APENDICULAR PLASTRON PDF
Pan Afr Med J. Jan 8; doi: /pamj eCollection [Appendicular plastron: emergency or deferred surgery: a series of. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s. mechanisms and form an inflammatory phlegmon Complicated appendicitis was used to describe a palpable appendiceal mass, phlegmon.
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At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The management of these patients is controversial.
Immediate appendectomy may be technically demanding. Plastton exploration often ends up in an ileocecal pkastron or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier.
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New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. This report aims at reviewing apendiculae treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.
The management of adult patients with inflammatory appendiceal masses plastroj controversial. This report aims at reviewing the treatment options of these patients, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence. The debate arises over the importance of the complication rate of interval appendicectomy.
Moreover, if appendicectomy is not performed, consideration needs to be given to what investigations should be undertaken and in which patients. It is also worth recalling that the appendix is used in reconstructive surgery.
Acute appendicitis is one of the most common causes of acute abdomen and can be classified into uncomplicated and complicated. The inflammation in acute appendicitis may sometimes be enclosed by the patients own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess.
Immediate appendectomy may be technically demanding because of the distorted anatomy and the difficulties to close the appendiceal stump because of the inflamed tissues. The exploration often ends in ileocecal resection or a right-sided hemicolectomy due to the technical problems or a suspicion of malignancy because of the distorted tissues[ 1 – 9 ]. Plasstron, the conditions for conservative management of these patients has changed due to the development of computed apendidular CT and ultrasound USwhich has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal pladtron easier[ 10 – 15 ].
New efficient antibiotics have also given new opportunities for nonsurgical treatment of appendicitis[ 16 – 21 ]. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small[ 22 – 27 ]. This report reviews the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, plaxtron risk of undetected serious disease, and the need for interval apenricular to prevent recurrence.
The apsndicular arises over the importance and level of the complication rate of interval appendicectomy. It is also worth recalling that the appendix is occasionally used in reconstructive surgery[ 2628 ]. Acute appendicitis is inflammation of the vermiform appendix and remains the most common cause of the acute abdomen in young adults.
Treatment options of inflammatory appendiceal masses in adults
The term complicated appendicitis is often used to describe a palpable appendiceal mass, an appendiceal phlegmon, or a localized abscess without distinction. A phlegmon is an inflammatory tumor consisting of the inflamed appendix, its adjacent viscera and the greater omentum, whereas an abscess is a pus-containing appendiceal mass[ 27 – 31 lpastron. The diagnosis of enclosed inflammation is made by finding a palpable mass at clinical examination before or after anesthesia, or by finding an inflammatory mass or a circumscribed abscess by CT, US or at surgical exploration of the abdomen.
We consider apendciular nonsurgical treatment has failed when the patient undergoes appendectomy during the same hospital stay after attempted nonsurgical treatment. The patients treated with drainage are those who had drainage without appendectomy of an abscess either percutaneously or by surgical exploration. Morbidity includes postoperative infectious complications, intestinal fistula, small bowel obstruction, and recurrence after initially successful nonsurgical management[ 27 ].
Although the etiology of acute appendicitis is poorly understood, it is probably caused by luminal obstruction in the majority of cases. Luminal obstruction can be caused by fecaliths, lymphoid hyperplasia, foreign bodies, parasites and both primary carcinoid, adenocarcinoma, Kaposi sarcoma and lymphoma and metastatic breast and colon tumors. Once appendiceal obstruction occurs, the continued secretion of mucus results in elevated intraluminal pressure and luminal distention.
This eventually exceeds capillary perfusion pressure, which leads to venous engorgement, arterial compression, and tissue ischemia. As the epithelial mucosal barrier becomes compromised, luminal bacteria multiply and invade the appendiceal wall, which causes transluminal inflammation.
The most common bacteria that can cause acute appendicitis are intestinal bacteria including Escherichia coli and bacteria belonging to the Bacteroides fragilis group. Continued ischemia results in appendiceal infarction and perforation[ 29 – 31 ]. However, the observation of spontaneous resolution of acute appendicitis cases and some reports of a good outcome in patients treated with antibiotics suggest that not all cases of acute appendicitis are caused by mechanical obstruction and progression to complicated disease.
Some researchers have suggested that uncomplicated and complicated forms of appendicitis are two distinct diseases, with different etiologies. As in other intra-abdominal infections, such as salpingitis, diverticulitis and enterocolitis, which are often treated only with antibiotics, the infectious etiology of acute appendicitis is advocated by some scholars. Conservative treatment is most effective when administered within 12 h of symptom onset, ideally within the first 6 h[ 16 – 2129 – 33 ].
At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical open or laparoscopy and it is the gold standard. The most common operative complications are wound infection, intra-abdominal abscess, and ileus caused by intra-abdominal adhesions Dindo et al[ 34 ] classificationwhich vary in frequency between open and laparoscopic appendectomy. The overall complication rates for open and laparoscopic appendectomy are respectively The exclusive treatment with antibiotics cannot be routinely recommended in current medical practice and should only be considered in selected patients apfndicular conditions in which surgery is contraindicated or in the context of clinical studies[ 1819 plasteon, 3132 ].
Circumscribed appendiceal inflammation is common and often undiagnosed preoperatively. The proportion of all patients with appendicitis treated for enclosed inflammation is 3. The risk of perforation is negligible within the first 12 h of untreated symptoms, but then increases to 8. It then decreases to 1. Patients with hyperbilirubinemia and clinical symptoms of appendicitis should be identified as having a higher probability of appendiceal perforation than those with normal bilirubin levels[ 4849 ].
Enclosed inflammation is found more often in studies in which the diagnosis is based on CT or US than in those based on clinical diagnosis It is also more common in children than in adults as shown by the trend of 8. There is an early risk of perforation even within the first 36 h of symptom onset, which may be higher in men than women. This suggests that diagnostic imaging should be used more frequently in children, in qpendicular with a long duration of symptoms, and in patients with a palpable mass.
There is continued debate about the relative merits of US and CT[ 10 – spendicular50 – 59 ]; the latest meta-analysis has concluded that Apendicylar 60 – plsstron ] is significantly more sensitive than US for the diagnosis of appendicitis, but that US should be considered in children.
The major area of debate is regarding which patients suspected of having acute appendicitis should have a CT scan before appendectomy.
There are several articles in the literature that argue against routine preoperative imaging of patients with suspected acute appendicitis. In these articles, the routine use of imaging has not been shown to decrease the rate of negative appendectomy, and may actually delay the diagnosis and appropriate intervention in cases of acute appendicitis.
A review of a large, prospectively gathered database of general surgical procedures in Washington state has found the negative appendectomy rate to be 9.
This difference was statistically significant. Based on these findings, CT scans seem to have significant benefit in the evaluation of patients with suspected acute appendicitis, to exclude other pathology, in selected patients such as elderly people[ 5270 ]. Various CT techniques have been described for diagnosing acute appendicitis, including enhanced CT with rectally administered colon contrast medium, enhanced focused CT with thin collimation mmnonfocused technique with oral and intravenous contrast material, focused technique with oral contrast medium, and focused helical CT with colonic contrast medium, and have a high diagnostic accuracy.
The obvious disadvantages of CT include exposure to ionizing radiation and the apendiicular for contrast medium reactions.
Those who benefit most from preoperative imaging are those with an atypical presentation and women of childbearing age. Plastdon, it is recognized that this is not without increased cost, radiation exposure and a potential delay in diagnosis. The use of US is particularly p,astron in children and can be of use in premenopausal women[ 50 – 5258 ].
CT has greater potential than US to reveal alternative diagnoses and complications, such as perforation and abscess formation. US has lower sensitivity than CT in the setting of appendiceal perforation. The appendix is significantly larger in diameter in perforated appendicitis than in appendicitis with no perforation 15 mm vs 11 mm.
Direct CT signs i. Indirect signs bowel wall thickening, ascites, ileal wall enhancement, intraluminal air, and combined intraluminal air and appendicolith are also found with higher incidence in appendiceal perforation[ 1353546163 ].
Intraluminal appendiceal air in the setting of acute appendicitis is a marker of perforated or necrotic appendicitis. Recognition of this finding in otherwise uncomplicated appendicitis at imaging should raise suspicion for image-occult perforation or necrosis[ 56 ].
Defect in the enhancing appendiceal wall allows excellent sensitivity A defect in the enhancing appendiceal wall has the highest sensitivity Detecting a defect in the enhancing appendiceal wall by using cine mode display of transverse thin-section CT images allows In one series, appendicolith, free fluid, a focal defect in the enhancing appendiceal wall, and enlarged abdominal lymph nodes were not sensitive or specific for the presence of perforation.
That study has concluded that unless abscess or extraluminal gas is present multidetector CT cannot establish the diagnosis of perforation[ 63 ]. CT is useful in differentiating between these disorders[ 63 ]. Magnetic resonance imaging MRI has had little role in the evaluation of acute abdominal pain. However, increasing concerns over the potentially hazardous effects of ionizing radiation associated with CT have made MRI the study of choice to evaluate pregnant women and children with symptoms of appendicitis and equivocal US findings.
Although MRI may be used in any patient with suspected acute appendicitis, there is a special role for MRI in pregnant women with new-onset abdominal pain. MRI has many advantages.
It is valuable in the imaging of pregnant women and children because there is no exposure to ionizing radiation. Although MRI is safe during pregnancy, no intravenous contrast should be used during pregnancy because gadolinium is a category C drug and potentially teratogenic. However, apdndicular MRI provides detailed images, which usually provide the correct diagnosis. MRI is operator independent and the results are highly reproducible. MRI is more useful than US in obese patients and in patients with a retrocecal appendix, which is difficult to visualize on US.
Drawbacks of MRI are plawtron it is more expensive than other imaging modalities and not as widely available. The examination itself takes longer to perform and may be degraded by motion artifact. There are concerns that, with the exception of trained radiologists, other health care providers are not comfortable interpreting MRI findings[ 5270 – 73 ].
Emergency appendectomies are still considered the primary means of treating acute appendicitis, with mortality rates of 0. Perforation increases the mortality rate of acute appendicitis from 0. Perforated appendicitis may be treated first by conservative apendiculag or percutaneous abscess drainage with great improvement of the clinical symptoms[ 74 plastrn 80 ]. This is in contrast to nonperforated appendicitis, which requires operation as early as possible in order to reduce morbidity.
Most perforated appendicitis give way to generalized peritonitis and cannot be drained. Indications of drainage are aapendicular of generalized peritonitis and presence of percutaneously or surgically drainable abscess[ 75 – 78 ]. Nonsurgical treatment is associated with lower morbidity and shorter hospital stay compared with immediate appendectomy.