27) The Vermiform Appendix скачать в хорошем качестве

27) The Vermiform Appendix

The vermiform Appendix - The appendix is a continuation of the caecum from its inferior tip and the appendix is shaped like an inverted pyramid. -the base of the appendix can be marked on the surface as the ‘Mc burney’s point’, which is situated at the junction of the later 1/3rd & medical 2/3rds of the line joining the ant. Sup. iliac spine & the umbilicus. -Mcburney’s point is the classical site of tenderness in appendicitis -The vermiform appendix is present only in human beings and certain anthropoid apes. -presence of lymphoid tissue in wall of the appendix is characteristic of human vermiform appendix. Structure - from outsides to inwards the structure of appendix is - i) A serous coat ii) Muscle coat iii ) Sub mucosa -The submucous coat of the appendix is very rich in lymphoid tissue. -it contains lymphoid follicles which are known as,’ abdominal tonsil’. iv) Mucous coat – Blood supply - Appendicular artery – branch of lower division of ilecolic artery. Various anatomical positions- i) Retrocaecal position ( commonest position 70%) – lies behind the caecum. ii) Pelvic position – (IInd most common position 25% )- tip lies near beam of pelvis. iii) Subcaecal (2%) iv) Splenic (1%) – tip towards the spleen v) Para caecal –(1%) vi) Paracolic -(1%) side of ascending colon on rt. side Functions of appendix - Appendix is not a vestigeal –organ and it does play a useful role in the defence mechanism of the body. i)The lymphoid follicles present in the appendix act for maturation of B lymphocytes. ii)The appendix participates in the secretary immune mechanism in the gut & forms globulin for immune mechanism. Appendicitis - 4 types - i)Acute ii)Sub acute iii)Recurrent iv)Chronic Acute appendicitis - most common acute surgical condition. Acute appendicitis may occur at all ages. Aetiology of pathogenesis— 1) Obstruction of the lumen – a) In the lumen- Faecolith & hyperplasia of submucosal lymphoid follicle, intestinal worms. b) In the wall -Stricture (due to fibrosis ) from earlier inflammation c) Out side the wall – adhesions & kinks are common . 2) Diet - Play an important role in producing appendicitis- diet with fish and meat. 3)Social status- diseases of aristocratic families. 4)Familial susceptibility – In certain families this disease is more often seen due to the peculiar position of the organ, which predisposes to infection. Clinical features- i)Pain – presents in all patients with appendicitis. ii)Nausia- Present in 9/10 patients, vomitting is variable. Murphy’s triad – Pain,Vomitting & Temp. iii)Anorexia. Physical examination – Palpation- (i) Systemic gentel palplation will detect an area of maximum tenderness that corresponds to the position of the appendix at or near Mcburney’s point. ii)Muscle guarding or resistance to palpation roughly to the severity of the imflammatory process. iii)Cutaneuous hyperaesthesia – found over Sherren’s tringle (formed by ant. Sup. iliac spine, the symphysis pubis & the umbilicus) iv)Rebound tenderness - the classic method of demonstrating peritoneal imflammation is rebound tenderness. v)Rovsing sign vi)Psoas sign v ii)Obturator test vii)Percussion viii)Auscultation x)Rectal examination – Purpose –(i) to exclude any pelvic lesion (in females), ii) to elicite tenderness (in pelvic appendicitis) Alvarado – score- (Clinical & laboratory based scoring system ) Score more than 7 (Acute Appendicitis, immediate operation required ) = 5 -6 ( borderline cases, where further investigation is required) Investigations – 1)Blood – Reveal moderate leuococytosis- ranging – 10,000-18,000/cumm. –Sr.electrolytes & RFT. 2)Urine exam- Increased Sp. gravity due to dehydration, 3)X- ray exam - no pathognomonic sign of appedndicitis in x-ray exam. 4)Barium enema exam. 5)Chest x-ray 6)USG 7)CT Scan- Complications- 1) Appendicular rupture, 2)Apppendicular mass (Phlegmon), 3)Appendicular abscess (omentum & coils of small intestine covers the imflammed appendix. ) 4)Suppurative Pylephlebitis RX - Immediate appendicectomy is Rx of choice. Operation incision – 1)McBurney’s Grid-Iron incision 2)Lanz’s transverse incision 3)Paramedian incision 4) Rutherford Morrison’s incision 5)Battl’s pararectal incision – Technique of opration - 1)Isolation of the appendix, 2) Division of the meso-appendix, 3)Removal of the appendix (purse string or figure of ‘N’) . Treatment of Appendiculer mass (Phelegmon)- -Conservative treatment (Ochsner-sherren regimen ) should be started immediately includes – i) I/V fluids, ii) RT aspi., iii)NBM, iv)Antibiotics, v ) I/O ,U/O charting. Complications of appendicectomy – 1)Wound infection, 2)Pelvic subphrenic or intra abdominal abscess. 3)Faccal fistula – if ligature slips from a tied,These fistulas usually close spontaneously. 4)Pylephelebitis or portal pyemia. 5)Intestinal obstruction, 6) Rt. inguinal hernia (due to injury to ilio- hypogastric nerve.)