Acute Appendicitis

Pathology

 Most common abdominal emergency and cause of acute abdominal pain

a. Cause is unknown but occurs due to luminal obstruction by fecalith (stone of
feces) or foreign body in the lumen
b. Inflammation or enlargement of Peyer patch/lymphatic follicles (small masses of
lymphatic tissue found throughout the ileum which monitor intestinal bacteria
populations and prevent the growth of pathogenic bacteria) (children)
c. Rarely obstructing carcinoma tumor at the base
d. Non-obstructed appendicitis occurs due to direct infection of the lymphoid
follicles from the appendix lumen or hematogenous (rare streptococcal
appendicitis). This type of appendicitis is more likely to resolve

 Occasionally acute appendicitis occurs proximal to an obstructing lesion (carcinoma) in

the caecum or ascending colon (obstruction of the bowel)

 Very rare at the two extremes of life

a. In infants the appendix is wide mouthed and well drain
b. Old age the lumen of the appendix is almost obliterated
c. Affects young adults and teenagers 5-35

 Obstructed appendix acts as a closed loop

a. Bacteria proliferate in the lumen and invade the appendix wall causing
inflammation and swelling
b. The wall is damaged by pressure necrosis (increased intraluminal pressure
causes occlusion of veins and arteries
c. Vascular supply to the appendix is end- arteries (no collateral circulation)
appendicular branch of the ileocolic artery
d. When thrombosed, gangrene occurs, follow by perforation (rupture/hole in GI
tract)
e. Can take under 12 hrs to perforate - >4 days resulting in generalized peritonitis or
more fortunately localized appendix abscess

Clinical Features
1. History
a. Marked localized pain and tenderness in the right iliac fossa
i. Pain typically begins in the central periumbilical colic (severe pain in the
abdomen caused by obstruction or intestinal gas) which shifts after 6
hours to the RIF(or a few days). This pain is visceral (covers organ) in
origin and the shift is due to later involvement of the parietal peritoneum
 by inflammatory process. It is called referred pain from the 10th thoracic
spinal segment of the visceral innervation
ii. Pain is aggravated by movement, patient prefers to lie still with hips and
knees flexed
iii. The appendix is 7-10cm long and is proximal to the caecum near the
ileocecal junction. The tip may lie behind the caecum (retrocaecal, most
common), adjacent to the ileum or down in the pelvis lying against the
rectum or the bladder
iv. In pelvic position, pain becomes suprapubic /hypogastric (below umbilical
region) with urinary frequency as the bladder is irritated, dysuria(painful or
difficult urination)
v. In the retrocecal region the pain may be localized in the right loin with less
tenderness on palpation
vi. Rarely the tip can extend to the left iliac fossa
b. Nausea and vomiting
i. Occurs on the onset of pain
ii. Sequence colicky central abdominal pain, anorexia,following vomiting,
followed by movement of pain to the RIF.
c. Anorexia (loss of appetite)
d. Constipation is usual but diarrhea can occur
Examination
1. Pyrexia (> 37.5 degrees) and tachycardia are usual
2. Patient is flushed (redness of the skin-neck cheeks), may appear toxic and in pain
3. Movement exacerbates pain
4. Fetor oris/ halitosis/bad breath is present, and the tongue is coated
5. Tenderness in the inflamed region and guarding of the abdominal muscles. Coughing
mimics release test for rebound tenderness
a. Pain is felt the most at McBurney point- 1/3rd the distance laterally from the
umbilics to the right ASIS (base of the appendix)
6. Rectal examination reveals tenderness when the appendix is in the pelvic position or
when there is puss in the rectovesical or Douglas pouch
7. Late case of peritonitis, the abdomen become tender and rigid, bowel sounds are absent
a. Advance peritonitis- tympanitic /hyperresonant and distended GIT from gas
accumulation
b. Hippocratic face (near dead face)
8. ROVSING’S SIGN- palpation or pressure on the left iliac fossa causes pain on the right
9. The mass is dull on percussion and on auscultation bowel sounds are present unless
general perforation occurs leading to general peritonitis leading to paralytic ileus
Special investigation to rule out differential
1. Leucocyte count- mild polymorph leukocytosis
2. Computed tomography/CT – used to evaluated atypical presentations
3. Ultrasound
Differential diagnosis
Intra-abdominal disease
Meckels diverticulitis, Gastroenteritis, Acute intestinal obstruction (noisy bowel sounds) ,
Perforated peptic ulcer, Acute cholecystitis, Pancreatitis.

Urogenital tract
Ureteric colic and acute pyelonephritis- urine must be tested for blood and pus every case of
acute abdominal pain. Testicular torsion

Gynecological emergencies
Acute salpingitis, ectopic pregnancy (HcG test) and ruptured cyst of the corpus luteum

CNS
Herpes Zoster affects 11th and 12th dorsal segments

Treatment

 Using Laparoscopy and appendicectomy is performed

 Contraindications for immediate appendicectomy
o Patient is moribund (at the point of death) with advance peritonitis
 Resuscitation with IV fluids and antibiotics
o The attack is already resolved
o Appendix mass has formed without evidence of general peritonitis
 Surgery
o Antibiotics prophylaxis is given preoperatively
o Lanz aka McBurney incision- Transverse incision in RIF. Gridiron aka Rockey-
Oblique incision RIG
o During operation if peritonitis is discovered, antibiotic therapy continued-
metronidazole, gentamycin, cephalosporin. These needed to be changed and
supplemented after 24-48 hrs
o After appendicectomy, a drain is inserted when there is severe inflammation or a
local abscess present, or when the appendix stump is not perfectly sound. 3
months healing
o Alvarado score is used to determine if appendicectomy is performed 7-9
 Appendix Mass
o Localized mass in RIF
o Present bowel sounds and no sign or peritonitis
o Carcinoma of the caecum, Crohn disease, distended gallbladder, ovarian mass,
pelvic kidney
o Treatment- Fluid, Metronidazole but antibiotics are not prolonged as it causes a
chronic inflammatory mass honey-combed with abscess- antibioticoma
 o When the mass is resolved appendectomy is carried out after 3 months
 Appendicitis in pregnancy
o Higher mobility and morbidity due to confusion of other complications associated
with pregnancy( ovarian cyst, vomiting of pregnancy) , common