Full transcript
0:08what's up Ninja nerds in this video
0:09today we're going to be talking about
0:10appendicitis is a part of our clinical
0:11medicine section and if you guys like
0:13this video it helps you please support
0:14us some of the ways that you guys can do
0:16that is by hitting that like button
0:17commenting down the comment section
0:19please subscribe something I really urge
0:21you guys to do because I really think it
0:22would be beneficial for you is to go
0:24down in the description box below it get
0:25there's a link there it takes you to our
0:27website on our website we have amazing
0:29notes it'll ations we have quiz
0:31questions that we're developing as well
0:32as exam prep courses that are in process
0:34and you guys can keep an eye out there
0:36so please go check that out a lot more
0:37to offer there on that website all right
0:39let's talk a little bit about
0:40appendicitis we're going to first
0:42discuss the pathophysiology of
0:43appendicitis so that includes going over
0:45a little bit about the mechanisms behind
0:47how it develops talking about the causes
0:49and talking about primarily some of the
0:52classic clinical findings that we see in
0:54patients with appendicitis or acute
0:55appendicitis so this is one of those
0:57like medical emergencies you have to be
0:59able to pick it up when a patient comes
1:01in with acute appendicitis the
1:03appendicitis is inflammation and usually
1:06infection of the appendix it's this
1:08little thing this little kind of like
1:10organ or piece of tissue that hangs off
1:12of the seeum so you know how you have
1:15your large intestine this would be a
1:17part of the ascending colon that we're
1:18taking a section out of right this is
1:20the ascending colon this would be like
1:21the ilium which is the distal part of
1:23the small intestin this would be the
1:25seeum and then hanging off here off the
1:27seeum is the appendix now in true
1:30anatomical Concepts which we've talked
1:32about before there's different ways that
1:34the appendix can lay we're not going to
1:37focus on that what I want to focus on is
1:39how does the appendix become inflamed
1:41what's the path of physiology what's the
1:43causes and what's some particular
1:45epidemiological cues that can cue you
1:47off on the exam so first one is a falth
1:51it's literally what it sounds like it's
1:52a poop Stone so this is usually
1:55something where you have like hard like
1:57feal material and what happens is it
2:00kind of gets stuck right here within the
2:02Lumen which is connecting between the
2:05seeum and the appendix now when that
2:08stone gets stuck there what happens is a
2:11bunch of pressure builds up just
2:15proximal to that actual feal stone so
2:19here we'll represent that by putting
2:20like an up Arrow here we'll say here
2:22what's happening inside of this appendix
2:24you're having an
2:26increase in the
2:28pressure and we'll talk about all the
2:30downstream effects of having that
2:31increased pressure with inside of the
2:33appendix but not only is there an
2:35increase in pressure sometimes what
2:37happens is you have bacteria that
2:40naturally sit they're part of our floor
2:43there is going to be bacteria that sit
2:45in parts of your actual
2:47mucosa if it can't get moved out what
2:50happens to the amount of bacteria inside
2:52of the Lumin of the appendix it goes up
2:55so another thing that you'll have is not
2:56only just an increase in pressure but
2:59you'll have an Inc increase in like
3:00what's called bacterial colonization but
3:02for right now we'll say that there's
3:03lots of bacteria the combination of
3:06these two which we'll go over in detail
3:08is what really leads to the fact of
3:10appendicitis the inflamed appendix now
3:13with a
3:14fecalith what patient population you're
3:17reading the clinical vignette patient
3:19comes in we'll talk about the classic
3:20findings they're this age what is a
3:23falth age usually supposing of it's
3:26usually more particularly seen in those
3:29that are of the infants or the young
3:31adult age so I would think about this
3:33more and we're just going to use the
3:34terminology of children you're going to
3:36see this more in that younger population
3:39as the primary cause but it's an
3:40obstruction so the key thing here is it
3:43is an
3:45obstruction where within the appendiceal
3:48Lumen that's blocking flow of particular
3:51contents out of the appendix creating a
3:54increase in back pressure and an
3:55increase in bacterial colonization
3:58you're going to notice the same thing
3:59out of each one one of these except in
4:01this one a patient has what's called
4:03lymph node hyperplasia so in other words
4:06you are going to have a bunch of lymph
4:07nodes in the actual surrounding vicinity
4:10but let's say that you have some lymph
4:11nodes that are just a little bit thicker
4:13a little bit bigger and these things are
4:15pressing on the outside of the appendix
4:18near the actual Lumen so because of that
4:21what's going to happen it's going to be
4:22hard to move contents out it'll create a
4:25increase in back pressure and then again
4:29bacteria colonization so you get the
4:31same concept I want this to become
4:32ingrained into your brain that you'll
4:34have an increase in
4:37bacteria and an increase in the back
4:39pressure and these two combinations will
4:41then lend to what we call
4:44appendicitis now what is the particular
4:46age Ranger epidemiological cues that
4:48will usually make you think about this
4:49one this is usually going to be more in
4:51the
4:53adults so if you have an adult who comes
4:55in with that right lower quadrant pane
4:57appendicitis signs then you want to
4:59definitely be thinking could it be lymph
5:00node hyperplasia either way it's causing
5:03some type of obstruction if you will of
5:06the appendiceal Lumen leading to this
5:08high back pressure and bacterial
5:11colonization all right last one
5:13straightforward neoplasm now in this you
5:16have some type of tumor it could be
5:18extraluminal so you could have a tumor
5:19sitting out here or a mass compressing
5:22on the outside or you could have some
5:23type of mass that's intraluminal and
5:26it's again obstructing the actual what
5:29contents from being able to move be
5:30moved out of the appendic alumen so
5:33here's our
5:35obstruction and what we know is is if
5:37you have this particular obstruction
5:39here you can't move things forward out
5:41of this appendic alumin increases what
5:44happens it's becoming a little bit of a
5:45trend here I believe you're going to
5:47have a increase
5:49in your pressure the back
5:53pressure and an increase in what else
5:56the bacterial
5:58colonization okay okay now who would you
6:00see this in neoplasia it's going to be
6:03usually those of older age particularly
6:06greater than 50 years of age so what I
6:08really want you to be looking for here
6:09is going to be that greater than 50y old
6:12patient okay now with that being said
6:17patient comes in they have
6:19appendicitis they have an obstruction of
6:21the appendic Lumin back pressure
6:23increases bacteria colonize leads to
6:25appendicitis how exactly let me quickly
6:28go over that
6:30so this appendix here is super
6:34inflamed now the reason why is we
6:36already talked a little bit about this
6:38let's just say here is going to be our
6:40obstruction Point here's the
6:42obstruction the back pressure is going
6:44to be one of the big problems here right
6:46so we said okay here's our obstruction
6:48it'll cause an
6:49increase in the back pressure that's one
6:53particular
6:55thing the other thing is that you're
6:58going to cause
6:59a increase we talked about this one as
7:02well and it's a pretty recurring theme
7:03that we mentioned multiple times you're
7:05going to increase
7:08bacterial
7:13colonization so now from this you're
7:15going to have all kinds of stuff in here
7:17you may have a lot of fluid and you may
7:20have a lot of bacteria so here's going
7:23to be a lot of bacteria you potentially
7:25are going to have some fluid kind of
7:26sitting in here as well because there's
7:28naturally going to be some fluid within
7:29the actual G Lumen and so now all of
7:32this stuff is going to sit here all
7:34right because of this obstruction now if
7:37the back pressure is really really high
7:38what's going to happen you can't move
7:39this fluid and bacteria and other
7:41contents out it's going to start
7:43distending and so what you're going to
7:45have from this increased back pressure
7:47is you're going to have an increase in
7:50distension and whenever you have this
7:52stretched out or stretched out appendix
7:56or distended
7:57appendix that's going to going to be one
7:59potential manifestation when this sucker
8:01is really really big and on top of that
8:04it's inflamed and infected it starts
8:06actually causing a lot of pain in
8:08particular areas that we'll talk about
8:11the other thing is as the bacteria
8:12colonize if you have more and more of
8:14this bacteria what happens is they can
8:17actually start causing damage to the
8:18actual appendix tissue now what will
8:22happen is the appendix will start
8:24getting super inflamed because of the
8:26bacteria which will actually start to
8:27precipitate infection so you'll have
8:29infection and inflammation of the
8:32appendix and now this puppy is so hot
8:35angry and
8:37large so now again what happens here you
8:40get
8:41increase
8:43inflammation and
8:49infection and then as a
8:52result if you inflame inflame infect the
8:55appendix and stretch it out the
8:57combination of these two
9:00is what you see in a patient who
9:01presents
9:04with
9:06appendicitis okay now when a patient has
9:08appendicitis they have an inflamed
9:10appendix what is going to be their
9:11presentation well generally what happens
9:13is whenever their appendix is super
9:15inflamed it's going to be in that right
9:16lower quadrant and so what they'll have
9:19is they'll have what's called a
9:20migrating abdominal pain and so it'll
9:22potentially start here in the per
9:23umbilical region and then it'll move
9:25down to What's called the right lower
9:27quadrant so that's one very common
9:29manifestation the other thing is is if
9:32you press in the right lower quadrant we
9:35call this MC Bernie's point or that
9:36right lower quadrant tenderness whenever
9:38you press on that area it's going to
9:39relit a lot of pain why because it's
9:41inflamed it's big and it's infected the
9:44other concept is when you do specific
9:46signs appendicitis signs it'll really
9:48help you to think about patient who has
9:49appendicitis so if they come in right
9:52lower quadrant pain tenderness in that
9:54area or the migrating per umbilical to
9:56right lower quadrant MC Bernie's point
9:58tenderness and you do special tests so
10:00you have them lay on their back and
10:02we'll show you guys this what you do is
10:03you have them lay on their back kind of
10:05keep their legs straight and what you're
10:06going to have them do is try to flex at
10:08the hip while you're trying to give her
10:09some resistance what that does is that
10:10really kind of causes a lot of pain if
10:13they have like a retro secal appendix
10:14but that could be one sign all right
10:17that's called the soas
10:22sign another one is if you have them
10:25again they can have their knee flexed
10:27and then what you do is is you try to
10:29internally rotate around that hip and
10:33what it can do is it can kind of Smash
10:34down on that big inflamed angry appendix
10:37and precipitate pain that's called an
10:38opat
10:43sign there's also other ones that can be
10:46very very suggestive so it's called the
10:48rosing sign and it's very interesting
10:50it's kind of like whenever you press
10:52down in the left lower quadrant like the
10:53pendix ain't there but if you press
10:56there and it precipitates this kind of
10:58referred pain to to the right lower
10:59quadrant that could be also very
11:01suggestive of
11:07appendicitis so again look for right
11:09lower quadrant pain usually migrating
11:11from a per umbilical MC Bernie's point
11:14tenderness soaz sign operator sign
11:17rosing sign these are all very
11:19suggestive of pentis which could be
11:21secondary to a falth lymph node
11:23hyperplasia or neoplasia causing
11:25obstruction of the appendic alumin
11:27increased back pressure distend
11:29bacterial colonization infection
11:31inflammation and therefore we have this
11:33problem let's now talk about the
11:34complications all right my friends so
11:35now we're going to talk about the
11:36complications of appendicitis patient
11:37comes in right lower quadrant pain maybe
11:40they started off with some par umbilical
11:41pain that migrated there they got MC
11:42Bernie's point tenderness they got some
11:43of those appendicitis signs so you're
11:45thinking H I got a pentis I know the
11:47potential causes are they young could be
11:49a fecalith are they adult age could be
11:52lympo hyperplasia are they greater than
11:5350 you're thinking about neoplasia but I
11:55think some of the other things that you
11:57have to be watching out for when a
11:58patient comes in in with suspected
11:59appendicitis is the downfall the
12:02complications if that sucker bursts and
12:04so what happens is the first thing that
12:06you want to watch out for is a
12:08perforation of the appendix it's pretty
12:10straightforward how this is all
12:11happening we already know that there's a
12:13lot of back pressure we already know
12:15that there's bacterial colonization that
12:17causes what distension of the appendix
12:20via the back pressure infection
12:22inflammation via the bacterial
12:23colonization accumulating there and you
12:25got an inflamed and angry
12:27appendix what's really interesting is
12:29though as this kind of accumulates more
12:32and more pustulent type of material
12:34it'll start to really stretch and the
12:36intraluminal pressure will rise and
12:38it'll start compressing and kind of
12:40transmitting this Force onto the wall of
12:43the
12:43appendix now as you start to increase
12:46the actual intraluminal pressure what
12:49this will do is this will start to
12:51squeeze a couple different things so
12:53let's write this down so first thing is
12:55you're going to increase the
12:57intra luminal pressure we already know
12:59why we have an obstruction of some sort
13:02it's the overall concept that we've
13:04built already in the pathophysiology
13:06portion as that pressure Rises you start
13:09causing Venus compression you start
13:12causing lymphatic compression that
13:14causes swelling of the appendix so
13:16you're going to get more edema more
13:18swelling but here's the scary thing you
13:21see these arteries you see how they're
13:23supposed to be supplying like parts of
13:25the appendix what if the pressure is so
13:28high you start compressing the arteries
13:30pinching them off and now these arteries
13:33are supposed to be supplying oxygen rich
13:36blood to this tissue they're being
13:39compressed what starts arising let's say
13:41in this portion here oxygen rid blood is
13:44not actually being supplied so what will
13:46start to occur here is you'll start to
13:49experience something called es schema so
13:51now this area which I'm going to
13:52represent in black is now all es schic
13:56so that's one potential complication
13:57that can arise as as the increased
13:59intraluminal pressure occurs you're
14:01going to increase esea to the actual
14:05appendix wall so you're going to cause
14:06es
14:09schia of
14:12appendix now this is because of why we
14:16said this is going to be because of a
14:17couple different things one is the
14:19pressure Rises and it compresses veins
14:21so you're going to get a couple
14:21different things that occur you're going
14:23to get vein
14:25compression you're going to get
14:27lymphatic compression
14:31and all of this is going to increase
14:33kind of that edema factor which is going
14:36to make it more swollen increase the
14:38intraluminal pressure even more but the
14:40scariest one that's going to cause this
14:41esea is going to be the artery
14:44compression as you start to compress
14:46that artery you're going to reduce the
14:48blood supply and that's what going to
14:51cause this esema of the appendix now
14:53here's the problem whenever you have a
14:54scheme of the appendix that wall now
14:56that tissue right there is super weak
14:59and it's very susceptible so now let's
15:00say for example if we have this area
15:02being super susceptible so it's super
15:05esmic we're going to draw it right here
15:06now this area is all esic so this was an
15:10area
15:12of esea right here but now it's so weak
15:17that what happens is the Walls Start to
15:20erode and as it erods you increase a
15:23tract that'll then form between
15:27what between the intraluminal like this
15:30luminal side and the
15:32parium and now all of this stuff this
15:35pushed material all this like bacteria
15:38cells fluid all of this will leak out
15:42air which is a part of our git will leak
15:45out and that's how a perforation arises
15:50so then you develop a
15:51wall perforation from that persistent
15:54esema and then you're going to see the
15:56downfall of this
15:59what is that downfall let's come
16:01down no pun in it but whenever this
16:04actually occurs we have rupture right we
16:07have this perforation of the appendix
16:09wall so here's a couple different
16:10anatomical features this is going to be
16:12the anterior side this is the posterior
16:14side this is the superior this is the
16:17inferior we're looking at the th thorax
16:19here and the abdomen here separated by
16:21this red line which is the diaphragm all
16:23of this in pink here is your perenium
16:25your parium is double layered the
16:27parietal perum which covers the wall of
16:29the abdominal cavity and then the
16:31visceral perum which covers the organ
16:33that's in that peronal cavity this is
16:36going to perforate and all that material
16:39that we talked about is going to
16:42enter into this perenium all this
16:45material this could be things like air
16:47I'm just going to use write a couple
16:49things here one is it could be air that
16:51could definitely accumulate out here
16:53there could be some degree of fluid that
16:56accumulates out here or there could be
17:00bacteria that accumulate out here but
17:02you're going to have all of these things
17:04kind of flinging out into these
17:05particular
17:06areas whenever a patient has this
17:09perforation often times the
17:11complications we'll talk about will be
17:13progressively as we go to the right of
17:14the board but one of the biggest things
17:16is whenever you perforate it produces a
17:18couple different features that I think
17:20are important to remember one is intense
17:23abdominal pain so usually they have you
17:26know that that specific right quadrant
17:29that migrates from the emperia umbilical
17:31area that's super suggestive but if the
17:34abdominal pain drastically increases
17:37that could be indicative of a
17:39perforation much more so than their
17:41usual kind of pain that they've been
17:42having the other thing is as if they're
17:46guarding or they're have exhibiting
17:48what's called
17:50rigidity so let me explain what that
17:52means so guarding is you come to the bed
17:55you're getting ready to palpate they're
17:56like no no no don't touch me because
17:58their abdomen is so sore and so
18:00sensitive that if you touch it they'll
18:01scream or if you go and touch the
18:04abdomen because of all this kind of
18:06perforation their abdomen could be super
18:08rigid and hard and that could be also
18:10indicative the other thing I would
18:12really also watch out for is especially
18:14air when air leaks into the actual
18:17peritoneum we call it a num numo parium
18:20and this can be identified sometimes um
18:23especially off of Imaging and so this is
18:27not NE necessarily a clinical finding
18:30it's more of a Imaging finding that
18:32could be potentially found so watch out
18:34for potential penum watch out for an
18:37increase in abdominal pain guarding
18:39rigidity another one could be even like
18:41rebound tenderness as well where you try
18:43to push down so they could have
18:45something called rebound
18:49tenderness and this is basically when
18:50you try to like press down in the
18:52abdomen and then you release really
18:54quickly whenever you're kind of
18:55releasing the pain is intense and so
18:58that that's kind of an interesting
18:59finding and that's usually suggestive of
19:01perforation or related
19:03peritonitis okay so that's perforation
19:07if a patient comes in they have that
19:09original pain that we talked about
19:10that's classic of appendicitis and then
19:11the the pain gets worse they have
19:13rigidity guarding rebound
19:15tenderness definitely think about a
19:18perforation especially if you get an
19:20x-ray or an Imaging and you see air that
19:23sits right underneath the diaphragm
19:25that's called a num numo parium okay
19:27cool
19:28the next one often times a perforation
19:32will progress to an abscess so if a
19:34patient develops a
19:38perforation this can then stimulate what
19:41process well here's they they've perfed
19:43okay because of the esea from int the
19:46intraluminal pressure Rising compressing
19:48the vessels causing esea boom wall perer
19:53what can happen is Lally what it sounds
19:55like you see how these green things
19:57these are the bacteria
19:59they kind of try to go out and Escape
20:01outside here but they're smart and what
20:04they do is is they cre they wall
20:07off this area here so they escape out
20:10here and whenever these bacteria come
20:13and Escape out into this parital area
20:16and then they kind of wall themselves
20:18off so here's going to be a kind of a
20:20mixture of pus which is going to be
20:22cellular debris and white blood cells
20:24and bacteria and all that kind of stuff
20:26it's going to sit out here outside of
20:28the Lumen that's an
20:30abscess so again it's a
20:33perforation that leads to
20:37bacterial
20:40organization outside of the
20:44Lumen outside the
20:48Lumen and this is the scary thing that
20:51you can see here so this is going to be
20:53indicative of an abscess all right now
20:56these are really really nasty what are
20:57some of of the potential findings that
20:59you'll see with these patient
21:00populations when a patient has an
21:02abscess again they could come in with
21:04that right lower quadrant pain they
21:05could still have that sometimes this is
21:07really difficult to identify so they
21:09could still have let's say here bacteria
21:12kind of comes out here into this peronal
21:15area and then decides the wall itself
21:17off here so what happens here is they
21:20may have like if you go on the right
21:22lower quadrant and you try to palpate if
21:24the abscess is big enough you may be
21:27able to palpate a mass and so one thing
21:29is you may have this right lower
21:32quadrant mass that is extremely
21:36tender okay so when you kind of palpate
21:38on that area you may feel somewhat of a
21:40bumpy area there but again it's usually
21:43going to be super super tender to
21:45palpation the other thing here is that
21:47this is bacteria man and bacteria
21:49naturally will precipitate cines so
21:53let's say here in this blue is going to
21:54be these cyto kindes and these get out
21:56into your systemic circulation we'll put
21:58here's your bloodstream right and what
22:01happens is when these cyto kindes that
22:03are released get kind of put into the
22:06bloodstream they activate your immune
22:09system and whenever they activate your
22:11immune system what will happen is why
22:14blood cells will start increasing in
22:16number to try to come to the area and
22:19fight off that particular infection so
22:21you'll have white blood cells that'll
22:23enter into your bloodstream and that's
22:25going to be one thing so you may have an
22:27increase in your white blood cell count
22:29because they're going to try to come to
22:30this area and fight off this infection
22:32but the other thing is these cyto kindes
22:34not only do they stimulate this process
22:36they get out into the bloodstream and we
22:38all know that cyto kindes are really
22:40good at stimulating your
22:42hypothalamus to increase your body
22:44temperature and they may precipitate
22:47fever and so one of the things that you
22:49want to watch out for is a increase in
22:51fever with a right lower quadrant mass
22:54and an increase in the number of white
22:57blood cells in a patient who has
22:59appendicitis and the only way that
23:00you'll be able to identify this is
23:02usually getting Imaging to find that
23:03particular abscess it's really difficult
23:05to identify sometimes just on physical
23:09examination but look for these
23:10particular things the last scenario here
23:13is a patient Who develops peritonitis
23:15it's the same exact concept they have to
23:18perf to develop this so if they develop
23:20a perforation bacteria can organize
23:22outside the Lumen if they perforate as
23:25well so let's say here we have a perfor
23:28ation same concept exists here
23:31perforation that occurs here what's the
23:33problem with this well again we already
23:36talked about how things can leak out
23:38fluid bacteria air all that kinds of
23:42stuff same thing but here's the problem
23:45we didn't talk about anything over here
23:48about that bacteria or other types of
23:49molecules or fluid how it agitated the
23:52parium we just said it went out into the
23:55parium if this stuff gets out into the
23:57the perenium and then starts causing
23:59inflammation of this pink layer now we
24:01have peritonitis perforation and
24:03peritonitis are very very similar so
24:04remember perforation can lead
24:08to a
24:10leakage so you'll have leakage of
24:11intraluminal contents but particularly
24:15bacteria
24:17spill into perenium so you see how we
24:21kind of have like a comparison here this
24:23is really kind of interesting bacteria
24:25can organize outside the Lumen and not
24:26spill directly all over the parium here
24:29they can diffusely spread throughout the
24:31perum this will cause a walled off area
24:33like an abscess this will cause defuse
24:36inflammation and infection of the parum
24:38let's come down and talk about what that
24:39would look like though so if this
24:44bacteria which is here doesn't wall off
24:46instead it spreads out here into the
24:52actual abdomen and then as it does that
24:56it causes inflammation of the wall of
24:58the
24:59parium this is going to be a very common
25:01thing you're going to get all the stuff
25:03that you would have so it's basically
25:05all the perforation
25:07findings all right so all the
25:09perforation findings that we discussed
25:12would be present here that's no
25:14different you're going to have air fluid
25:15bacteria that'll leak out there so
25:17you're still going to get what kind of
25:18things here intense abdominal pain
25:21you're going to have rigidity you're
25:23going to have guarding you can have
25:24rebound tenderness one of the things I
25:27think that's a little bit more
25:28suggestive though of
25:31peritonitis is that it's inflammation of
25:34that perenium and as you inflame the
25:36parium any inflammation generally what
25:39that'll start to do is is it'll cause
25:42cyto kindes to be released these cyto
25:45kindes will then do what pump up your
25:48immune system kind of try to drag in
25:52tons of neutrophils it'll also go to
25:55your central nervous system particularly
25:57the hypothalamus and say hey lots of
26:00inflammation going on maybe you should
26:01kind of jack up the body's thermostat
26:04and increase the actual body temperature
26:06so things that you may start to notice
26:07from these cyto kindes is an
26:10increase in the white blood cell count
26:13and increase in the patient's body
26:15temperature like a
26:18fever but the other thing that's going
26:20to be really really helpful so here's
26:21your cyto kindes all these cyto are
26:24really precipitating this and this right
26:27so it's stimulating white blood cells to
26:29come to the area to fight off the
26:30infection stimulating an increase in
26:32body temperature to make it difficult
26:33for bacteria to survive all of this is
26:35from the cyto kindes from the
26:36inflammation of the
26:38peritoneum the last thing that I think
26:40is also important here and this is where
26:42it gets really scary bacteria in the
26:45peritoneum there's a lot of blood
26:48vessels that are in that parium area if
26:50the
26:51bacteria have an opportunity to spread
26:55into the bloodstream now you have
26:59bacteremia and that bacteremia could
27:01potentially lead to a systemic infection
27:05and so that's where you really want to
27:07be careful of because if this bacteria
27:09gets into the bloodstream it can
27:10precipitate a patient de developing
27:12sepsis so the last thing that you want
27:14to watch out for here is potential
27:17increased risk of
27:20sepsis if the bacteria do leak into the
27:23bloodstream so often times a patient who
27:27has peritonitis has findings of
27:29perforation plus maybe a fever a
27:32lucyisanerd
27:57and then cyto kind mediated types of
27:59presentations as well such as fever
28:15lucyisanerd pan right and they had
28:18appendicitis signs all of a sudden
28:20they're diffus abdominal pain rigidity
28:24guarding and they also have rebound
28:26tenderness if that's the case now I'm
28:28scared that they went from appendicitis
28:31to a perforated appendix first thing I
28:33should do is get an abdominal x-ray the
28:35reason why is I want to see do they have
28:37any evidence of pneum parium the other
28:39thing is it could happen they could
28:40develop peritonitis they may have
28:42peritonitis actively what did I tell you
28:44what happened maybe they could have a
28:45fever maybe they could have a
28:48lucyisanerd dominal x-ray and on top of
28:52that I find hemodynamic instability now
28:54I'm worried that they've progressed
28:56already to parir ini itis and maybe
28:58sepsis I'm not even going to wait to do
29:01other Imaging I'm going to take this
29:02patient straight to the O and they need
29:04an emergency laparotomy and will provide
29:07an intraoperative diagnosis at that
29:09point in time now if they have no
29:12perforation features no numo parum and
29:15they're hemodynamically stable oh then I
29:18have time and I can start working this
29:20patient up so what I'll do is I'll get
29:22one of two studies I'll get an
29:23ultrasound right of the abdomen or I'll
29:26get a CT of the abdomen and pelvis and
29:29so what I'll do is I'll get the
29:30ultrasound really in patients who are
29:32pregnant the reason why is I want to
29:34reduce any risk of radiation especially
29:36with CT scans and a child again I want
29:38to reduce the risk of radiation all
29:40right especially from the CT scan and so
29:42I'd get an abdominal ultrasound and
29:44these are actually pretty good they can
29:45definitely identify areas of a lot of
29:47appendix thickening a lot of
29:49inflammation of the appendix distension
29:52and so this is a really good test at
29:53being able to identify appendicitis
29:55especially in that particular population
29:59if the patient is not pregnant they are
30:01not a child okay well then I don't have
30:03the need to really push an abdominal
30:05ultrasound I could get an abdominal CT
30:07scan but the other thing is if I got an
30:10ultrasound initially and it wasn't
30:11really conclusive I can definitely get
30:13at a CT scan and these are pretty good
30:15because they're definitely going to be
30:16able to identify areas of a very
30:18distended and thickened appendix wall
30:21right I'll also be able to identify if
30:22there's any complications like a flegman
30:24or an abscess look you can see here
30:26where it per perforated so you'll be
30:28able to identify both a pentis and
30:30identify the complications associated
30:32with pendis and that's why I think the
30:34CT scan is just a little bit better
30:36because it will show definitely oh they
30:38have a pentis but it could show oh they
30:40have like an abscess or it shows a
30:41perforation so it can show findings of
30:43complications which is very
30:45helpful all right that's how we would
30:47diagnose appendicitis the question comes
30:51okay I have a patient with appendicitis
30:53all right they didn't perforate all
30:55right so I see no evidence of perfor
30:57ation on their exam so no distended AB
31:00like no diffuse abdominal pain no
31:02guarding rigidity no rebound tenderness
31:04no numo perenium and their CT scan
31:07doesn't really show perforation same
31:09thing I don't see a very high white
31:10count a fever a palpable mask and I see
31:13no abscess on their uh CT scan in that
31:16case it's a straightforward
31:18uncomplicated appendicitis you can just
31:20go ahead and just get them to an
31:22appendectomy it doesn't have to be a
31:24mergent but you should try to get them a
31:25laparoscopic appendectomy as soon as you
31:27possibly can the other thing is that you
31:29want to start treating their infection
31:31you want to clear out the infection that
31:32they may have and so often times these
31:34patients may be started on something
31:35like seph triaxone to cover some of the
31:38gram negatives and then often times they
31:40may also be put on like metronidazol to
31:42cover a little bit more of the um Anor
31:44robic bacteria that may be a part of our
31:45GI Flora so this would be started
31:47pre-operatively and probably even
31:49continued postoperatively and then
31:51you're going to remove the source of the
31:52infection which is by the
31:54appendectomy now if it's complicated
31:57that means that they perfed or they have
31:59an abscess if they perforated I don't
32:03have a lot of time to be wasting on
32:06these patients and saying oh we'll get
32:07an appendectomy later today or tomorrow
32:10no no no no no they need to get to the O
32:13immediately so you get them on
32:14antibiotics seph triaxone metronidazol
32:17and get them to the O as soon as
32:19possible and do an emergent appendectomy
32:22often times this is usually laparoscopic
32:24but in certain scenarios maybe they have
32:25to do it open and then what you do is
32:27again continue the antibiotics pre and
32:29postoperatively and then you'll cut out
32:30the infected tissue where it may change
32:33a little bit in the complicated patient
32:34is if they have an abscess abscesses can
32:37cause a lot of problems they can inflame
32:40a lot of the tissue nearby not just the
32:43appendix but some of the other eye
32:45nearby tissue and it can Muck up the
32:47area of the surgical field so you should
32:49start antibiotics and then since the
32:52appendix is relatively close to the
32:53abdominal wall if the abscess is present
32:57and it's visual sometimes you can do
32:59ultrasound or ctg guided percutaneous
33:02drainage and you can suck some of the
33:04actual infected material out so that's
33:06your relative degree of source control
33:08so start them on seph triaxone
33:10metronidazol often times a percutaneous
33:13drainage of the abscess and then just a
33:15couple weeks later to allow the
33:17inflammation of the appendix to start to
33:19subside a little bit a lot of the areas
33:21of inflammation around that vicinity of
33:23the appendix to settle down then you can
33:25go in and do an interval appendectomy it
33:27makes the appendectomy much smoother and
33:29it prevents the the risk of recurrence
33:32of
33:32appendicitis and that's the only big
33:34difference here all right my friends
33:36that's appendicitis I really hope that
33:38you guys enjoyed it it made sense and as
33:40always until next
33:46[Music]
33:51[Music]
33:55time
33:58[Music]