PRACTICE TEACHING
ON
APPENDICITIS
Presented by:
Bamesha Dona Shira
Roll No. 04
Post Basic BSc 2nd Year
INTRODUCTION
DEFINITION
Appendicitis is an
inflammation of appendix,
a narrow blind tube that
exdends from the inferior
part of cecum.
INCIDENCE
• Commonly occur between 10-20 years old and predominantly male (M:F,
4:1).
• Mortality rate:
- 20 fold decline from that reported 50 years ago.
- In general population 4/1000000.
- For infant increase to 9%.
- For patient above 65 years old is 15%.
- For ruptured appendicitis 4-5%.
- For unruptured appendicitis -0.1%.
• For women, RIF pain with normal gynae exam and normal leukocyte
count, the 90-99% of cases usually reveal acute appendicitis.
ANATOMY AND PHYSIOLOGY
PARTS OF APPENDIX
1. Base – It is attached to posteromedial wall of caecum about 2m
below the ileocaecal junction. - All taenia of caecum converge to
the base and serve as a guide for identification of the appendix.
2. Body – Body is narrow, tubular and contain a canal which opens
into the caecum. - The caecal opening is guarded by an
incomplete mucous fold called as “the valve of Gerlach”.
3. Tip – It is the least vascular and directed in various direction.
TYPES/POSITIONS OF APPENDIX
• Blood Supply
- appendicular artery
- end artery
- posterior caecal artery
• Nerve Supply
- parasympathetic: VAGUS
- sympathetic: T10 segment
of spinal cord
• Lymphatic Drainage
- lymphatic drain into
superior mesenteric lymph nodes
via ilea- colic nodes
ETIOLOGY
1. The exact cause is unknown.
2. Possible causes include:
- obstruction of the lumen by a
fecalith (accumulated feces)
- appendiceal tumors such as
carcinoid tumors
- intestinal parasite
- hypertrophied lymphatic tissue
- kinking of the appendix
RISK FACTOR
• Age: Appendicitis most often affect people between the ages of 15
and 30 years old.
• Sex: Appendicitis is more common in males than females.
• Family history: People who have a family history of appendicitis
are at heightened risk of developing it.
• Low fiber diet might also raise the risk of appendicitis.
TYPES
• Acute Appendicitis:
Develop very fast, usually in a span of several days or hours i.e. within
24 to 48 hours. It is easier to detect and requires prompt medical
treatment, usually surgery.
Acute appendicitis occurs when the vermiform appendix to completely
obstructed, either because of a bacterial infection fees or types of
blockage. Infection may also cause swelling of the lymph nodes, which
then adds pressure on the appendix cutting off its blood supply.
• Chronic Appendicitis:
It is an inflammation that can last for a long time.
Usually occurs as a less severe, nearly continuous
abdominal pain lasting longer than 48 hours period,
sometimes extending to weeks, months or even years.
• Stump Appendicitis:
It is defined as the interval repeated inflammation of
remaining residual appendiceal tissue after an appendectomy.
Partially removing an appendix leaves a stump behind which
allows for recurrent appendicitis. It is a rare post surgical
complication, with a reported incidence of 1 in 50,000 cases. The
incidence of stump perforation is approximately 60% to
70%.
PATHOPHYSIOLGY
Due to etiological factor (for e.g. obstruction of the appendix lumen by fecalith)
Decrease flow or drainage of mucosal secretion
Increase intraluminal pressure in the appendix
Vasocongestion
Decrease blood supply in the appendix
Decrease supply of oxygen and nutrition in the appendix
Necrosis and perforation of the appendix
Bacteria invade in appendix
Disruption of cell membrane of the appendix
Inflammation of appendix
Appendicitis
CLINICAL MANIFESTATIONS
The following signs may be present in
a minority of patients :
1. Rovsing sign: Apply hand pressure
to the lower left side of the
abdomen, pain felt on the lower
right side of the abdomen upon the
release of pressure on the left side.
(Suggest peritoneal irritation)
2. Obturator sign:
i. Patient lies supine with right thigh
flexed 90 degrees.
ii. Examiner immobilizes right ankle
with right hand.
iii. Left hand rotates right hip by;
- pull right knee laterally
(hip external rotation)
- pull right knee medially
(hip internal rotation)
3. Psoas sign: Lower right quadrant pain with extension of the right hip or
with flexion of the right hip against resistance. (Suggest that an inflamed
appendix is located along the course of the right psoas muscle)
4. Dunphy sign: Sharp pain in the right lower quadrant elicited by
a voluntary cough. (Suggest localized peritonitis)
DIAGNOSTIC EVALUATION
• History and physical examination
• Blood test:
- complete blood count to check for the sign of infection
- C-reactive proteins
- electrolyte (fluid electrolyte imbalance)
• Urinary analysis
• Imaging test:
- abdominal X-ray
- ultrasonography
- CT scan
• ALVARADO scoring system
MANAGEMENT
Medical Management:
• Antibiotic:- Broad spectrum antibiotic e.g. Metronidazole 500mg TDS,
cefotaxime 500mg BD, levofloxacin 500mg BD.
• Analgesic:- Inj morphine sulfate, fortwin.
• Antiemetic:- Inj Ondansetron.
• IV fluids.
• Soft diet until infection subsides (soft diet low in fiber easily digestible in
G.I tract).
Surgical Management:
• Appendectomy :-
Two ways - 1) Laparotomy
2) Laparoscopic Surgery
1) Laparotomy :- removes the appendix through a single incision in
the lower right area of the abdomen.
2) Laparoscopic Appendectomy :- it is the surgical removal of the vermiform appendix
using a laparoscope (a tiny peritoneoscope using camera at the tip of visualize internal
organs in the abdomen cavity) which is inserted through a small incision in the abdomen
and the image is displayed on TV screen.
COMPLICATION
• Perforation (in 95% of cases)
• Abscess
• Peritonitis
NURSING ASSESSMENT
• Obtain history for location and extent of pain.
• Auscultate for presence of bowel sounds; peristalsis may be
absent or diminished.
• On palpation of the abdomen, assess for tenderness anywhere in
the right lower quadrant, but usually localized over Mc Burney’s
point (point just below midpoint of line between umbilicus and
ileac crest on the right side). Assess for rebound when palpating
the left lower quadrant.
• Assess for positive psoas sign by having the patient
attempt to raise the right thigh against the pressure of our
hand placed over the right knee. Inflammation of the
psoas muscle in acute appendicitis will increase abdominal
pain with maneuver.
• Assess for positive obturator sign by flexing the patient’s
right hip and knee and rotating the leg internally.
Hypogastric pain with this maneuver indicates
inflammation of the obturator muscle.
NURSING DIAGNOSIS
• Acute pain related to inflamed appendix.
• Imbalanced nutrition less than body requirement related to
anorexia and vomiting.
• Disturbed sleeping pattern related to pain/discomfort.
• Knowledge deficit related to lifestyle change and follow up care.
• Risk for infection related to perforation.
HEALTH EDUCATION
incision care
Diet
Activity
To call healthcare provider
PROGNOSIS
CONCLUSION
THANK YOU
