Appendicitis | Clinical Medicine

what's up Ninja nerds in this video today we're going to be talking about appendicitis is a part of our clinical medicine section and if you guys like this video it helps you please support us some of the ways that you guys can do that is by hitting that like button commenting down the comment section please subscribe something I really urge you guys to do because I really think it would be beneficial for you is to go down in the description box below it get there's a link there it takes you to our website on our website we have amazing notes it'll ations we have quiz questions that we're developing as well as exam prep courses that are in process and you guys can keep an eye out there so please go check that out a lot more to offer there on that website all right let's talk a little bit about appendicitis we're going to first discuss the pathophysiology of appendicitis so that includes going over a little bit about the mechanisms behind how it develops talking about the causes and talking about primarily some of the classic clinical findings that we see in patients with appendicitis or acute appendicitis so this is one of those like medical emergencies you have to be able to pick it up when a patient comes in with acute appendicitis the appendicitis is inflammation and usually infection of the appendix it's this little thing this little kind of like organ or piece of tissue that hangs off of the seeum so you know how you have your large intestine this would be a part of the ascending colon that we're taking a section out of right this is the ascending colon this would be like the ilium which is the distal part of the small intestin this would be the seeum and then hanging off here off the seeum is the appendix now in true anatomical Concepts which we've talked about before there's different ways that the appendix can lay we're not going to focus on that what I want to focus on is how does the appendix become inflamed what's the path of physiology what's the causes and what's some particular epidemiological cues that can cue you off on the exam so first one is a falth it's literally what it sounds like it's a poop Stone so this is usually something where you have like hard like feal material and what happens is it kind of gets stuck right here within the Lumen which is connecting between the seeum and the appendix now when that stone gets stuck there what happens is a bunch of pressure builds up just proximal to that actual feal stone so here we'll represent that by putting like an up Arrow here we'll say here what's happening inside of this appendix you're having an increase in the pressure and we'll talk about all the downstream effects of having that increased pressure with inside of the appendix but not only is there an increase in pressure sometimes what happens is you have bacteria that naturally sit they're part of our floor there is going to be bacteria that sit in parts of your actual mucosa if it can't get moved out what happens to the amount of bacteria inside of the Lumin of the appendix it goes up so another thing that you'll have is not only just an increase in pressure but you'll have an Inc increase in like what's called bacterial colonization but for right now we'll say that there's lots of bacteria the combination of these two which we'll go over in detail is what really leads to the fact of appendicitis the inflamed appendix now with a fecalith what patient population you're reading the clinical vignette patient comes in we'll talk about the classic findings they're this age what is a falth age usually supposing of it's usually more particularly seen in those that are of the infants or the young adult age so I would think about this more and we're just going to use the terminology of children you're going to see this more in that younger population as the primary cause but it's an obstruction so the key thing here is it is an obstruction where within the appendiceal Lumen that's blocking flow of particular contents out of the appendix creating a increase in back pressure and an increase in bacterial colonization you're going to notice the same thing out of each one one of these except in this one a patient has what's called lymph node hyperplasia so in other words you are going to have a bunch of lymph nodes in the actual surrounding vicinity but let's say that you have some lymph nodes that are just a little bit thicker a little bit bigger and these things are pressing on the outside of the appendix near the actual Lumen so because of that what's going to happen it's going to be hard to move contents out it'll create a increase in back pressure and then again bacteria colonization so you get the same concept I want this to become ingrained into your brain that you'll have an increase in bacteria and an increase in the back pressure and these two combinations will then lend to what we call appendicitis now what is the particular age Ranger epidemiological cues that will usually make you think about this one this is usually going to be more in the adults so if you have an adult who comes in with that right lower quadrant pane appendicitis signs then you want to definitely be thinking could it be lymph node hyperplasia either way it's causing some type of obstruction if you will of the appendiceal Lumen leading to this high back pressure and bacterial colonization all right last one straightforward neoplasm now in this you have some type of tumor it could be extraluminal so you could have a tumor sitting out here or a mass compressing on the outside or you could have some type of mass that's intraluminal and it's again obstructing the actual what contents from being able to move be moved out of the appendic alumen so here's our obstruction and what we know is is if you have this particular obstruction here you can't move things forward out of this appendic alumin increases what happens it's becoming a little bit of a trend here I believe you're going to have a increase in your pressure the back pressure and an increase in what else the bacterial colonization okay okay now who would you see this in neoplasia it's going to be usually those of older age particularly greater than 50 years of age so what I really want you to be looking for here is going to be that greater than 50y old patient okay now with that being said patient comes in they have appendicitis they have an obstruction of the appendic Lumin back pressure increases bacteria colonize leads to appendicitis how exactly let me quickly go over that so this appendix here is super inflamed now the reason why is we already talked a little bit about this let's just say here is going to be our obstruction Point here's the obstruction the back pressure is going to be one of the big problems here right so we said okay here's our obstruction it'll cause an increase in the back pressure that's one particular thing the other thing is that you're going to cause a increase we talked about this one as well and it's a pretty recurring theme that we mentioned multiple times you're going to increase bacterial colonization so now from this you're going to have all kinds of stuff in here you may have a lot of fluid and you may have a lot of bacteria so here's going to be a lot of bacteria you potentially are going to have some fluid kind of sitting in here as well because there's naturally going to be some fluid within the actual G Lumen and so now all of this stuff is going to sit here all right because of this obstruction now if the back pressure is really really high what's going to happen you can't move this fluid and bacteria and other contents out it's going to start distending and so what you're going to have from this increased back pressure is you're going to have an increase in distension and whenever you have this stretched out or stretched out appendix or distended appendix that's going to going to be one potential manifestation when this sucker is really really big and on top of that it's inflamed and infected it starts actually causing a lot of pain in particular areas that we'll talk about the other thing is as the bacteria colonize if you have more and more of this bacteria what happens is they can actually start causing damage to the actual appendix tissue now what will happen is the appendix will start getting super inflamed because of the bacteria which will actually start to precipitate infection so you'll have infection and inflammation of the appendix and now this puppy is so hot angry and large so now again what happens here you get increase inflammation and infection and then as a result if you inflame inflame infect the appendix and stretch it out the combination of these two is what you see in a patient who presents with appendicitis okay now when a patient has appendicitis they have an inflamed appendix what is going to be their presentation well generally what happens is whenever their appendix is super inflamed it's going to be in that right lower quadrant and so what they'll have is they'll have what's called a migrating abdominal pain and so it'll potentially start here in the per umbilical region and then it'll move down to What's called the right lower quadrant so that's one very common manifestation the other thing is is if you press in the right lower quadrant we call this MC Bernie's point or that right lower quadrant tenderness whenever you press on that area it's going to relit a lot of pain why because it's inflamed it's big and it's infected the other concept is when you do specific signs appendicitis signs it'll really help you to think about patient who has appendicitis so if they come in right lower quadrant pain tenderness in that area or the migrating per umbilical to right lower quadrant MC Bernie's point tenderness and you do special tests so you have them lay on their back and we'll show you guys this what you do is you have them lay on their back kind of keep their legs straight and what you're going to have them do is try to flex at the hip while you're trying to give her some resistance what that does is that really kind of causes a lot of pain if they have like a retro secal appendix but that could be one sign all right that's called the soas sign another one is if you have them again they can have their knee flexed and then what you do is is you try to internally rotate around that hip and what it can do is it can kind of Smash down on that big inflamed angry appendix and precipitate pain that's called an opat sign there's also other ones that can be very very suggestive so it's called the rosing sign and it's very interesting it's kind of like whenever you press down in the left lower quadrant like the pendix ain't there but if you press there and it precipitates this kind of referred pain to to the right lower quadrant that could be also very suggestive of appendicitis so again look for right lower quadrant pain usually migrating from a per umbilical MC Bernie's point tenderness soaz sign operator sign rosing sign these are all very suggestive of pentis which could be secondary to a falth lymph node hyperplasia or neoplasia causing obstruction of the appendic alumin increased back pressure distend bacterial colonization infection inflammation and therefore we have this problem let's now talk about the complications all right my friends so now we're going to talk about the complications of appendicitis patient comes in right lower quadrant pain maybe they started off with some par umbilical pain that migrated there they got MC Bernie's point tenderness they got some of those appendicitis signs so you're thinking H I got a pentis I know the potential causes are they young could be a fecalith are they adult age could be lympo hyperplasia are they greater than 50 you're thinking about neoplasia but I think some of the other things that you have to be watching out for when a patient comes in in with suspected appendicitis is the downfall the complications if that sucker bursts and so what happens is the first thing that you want to watch out for is a perforation of the appendix it's pretty straightforward how this is all happening we already know that there's a lot of back pressure we already know that there's bacterial colonization that causes what distension of the appendix via the back pressure infection inflammation via the bacterial colonization accumulating there and you got an inflamed and angry appendix what's really interesting is though as this kind of accumulates more and more pustulent type of material it'll start to really stretch and the intraluminal pressure will rise and it'll start compressing and kind of transmitting this Force onto the wall of the appendix now as you start to increase the actual intraluminal pressure what this will do is this will start to squeeze a couple different things so let's write this down so first thing is you're going to increase the intra luminal pressure we already know why we have an obstruction of some sort it's the overall concept that we've built already in the pathophysiology portion as that pressure Rises you start causing Venus compression you start causing lymphatic compression that causes swelling of the appendix so you're going to get more edema more swelling but here's the scary thing you see these arteries you see how they're supposed to be supplying like parts of the appendix what if the pressure is so high you start compressing the arteries pinching them off and now these arteries are supposed to be supplying oxygen rich blood to this tissue they're being compressed what starts arising let's say in this portion here oxygen rid blood is not actually being supplied so what will start to occur here is you'll start to experience something called es schema so now this area which I'm going to represent in black is now all es schic so that's one potential complication that can arise as as the increased intraluminal pressure occurs you're going to increase esea to the actual appendix wall so you're going to cause es schia of appendix now this is because of why we said this is going to be because of a couple different things one is the pressure Rises and it compresses veins so you're going to get a couple different things that occur you're going to get vein compression you're going to get lymphatic compression and all of this is going to increase kind of that edema factor which is going to make it more swollen increase the intraluminal pressure even more but the scariest one that's going to cause this esea is going to be the artery compression as you start to compress that artery you're going to reduce the blood supply and that's what going to cause this esema of the appendix now here's the problem whenever you have a scheme of the appendix that wall now that tissue right there is super weak and it's very susceptible so now let's say for example if we have this area being super susceptible so it's super esmic we're going to draw it right here now this area is all esic so this was an area of esea right here but now it's so weak that what happens is the Walls Start to erode and as it erods you increase a tract that'll then form between what between the intraluminal like this luminal side and the parium and now all of this stuff this pushed material all this like bacteria cells fluid all of this will leak out air which is a part of our git will leak out and that's how a perforation arises so then you develop a wall perforation from that persistent esema and then you're going to see the downfall of this what is that downfall let's come down no pun in it but whenever this actually occurs we have rupture right we have this perforation of the appendix wall so here's a couple different anatomical features this is going to be the anterior side this is the posterior side this is the superior this is the inferior we're looking at the th thorax here and the abdomen here separated by this red line which is the diaphragm all of this in pink here is your perenium your parium is double layered the parietal perum which covers the wall of the abdominal cavity and then the visceral perum which covers the organ that's in that peronal cavity this is going to perforate and all that material that we talked about is going to enter into this perenium all this material this could be things like air I'm just going to use write a couple things here one is it could be air that could definitely accumulate out here there could be some degree of fluid that accumulates out here or there could be bacteria that accumulate out here but you're going to have all of these things kind of flinging out into these particular areas whenever a patient has this perforation often times the complications we'll talk about will be progressively as we go to the right of the board but one of the biggest things is whenever you perforate it produces a couple different features that I think are important to remember one is intense abdominal pain so usually they have you know that that specific right quadrant that migrates from the emperia umbilical area that's super suggestive but if the abdominal pain drastically increases that could be indicative of a perforation much more so than their usual kind of pain that they've been having the other thing is as if they're guarding or they're have exhibiting what's called rigidity so let me explain what that means so guarding is you come to the bed you're getting ready to palpate they're like no no no don't touch me because their abdomen is so sore and so sensitive that if you touch it they'll scream or if you go and touch the abdomen because of all this kind of perforation their abdomen could be super rigid and hard and that could be also indicative the other thing I would really also watch out for is especially air when air leaks into the actual peritoneum we call it a num numo parium and this can be identified sometimes um especially off of Imaging and so this is not NE necessarily a clinical finding it's more of a Imaging finding that could be potentially found so watch out for potential penum watch out for an increase in abdominal pain guarding rigidity another one could be even like rebound tenderness as well where you try to push down so they could have something called rebound tenderness and this is basically when you try to like press down in the abdomen and then you release really quickly whenever you're kind of releasing the pain is intense and so that that's kind of an interesting finding and that's usually suggestive of perforation or related peritonitis okay so that's perforation if a patient comes in they have that original pain that we talked about that's classic of appendicitis and then the the pain gets worse they have rigidity guarding rebound tenderness definitely think about a perforation especially if you get an x-ray or an Imaging and you see air that sits right underneath the diaphragm that's called a num numo parium okay cool the next one often times a perforation will progress to an abscess so if a patient develops a perforation this can then stimulate what process well here's they they've perfed okay because of the esea from int the intraluminal pressure Rising compressing the vessels causing esea boom wall perer what can happen is Lally what it sounds like you see how these green things these are the bacteria they kind of try to go out and Escape outside here but they're smart and what they do is is they cre they wall off this area here so they escape out here and whenever these bacteria come and Escape out into this parital area and then they kind of wall themselves off so here's going to be a kind of a mixture of pus which is going to be cellular debris and white blood cells and bacteria and all that kind of stuff it's going to sit out here outside of the Lumen that's an abscess so again it's a perforation that leads to bacterial organization outside of the Lumen outside the Lumen and this is the scary thing that you can see here so this is going to be indicative of an abscess all right now these are really really nasty what are some of of the potential findings that you'll see with these patient populations when a patient has an abscess again they could come in with that right lower quadrant pain they could still have that sometimes this is really difficult to identify so they could still have let's say here bacteria kind of comes out here into this peronal area and then decides the wall itself off here so what happens here is they may have like if you go on the right lower quadrant and you try to palpate if the abscess is big enough you may be able to palpate a mass and so one thing is you may have this right lower quadrant mass that is extremely tender okay so when you kind of palpate on that area you may feel somewhat of a bumpy area there but again it's usually going to be super super tender to palpation the other thing here is that this is bacteria man and bacteria naturally will precipitate cines so let's say here in this blue is going to be these cyto kindes and these get out into your systemic circulation we'll put here's your bloodstream right and what happens is when these cyto kindes that are released get kind of put into the bloodstream they activate your immune system and whenever they activate your immune system what will happen is why blood cells will start increasing in number to try to come to the area and fight off that particular infection so you'll have white blood cells that'll enter into your bloodstream and that's going to be one thing so you may have an increase in your white blood cell count because they're going to try to come to this area and fight off this infection but the other thing is these cyto kindes not only do they stimulate this process they get out into the bloodstream and we all know that cyto kindes are really good at stimulating your hypothalamus to increase your body temperature and they may precipitate fever and so one of the things that you want to watch out for is a increase in fever with a right lower quadrant mass and an increase in the number of white blood cells in a patient who has appendicitis and the only way that you'll be able to identify this is usually getting Imaging to find that particular abscess it's really difficult to identify sometimes just on physical examination but look for these particular things the last scenario here is a patient Who develops peritonitis it's the same exact concept they have to perf to develop this so if they develop a perforation bacteria can organize outside the Lumen if they perforate as well so let's say here we have a perfor ation same concept exists here perforation that occurs here what's the problem with this well again we already talked about how things can leak out fluid bacteria air all that kinds of stuff same thing but here's the problem we didn't talk about anything over here about that bacteria or other types of molecules or fluid how it agitated the parium we just said it went out into the parium if this stuff gets out into the the perenium and then starts causing inflammation of this pink layer now we have peritonitis perforation and peritonitis are very very similar so remember perforation can lead to a leakage so you'll have leakage of intraluminal contents but particularly bacteria spill into perenium so you see how we kind of have like a comparison here this is really kind of interesting bacteria can organize outside the Lumen and not spill directly all over the parium here they can diffusely spread throughout the perum this will cause a walled off area like an abscess this will cause defuse inflammation and infection of the parum let's come down and talk about what that would look like though so if this bacteria which is here doesn't wall off instead it spreads out here into the actual abdomen and then as it does that it causes inflammation of the wall of the parium this is going to be a very common thing you're going to get all the stuff that you would have so it's basically all the perforation findings all right so all the perforation findings that we discussed would be present here that's no different you're going to have air fluid bacteria that'll leak out there so you're still going to get what kind of things here intense abdominal pain you're going to have rigidity you're going to have guarding you can have rebound tenderness one of the things I think that's a little bit more suggestive though of peritonitis is that it's inflammation of that perenium and as you inflame the parium any inflammation generally what that'll start to do is is it'll cause cyto kindes to be released these cyto kindes will then do what pump up your immune system kind of try to drag in tons of neutrophils it'll also go to your central nervous system particularly the hypothalamus and say hey lots of inflammation going on maybe you should kind of jack up the body's thermostat and increase the actual body temperature so things that you may start to notice from these cyto kindes is an increase in the white blood cell count and increase in the patient's body temperature like a fever but the other thing that's going to be really really helpful so here's your cyto kindes all these cyto are really precipitating this and this right so it's stimulating white blood cells to come to the area to fight off the infection stimulating an increase in body temperature to make it difficult for bacteria to survive all of this is from the cyto kindes from the inflammation of the peritoneum the last thing that I think is also important here and this is where it gets really scary bacteria in the peritoneum there's a lot of blood vessels that are in that parium area if the bacteria have an opportunity to spread into the bloodstream now you have bacteremia and that bacteremia could potentially lead to a systemic infection and so that's where you really want to be careful of because if this bacteria gets into the bloodstream it can precipitate a patient de developing sepsis so the last thing that you want to watch out for here is potential increased risk of sepsis if the bacteria do leak into the bloodstream so often times a patient who has peritonitis has findings of perforation plus maybe a fever a lucyisanerd and then cyto kind mediated types of presentations as well such as fever lucyisanerd pan right and they had appendicitis signs all of a sudden they're diffus abdominal pain rigidity guarding and they also have rebound tenderness if that's the case now I'm scared that they went from appendicitis to a perforated appendix first thing I should do is get an abdominal x-ray the reason why is I want to see do they have any evidence of pneum parium the other thing is it could happen they could develop peritonitis they may have peritonitis actively what did I tell you what happened maybe they could have a fever maybe they could have a lucyisanerd dominal x-ray and on top of that I find hemodynamic instability now I'm worried that they've progressed already to parir ini itis and maybe sepsis I'm not even going to wait to do other Imaging I'm going to take this patient straight to the O and they need an emergency laparotomy and will provide an intraoperative diagnosis at that point in time now if they have no perforation features no numo parum and they're hemodynamically stable oh then I have time and I can start working this patient up so what I'll do is I'll get one of two studies I'll get an ultrasound right of the abdomen or I'll get a CT of the abdomen and pelvis and so what I'll do is I'll get the ultrasound really in patients who are pregnant the reason why is I want to reduce any risk of radiation especially with CT scans and a child again I want to reduce the risk of radiation all right especially from the CT scan and so I'd get an abdominal ultrasound and these are actually pretty good they can definitely identify areas of a lot of appendix thickening a lot of inflammation of the appendix distension and so this is a really good test at being able to identify appendicitis especially in that particular population if the patient is not pregnant they are not a child okay well then I don't have the need to really push an abdominal ultrasound I could get an abdominal CT scan but the other thing is if I got an ultrasound initially and it wasn't really conclusive I can definitely get at a CT scan and these are pretty good because they're definitely going to be able to identify areas of a very distended and thickened appendix wall right I'll also be able to identify if there's any complications like a flegman or an abscess look you can see here where it per perforated so you'll be able to identify both a pentis and identify the complications associated with pendis and that's why I think the CT scan is just a little bit better because it will show definitely oh they have a pentis but it could show oh they have like an abscess or it shows a perforation so it can show findings of complications which is very helpful all right that's how we would diagnose appendicitis the question comes okay I have a patient with appendicitis all right they didn't perforate all right so I see no evidence of perfor ation on their exam so no distended AB like no diffuse abdominal pain no guarding rigidity no rebound tenderness no numo perenium and their CT scan doesn't really show perforation same thing I don't see a very high white count a fever a palpable mask and I see no abscess on their uh CT scan in that case it's a straightforward uncomplicated appendicitis you can just go ahead and just get them to an appendectomy it doesn't have to be a mergent but you should try to get them a laparoscopic appendectomy as soon as you possibly can the other thing is that you want to start treating their infection you want to clear out the infection that they may have and so often times these patients may be started on something like seph triaxone to cover some of the gram negatives and then often times they may also be put on like metronidazol to cover a little bit more of the um Anor robic bacteria that may be a part of our GI Flora so this would be started pre-operatively and probably even continued postoperatively and then you're going to remove the source of the infection which is by the appendectomy now if it's complicated that means that they perfed or they have an abscess if they perforated I don't have a lot of time to be wasting on these patients and saying oh we'll get an appendectomy later today or tomorrow no no no no no they need to get to the O immediately so you get them on antibiotics seph triaxone metronidazol and get them to the O as soon as possible and do an emergent appendectomy often times this is usually laparoscopic but in certain scenarios maybe they have to do it open and then what you do is again continue the antibiotics pre and postoperatively and then you'll cut out the infected tissue where it may change a little bit in the complicated patient is if they have an abscess abscesses can cause a lot of problems they can inflame a lot of the tissue nearby not just the appendix but some of the other eye nearby tissue and it can Muck up the area of the surgical field so you should start antibiotics and then since the appendix is relatively close to the abdominal wall if the abscess is present and it's visual sometimes you can do ultrasound or ctg guided percutaneous drainage and you can suck some of the actual infected material out so that's your relative degree of source control so start them on seph triaxone metronidazol often times a percutaneous drainage of the abscess and then just a couple weeks later to allow the inflammation of the appendix to start to subside a little bit a lot of the areas of inflammation around that vicinity of the appendix to settle down then you can go in and do an interval appendectomy it makes the appendectomy much smoother and it prevents the the risk of recurrence of appendicitis and that's the only big difference here all right my friends that's appendicitis I really hope that you guys enjoyed it it made sense and as always until next [Music] [Music] time [Music]