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OK. Hello everyone. We are live now. Welcome to today's teaching events from general surgery community. Um, here with me is Mr Ong, who is gonna be the speaker for tonight's teaching. Um It's acute appendis. Um Could you just indicate in the chat box? You can hear me clearly confirmation that everyone can hear me? Mhm. Yeah. Yeah. Can everyone hear me? No. Hey, that I OK, perfect. Um I think I've got, I've got an answer on the chat box on board and I'm audible. Um Mr speaker. Oh, she proceed. I'm going to be you on now in a couple of minutes, but we just wait for more orders to join. We just give them like um say the next uh five minutes thereabouts just because there is 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've just rounded off so we'll just give them a bit of time to join us if that's all right. Oh, 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 715 on the dot Officially, we just be waiting for others to join in. Ok. Ok. And 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 rounded up and uh we wanted um the attendees of that event to also participate fully in these events. 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, Sho um, the SG General Surgical Lead and um, Sigal stands for Surgery interest Group of Africa. We've got um, lots of communities in SG, a general surgery is just one of them. And um at present is the most populous community in CG. So if you wanna join CV, um I'll put a link in the chat 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 Mr O Yeon is um y who um finished from lawsuits as um the best student developed. How do you call that? But oh, my tongue is twisting. Now, help me someone actually. So, um if 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 in last, in 2017 is presently in the UK. And um, he's um, a clinical fellow at um, the Friendly Park Hospital in 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, my two drive the box. Thank you. You can unmute yourself, sir. Yeah, good evening. Thank you very much doctor, uh doctor. You know, the name sounds like my, you know, anyway, it's nice to be here and good evening everyone. My name is ok. There you go. And I'm here today to have a chat with us about a, uh, a exercises, just a friendly chat. And I think you can always talk me or mute yourself. If there's any clarification or you want during the presentation or you can decide to wait to the end for the questions or clarification. I think anyone's fine by me. And yeah, do doctor introduced to 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 II can't see how many people are currently on the uh uh let me see if we are ready to start and yeah, so we we've got at the minute we got, I think I can see you about 20 on the call. I sure that 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. Mhm Yeah. Can you hear me loud and clear? And can you see my sl Yeah, very clearly. Ok. Yeah, that's fine then. Good. Ok. Um Once again, my name is and Greta from Lau I Lagos, Nigeria and we can move on. So as an introduction, um I'm sure every single person will a bed or seen a a patient with it acute appendicitis, whether confirmed or as a differential diagnosis. And it is the most common general surgical pathology in all part of the world. No matter where you come from, hyper appendicitis will always stop in terms of the surgical, general surgical diagnosis. And as a trainee, I think that's one of the, uh, main surgical procedure that we all want to do as the first mi, um, surgery. And I think that's the first one. we consult and we feel, um, will feel the ease to, to let you do whether supervised or not supervised. But as it, 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 minute to talk about the appendix. And the full name is the very form of appendix. And it's a one like diverticulum that arises from the poster medial wall of the cecum very close to the lal junction in terms of the size diameter and position. It varies, not just with age, even in the same age group, you have it in different size diameter and position. And I can tell you, um you can have an appendix as long as 20 centimeter and I've seen some acute uh uh some appendectomy done with a very, very large and dilated appendix. You almost think it's another organ entirely. I it is usually intraperitoneal. It has its own meso appendix, which is very important in the surgery and the dissection to remove the appendix and to supply by a single end artery, the appendicular artery from your colic artery. I will sure this, I hope you can see my coop. So if this is the appendage, then the whitish stuff here will be the mesoappendix and the appendicular aone along is free edges. So it says an tree. So in any thrombosis occurring within the appendix artery, the tip of the appendix will suffer most lymph nodes from the appendix and all the surrounding structures usually who end up in the ileocolic node very close to d appendix. And this is very important because of some differential diagnosis that we usually come across in acute 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 vital when the appendix goes behind the cum, uh you probably need to fling the cum to be able to assess the appendix that will cause us 74% of the time. I think the next one would be the pelvic. Also the full 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 one. 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 muscularly and the CSA. But the histology is more renowned because of the lymphoid follicles with some individuals are postulated that this is actually the function of appendix to help with, um, immunity. Well, there are some questions here. Just some green cigars just for us to something to think about before the, before we start the main presentation. Um, I don't know if doctor that can build up the pool now or I have to be the one to do it. Uh Yeah. Yeah, I can bring it up. Um Do you want this particular one you're sharing now or? Yes. Yes. This particular 1. Uh 2525 year old. The, the, so um I don't think we've got this particular one. OK. I think I'm just, you know, I do. You want to include it yourself now? Yeah, I think. Yeah. No, no, no, it's already 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 II II did something like this. OK. Yeah, I didn't include the old 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. And the question is already on the screen. So it's about a 25 year old male with migrate the right electro clean. He has some fever. He's nauseous anor on examination. We b tenderness in the right electro leukocytosis. And the clinician thought that this was aci and he decided operative management was the way to go. But sometimes during acute appendi uh doing 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 organs it 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 answers. Good, good. No. Yeah. So we, 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. Oh, 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. But again, we just test running a particular function in this event and that might give few persons access to use the mic. If you are able to use the mic, just put it on the, you can unmute 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 polls 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. We'll wait. So we just, we just, we just collect the answers and then we wait to the end to see to be fine before. Yeah. OK. Thank you. 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 sounds. So the second pole is on. If you want to cast your votes, you've got five options. The following can cause acute appendicitis. Except if we call it B intestinal worms, C, cecal tumor, 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. Ok. Moving on, um, acute appendicitis can resolve by itself without surgery or the use of antibiotic. Do you think that is true or false? Do we think a, a, an ultrasound for example, an ultrasound called a appendicitis. Do you think it can resolve by itself without surgery or do you have antibiotic? Yeah. So that's also live. Now depo is live cast your vote for either true or false. Give it another 15 seconds and the speaker will carry on. Thank, you can carry on. It's anonym. 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 40 degrees. He has also had an upper respiratory tract for the past week and on examination, it was mildly tender anac fossa but it was not ging, there was no rebound tenderness, white cell was normal and there was no neutrophilia. Yeah. 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 leg was uh a day history, 40 degree fever, some, some upper respiratory tract infection with a and if we, if yeah, because we do see a lot of Children uh um uh maybe up to five years, this can up, 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. Ok. Oh, this is not part of the pool So I just run over it. A 20 year old male with migratorius pain has fever, nausea is an abound tenderness and examination in the fusa. Um He has leukocytosis. What do we usually do to compound the diagnosis? I'm sure everyone sees this in whatever practice they do. Question six is part of the po 2. Um 70 year old male with might get to right electro pain, fever, nausea, anorexic A 10 in the right electro cle leukocytosis. How will you confirm this diagnosis? What 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 chat 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 pool. 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 II was gonna say a 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 inside is a very, um, popular topic. So I'm sure everyone has a very good idea of the questions even before the presentation. Yeah, I think you can continue on boss. Ok. Um, yeah, we'll come back at the end to have a look at this. So acute appendicitis, I'll 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 let it. So a form of e epidemiology aci is relatively rare in infants. 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 tests would say uh it peaks between 20 to 30. But I would say this is a disease of adolescent and very young adults. Yeah. After middle age, the risk of developing acute appendicitis is quite very small but somehow we still see 60 year old, 70 year old come with a appendicitis. The incidence of um appendicitis is equal among male and female before puberty. After puberty, there is a little bit more male than compared to females uh in take of ology in, in um n 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 that they do have fluid culture and the most common organ was um E coli but s generally, but even though G negatives are the ones being cultured more often, it is actually a mix of both S and anaerobes. So in terms of active side, is causative organism need to be mixed majorly gram negative with anaerobes. And which is why our antibiotic therapy needs to cover both anaerobes and GM negative. Even though a little bit, maybe about 2% can also um be caused by GM positive in addition to the ana and ana. But the major part of ology is that there is Luminal obstruction of the appendix, the appendix as you know, is blind, it has a lumen just like any other bowel and anything any material can enter into the lumen and obstruct the append most commonly, this is done by Folli, but any other structure has also been found to cause things. Any foreign body, me 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 active appendicitis upon in the distal end, not the whole length of the appendix. If the obstruction or caused just at the beginning of the appendix, then you then most of all the appendix throughout his legs would then be inflamed, strictures, foreign body. I have weakness and appendicectomy in a child. We made a cut on the appendix after dissected and we're almost done. And immediately we cut the appendix worms were entering into the peritoneal cavity. It was really good. So I I'm sure you can imagine loads of very tiny worms. So worms could also obstruct a cup of tubal. If there is a tumor in the cecum very close to the opening of the appendix, or the tumor migrates towards the opening and obstructs it, that can also cause acute appendicitis. Because once this happened, the appendix mucosa keeps on producing mucus, the mucus distends, the appendix, the mucos cannot backflow because of the obstruction. This causes an increased pressure within the appendix lumen. The pressure eventually will cause the venous, a 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 stasis 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 then absorb the artery. Uh once the arteries, when the flow of the art of the appendix artery is reduced, then it's ischemia of the tip. Like we said, the main artery of the tip of the appendix, it becomes ischemic, gangrenous pate and release the pus, which is the mucose that has now been to, to pus by the bacteria a acting on it. And in terms of if you're wondering what efi it is efate contains of some is in which is means very dry material that is mixed with some calcium salt. A lot of bacteria, of course, the pilar shedding also everything together forms a fate and it is usually pain with your big on X ray ct scan, you can always see it very with your because of the calcium content. And in most cases, that is what obstruct the appendiceal lumen. But one other very important cause of obstruction, different from foreign body or something physical entering into the lumen is lymphoid hypoplysia, just like you said, the appendiceal histology we showed earlier is renowned because of the presence of the lymphoid follicles. So when we have some respiratory illnesses via volemia or for whatever reason, this lymphoid tissue or lymphoid follicle within the appendiceal mucosa can multiply lymphoid hypolasia and this multiplication makes the mucosa more swollen and then they can occlude the narrowing. So the lymphoid in the two wall of the appendix because the appendix abdomen is actually quite very small, usually about two millimeter. So the uh the hyperplasia going on with two mucosa and gorges the mucosa and that can also close the lumen if the whatever whatever causing the um immune to the gone, if that's is affected. Well, the lymph hyperia can resolve whatever is in the appendiceal can drain. But if that doesn't a the same part of physiology that was explained them a and cause ay. And it is because of the 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 cataract. Like someone having an upper tract infection with the bia from whatever cause can cause the lymphoid hyperplasia or if not the lympho hyperplasia, it could be directed from a physical body which is explained causing the obstruction. We've already explained how the ischemias will occur. But if you remember our anatomy, the policeman of the abdomen, which is the great a it goes everywhere there is inflammation. So if there is an inflammation in, in the appendix, it goes there far 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 prevalent materials. And the like if the appendix eventually perates. But this caused something also in, in, even though the great element is trying to do a great job being a policeman, it can form a flag mono mass. And what this means is that while trying to rub the appendix, it can rub the s with it, it can rub the terminal along with it and everything becomes a mass in the and within the mass. If the appendix successfully ruptures, pulling out the pus in it and it can form an abscess also within the mass. Very rarely, appendiceal inflammation can resolve. And when it resolves the pa within, it can become cleared to leave just the appendi itself filled with mucus. And that is what we call a mucocele of the appendix. You have an obstruction, the appendiceal lumen, the only thing you have in it is mucus, no bacteria, no infection, whatever inflammation that was starting initially did not progress. It has requested. Maybe because there was some successful drainage or backflow of the mucus back into the cecum or for whatever reason, the inflammation set to the appendiceal has very clean mucus, very sterile, of course. And then all the symptoms are big. So what are the different things that can happen from a patient has just like we've tried to explain, I just want to it, there could be a resolution whether spontaneously or with the use of antibiotics. I we understand how this can um resolve based on the path of theology that we explained. An abscess can form the access 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 cecum. 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 Doctor can get into the subhepatic space and get just beneath the. And in some cases, just like Thursday, we did a case, the pulse was found in all the quadrant of the abdomen, puss in the pelvis, pulse in the right, in the pa S area, right gutta, there was pus su surrounding the liver, it was p around the spleen. There was pus in the left, left psa this can happen. Uh And of course, that is because of the confirmation they have there. And in that type of situation, we say the patients will probably be with the generalized the appendix. The old appendix can become gangrenous. It's not just the tip, the tip is the most um the teeth based on the end that form supply is the one that is most prone. But your appendix can from umbrellas, there could be an appendiceal mass, which is the phlegma that we discussed. Sometimes the infection can track to the appendiceal vein back into the portal vein into the liver. And there is a 10 subacute appendicitis, chronic appendicitis. I think recurrent appendicitis, subacute appendicitis, chronic appendicitis. I think they also spread of the same thing. Basically, someone had resolved for whatever reason came back, result for whatever reason. And then we said patient has maybe now one makes the appendix or what are the risk factor. Why an appendix? Will it very, very early. There are some patients that will tell you, oh, these history started yesterday. Are you going for the surgery and you find pulse everywhere. How come you palate 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 operate early because it is going to perforate very early elderly patients, patients that are immunosuppressed, there's nothing stopping the inflammation going on diabetes mellitis. So we can we know why that would be. And of course, if we call it obstruction. So because so if if we do a scan, even an ultrasound and they tell you, oh, this patient has A B and not just that we could actually visualize the fit, then you know, this will more likely it is not treated because the fecal it is not just going to dissolve, it has calci, it does everything. So it will probably progress through the continuum of the part is a pelvic a, a pelvic appendix, a pelvic appendix is not surrounded by anything. It's very hard for the policeman of the abdomen to go and contain that may likely 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 I did a lot of artesian has stopped the migration of the greater omentum and that can also cause a perforation of the appendix, obesity because you don't detect it in time because of so much fat. There is no localization, even though there is localization, you probably need a very deep pressure, you're able to get it. And before you know it, you waste your time on this operation. Everyone knows the typical history of a starting periumbilical moves to the right side. 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 electro and has been in the right electro face, maybe 40%. You say that then the other 10% the one out of 10 will tell you where is the all lower abdomen. It pains that it is all lower abdomen, it is through the lower abdomen. But one symptoms which are not usually happy when um an individual class is suspected acute appendicitis and does not act for anorexia. Because this is like the most common feature. Like we said, the Migra 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 re or symptoms of aci anorexia. And that is why we have the famous AM sign. The Ambu 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 restaurant would like an hamburger. And once they tell you and this, you ask, oh, ok. Do you feel like eating this particular food? Now, if you bring it to you and if you say no, I don't feel like eating, why would you know, to eat your best food? Probably because you are a and that means you're positive and of sign nausea. Most patients are nauseous apart from being an and they will usually have one or two episodes of vomiting, especially in Children. If your pa if your patient presents to me and is telling me I vomited about 10 times. Mm My mind is already biased. This cannot be out to the side if you will be permitted, not so much pain in the right and left. First, of course, I think that is also one of the most constant symptoms, whether it was migrating or whether it started the it still the 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 acute 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 referral from Ed and the 12, this patient is having low 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 acute appendicitis. And I would not expect the 24 hours acute appendicitis have been so complicated that you're already very septic. I mean, 3940 degrees. So usually if a child especially comes with a fever, greater than 38.5 most times appendicitis, usually less than 38. But if they are coming with a fever better than 38.5 I will be thinking of something else. But if they have fever, I still tender in, in the right electro, then the diagnosis will probably be mesenteric adenitis and that is inflammation of the lymph node present within the mesentery 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 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 a diagnosis of mesenteric adenitis. Some people makes may tell you the about this type of pain before. Well, that doesn't mean it's not a appendicitis. Like we said, there's a thing called recurrence of a chronic appendicitis. So maybe just maybe and there might be positive and you see all these are normal, really important. But the few um history is given both is the main history that you would get from a patient with appendicitis. Sometimes it can be atypical, maybe 10%. Usually in adults. Oh, my pins are in right and left side, it right and left side. That means is predominantly somatic or it could be predominantly visceral and it's poly localized. Oh, well, between just around my umbilical cross. And yeah, I can't really describe it. Uh Yeah, fine, but it could still be a appendicitis that very atypical the inflamed appendix is a pelvic type just lying on the bladder on the rectum, all the free space between the rectum and the bladder. Mm That could cause suprapubic tenderness that could cause the rectum to keep pushing. That is tennis mo and it can be passing loose stool and still having the urge to pass most too. Even if nothing comes because of the stretching, tennis, most of the rectum because of the inflamed appendix on it. Yeah. But sometimes we'll get this through examination. Some of these signs include fever tenderness c which you said your bund tenderness is very, is very important. A lot of science has been described sw some of the signs are depicted here. So sign means you um I stand a while I standing, you are stretching the swab and the append this line or need will get displaced and that causes pain obturator, the patient flexes the hip internally rotate and that the OBT and the ator touches the in the pain and the pain. Um Do you want the ed physician like a lot is the same? You put the left, left fossa and then the patient has pain in the right left fossa. We discuss about um the different presentation based on where it is. Some people have diarrhea because of the position of the appendage, which you said also appendicitis in pregnancy is something we see also usually more than every 2000 pregnancy. It is the most common acute adenic condition in pregnancy. It might well, uh it should be remembered as a differential diagnosing patients who are pregnant with um abdominal pain because it is associated with about 3 to 5% fatal loss. And in a lot, in many of them, the appendix can also perforate and that also um is very important because the perforated appendix increases the risk of fetal loss also. But the way we diagnose is uh most times the s home is not so mobile. So even with the pregnancy, the typical right and left flu pain and tenderness will probably still be there. And a lot of depression diagnosis are there for a gastroenteritis and adenitis make diverticulitis which needs to be suspected in surgery when the appendix looks normal into cept lumbar pneumonia on the right in adults. Any other form of enteritis, I do have a lot of ureteric colleagues, especially when the stone is now in the V UJ, the pain is localized in the right path pertricosa. I think this is what we call the Valentino fine when uh the perforated gastric or Aaden and the content migrates to the right, uh it got down to the right left and you feel the where the patient has a per to you should always check the tests. And I think especially in Children of caution because sometimes we can really tell you all the there is also pain in my testis female population pain P ID uti atopic 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 divertic colitis and also the colonic carcinoma in elderly, they have a lot of diverticulitis that mimic. I seen someone taking a divertic to take that because he said he did a clinical diagnosis of ait and in surgery, appendix was fine. The sigmoid colon was extremely inflamed. The colon can flo and move around causing pain with elevated white cell course colonic cancer, especially the cecal cancer. The cecal cancer in elderly can also cause pain and also cause appendicitis. And everyone should try and know the score also called the mantel score. The man score is a new for us to remember the um what are the things that are scored in Aldo called in mantra? Ma N Tr E LS. And these are the score and it's just the typical symptoms. If these are the only things you ask from your history, I think your history is good enough. Is it migratory or is there an noia? Is there nausea? Is there vomiting on the examination? The fossa is there localized peritonism which we don't tenderness is there, fever is there elevated white cell count? My second is usually elevated in about 90% of the side. So this is the most common score and I think we should familiarize myself with this. 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 others going most of them, the score score and a lot of others in terms of investigation, investigation for blood count, he 90%. So the things that you, yeah, you for surgery, pregnancy test in female group on co in case you want to do surgery, most anesthetist will not let you do an appendectomy. We have at least one group and say um a xray most times we don't do it. But if there's an I call it, if we call it, it is also called appendicular, then you might see that if the appendix has ruptured already, you may have some FG ultrasound most times, especially in Children and teen adults. So we cannot go obese 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 will be about eight mi eight millimeter or more in the end is distended and dilated and some other secondary changes of ACI 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 older patients because in a lot of older patient, you think they have a appendicitis, they are not in the age range of retina app even the C we need to rule out. Could it be diver lysis? Could it be personal obstruction with sick and dilatation and pain? B A seal tumor uh by an MRI and an 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, but usually we'll probably do an ultrasound test in both groups. Well, this is CT scan very sensitive and there's a lot of research going on that all patients with suspected acute appendicitis should have act scan in the western world in the United States. Many of they are trying to ensure that all patients after surgery have act scan because ultrasound keeps missing because it's operator dependent even though you are very secure about those 80% and you miss the two out of 10, that kind of service. And you say, oh, the ultrasound say there is one so 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 it or can it? This is the CT scan. If we look here, we can see this dilation here and the fat stranding. 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 so fat strength and that is inflammation. So inflammation with a structure here that is dilated, um blind ending. That will probably be the it's called the s will be somewhere here in your right. That same here, you can see this distended structure coming from somewhere around the s here. And you can see it has two things you call it one here and this is probably the one causing the obstruction because the lesion starts here and there's another one there. So that will also be a appendicitis in terms of treatment. Um majorly all over the world, it is accepted that appendicectomy should be the treatment but however, um you can also support patient, especially if patient is septic with intravenous fluid antibiotics and it gives the antipyretic. But recently, also, there is a lot of study if, especially if you are in the UK, there is ac a trial that compared what if we don't do appendectomy for our patient. What if we chose do antibiotics? And it has been a lot of interesting um results and about 25% 75% of patients with antibiotic will actually recover and doing the surgery. And the recurrence is if the study, different study with different data, but most times about 25% of patients you treated with antibiotic, that is one out of four will come back with appendi appendicitis the next year. So I think that is very important when consulting your patient or you don't have to have surgery. Antibiotic also works in up to 90% of cases. But even though it works and you're able to go painfree in the next one year, there is a one in four chance that you come back with appendicitis. Again, he love of study. We talked about what an appendiceal mass is. We talked about what an appendiceal abscess looks like. Mm We said that because then how do we then manage a complicated appendicitis? If even though we know no complicated app, we go ahead and remove the appendix. What if there's an appendi abscess? An appendix 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 appendix. You drain the abscess, then you then excise the appendix. Sometimes you go, you don't see the appendix but uh from the mask, 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 a stone left that you can tie occasionally dual appendices, gangrenous. And then that there is a problem there. If you remove the appendix, 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 gi stapler, anest stapler across the base of the second just to close the o and a lot of other things um works appendix, you can toilet, pour a lot of water in the pollution to uh solution to pollution is dilution and they remove the appendix after you. You will get the well, then there is something called appendiceal mass which you said, which is the one and there's something called national regimen. This is not usually used anymore, but I think it's still something that we need to know. You are not meant to do appendectomy. If you think the patient has an appendiceal mass because you can't even see the appendix, everything is loaded up with the little mental force and everything. So most time it just, and the process of treating is called sharing regimen. 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 g peritonitis. Then you need to do a consult. You probably ignited. Uh These are the things we do in surgery. A lot of different sensations, laparoscopic appendectomy is what is recommended worldwide for all sort of patients. Whether pregnant patient, Children, adults, where you put three parts 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 three walking instrument and that is that this, this will be the cum and we don't really want to talk about appendicectomy for. These are just things about appendicectomy and we'll talk about appendiceal mass, just natural regimen. And what it entails managing conservatively weak IV antibiotics. Keep checking the vital signs as frequently as you can and show an input 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 palpate none of these patients to see if the mass is increasing. Despite your conservative management, if there's an abscess, you can always do the abscess, ultrasound, guided or c guided. You don't need to do surgery. And again, something called interval appendicectomy in which you do six matrix has also been abandoned. Most people also don't do that anymore. Once the flare is gone, you just let it be because it has also been safe 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 ill, we we take you to examine just like any other surgery because the cause of the fever and being unwell can be familiar with postoperative complication with infection, abscesses in different places. Uh leaky pillars, atelectasis, clots, enterocutaneous fistula. If the stump is leaking many years, they can always developed by dec biosorption. So I think in conclusion, because the time is far spent in conclusion, like appendicitis is probably not preventable and this will continue to occur and see a lot of doctors in this group, some of us will probably have had appendectomy before, but it's also very common and there is nothing we can do to prevent it. So surgeons need to continue to learn more on the different surgical technique required in this management and a lot of research we keep on ongoing to see what other way we can manage. Appendectomy. What did I will we can manage to back it up and decide it? 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 were 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 for that amazing presentation. I learned a lot personally and I'm sure every other person as land at least one or two things from what's you've um spoken to us about today. Yeah. Uh Before we take questions, I think I'll just quickly go through the pool and see. Yes, we, yes. Before the give me more. 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 poll now, one after the other and um would take other questions afterwards. Thank you. Yeah, thank you very much. Um, looking at the poll now I think the first question I have here is what type of obe is usually cultured in a appendicitis. And I think, like I said, it is a very popular topic and 42% said it's probably a mixed floor which we probably saw, uh, during the present. And that is absolutely right. All right. Um, sorry to, um, interrupt the first po is actually, um, acute appendicitis can resolve by itself without surgery or antibiotics if you go up a little bit more. Yes, II can see that. Um Yeah, about 78 percent. So, 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 appendicitis where the obtrusion was caused by the uh lympho hyperplasia, including the lumen. Or if the bia resolves, then that of occlusion can resolve and appendicitis can resolve. Then we've talked about the organism involved and we talked about which of the following can cause heart attack and the sides except uh, yes. Again, everyone picked excessive large me by its own side of side effects of that. Yes, that would not be a cause, but we call it worms, fruit and vegetable materials. Cum more. All these can cause obstruction of the appendiceal do and cause which you also said. Then we talk about a three year old boy with um, a day history of abdo pain, 40 degree fever. And the list of tract infection was tender in the right elect. But there was no lo um, no local per white cell was normal and 94% of people think it's probably another diagnosis. And I'm so we see that also a day to 40 degree active, there is no complicated, less than 24 hours of onset of abdominal pain or probably not have a fever of the not talk of 40. But still, we can always still do an ultrasound. And the ultrasound will confirm the diagnosis, which is most likely in the same pain adenitis. And finally, a 70 year old male who are all the signs and symptoms of appendicitis. And you wanted to confirm and they t between ultrasound and ct abdomen is THS 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 duct appendicitis. What we usually do is a CT scan abdomen and the to out especially a tumor, including the appendix lumen or a diverticulitis, which is very common within the age group. But any which way we will probably after discharge also do. There's a question like that. We probably after discharge also do a colonoscopy, even though the CT scan doesn't show a tumor, we still do a colonoscopy because the CT scan can always miss a tumor. In fact, ct abdomen pelvis is not the good standard for picking up the bowel cancer, the colonic cancer. And I think that's the end of the poll 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 chat box, the ultrasound. I think everyone outside that said ultrasound. So yeah, exactly. So you, you need, you can just read out the question to them so that they can know which one we are addressing now if that's all right, please. So if so if we look at this question, we said a 20 year old male with mito pain fever, nausea. And also as you, then I will confirm the diagnosis. Obviously, just like everyone has said, you will need to um confirm the diagnosis with an ultrasound. There is no need to do act scan for 20 years. We're not really thinking of any major pathology in the right, especially in your know, even if it is a few will still be the best because an ul will still tell us about uh an o pathology even though it might, it might not be as accurate as it ultrasound. So this will definitely be the way to go. And yeah, we already talked about single most important outpatient investigation with this patient now. So usually there is a debate within what the cutoff should be in converting from ultrasound to act 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 acute appendicitis, you, uh we've already said, um it's more common within adolescents, early, uh young adults. Anyone above 40 should probably have act scan and I'm sure if you win, they'll probably agree to do abdomen. Probably see, you might be it up inside. And so, and almost get it. I also said that in pregnant women, laparoscopic appendectomy is still what most people will do if the uterus has pushed away the appendix on the right and left side, it is very easy to tackle compared to if you do an open in the MB point and you don't find the appendix because the uterus are pushing a very mobile s up into the subhepatic 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 laparoscopy open is very well. Ok. We already talked about the constitute of the mass of the appendiceal mass. And we also said a little about how to manage an appendiceal mass. So if you have an interview and the patient is free appendicitis act scan, confirmed in mass, it is better. You tell them you will not manage operative. Yeah, thank you. Awesome. Awesome. So I think someone said, is there any atypical symptoms in diabetic patients or who are 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 atypical. 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 in the tummy, but the patient is immunocompromised or what whatever reason, immunosuppressive medication from transplant chemo or radiotherapy. But they complain of abdominal pain. Usually they complain of abdominal pain with the rising white cell shoot while I see the abdomen and pelvis to rule out any pathology going on because you can't really assess them. The local irritation in the right left fossa is usually due to you being immunocompetent 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 loss of really of uh suppress, you can't fight the infection. Your appendix can be inflamed and there is nothing to suggest it on the examination because the look, the peritoneum, the pata peritoneum, the right is not inflamed. You can't respond to the inflammation. So typical atypical will still be patient is nauseous. Complain of abdominal pain is analgesic blood are the veins elevated C RP white cell. Then you probably need to get an abdominal pelvis ct scan. Now someone told me to clarify, someone put in the chat first to clarify the part of the, of the migration. I remember this was a very common question by so usually OK, the appendis or the bar generally the full got mid got and got that. They usually get pain. Fibers are usually autonomic, meaning what carries the pain sensation is usually sympathetic or pass. But most times the pain is from sympathetic and sympathetic to the abdomen to the uh bowel would be from the plastic nerve, but most especially the one to the appendix is the 310 sympathetic nerve fiber that takes it to the spinal cord to the CNS. And we know that the dermato for 310 is around the umbilical. So when there is a visceral pain, pain from stretching or ischemia of the appendix, the teeth, pain, sympathetic fiber carries it to the C NS and the CNA reads it as a somatic pain occurring in dermatum of teeth pain. And then you have pain around your umbilical. But once the inflammation in the right push up progresses. The main fact that the appendix is touching your arteria, abdominal wall is touching the peritoneum, the peritoneum on the arter abdominal wall, that inflammation in the appendix will cause the pa peritoneal to also be inflamed. The peritoneum is somatic. And that experience pain, appendis itself does not experience pain because it's vis if it stretches or ischemic, that's the only pain that bowel can feel. And if, for example, if we don't do bowel resection, 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 Viser. The Viser pain is usually from distension. But the Pieta Peritonei, the inflammation from the appendix that touches the Pieta Peral, it makes a very distinct pain in the right left. F and when you disturb that with pressure, the patient has a lot of pain. And by that time, the C Ns forget about the very dull visile pain occurring in the pain um and concentrate on the immune, severe pain in the right leg vessel. I hope I tried to simplify that as much as I could. So someone said, would non radiating MRI scanning be more sensitive and safer than when treatment for possible. My league me. Yes. OK. So now the thing is that what in the setting of a an 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 AIT is there two MRI is always very expensive. Even the hospital do not want people to, to for MRI, even though they can, it as long 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 a appendicitis has been recorded to be up to 1% in some studies. So in terms of being very sensitive is comparable to MRI, you know, from CT scan abdomen and MRI, but it does obesity but maybe, but that you said, you know, the price of MRI and the time it takes for MRI, maybe CT scan will still be the go through and most times c um colonic tumor are not to be treated immediately. They usually go to an MDT before a decision is made. So CT scan, colonoscopy and outpatient will probably still be better. And that is the guideline. You 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 cut off um for a few seconds at some point. So I have to switch to another gadget. Um Anyways, I think we are all caught up with the questions in the chat box. We've, um, talked about the polls 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, I think, um, it's safe to say we could wrap up this session very soon if there are still other 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 act depending on whether it's a child or an adult and depending on their, their age basically and other other symptoms and, um, signs you've 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, routinely done. Um, colonoscopy should be something, it's like an added, 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 mildly 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 Mr Yom for that lovely presentation. Um I don't think, OK, the other question that I think it hasn't been answered yet, it's about the slides. I'm not sure whether when I veered off for a few seconds, you've answer that someone else, whether these slides will be provided. I've only replied in the chat box. That's um normally if the speaker is happy for the slides to be shared, then we would upload it on meal as a catch up content. And um of course for the recording. Yeah, for the recorded version. I think someone asked about whether there is gonna, whether it's gonna 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 just saw your chart pop up. Now, let me have a look, but that's 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 broadcasted on um all the communities or in all the communities. If you're a me, if you're a member of CV, definitely you should get an invitation. And if you're not a member of G CGI will join you, see to join via the, the link CG dot org. I've um popped that onto, onto the chat box earlier on and I'm doing that again. Now, if you check the chat box, you should see the link to gov if you wanna 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 until the end. I know this is um, weekend that you could have just used this time to do something else. But 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 on the executives there, feel free to email any one of them if you have further questions. Thank you very much and we'll call it a wrap now as dear. I know 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 ad what, what do you mean by the account has been suspended? Is it your account or someone else's account or do you mean the link to CV? Oh, I see. I see what you mean. Um Let me have a look. That would be, I shouldn't be, except there's a new development. Um, one second, I'll just have a look. 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 had 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 at the time. Second. Yeah. Yeah. Yeah. Mhm. Yeah. Ok. It.