What is Appendix| Appendix anatomy | Apeendix Pain| when appendix is removed|

 

Let’s start with anatomy the appendix

I located at the inferior cecum and is about four to twelve centimeters long. The arterial supply is the appendiceal artery which is a branch of the ileocolic artery. The Appendix can be located in a retrocecal position in about two-thirds of people appendicitis is the inflammation of the appendix.

The most common symptoms of appendicitis are pain initially around the umbilicus, then it can migrate to the right lower quadrant to McBurney's point which is one-third of the way between the anterior superior iliac spine and the umbilicus.   the pain precedes nausea patients usually don't want to eat so if you ask a kid if they want a hamburger and they say no that is sometimes called the hamburger sign always ask about diarrhea which can occur with appendicitis but could also be due to infectious colitis, Which can sometimes also present with right lower quadrant pain such as in Yersinia infections.   sometimes children will have large inflamed lymph nodes in the bowel mesentery called mesenteric adenitis, that can mimic appendicitis and needs no treatment the other named signs of appendicitis include Rovsing's sign, which is a pain in the right lower quadrant with palpation of the left lower quadrant. Right lower quadrant pain with coughing called Dunphy sign and pain with extension or internal rotation of the right leg known as the psoas sign. The Alvarado score takes all of these factors along with some lab findings to grade the likelihood of appendicitis a ruptured appendix and a right inguinal hernia is called an Amyand hernia.

 

 if an appendix is causing pain and then ruptures the patient can feel better for a short while then gradually get sick again. The most common location for rupture is the anti-mesenteric appendix about halfway down as the blood supply is the worst here.   The differential diagnosis for right lower quadrant pain in a woman is the mnemonic. ROPE appendicitis ruptured ovarian cyst ovarian torsion PID endometriosis and ectopic pregnancy.   So also consider pelvic ultrasound and always do a pregnancy test in a woman of childbearing age. Appendicitis is diagnosed on ultrasound as a thick-walled over two millimeters thick dilated over seven-millimeter non-compressible structure in the right lower quadrant.  The most sensitive and specific test is a ct scan.

Classic symptoms in a male may not need any imaging, although I think at least an ultrasound is not a bad idea because I've been fooled by terminal ileal  Crohn's disease in the past appendectomy is generally still considered the best treatment for non-ruptured. Or recently ruptured appendicitis laparoscopic or open through McBurney's incision muscle splitting in the right lower quadrant.  if it's a ruptured appendix and you do a good abdominal washout only continue the post-operative antibiotics for four days as per the STOP-IT trial non-operative treatment with antibiotics alone.

 as studied in the landmark   CODA which stands for comparison of outcomes of antibiotic drugs and appendectomy trial can be considered in some early appendicitis although 30  percent still needed surgery within a few months also know that a fecalith or an appendicolith which are calcified stool balls in the base of the appendix.  immunosuppression and peritoneal signs should be considered contraindications to trying non-operative treatment of acute appendicitis.

 

 I would also consider appendectomy more in the elderly population or if there was any evidence of a mass on imaging. Since cancer is more of a concern a pregnant woman's evaluation should start with an ultrasound but the appendix can be hard to find so they can also have a non-contrast MRI which is good imaging for appendicitis.   Ruptured appendicitis is a risk for a fetal loss so be careful in pregnant patients not to miss appendicitis because of the gravid uterus. The appendix can be near the right upper quadrant sometimes a supraumbilical Hassan trocar is safer and all ports should be in the upper abdomen to stay away from the uterus. if you explore for right lower quadrant pain and the appendix is normal check for terminal ileum Crohn's disease also check for Meckel's Diverticulum which should be within two feet of the ileocecal valve and check for GYN causes in a woman if you find terminal ilium Crohn's disease that does not involve the cecum then remove the appendix.

 if your Crohn's disease involves the base of the appendix. but the appendix is normal then leave the appendix since removal has a high rate of fistula if there is a drainable abscess and the patient is otherwise stable   IR drainage and antibiotics is best don't do surgery right away if there is a phlegmon without a drainable abscess just antibiotics and no immediate surgery also if you treat a ruptured appendix that has an abscess or a phlegmon non-operatively you will need to decide if you will offer an interval appendectomy usually in about six weeks this is a divided issue. a safe answer is that anybody with imaging six weeks later showing a mass in the appendix should have it removed to rule out cancer older patients may want it removed also to rule out cancer and certainly anybody over the age of 40 should at least have a barium enema or a colonoscopy to be sure the appendicitis is not related to malignancy. The trend is away from routine interval appendectomy in everybody certainly appendiceal cancer is a common question the appendix is one location you can find neuroendocrine or carcinoid tumors.

the most common location for carcinoids in the ileum but the appendix is the second most common location if an appendiceal carcinoid tumor is less than two centimeters and is at the tip of the appendix then appendectomy alone is sufficient appendiceal carcinoid over two centimeters at the tip of the appendix needs a right hemicolectomy. if appendiceal carcinoid of any size is at the base of the appendix then you need a right hemicolectomy.

 

Any adenocarcinoma of the appendix no matter what size gets a right hemicolectomy adenocarcinoma tumors of the appendix get a right hemicolectomy and adenocarcinoma of the terminal ileum gets a right hemicolectomy a Mucocele is a dilated appendix filled with mucin .these are not all malignant but should be treated as possibly malignant until they have removed the general term now is appendiceal mucinous neoplasm or AMN and they range from low grade to high grade the following decision tree is generally recommended if a Mucocele is found on imaging strongly consider a colonoscopy to look at the cecum and the base of the appendix for tumor if there is no obvious tumor and colonoscopy prepare for an appendectomy but consent the patient for a possible right hemicolectomy appendectomy can be done laparoscopically but you must be careful not to rupture the appendix if you can't remove adhesions without risk of rupture then do the appendectomy open.

 if the appendix is ruptured even low-grade  appendiceal mucinous neoplasms can cause   diffuse mucin throughout the abdomen this is known  as pseudomyxoma peritonei or pmp if possible take   a little cecum with the appendix especially if the  base of the appendix is also dilated with mucin   once you remove the appendix if you can  you should send it for frozen section   if it is benign or a low grade appendiceal  mucinous neoplasm which has not penetrated   the muscularis propria and if the margins  are negative and if the appendix is not   dilated to more than two centimeters then  you can stop after appendectomy alone but any higher grade appendiceal mucinous neoplasm  or mucinous adenocarcinoma or if the appendix   is dilated to more than two centimeters  then you should do a right hemicolectomy   if somebody gets pseudomyxoma peritonei then  the patient should be referred for debulking   and heated intraperitoneal chemotherapy or HIPEC  Typhlitis is inflammation of the cecum related   to neutropenia the classic presentation is a  neutropenic patient with right lower quadrant   pain and dilated inflamed cecum on the ct  scan you have to operate.

if they are septic or free air,  but most Typhlitis is treated with iv antibiotics and bowel rest patients with HIV   can also get CMV colitis of the right colon with Hemorrhagic ulcerated lesions of the mucosa. The pathognomonic finding is owl-eyed nuclear inclusions in colonocytes on endoscopic biopsy intussusception is common at the ileocecal valve, In children, it is commonly due to benign enlarged lymph nodes. So trying air contrast enema to reduce it and don't operate in adults, however there is usually a  lead point that is malignant or will lead to recurrent episodes, so take ileocecal intussusception in adults to the or for resection Ogilvie's syndrome is also known as colonic pseudo-obstruction classic presentation is an elderly patient with electrolyte abnormalities or recent back surgery or retroperitoneal inflammation of some sort it is thought to be caused by too much sympathetic tone.

  the cecum will be dilated typically about  8 to 10 centimeters and a patient will have   right lower quadrant pain and bloating  initial treatment is ng tube bowel rest   and correcting any underlying electrolyte  problems and minimizing narcotics i would   try and do a gentle gastrographin enema to rule  out distal obstruction if no distal obstruction   and conservative measures are not working try  two milligrams of iv neostigmine which increases   parasympathetics and should make the colon  contract and the patient have a big bowel movement it can cause bradycardia though so have  atropine half a milligram up to a milligram   iv ready to counteract this atropine will  block the parasympathetic action on the heart   don't use neostigmine if a patient has  heart block neostigmine can be repeated    but probably only try it twice before  moving on colonoscopic decompression is   an option if neostigmine doesn't work although  minimal insufflation is used failure of these   dilation over 12 centimeters peritoneal  signs or free air would be indications   to operate for right colon resection and likely  an ileostomy and a mucous fistula at that point Cecal volvulus occurs in younger patients  than sigmoid volvulus and is due to abnormal   attachments of the right colon Cecal volvulus  is not treated with decompressive endoscopy .

 it requires surgery the most safe  surgery is a right hemicholectomy   simple cecopexy is associated  with high recurrence risk   cecal bascule is when the cecum folds up and over  on itself probably resection is the best to treat   this since it is common in younger women  and you want to decrease future recurrence   right side colon diverticula is unusual but  it is more commonly found in asian populations   sometimes actual diverticulitis of the cecum and  or right colon can occur this usually responds to   conservative measures but once resolving you  definitely need to do a colonoscopy to rule   out cancer occasionally an AVM also known  as angiodysplasia of the right colon can   be a source of gi bleed a tagged rbc scan can  pick up bleeding of 0.5 cc's per minute or more   an angiogram needs bleeding  of 1 cc per minute or more   if bleeding scans show blush in the right colon  try an angiogram and embolization colonoscopy   with injection or cautery may also work if  neither of these work and the bleeding continues   then do a right hemicolectomy or a subtotal  colectomy if the source is unclear that's it for   appendix and cecum there will be a separate talk  on the rest of the colon. If you like this information, kindly shares it with other peoples.

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