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Actually, hello, everyone. We are live now. Welcome to today's teaching event from see a general surgery community. Um Here with me is Mister Kong who is gonna be the speaker for tonight's taking um It's acute appen. Um Could you just indicate in the chart board? You can hear me clearly, confirmation that everyone can hear me? OK. Yeah. Yeah. Yeah. Can everyone hear me? Oh, I like I just tired. Um OK, perfect. Um I think I've got, I've got an answer on the chart box on a um mister speaker. She, I'm going to be continue on now in a couple of minutes, but we just wait for orders to join. We just give them like um say the next uh five minutes thereabouts just because there's an event that just finished. Not quite long. And um everyone on that event also would like to join these. So I think they, they just round it off. So we'll just give them a bit of time to join us if that's all right. Hello. So I'm gonna go mute for a couple of seconds or minutes and I'll come back to you guys. We would be starting at 7 15 on the dots. Officially, we just be waiting for orders to join in. Ok. Yeah, yeah, thank you. Hello everyone. Um We're back and we'll be starting right away. Um sorry and apologies for um taking a bit of time. Uh We just needed to do that so that we could get orders to join in. Um Reason being that there was an event earlier on that just round it up and um we wanted um the attendees of that event to also participate fully in this event. So, um I'll be introducing um our speaker right away and shortly after then, um he would take over the stage. Um You can check the polls for questions and you can put in your answers. And um also, I believe you all would get um a feedback form to be filled after the session. Make sure you do that because um that's the only thing that would give you access to the certificates that we, we will be issuing after the session today. So my name is um Mo Ashida, um the CG of General Surgical Lead and um Siga stands for Surgery Interest Group of Africa. We've got um lots of communities in guff. General Surgery is just one of them and um at present is the most populous community in Guff. So if you want to join C A, um I'll put a link in the chart box at some point and you can, if you're not a member yet, you can click the link and you'll be able to join. It's so, so straightforward, you can join whichever community you want to join. And um basically, um today's session is gonna be um anchored by ko he's who um finished from law suits as um the best student. The How do you call that? Oh My tongue is twisted. Now, help me someone actually. So um you finished as the valedictorian. if I'm correct, I can't even, I don't even know anymore. So, um I think I had a lot of food. Not quite long. My brain is sleeping. So um we've got the opportunity to be having these um session anchored and um delivered to us by the best student and law in 2017 is presently in the UK. And um he's um a clinical fellow at the Friendly Park Hospital in the UK. He's also a member of the Royal College of Surgeons of England. So um with no further ado I would uh bring up to the stage, MS Taiko to drive the box. Thank you. Can I mute yourself, sir? Yeah, good evening. Thank you very much. Do uh doctor. The name sounds like my. Anyway, it's nice to be here and good evening everyone. My name is. Oh, you can and I'm here today to have a chat with us about a uh a just a friendly chat and I think you can always stop me or mute yourself if there's any clarification you want doing the presentation or you can decide to wait to the end for the questions or clarification. I think anyone is fine by me and yeah, do doctor has the introduced me? I don't think I need to do anything more about that. Um Once he says he's ready, I'll share my screen and we can start. I, I can't see how many people are qu home though. So um let me see if we are ready to start. Yeah. So we we've got at the minute we on the call, I'm sure the people will still join. Yeah. So if you want me to start, just let me know, I'll start as soon as you say. Yeah, please um feel free to start and share your screen, sir. Ok. Yeah. Can you hear me loud and clear and can you see my slide? Yeah, very clearly. OK. Yeah, that's fine. Good. Ok. Um Once again, my name is and got it from in Lagos Nigeria and we can move on. So as an introduction, um I'm sure every single person will have it or send a a patient to it acute appendicitis, whether confirmed or has a differential diagnosis. And it is the most common general surgical pathology in all part of the world. No matter where you come from, a heis will always stop in terms of the surgical, general surgical diagnosis. And as a training, I think that's one of the uh main surgical procedure that we all want to do as the first m um surgery. And I think that's the first one. we consultant will feel, um will feel the ease to, to let you do whether supervise or not supervise, well as, as very common as it is. And as uh very well known, I think it still cause a significant morbidity and mortality for me, especially when it is not diagnosed early or even when diagnosed. What for whatever reason there is delay in intervention. Well, before we move into the inflammation itself, I just take a brief minutes to talk about the appendix. And the full name is the very formal appendix. And it's a one leg diverticulum that arises from the posteromedial wall of the si very close to the cal junction in terms of the size diameter and position. It varies, not just with age, even in the same age group, you are within different size diameter and position. And I can tell you, um you can have an appendix as long as 26 centimeter and I've seen some acute uh uh some appendectomy done with a very, very large and dilated appendi. You almost think it's another organ entirely. Ok. It is usually intra toia. It has its own meso appendix, which is very important in the surgery and the dissection to remove the appendix and is supplied by single end art, the appendicular artery from the artery. I will sure this I hope you can see my co so if this is the appendix, then the whitish stop here will be the meso appendix and the appendicular artery wall along these three edges. So it says I need that tree. So in any thrombosis or colon within the appendi artery, the tip of the appendix will suffer most lymph nodes from the appendix and all the surrounding structures. Usually we end up in the ileocolic not very close to d appendix. And this is very important because of some differential diagnosis that we usually come across in acu appendicitis. And in terms of position of the appendix, as you can see, we have all, all sort of position, but the most common is the visa when the appendix goes beyond the cm and you probably need to fill the sitcom to be able to assess the appendix that will cost us 74% of the time. I think the next one would be the pelvic. Also the four clot that points directly into the pelvis probably can be on the bladder just beside the rectum in between both the bladder and the rectum. But that is the second. But as you can see, there are so many variations of this position. Histology is just like any other part of the bowel for mucosa or mucosa muscular, muscular. And the, but the histology is more renown because of the lymphoid follicles, which some individuals have postulated that this is actually the function of the appendix to help with, um, immunity. Well, there are some questions here. Just some brief thing that just for us to, something to think about before the, before we start the main presentation. Um, I don't know if doctor can build up the pool now. I have to be the one to do it. Yeah. Yeah, I can bring it up. Um, do you want this particular one you're sharing now, or? Yes. Yes. This particular 1 2025 year old. So um I don't think we've got this particular one. OK. I think I'll just, you know, so I don't know. Do you want to include it yourself now? Yeah, I think. Yeah. No, no, no, it's everything included. I just need to. We've got a 70 year old one but not the 25 year old one. Yeah. OK. Yeah, I think III I did something like this. OK. Yeah, I didn't include the whole question. OK. So the one I brought it up already. I don't know if any other person can see this. So the one we are seeing now is what type of organism is the culprit in acute appendicitis? Is that what you want? Yes, that is what I want. Uh The question is already on the screen. So it's about 25 old male. We mi right? Ee has some fever is nauseous. An on examination with bur tenderness in the right Ela Leko and the clinician felt that this was aapis and he decided operative management was the way to go. But sometimes during acute appendicis, uh, during appendectomy, we usually sometimes very rarely take peritoneal fluid for, uh, M CS. And I just wanted to know if we have any idea what type of organism it's usually grown in patients with acute appendicitis. So, we've got, we've got, um, some answers already just waiting for orders to, to put in their s Yeah, so we give it a few more seconds in the next 10 seconds. We would carry on with whatever answers we've got. Yeah, the answers are coming in. Well, we're just trying to make it as interactive as possible. There are quite a few questions. Um, ok. Can I just double check with, um, with us if anyone has got access to the mic to unmute themselves? Has anyone got access to the mic to, to speak? Just wanted, just want to be sure you might not. Well, again, we just test running a particular function in this event and that might give few persons access to use the mic. If you're able to use the mic, just put it on the, you can mute yourself and talk and of course, I'll get a confirmation from there. If you're not. If I don't get anyone talking, then I'll assume no one has got access to the mic. So you can just put your questions, your comments and everything you want on the chat box and we'll pick it up from there. You can begin to ask your questions now, as the speaker goes on with the um teaching or you can wait till the end. So, yeah, we've got um the pause already. Do you want me to um let everyone know what results we've got? Um I, yeah, I think we can wait to the end. Yeah. OK. To the end. OK. Fine, fine. So we, we, we just collect the answers and then we'll wait to the end to see. Yeah. And uh another question is in terms of the pathogenesis of acute appendicitis. What which of the following do we think cannot cause acute appendicitis? Cause it has a patho ology? OK. Mhm. So the second pole is on. If you want to cast your votes, you've got five options. The following can cause acute appendicitis. Ex except if we call it b intestinal worms, see, seek out some more d fruit and vegetable materials e excessive large meals. So we'll give that another 10 seconds and the speaker will carry on as well. You see moving on um achy appendicitis can resolve by itself without surgery or the use of antibiotic. Do you think that is true or false? Do we think ai it an ultrasound? For example, an ultrasound can confirm ach appendicitis. Do we think it can resolve by itself without surgery or the use of antibiotic? Yeah. So that's also live. Now, the pole is live cast your vote for either true or false. Give it another 15 seconds and the speaker will carry on. Thank you. Yeah, can carry on. It's an, it's, it's anonymous. Anyway, we just want to see what people feel. Um So question four, a three year old boy with a day history of abdominal pain has fever of 30 degrees. He has also had an upper respiratory tract for the past week and on examination was mildly tender and du went to la fossa but it was not gay. There was no tenderness, white cell was normal and there was no neutrophilia. Do we think this history is um in keeping with appendicitis or do we think it's probably another history patient doesn't have any diarrhea, doesn't have any urinary tract symptoms, no dysuria, no diarrhea or anything else. Just abdo pain in the right uh ad 3 40 degree fever. So some upper respiratory tract infection with a and if we can, if yeah, cause we do see a lot of Children. Um uh maybe up to five years. This can uh this can occur as a form of presentation in our patient for a surgical review. Most times the pediatrician wants us to rule out a cancer. Yeah. Oh, this is not part of the pool. So just one it a 20 year old male with Migra, right? Postal pain has fever, nausea is an sic and the bone tenderness on examination in the right tosa. Um He has leukocytosis. What do we usually do to confirm the diagnosis? I'm sure everyone sees this in whatever practice they do. Question six is part of the poll. Ok. Um 70 year old male with negative, right? Elect pain fever, nausea, anorexic A 10 in the right. Elect leukocytosis. How will you confirm this diagnosis? Fourth investigation will give you diagnosis in this patient. So all the polls are still live even if you've not um, voted for the previous ones, you can check the chart box and still cast your votes. So for the, for the last one, um, I think we've got fewer responses at the minute. So I will need you guys to vote more to get more. Yeah. Yeah, I think it's coming up now. The one that the 70 year old one, um, we can also put our answers in the chat box because it's not part of the poll. So we can just put our answer in the chat box. I think the 70 year old should be part of the pool. Sorry, the 20 year old, I was gonna say that the 20 year old you can possibly go back to the slide for the 20 year old. Just so everyone sees that again. They can just pop the answers in the chat box. A is a very, um popular topic. So I'm sure everyone have a very good idea of the questions even before the presentation. Yeah, I think you can continue both. Ok. Um yeah, we'll come back at the end to have a look at this. So I get appendicitis. I try not to take too much of that time, but in case I'm going too fast or there's something that we don't understand, we can always interject or we can decide to get to the end. So the form of e epidemiology appis is relatively rare in infant. I don't think it's an infant diagnosis but become increasingly common in childhood and early adult life and it peaks in uh early twenties. But I think um usually most pe would say uh it peaks between 20 to 30 but I would say this is a disease of adolescent and very young adult. Yeah. After we do age, the risk of developing a appendicitis is quite very small for some, we still see 60 year old, 70 year old coming with a appendicitis. The incidence of uh appendicitis is equal among male and female before puberty. After puberty, there is a little bit more male than compared to females. Uh The types of ecology in in um no unifying hypothesis, but we've been able to culture um fluids in patient with acute appendicitis. There have been a lot of research on it. Some, there are some um there are some meta-analysis with about 1000 patients with acute appendicitis. They had, they have a food culture and the most common organism was um e coli both enteric generally. But even though gram negatives are the ones being cultured more often. It is actually a mix of both S and Ns. So in terms of its ca organ to be mixed majorly, gram-negative with A and which is why our antibiotic therapy needs to cover both ans and gram negative. Even though a little bit, maybe about 2% can also uh be caused by gram positive in addition to the other lobes and an los. But the major part of physiology is that there is Luminal obstruction of the appendix. The appendix as we know is blind, it has the lumen just like any other bowel and anything, any material can enter into the lumen and obstruct the appendiceal dume most commonly. This is done by feli but any other structure has also been found to cause any foreign body, mules, bones, little bones as long as they can navigate their way into the very narrow appendiceal lumen, then they can cause obstruction. And which is why when they enter into the lumen, if they cause obstruction at the middle of the appendix, then the appendicitis happen in the distal end, not the whole length of the appendix. If the obstruction of cause just at the beginning of the appendi, then you then most of all the appendix throughout his length would then be inflamed, strictures, foreign body. I have witnessed an appendicectomy in a child. We made a cut on the appendis after dissect it and we almost done and immediately we cut, the appendi worms were entering into the perit cavity. It was really good. I I'm sure you can imagine loads of very tiny worms. So bones could also obstruct it a couple tubal. If there is a tumor in the sitcom, very close to the opening of the appendix, or the tumor migrates through the opening and obstructs it. That can also cause acute appendicitis. Because once this happen, the appendi mucosa keeps on producing mucus, the mucus distends, the appendix, the mucus cannot backflow because of the obstruction. This causes an increased pressure within the appendi movement. The pressure eventually will cause the venous, it collapse of the venous system because they are low pressure flow. But if the obstruction continues because of the increased secretion of mucus, the mucus gets infected just like any species of any fluid in the body. It gets infected. And then later on the uh the appendiceal wall gets inflamed because of the ongoing infection. And eventually the pressure within the lumen can obstruct the artery. And once the art is when the flow of the art of the appendis artery is reduced, then there's ischemia of the tip. Like we said, the main artery of the tip of the appendix, it becomes ischemic ganges, Pao it and release the pus, which is the mucus that has now been known to cause by the bacteria acting in it. And in terms of if you're wondering what ecoli is ecoli contains of some epi which is means very dry ear material that is mixed with some calcium salts. A lot of bacteria, of course, the ella shedding also everything together forms a PCO it and it is usually pain with your pick on x-ray ct scan. You could always see ple it very with your peak because of the calcium content. And in most cases, that is what obstruct the appendi lu. But one other very important cause of obstruction, different from foreign body or something physical entering into the lumen is lymphoid hypoplasia, just like you said, the appendiceal histology we show earlier is renowned because of the presence of the lymphoid follicles. So when we have some respiratory illnesses, vi vole or for whatever reason, this lymphoid tissue or lympho fou within the appendi mucosa can multiply lympho Ayia. And this multiplication makes the mucosa more swollen and then they can occlude the narrowing. So the lymphoid in the two wall of the appendi because the appendi abdomen is actually quite, very small, usually about two millimeter. So the a uh the hyperplasia going on two mucosa and gorgeous de mucosa and that can also close the lumen if the whatever know whatever causing the um I immune to respond if that's is abate where the lympho hyperplasia can resolve whatever is in the appendi can drain. But if that does in aone, the same part of his surge that will be explained to pain, aone and cause and it is because of is that we have two main forms of acute appendicitis. I think this is very important to know and that is what we call the obstructive. And also the non-obstructive and the non-obstructive is also called the cata like someone having an upper respiratory tract infection, ria from whatever cause can cause the lymphoid hyperplasia or if not the lympho hyperplasia, it could be directed from a physical body which is the explain causing the obstruction. We've already explained how the ischemia will occur. But if you remember our anatomy, the policeman of the abdomen, which is to get a, it goes everywhere there is inflammation. So there is an inflammation in, in the appendix, it goes there part to it, um perforating, it goes there and wraps around it. So you do the, the perforation, the greater omentum is already covering it so that I can limit the spread of purulent materials. And the like if the pain this eventually Perth but this cause something also in, in, even though the great elemental is trying to do a great job being a policeman, it can form a flag mono's mass. And what this means is that while trying to wrap the appendix, it can the c with it, it can lab the terminal along with it and everything becomes a mass in there and within the mass, if the appendix successfully ruptures, pulling out the po in it and it can form an abscess also within the mass, very rarely appendix, inflammation can resolve and when it resolves the p within, it can become cla to leave just the appendix itself filled with mucus. And that is what we call a mucocele of the appendage. You have an obstruction, the appendi remain. The only thing you have in it is mucus, no bacteria, no infection, whatever inflammation that was started initially did not progress. It has regressed maybe because there was some successful drainage of backflow of the mucus back into the system. But for whatever reason, the inflammation set to the appendi only has very clean mucus, very sterile mucus. And then all these symptoms are bit. So what are the different things that can happen from a patient having an attack, appendicitis? Just like we tried to explain, I just want to, it, there could be resolution whether spontaneously or with the use of antibiotics. And we understand how this can um resolve based on the pathophysiology that I explained. An abscess can form the abcess can. If the policeman of the abdomen doesn't get to the appendix in time, there are many reasons why that will happen if that happens. An abscess can form just beside the appendix just beside the sacrum. It can move into the pelvis and the most dependent area. If the patient is lying so fine, it can track down the right uh can get into the subic space and get just beneath the cat and in some cases just like Thursday, we did the case, the pulse was found in all the quadrant of the abdomen, pulse in the pelvis p in the right in the PSA area, right there was ps surrounding the liver, there was po around the spleen, there was po in the left, left SSA this can happen. Uh And of course, that is because of the perforation, the abscess and in that type of situation, we say the patient will probably will present with a generalized peron. The appendi, the old appendix can become not just the, the tip is the most. Um the ti based on the end form of supply is the one that is most prone. But the dual appendix from there could be an appendiceal mass which is the matter that we discussed. Sometimes the infection can through the appendicis vein back into the portal vein into the liver. And there is a 10 subac appendicitis, chronic appendicitis, I think recurrent appendicitis. So back appendicitis, chronic appendicitis, I think they also a spectrum of the same thing. Basically, someone that resolved for whatever reason came back result for whatever reason. And then we said the patient has maybe colic appendicitis. Now what makes the appendix or what are the risk factor? Why an appendix will pass away very, very early. There are some patients that will tell you, oh, these started yesterday. Are you going for the surgery? And you find pul everywhere, how come you perforated in just 24 hours is the patient lying about the onset of symptoms, maybe, but sometimes in the extreme of ages when a child has acute appendicitis, you better or quit early because it is going to perforate very early elderly patients, patient that are immunosuppressed. There's nothing stopping the inflammation going on. Diabetes. Me like too. So we can, we know why that would be. And of course, if we call it obstruction. So it because so if, if we do a scan, even an ultrasound and they tell you, oh, this patient has acute and not just that we could actually visualize if you call it, then you know, this will more likely possibly if not treated because difficult, it is not just going to dissolve, it has calcium, it does everything. So it will probably progress through the continuum of the pa surgery. Is it a pelvic ab a pelvic appendix? A pelvic appendix is not surrounded by anything. It's very hard for the policemen of the abdomen to go and contain gout mean like you perforate easily because it's just very full dangling down previous abdominal surgery because the greater omentum has already done a lot of things. He's already added a lot of addition and stop the migration of the greater omentum. And that can also cause I per of the appen obesity because you don't detect it in time because of so much fat. There is no localization even though the localization probably need a very deep operation, you able to get it and before you know it, you waste your time on this operation. Everyone knows the typical history of ASIS scar periumbilical moves to the right in the. But I think the message I can I will pass will be that this only happens in 50% of cases. Five out of 10, the other five will just tell you, I noticed the pain in the right left foot and has been in the right left face, maybe 40% will say that. Then the other 10% then one out of 10 will tell you where is the whole lower abdomen. It means that it the whole lower abdomen, which is still the whole lower abdomen. But one symptoms which I'm not usually happy when um an individual attacks a suspected acu appis and did not act for anorexia because this is like the most common feature. Like we said, the my pain is only uh present in about 50% of cases. Anorexia has been shown to occur in about 80 to 85% of patients. And I think that is the most common East or symptoms of ais anorexia. And that is why we have the famous Gan sign. The Amburg sign is when you ask a patient, what food do you like most? And they say whatever it is called hamburger. Because I think a lot of Children in the Western world like an hamburger and once they tell you and this, you ask, oh, ok. Do you feel like eating this particular food? Now you could bring it to you. And if you say no, I don't feel like eating win, you know, to eat your best food. Probably because you are an already and that means a positive end of that sign nausea. Most patients are Children also nauseous apart from being anor and they will usually have one or two episodes of vomiting, especially in Children. If your pa if a patient presents to me and is telling me I vomited about 10 times. Hm. My mind is already biased. This cannot be add to it if you will be permitted. Not so much pain in the writing life. First, of course, I think that is also one of the most constant symptoms, whether it was Migra or whether it started there, it's still there. Cough makes it worse, moving, makes it worse. You want to just stay still because you don't want to move. Then. Yes, fever, even though we say fever is present in active app because of course, it's an infective process. I think you should know that early appendicitis will only cause a mild fever and uncomplicated appendix will only cause a mild fever. So usually I get a from Ed and the 12, this patient is having no abdominal pain, fever of 40 degree started this morning. Oh, pain started this morning. Are you having 40 degree Oh, pain started yesterday. You're having 39 degree, uh, high fever. I wouldn't expect that from a noncomplicated acu appendicitis. And I would not expect the 24 hours a appendicitis have been so complicated that you're very, very septic. I mean, that 9 40 degrees. So usually if a child especially comes with a fever greater than 38.5 most times appendicitis is usually less than 38. But if they are coming with a fever better than 38.5 I would be thinking of something else. But if they have fever has still tender in, in the right iliac fossa, then the diagnosis will probably be mesenteric adenitis. And that is inflammation of the lymph nodes present within the mes entry of the abdomen. Ultrasound can actually give you this diagnosis because the lymph node will be very enlarged more than normal and there will be many of them and they usually present with a very high fever and we see that a lot, but still we still do the ultrasound because at least it will also give us the diagnosis of mesenteric adenitis. Some people makes may tell you they had this type of pain before. Well, that doesn't mean it's not a appendicitis. Like we said, there is a term called recurrence of a chronic appendicitis. So maybe just maybe and there might be positive from all these are not really important, but the few um history giving are both is the main history that you would get from a patient with appendicitis. Sometimes it can be atypical, maybe 10%. Usually in adult. Oh my p are like electro white. Electro. That means it's predominantly somatic or it could be predominantly viscera and it's poly localized. Oh, well, the pain shows a lot of my um really cause and yeah, I can't really describe it. Uh Yeah, fine. But it could still be a appendicitis. That's very typical. The inflamed appendix is a pelvic type just lying on the bladder on the rectum or the free space between the rectum and the bladder. Mm. That could cause suprapubic tenderness that could cause the rectum to keep retching. That is tennis mo and they can be passing loose stool and still having the urge to pass most to even if nothing comes because of this stretching, tennis, most of the and because of the in the appendix on it. But sometimes we will get this through at the examination. Some of these signs include fever tenderness gain, which we said rebo tenderness is very, is very important. A lot of signs has been described work since. So obturator, some of the signs are depicted. Yeah. So sign means you um I I stand and while I I is standing, you are stretching the swe and they point this line you need to get displaced and that causes pain obturator. The patient flexes the hip internally rotate and that the obturator and the obturator touches the inflam, the pain and the pain. Um Do you want the ed physician like a lot is the same? You play the left, left fossa and then the patient has pain in the right left foot. We discuss about um the different presentation based on where it is. Some people have diarrhea because of the position of the appendix, which you said also appendicitis in pregnancy is something we see also usually more than every 2000 pregnancy. It is the most common acute adrenal condition in pregnancy. It might well, uh it should be remembered as a differential diagnosing patients who are Pregno with um abdominal pain because it is associated with about 3 to 5% with loss. And in a lot in many of them, the appendix can also perforate and that also um is very important because the perforated appendis increases the risk of hair loss also. But the way we diagnose is that most time the sitcom is not so mobile. So even with the pregnancy, the typical right postal pain and tenderness will probably still be there. And a lot of the facial diagnosis are there for Ocu appendicitis, gastroenteritis and eser adenitis make a divertic colitis which needs to be success suspected in surgery when the appendix looks normal intussusception, local pneumonia on the right in adult, any other form of enteritis. I do have a lot of ureteric, especially when the stone is now in the vug. The pain is localized in the right part of diverticula. I think this is what we call the valentin sign. When uh the perforated gastroduodenal ulcer and the content migrates to the right, go down to the left and you feel the tender where the patient has a per pe ulcer to show you should always check the test test and, and especially in Children for to because sometimes they can really tell you, oh the there's also pain in my test test. Female population pain P ID uti A two pregnancy, you should always do a PT test for a female in the reproductive age. I think whether they are contraceptive or not, we just have to do a pregnancy test. And in elderly patients, I think the one we should take note of is the diverticulitis and also the colonic carcinoma in elderly, they have a lot of diverticulitis that mix AIS. I have seen someone taking diverticulitis to take that because he said he did the C diagnosis of AIS and in surgery, appendix was fine. The sigmoid colon was extremely inflamed. The colon can flo or move around causing pic pain with elevated risk of cost colonic cancer, especially the S A cancer. The S A cancer in elderly can also cause pain and also even cause appendicitis. And everyone should try and know the score also for the mantel score. The Montrell score is a new for us to remember the um what are the things that are scored in I called in mantra ma NTRELS and this are the score and it's just the typical symptoms. If these are the only things you ask from your history, I think it is good enough. Is it like, is there anorexia? Is there nausea? Is there vomiting on the examination? The is there localized peronism which we don tenderness is there fever is there elevated white cell count? My second is usually limited in about 90% of what decided. So this is the most common score and I think we should ize it can also help you to judge if the patient has appendicitis or not. But then over the years, there have been a lot of other scoring. Most of them resembles the have of score, app appendicitis score and a lot of others in terms of investigation, routine investigation for blood count in 90%. So yeah, you for surgery, pregnancy test in female group and co much in case you want to do surgery most an not let you do an app having at least one group and say um I x-ray most times we don't do it. But if there's an I if you call it is also called appendicis, then you might see that if the appendis has ruptured already, you may have some free tests, ultrasound most time, especially in Children and clean adults. So we cannot go into base abdomen, you might not be able to get an ultrasound um ultrasound sensitivity is about 80% 70% different studies and how we will know usually Japan, this would be about eight mil eight millimeter or more in damage if the damage is distended and dilated and some other secondary changes of a appendicitis, which we might look out later. Uh If we want to, if anybody is interested, we can always come back to that. Um CT scan can also be done, especially in O A patient because in a lot of O A patient, you think they have a appendicitis, they are not in the age range of app even though it can we need to rule out, could it be directly, could it be personal obstruction with scal and dilatation and pain? Could be it's a couple tuna. Uh but an MRI and MRI can also be done especially in Children if the ultrasound is not conclusive and also in pregnant women if the ultrasound also is not conclusive. So usually we probably do an ultrasound test in both groups. Well, this is AC T scan very sensitive and there's a lot of research going on that all patients with suspected a appendicitis should have AC T scan in the western world, in the United States and many other places, they are trying to ensure that all patients have AC T scan because ultrasound keeps missing A because it's dependent even though you are very secured there about those 80% and you miss the two out of 10, that kind of services. And you say, oh, the ultrasound already said there's no so ct scan very important these days. Ultrasound. This is the appendix not dilated, but as we move on, there is something here and then the distal part is dilated, that will be an a appendicitis maybe of the tip. This is um a stone with an acoustic shadow that would be difficult, you call it or it in the CT scan. If we look here, we can see this dilation here and the fat strand, I don't know if you know if we know what fat stranding is. But this black stuff here is the fat. That is the normal color of fat where this normal color of fat changes to this white area that is all fat strand and that is inflammation. So, inflammation with a structure here that is dilated, um blind and then that will probably be the appendi cause the second will be somewhere here and you had that attack appendicitis. Same here. You can see this distended structure coming from somewhere around the second here. And you can see it has two appen it one e and this is probably the one causing obstruction because the lesion starts here and there's another one there. So that will also be at appendicitis in terms of treatment. Um majorly all over the world, it is accepted that appendicectomy should be the treatment. However, however, um you can also support patient, especially patient is with intravenous fluid antibiotics, ange antibiotic. But recently, also there is a lot of study if, especially if you're in the UK, there is a co a trial that compared what if we do the appendectomy for a patient? What if we just do antibiotics? And it has been a lot of interesting um results and about 25% 75% of patients with antibiotics will actually recover and do the surgery. And the recurrence is the, the study, different study with different data. But most times about 25% of patients you treated with antibiotics, that is one out of four will come back with appendi appendicitis the next year. So I think that is very important when coning patient or you do have to have surgery. Antibiotics also works in up to 90% of cases. But even though it works and you're able to go pain free in the next one year, there is a one in four chance that you come back with appendicitis. I think Law of study, we talked about what an appendicis mass is. We talked about what an appendi abscess looks like. Mm We said that because then how do we then manage a complicated appendicitis? If even though we know know complicated app, we go and remove the appendi what if there's an appendicis, abscess and appendi abscess, you really don't need to do surgery. You can just drain the abscess, ultrasound, guided ct guided or you can go in with the mindset of removing the appendage. You drain the abscess, then you then excise the appendix. Sometimes you go, you don't see the appendix but that from the mass, but you can see the abscess and you can drain gangrenous appendis. Luckily most times the gangrene is distal to the stone. So there is still a stone left that you can tie occasionally duo appendis Gare. And then that there is a problem there. If you remove the appendis, there is no stone for you to type. There are a lot of things that we can do. Some people in a resource poor country can do a right colectomy. Um For some people, they can put a, a, a uh G I stapler, intestinal stapler uh closed the base of the second chose to close the o and a lot of other things. Um work of the pain is you can toilet to a lot of water in it. Pollution to uh solution to pollution is dilation and they remove the appendix after you, you will get the drill. Then there is something called appendi mass which you said, which is the one and there's something called a regimen. This is not usually just any more, but I think it's just something that we need to know you are not meant to do appendectomy. If you think the patient has an appendi Ma because you can't go to the appendage, everything is up the little mental force and everything. So most time it just sleep and the process of treating is called of sharing reg. But if it's not success, um, if you're not uh successful, that means the vital signs keeps increasing, patient keeps spiking fever, abdominal pain is increasing signs of dinner peritonitis, then you need to do an open surgery probably for that. Uh These are the things we're doing surgery. A lot of different incisions, laparoscopic appendectomy is what is recommended worldwide for all sorts of patients. Whether pregnant patient, Children, adults, where you put three reports in 123, this will be the camera. You can see the light from the camera and the two will be your walking instrument. Usually this will be the picture you will see, this will be your full walk instrument and that is the, this will be the C and we don't really want to talk about appendicectomy or these are just things about appendicectomy. And we talk about appendiceal mass, this natural regimen. And what it can do is managing conservatively with IV antibiotics. Keep checking the vital signs as frequently as you can show an hete output. Examine the abdomen regularly recommended twice a day to be sure that the abdominal pain is not improving. Signs of generalized peritonitis is not um visible mark, the limit of the mass. If you can palpate it, you mostly would not be able to pulpy. None of this patient to see if the mass is increasing. Despite your conservative management, if there's an abscess, you can always change the abscess, ultrasound, guided, aesthetic, guided. You don't need to do surgery. And again, something called interval appendicectomy in which you do 6 to 8 weeks has also been abandoned. Most people also don't do that anymore. Once the flare is gone, we just let it be because it has also been said that a lot of patients do not have appendicitis again in their lifetime. So there's really no point if you have appendicitis fine, we remove it. But if not, let's just leave it. We've talked about what makes us to abandon conservative management. And if the patient that had appendectomy is you, we, we take history examine just like any other surgery because the cause of the and being we can be from anywhere postoperative complication with infection abscesses in different places are leaky, PLOS atelectasis, clots, enterocutaneous fistula is this pump is leaking many years. They can always develop adhesive bowel obstruction. I think in conclusion, because the time is fast spent in conclusion, a app, it is probably not preventable and this will continue to occur. I'm sure a lot of doctors in this group, some of those who probably has had appendectomy before, but it is very common and there's nothing we can do to prevent it. So, so just need to continue to learn more on the different surgical technique required in this management. And a lot of research to keep on, on going to see what other way we can manage. Appendectomy, what that way we can manage a appendicitis. Thank you very much. Um Thank you. Awesome. I was, I was so, so, so um soaked in that's teaching. Um I thought I knew a lot about appen, appendicitis and appendicectomy will looks like I was, I'm still learning. That's, that was, that was, that was very, very, very, very comprehensive. Uh Thank you Mr Yako for that amazing presentation. I learned a lot personally and I'm sure if you other person has lungs, at least one or two things from what's you've um, spoken to us about today. And before we take questions, I think I'll just quickly go to the pool and see. Yes. Yes, because yes, apparently, yeah, that's the next thing to do. So, um, we've got some questions but I believe, um, addressing the polls first might actually answer many questions already. So I know some of the questions has already been answered if you are very, if you were very attentive, some of the questions, um, you would have gotten answers to them in the course of the teaching. But, um, yeah, the speaker will just address the post now, one after the other and, um, we'll take other questions afterwards. Thank you. Uh Thank you very much. Um I'm looking at this to now. I think the first question I have here is what type of orb is usually Kosh in appendicitis. And I think, like I said, the app is a very popular topic and 42% said it's probably a mix floor which we probably saw, uh, during the presentation. And that is absolutely right. Sorry. Uh, sorry to, um, interrupt. The first pull is actually, um, acute appendicitis can resolve by itself without surgery or antibiotics if you go up a little bit more. Yes, I, I can see that. Um Yeah, at about 78 besides. So it's yes, that can resolve which we've already said, especially if it is in the pathophysiology. If it is the non-obstructive cataract form of pais where the obtrusion was caused by the uh lympho hyperplasia, including the lumen. Or if the dye resolves the that of occlusion can resolve an appendicitis can resolve. Then we've talked about the organism involved and we talked about which of the following can cause a appendicitis except uh yes. Again, everyone picked excessive large meal but its own type of side effects you had. Yes, that will not be a cause for we call it worms, fruit and vegetable materials. S all this can cause obstruction of the appendi lo and, and cause a which is also said also, then we talk about a two year old boy with um a day history of abdo pain, 40 degree fever and a history of upper respiratory tract infection was tender in the right. But there was no lo um no localism white cell was normal. And 94% of people think it's probably another divers. And I'm sure we explain that also in day 3, 14 degree ait there is no less than 24 hours of onset of abdominal pain will probably not have a fever of the night, not stop of 14. But still, we can always do an ultrasound and the ultrasound will confirm the diagnosis which is most likely mesa adenitis. And finally, a 70 year old male who are all the signs and symptoms of appendicitis. And you wanted to confirm and there is a tie between ultrasound and ct abdomen and pelvis. I don't know if every um I think with the presentation, people will probably choose something else. Now, however, 70 year old with classical presentation of acute appendicitis, we we don't do an ultrasound. I'm sure even the consultant will not be happy that you did an ultrasound for a 70 year old with his ava appendicitis. What we usually do is ac T scan abdomen pelvis to rule out especially a tumor, occluding the appendi lumen or a diverticulitis, which is very common within the age group. But in any which way we will probably after discharge also do. There's a question like that. We probably after discharge also do the colonoscopy. Even though the CT scan doesn't show a tumor, we still do a colonoscopy, but the CT scan can always miss a tumor. In fact, CT abdomen ps is not the good standard for picking out a bowel cancer, the colonic cancer. And I think that's the end of the pool so we can take questions now. Yeah. All right. Um, there was one other question that we didn't put on the pole, the 20 year old one. could you address that please? I think some people put in the chart box. The ultrasound. I think everyone that said, that said ultrasound in the chart. Exactly. So you can just read out the question to them so that they can know which one we are addressing. Now. That's all right, please. So, so if we look at this question, we said a 20 year old male with m pain, fever, nausea and that also has Leis, then we will confirm the diagnosis. Obviously, just like everyone I said, we will need to um confirm the diagnosis with an ultrasound. There's no need to do a CT scan for now. We're not really thinking of any major pathology, especially in the ne even a few will still be in because an ultrasound will tell us about uh my ovarian pathology even though it might, it might not be as accurate as the ultrasound will definitely be the way to go. Um Yeah, we've already talked about what single most important special investigation with this patient now. So usually the the debate within what the cut off should be in converting from ultrasound to ac tt scan. For most people anyone above 40 should have a CT scan because colonic tumor will start around 50. So, if someone is above 40 with attic appendicitis, you, uh, we already said, um, it's more common within adolescent, early, uh, young adults. Anyone above 40 should probably have a CT scan. And I'm sure if you win the radiologist, they'll probably agree to do a abdomal approach to see if they repeat, you might be app. And so, and almost, I also said that in pregnant women, laparoscopic appendectomy is still what uh most people will do if the uterus has pushed away the appendix on the right left side, it's very easy to pale compared to if you do an open in the bonus point and you don't find the appendix because the uterus are pushing a very mobile secu up into the subic region. But of course, you can always do everything you can do anyone open laparoscopic in any young, old, pregnant, nonpregnant. If you don't have the expertise for laparoscopic, open is very well. Ok. We already talked about the constitute of the mass of the appendiceal mass. And we also said, we li about how to man is an appendiceal ma. So if you have an interview and the patient is coen a CT scan, confirming mass, it is better, you tell them you will not manage operatively. Thank you. Awesome. Awesome. So I think someone said, is there any atypical symptoms in diabetic patient or who have neuropathy or having either chemo with you. I think just like we said, even though we can, even though they are diabetic, they are immunosuppressed for whatever reason, they might still present classically. However, there are a group of people that will still present it. Uh Most times you can have a patient telling you I'm having low abdominal pain and then you examine this patient. This patient is not tender at all on the tummy, but the patient is immunocompromised or what whatever reason, immunosuppressive medication from transplant chemo or radiotherapy. But the complaint of abdominal pain, usually they complain of abdominal pain with the rise in white cell shoot while I sit the abdomen and pelvis to rule out any pathology going on because you can't really assess the the local irritation in the right Latos are usually due to you being immuno competent because that has to do with all the cytokines and everything being produced by the white cells and everyone trying to fight infection. If you have loss of you immun of uh surprise, you can fight the infection. Your appendi can be inflamed and there is nothing to suggest it on examination because the look the peritoneum, the pata peritoneum is not inflamed. You can't respond to the inflammation. So typical, atypical will still be patient is nauseous complaint of abdominal pain is an sic bloods are the veins elevated crp white cell. Then you probably need to get an abdominal pelvic scan. Then someone told me to clarify, someone put in the chart for to clarify the path of so of the migration. I remember this is a very common question. I not gonna get. So usually OK, the app or the bowel generally the full gods, mid goats and goats that they usually they pain fibers are usually autonomic. Meaning what kind is the pain sensation is usually sympathetic or past. But most times the pain is from sympathetic and sympathetic to the abdomen to the uh be be from the craic nerve, but most especially the one to the appendix is the 3 10 sympathetic nail fiber that takes it to the spinal cord to the CNS. And we know that derma for 3 10 is around the umbilicus. So when there is a visceral pain, pain from stretching or ischemia of the appendix, the T 10 sympathetic fiber carries it to the CNS and the CN A leaves it as a somatic pain occurring the datum of t pain. And then you have pain around your um pa. But once the inflammation in the regular pushup progresses, the main fact that the appendix is touching your three abdominal wall is touching the peritoneum, the per peritoneum or the intra abdominal wall, that inflammation in the appendix will cause the pa peritoneum to also be inflamed. Per peritoneum is somatic. And that experience pain appendis itself does not experience pain because it's vial if it stretches or it's, that's the only pain that bowel can feel. And if for example, if we don't do both with sexual anastomosis, why the patient is awake. But I can tell you if your patient is awake and you bring the bowel out and you cut the bowel, the patient will not feel any pain because that type of pain is not felt by the vis. The visceral pain is usually from distension. But the pata peritoneum, the inflammation from the appendix that touches the beta peritoneum, it makes a very distinct pain in the right lasa. And when you dis stop that period, pain with pressure, the patient has a lot of pain. And by that time, the CN forget about the very dull vas pain occur in the pain and concentrate on the i severe pain in the right. I hope I try to simplify that as much as I could. So someone said, would non radiating MRI scanning be more sensitive and safer than CT when treatment for possible malignancy. Yes. OK. So now the thing is that what in the setting of a appendicitis, no one really urgently goes for an MRI even though an MRI might be sensitive. No, I think we need to first. Let's let's take it one after the other. I think the first thing would be that always remember that this is an acute situation in acute situation. It is always a good standard, MRI takes time. You don't want to put a septic patient with that and the site is there two MRI is always very expensive. Even the hospital do not want people coming to for MRI even though they can it as soon as they can get the diagnosis they need from another form of investigation. In terms of it being safer fine, in terms of it being sensitive, I think ct scan in diagnosing appendicitis has been recorded to be up to 100 studies. So in terms of being very sensitive is comparable to MRI, you know, from CT scan, abdominal pelvis and MRI. But that will be but maybe, but like you said, you know, the price of MRI and the time it takes for MRI, maybe CT scan will still be to go through and most times um colonic tumor are not to be treated immediately, they usually go to an MD three before a decision is made. So CT scan, colonoscopy and outpatient will probably still be better. And that is the deadline. I think that's all of the questions. If anyone has any other questions, I'm happy to. Awesome um apologies. I think I, I um sort of got caught off um for a few seconds at some point. So I have to switch to another gadget. Um Anyways, I think we're all caught up with the questions in the chart box. We've um talked about the post and we've um mister speaker has um kindly um gone through them again to clarify everything as far as I'm aware and, um, all the questions in the chat box I think have already been answered. So, um, it's think, um, it's safe to say we could wrap up this session very soon if there are still other of questions, probably someone is still typing and, um, once also give them a few more minutes, we can because we just, um, gonna be talking about further sessions that we'll be having in the next couple of minutes. But before then, yeah, I really enjoyed, um, today's teaching and I learned a lot. One thing I've learned today is if a child or even an adult is vomiting quite a lot in the background of every other thing that should point your attention to something else rather than appendix, but do not rule out appendix totally have a low threshold because of course, common things are called commonly. So still go ahead if you think there is a chance for it to be appendix. If it's not clear cut, go ahead to do an ultrasound or a CT, depending on whether it's a child or an adult. And depending on their, their age basically and all the other symptoms and, um, signs you elicited. Um, also I think I've learned about, um, about, um, even the, um, in our setting back in Africa, it's not routinely it done. Um, colonoscopy should be something, it's like another, um, investigation you can do, um, for someone you're suspecting to have, um, appendicitis, not necessarily as an inpatient, you can get that done after you've discharged the patient, even after you've, you've chopped off the appendix, you can actually go ahead um, book them for uh colonoscopy in the next couple of weeks to rule out any tumor. Because to be honest, you can miss that, you can really miss that and you just think um it's a nonspecific uh abdominal pain or even though you might go in and see that the appendix is Milly injected, it could just be a reaction from the tumor that is causing that. So it's um and ct scan is not the best in diagnosing. Um colonic tumors, colonoscopy is, is is better. So, um amongst other things, I think everyone else has um actually learned one or two things as well. Thank you very much. Um Mister for that lovely presentation. Um I don't think, OK, the other question that I think it hasn't been answered yet is about the slides. I'm not sure whether I, when I veered off for a few seconds, you've answered that. Someone asked whether the slides will be provided. I've only replied in the chart Boxx. That's um normally if the speaker is happy for these slides to be shared, then we would upload it on me as a catch up content. And um of course, for the recording. Yeah, for the recorded version, I think someone asks about whether it's gonna, whether it's going to be recorded or not Yeah, that's all our sessions are recorded. So you should have an access to that at some point later today or tomorrow um at the latest. So I would um I would let um everyone else. I don't think there is someone I just see. I think I also saw your chart pop up. Now, let me have a look at that a question. Please invite me to your future classes, hoping to review your video, hoping to review your video of this. OK. Yeah. Thank you. Thank you. Thank you very much for that. Um All of our subsequent sessions would always be the um be published and um broadcaster on um all the communities or in all the communities. If you a me, if you're a member of si definitely, you should get an invitation. And if you're not a member of G I will join you see to join via the, the link CgA dot org. I've um popped that onto, onto the chart box earlier on and I'm doing that again. Now, if you check the chart box, you should see the link to C gov if you want to join, if you are not yet a member and um you've, you've got access to all of our teachings, um mentorship and um also research activities. So once again, thank you, Mister speaker. Thank you everyone for joining us and waiting till the end. I know this is um weekend that you could have just used this time to do something else. Boy, you've um sacrificed these um few hours to join us and I'm sure it's um, it's worth it. Um, feel free to email us or um, you can get onto the website and you will see all the contacts of the, of the leads and the executives there. Feel free to email any one of them if you have further questions. Thank you very much. I will call it a wrap now as there and no, as there are no other questions. If I'm someone is asking about this account has been suspended. I'm not sure what that is all about. Um Can you make it clearer? Doctor Addy? What, what do you mean by the account has been suspended? Is it your account or someone else's account? What do you mean the link to C guff? Oh, I see. I see what you mean. Um Let me have a look. That would be, I shouldn't be except it's a new development. Um One second. Uh Yes, I will leak. Ok. You, I think you're right. There must be a glitch. There must be a glitch. I would feed that back to the technical team that must definitely be a glitch. Um The, the website was still working today earlier today, so I think something must have happened. Uh probably the traffic or whatever. I'm not sure, but I will get, I'll get that sorted. Thank you for raising that Doctor Adi and Um, hopefully the, the website should get back and running very soon, but I'm definitely sure it's just a glitch. Thank you. Thank you. Thank you everyone. Um, so we'll call this a wrap and, um, I'll say good evening to everyone. Thank you to our speaker again and we would see you all at our subsequent, um, sessions. Have a good night. Bye. Thank you. Bye bye. So, ok, the tunnel.