this is absite review for appendix and cecum as always let's start with anatomy the appendix
is 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
pain usually 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 a clue to infectious colitis
which can sometimes also present with right lower quadrant pain such as in yersenia 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 rovsings sign which is 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 actually 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 a 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 wash out
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 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 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 supra umbilical 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 ilium crohn's disease also check for meckels 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 that 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 is 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
adenocarcinoid tumors of the appendix get a right hemicolectomy
and adenocarcinoma of the terminal ilium 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 are removed the general term now is appendicile 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 typhilitis 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-eye nuclear inclusions in colonocytes on endoscopic biopsy
intussusception is common at the ileocecal valve in children it is commonly due to
benign and large 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
oglivie'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 gastrographing 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 cccopexy 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 hope that helped thanks