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Acute Appendicitis (Inflammation of the appendix)

- Appendix - true diverticulum of caecum that prone to inflammation and
obstruction, why???? (Empties inefficiently & small lumen)
- >> adolescent and young adults
- Males > females
- Diagnosis difficult to confirm :
DDx:
- Mesenteric lymphadenitis
- Acute salpingitis
- Ectopic pregnancy
- Mittelschmerz ( pain due to minor pelvic bleeding during ovulation)
- Meckel diverticulitis
- Etc
Predisposing factors/Etiology:

1) Obstructive agents:
- Foreign bodies:
animal (e.g. thread worms, round worms) ,
vegetables (e.g. seeds , date stones) ,
mineral (faecolith = common cause) *composed of inspissated feacal material, calcium
phosphate, bacterial and epithelial debris
submucous lymphoid tissue hyperplasia leads to obstruction


2) Infective agents:
Primary infection leading to lymphoid hyperplasia
Secondary infection caused by pressure of an obstructed agent leads to epithelial
erosion and bacteria gain access to the wall
Both aerobic & anaerobic organisms are involved including ( coliforms , enterococci ,
bacteroids & other intestinal commensals )
*no single organism responsible, mixed growth of aerobic and anaerobic is usual
Epidemiology
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Pathogenesis / Pathophysiology

Obstructive and infective agents
Obstruction of appendix lumen
mucosal secretion and
inflammatory exudation continue
to increase intraluminal pressure
Eventually, the increase in
intraluminal pressure leads to
arterial stasis, venous and
lymphatic obstruction
With vascular compromise,
ephithelial break down and
bacterial invasion occur
Tissue infaction
Appendix wall ischaemia
Ischaemic necrosis of appendix
wall
Perforation of appendix and
spillage of appendiceal content
into peritoneum
Generalized peritonitis
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Risk factors for perforation of the appendix
Extremes of age
Immunosuppression
Diabetes Mellitus
Faecolith obstruction
Pelvic appendix
Previous abdominal surgery (limit the ability of greater omentum to wall off the
spread of peritoneal contamination)

Clinical diagnosis
1. History:
Symptoms of appendicitis
Early stage
Poorly localized pain (midgut visceral pain in response to appendiceal inflammation
and obstruction)
Frequently first noticed in periumbilical/epigastric region
Similar but less intense than colic of small bowel obstruction
Normally associated with anorexia, nausea and vomiting
Progressive inflammation
More intense, constant and localized somatic pain (irritation of parietal peritoneum in
right iliac fossa (RIF) region
Patient complains of abdominal pain that shifted and change in character
*Summary of symptoms of appendicitis
Generalized Localised
Periumbilical Right iliac fossa
Less intense & colicky more intense & constant
Associated symptoms
Indigestion
Discomfort
Flatus
Need to defecate
Anorexia
Nausea
Vomiting
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2. Physical examination:
Clinical signs of appendicitis
Slight pyrexia (37.2 37.7c)
Slight tachycardia (80 90 bpm)
Localized tenderness in RIF region
Rebound tenderness (If gentle pressure is applied at the McBurneys point, it will feel
tender. If the pressure is released suddenly appendicitis pain often will feel worse
which is due to inflammation of the peritoneum overlying the appendix area.)
Guarding (the tensing of the abdominal muscles in response to touch. This is indicative
of diffuse peritonitis caused due to rupture of the inflamed appendix.)
Limitation of respiratory movement in the lower abdomen

Signs to elicit in appendicitis
McBurneys sign
- Deep tenderness at McBurney's point
- Specific localization of tenderness to McBurney's point indicates that inflammation is no
longer limited to the lumen of the appendix, and is irritating the lining of the
peritoneum at the place where the peritoneum comes into contact with the appendix.
- suggests the evolution of acute appendicitis to a later stage, and thus, the increased
likelihood of rupture












*McBurneys point is at #1
It is the point over the right side of the abdomen that is one-third of the
distance from the anterior superior iliac spine to the umbilicus (navel)
Rovsings sign
- If palpation of the left lower quadrant of a person's abdomen increases the pain felt in
the right lower quadrant, the patient is said to have a positive Rovsing's sign and may
have appendicitis.
- this maneuver stretches the entire peritoneal lining, then the muscle fibers in that area
will be stretched and will hurt
- Only causes pain in any location where the peritoneum is irritating the muscle
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Psoas sign
- Occasionally, inflamed appendix lies on psoas muscle and the patient will lie with right
hip flexed to relief pain
- Psoas sign : the patient is positioned on his/her left side and the right leg is extended
behind the patient and if this results in lower right sided abdominal pain the sign is
positive of inflammation of appendix












Obturator sign
- indicator of irritation to the obturator internus muscle
- first the patient lies on his back with the right hip flexed at 90 degrees. The examiner
then holds the patient's right ankle in his right hand.
- With his left hand, the examiner rotates the hip by pulling the right knee to and away
from the patient's body.
- The appendix may come into physical contact with the obturator internus muscle, which
will be stretched by this physical examination maneuver.
- This causes pain and is an evidence in support of an inflamed appendix.
















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3. Investigation
Investigations in appendicitis
Routine
Full blood count
- Mild leukocytosis 10,000 to 18,000/mm3 usually present
- Leukocytes above this level possibility of perforation with or without abscess
Urinalysis
- to make sure that a urinary tract infection or a kidney stone isn't causing the
pain.
- Presence of >20 WBC per field should increase consideration of urinary tract
pathology
- If it is a kidney stone, red blood cells are usually seen during microscopic
examination of the urine
Selective
Pregnancy test
- Women of child bearing age need pelvic exam and a pregnancy test
- rule out gynaecological pathology
Urea and electrolytes
- Rule out renal pathology
Erect/supine abdominal radiograph
- Abnormal findings include , fecolith, appendiceal gas, localized paralytic ileus,
blurred right psoas,and free gas
Ultrasound of abdomen/pelvis
Contrast enhanced ct scan of the abdomen







*Abdominal plain x-ray *USG of the appendix


Feacolith/appendicolth
- Note how round appendix is despite
compression with ultrasound transducer (non-
compressible appendix)
- Appendix diameter is larger than 6 mm
- Black shadow indicates intraluminal fluids
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Management
Non-operative and operative
Non operative treatment
Patients should be given IV fluids (to establish adequate urine output) and
pre-operative antibiotics (for peritonitis, preventing incidence of post-operative
wound infection and abscess formation)
Broad-spectrum antibiotic (to cover all gram positive, negative, aerobic and anaerobic)
Outcomes : Resolution(80%) , Deterioration(10%) , Abscess formation , No change for
days or weeks

Operative treatment
Appendicectomy & drainage of an abscess
Drainage alone if appendicectomy is hazardous
Disadvantages : dissemination of infected material , haemorrhage , faecal fistula ,
wound infection & residual abscess
Conventional appendectomy and laparoscopic appendectomy

Complications of appendicitis
Peritonitis
- Peritonitis is the painful swelling of the abdomen area around the stomach and
liver.
- The condition causes your normal bowel movements to stop and your bowel to
become blocked.
- This causes:
severe abdominal pain
a fever of 38C (100.4F) or more
a rapid heartbeat
If peritonitis is not treated immediately it can cause long-term
problems and may even be fatal.
Abscess
- Sometimes an abscess forms around a burst appendix.
- An abscess is a painful collection of pus that results from the bodys attempt to
fight an infection.
- Abscesses can be treated using antibiotics, but in some cases the pus may need
to be drained from the abscess.


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Types of acute appendicitis
Acute appendicitis Acute appendicitis with
inflammatory mass
Acute appendicitis with
generalized peritonitis
Organisms enter the wall
& lodge in submucosa ,
proliferate , wall becomes
red & turgid
Rate of acceleration of
inflammation increase in
presence of obstruction to
lumen of appendix
Obstruction and infection
lead to distension with
pus, hence increase
intraluminal pressure lead
to venous occlusion,
edema, arterial occlusion,
gangrene and perforation,
Rapidly localized by
defense mechanism
(greater omentum & coils
of bowel).
Appendix mass is formed,
can undergo suppuration
to produce an appendix
abscess
Free perforation following
obstruction + infection
allows infected material to
disperse widely in
peritoneal cavity lead to
intense peritoneal
reaction with outpouring
of fluid
Serosal surfaces of bowel
become injected flaked
with clotted lymph


*Normal vermiform appendix *Appendicitis
-Narrow lumen bounded by mucosa which
may be arranged in folds
-abundant lymphoid tissue in mucosa

Mucosal shows remnants of epithelium (loss
of epithelium
Shows inflammatory lymphocytes and
nutrophils