NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Appendectomy can be safely performed during pregnancy with minimal risk to the mother or fetus. Early operation is appropriate. A perforated appendix carries a significant risk to both mother and child; peritonitis, not appendectomy, poses the risk.

Case 8.15 Worsening Right Lower Quadrant Pain You see a 28-year-old woman in the emergency department who has a typical history of appendicitis. The pain, which began in the periumbilical region and mi- grated to the RLQ, is now very localized. There is marked tenderness over the McBurney point. Because her condition has worsened, you decide that exploration is appropriate. Q: How would you manage the following operative findings? Case Variation 8.15.1. A red, inflamed appendiceal tip with exudate ◆ ◆ This represents acute appendicitis, and it is necessary to ligate the appendix at its base and amputate the appendix, leaving a small stump beyond the ligature or stable line. ◆ ◆ When the base of the appendix is necrotic, it is still necessary to ligate and amputate the or- gan using sutures. Most surgeons then bury the base of the appendix into the cecum with a suture to lessen the chance of a “blowout” of the stump. If the cecum also appears involved, it is safe to invert a larger segment of the base of the cecum in most cases. If the cecum is in- volved in an inflammatory process or mass that seems to originate from the appendix, then a right colectomy is appropriate. This procedure is essential both to remove the necrotic appendix and cecum safely and to not miss a perforated colon cancer. Case Variation 8.15.2. Acute gangrenous appendicitis with necrosis extending up to the base of the cecum

Case Variation 8.15.3. Perforated appendicitis with localized abscess (Fig. 8-16) ◆ ◆ The abscess can be treated with percutaneous drainage and antibiotics with or without interval (delayed 6–9 weeks) appendectomy, or the patient can be treated operatively with drainage of the abscess and appendectomy either open or laparoscopically. ◆ ◆ It is necessary to examine for other causes of the pain. These include mesenteric adeni- tis, inflammation of a Meckel diverticulum, terminal enteritis, ovarian and fallopian tube disorders, and diverticulitis. Except under unusual circumstances, removal of the appendix is appropriate to eliminate the diagnosis of appendicitis in the future. SAMPLE Case Variation 8.15.4. Acute appendicitis with a 1-cm round, moveable mass ◆ ◆ This may be a fecalith, which is associated with appendicitis. A seed or similar-sized object was ingested. Fecaliths also are apparent on abdominal radiographs in some patients; this establishes the diagnosis of appendicitis and simplifies the decision to operate. Case Variation 8.15.5. Normal appendix