption
• Lifestyle factors
• Smoking
• Alcohol use
• Caffeine intake
• Genetics (family history)
Peptic ulcer
• Other causes
• Gastrinoma
• Systemic mastocytosis
• Basophilia
• Other factors
• Infection
• Chemotherapy
• Radiation
• Crack cocaine