Appendicitis

APPENDIX
● Develops from the midgut and first appears at 8 weeks of
gestation
● Measures 6 to 9 cm
● Blood supply: appendicular branch of the ileocolic artery.
● Location: intraperitoneal and retrocecal in location, but it can be
pelvic (30%) and retroperitoneal (7%)
 ACUTE APPENDICITIS
● The most common surgical emergency of the abdomen
● Appendectomy - one of the most frequently performed surgical
procedures
● Incidence of 8.6% in men and 6.7% in women, with the highest
incidence occurring in the second and third decade of life.
● ETIOLOGY;
○ Pediatrics:
■ due to luminal obstruction that occurs as a result of
lymphoid hyperplasia
○ Adults:
■ may be due to fecaliths, fibrosis, foreign bodies (food,
parasites, calculi), or neoplasia.
 ACUTE APPENDICITIS
● Obstruction generally leads to increased intraluminal pressure
and referred visceral pain to the periumbilical region.
● this leads to impaired venous drainage mucosal ischemia
leading to bacterial translocation, and subsequent gangrene and
intraperitoneal infection.
● Organisms: Escherichia coli and Bacteroides fragilis
 OPERATIONAL DEFINITIONS
● Uncomplicated Appendicitis
○ Includes the acutely inflamed, phlegmonous, suppurative, or
mildly inflamed appendix with or without peritonitis
● Complicated Appendicitis
○ Includes gangrenous appendicitis, perforated appendicitis,
localized purulent collection at operation, generalized peritonitis
and periappendiceal abscess
● Equivocal Appendicitis
○ A patient with right lower quadrant abdominal pain who
presents with an atypical history and physical examination and
the surgeon cannot decide whether to discharge or to operate
on the patient
 When should one suspect acute
appendicitis?

Patient presents with right lower quadrant abdominal pain

What clinical findings are most helpful in
diagnosing acute appendicitis?
● High intensity of perceived abdominal pain of at least 7-12 hours
duration
● Migration to the right lower quadrant
● Followed by vomiting
● Diagnosis becomes more certain
○ Right lower quadrant tenderness, guarding, rebound tenderness
and other signs of peritoneal irritation.
● Sequence of symptoms
○ Anorexia – 95%; 1st symptom
○ Abdominal pain – 2nd symptom
○ Vomiting
○ Murphy triad: abdominal pain + vomiting + fever
What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
● A. All Cases
○ 1. White blood cell with differential count
● B. Equivocal Appendicitis in Adults
○ 1. CT scan
○ 2. Ultrasound
● C. Equivocal Appendicitis in the Pediatric Age Group
○ 1. Ultrasound (graded-compression)
○ 2. CT scan
● D. Selected Cases
○ 1. Diagnostic Laparoscopy
What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
Features on a CT scan:

● enlarged lumen and double wall thickness (greater than 6 mm)

● wall thickening (greater than 2 mm)
● periappendiceal fat stranding
● appendiceal wall thickening
● and/or an appendicolith
What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
Features on an ultrasound:

● diameter of greater than 6 mm

● pain with compression
● presence of an appendicolith
● increased echogenicity of the fat
● periappendiceal fluid

An easily compressible appendix <5 mm in diameter generally rules

out appendicitis
What diagnostic tests are helpful in the
diagnosis of acute appendicitis?
The following examinations are generally not useful in the diagnosis
of acute appendicitis:

1. Plain Abdominal X-ray

2. Barium Enema
3. Scintigraphy
Management
What is the appropriate treatment for
acute appendicitis?

Appendectomy is the appropriate treatment for acute appendicitis.

What is the recommended approach
to the surgical management of acute
appendicitis?
Open appendectomy is the recommended primary approach to
the treatment of acute appendicitis in our setting while
therapeutic laparoscopic appendectomy is an alternative for
selected cases.
OPERATIVE INTERVENTION
 Uncomplicated Appendicitis
● The preferred approach to manage patients with uncomplicated appendicitis
is an appendectomy
● Timing of Surgery
○ Delaying surgery less than 12 hours is acceptable in patients with short
duration of symptoms (less than 48 hours) and in nonperforated,
nongangrenous appendicitis
● Approach of Surgery
○ Laparoscopic appendectomy
■ Shorter length of stay (LOS), faster return to work, and lower
superficial wound infection rates, especially in obese patients.
○ Open appendectomy
■ Shorter operative times and lower intra-abdominal infection rates.
 Complicated Appendicitis
● Perforated and gangrenous appendicitis and appendicitis with
abscess or phlegmon formation are considered complicated
conditions
● Patients with perforated appendicitis usually present after 24 hours
of onset
○ Often acutely ill and dehydrated and require resuscitation.
● Perforated appendicitis
○ Managed either operatively or nonoperatively.
○ Immediate surgery is necessary in patients that appear septic,
but this is usually associated with higher complications,
including abscesses and enterocutaneous fistulae due to dense
adhesions and inflammation.
 What is the role of laparoscopic
appendectomy in the management of
acute appendicitis in children?
Laparoscopic appendectomy may be recommended as an
alternative to open appendectomy in the pediatric age group.
 What is the role of antibiotics in the
management of acute appendicitis?
A. Is antibiotic prophylaxis indicated for uncomplicated
appendicitis?

Yes. Antibiotic prophylaxis is recommended for the

prevention of surgical site infection in patients who undergo
appendectomy and should be considered for routine use.
 What is the role of antibiotics in the
management of acute appendicitis?
B. What antibiotic/s is/ are recommended for prophylaxis in
uncomplicated appendicitis and what is the appropriate dose and
route of administration?

The following antibiotics are recommended for prophylaxis in

uncomplicated appendicitis:

Cefoxitin 2 grams IV single dose (Adults)

40 mg/kg IV single dose (Children)
Alternative agents:

Ampicillin-sulbactam 1.5-3 grams IV single dose (Adults)

75 mg/kg IV single dose (Children)

Amoxicillin-clavulanate 1.2-2.4 grams IV single dose (Adults)

45 mg/kg IV single dose (Children)

For patients with allergy to beta-lactam antibiotics:

Gentamicin 80-120 mg IV single dose plus

Clindamycin 600 mg IV single dose (Adults)

Gentamicin 2.5 mg/ kg IV single dose plus

Clindamycin 7.5-10 mg/kg IV single dose (Children)
 What is the role of antibiotics in the
management of acute appendicitis?
C. What antibiotic/s is/are recommended for the treatment of
complicated appendicitis and what is the appropriate dose, route
and duration of administration?

The recommended antibiotics for therapy of complicated

appendicitis in adults are

Ertapenem 1 gram IV every 24 hours

Tazobactam-piperacillin 3.375 grams IV every 6 hours
4.5 grams IV every 8 hours
For adults with beta-lactam allergy:

Ciprofloxacin 400 mg IV every 12 hours plus

Metronidazole 500 mg IV every 6 hours

The recommended antibiotic for therapy of complicated

appendicitis in pediatric patients is

Ticarcillin clavulanic acid 75 mg/kg IV every 6 hours

Alternative agents for pediatric patients include:

Imipenem-Cilastatin 15-25 mg/kg IV every 6 hours

For children with beta-lactam allergy

Gentamicin 5 mg/kg IV every 24 hours plus
Clindamycin 7.5 mg/kg IV every 6 hours
For gangrenous appendicitis, the recommended form of
management is to treat in the same manner as uncomplicated
appendicitis. (LEVEL II EVIDENCE, CATEGORY A
RECOMMENDATION)

The duration of the therapy may vary depending on the clinician’s

assessment after the operation. The therapy may be maintained for
5-7 days. Sequential therapy to oral antibiotics may be considered
when gastrointestinal function has returned. (LEVEL I EYTDENCE,
CATEGORY A RECOMMENDATION)

The absence of fever for 24 hours (temperature 38 C), the ability to

tolerate oral intake, and a normal WBC count with 3 percent or less
band forms are useful parameters for the discontinuation of
antibiotic therapy. (LEVEL II EVIDENCE, CATEGORY A
RECOMMENDATION)
 Should gram stain and culture and
sensitivity be routinely done?
Gram stain and culture with sensitivity testing of intraoperative
specimens (purulent peritoneal fluid or tissue) should not be
routinely performed except in high-risk and
immunocompromised patients.
 How should localized peritonitis be
managed?
No necrotic tissue or purulent material should be left behind as
much as possible. General peritoneal lavage is not recommended
for localized peritonitis. Intraperitoneal drain, while most useful
in patients with a well-established and localized abscess cavity,
should be selectively utilized.
 What is the appropriate method of
wound closure in patients with
complicated appendicitis?
The incision may be closed primarily in patients with
complicated appendicitis.
 What is the optimal timing of surgery
for patients with peri-appendiceal
abscess?
A patient with a peri-appendiceal abscess should undergo
surgery as soon as the diagnosis is made.
Thank
you,
Doctor!
 Table of contents

01 02 03
About the patient Discussion Diagnosis
You can describe the topic You can describe the topic You can describe the topic
of the section here of the section here of the section here

04 05
Treatment Patient monitoring
You can describe the topic You can describe the topic
of the section here of the section here
Introduction
You can give a brief description of the topic you
want to talk about here. For example, if you
want to talk about Mercury, you can say that it’s
the smallest planet in the entire Solar System
 01
About the patient
You can enter a subtitle here if you need it
 Identifying information

Fever Appetite loss Nausea

Mercury is the closest Venus has a beautiful Despite being red, Mars
planet to the Sun and the name and is the second is actually a cold place.
smallest of them all planet from the Sun It’s full of iron oxide dust
 Patient medical history

Age 30 y.o. Diseases None

Gender Female Location Spain

2005 2010 2015 2020

Jupiter is the Mercury is the Earth is where Venus is hotter

biggest planet smallest planet we all live than Mercury
Review of systems
Do you know what helps you make your point
crystal clear?
Lists like this one:

● They’re simple
● You can organize your ideas clearly
● You’ll never forget to buy milk!

And the most important thing: the audience

won’t miss the point of your presentation
 Physical examination
01 02
01
Colon Intestine
Venus is the second Jupiter is the biggest
planet from the Sun 02 planet of them all

03 04
03
Appendix Anal canal
Despite being red, 04 Saturn is a gas giant
Mars is a cold place and has several rings
 “This is a quote, words full of wisdom that
someone important said and can make the
reader get inspired.”

—Someone Famous
 Findings
Mars
It’s actually a cold place

Venus
It’s hotter than Mercury

Jupiter
Jupiter is the biggest planet

300,000,000
Follow the link in the graph to modify its data and then
Earth is where we all live paste the new one here. For more info, click here
 Discussion

Dr. Timmy Lee Dr. Sophia White

“Jupiter is the biggest planet in “Venus has a beautiful name
the entire Solar System” and high temperatures”

Dr. Anna Doe Dr. Sara James

“Despite being red, Mars is “Earth is the third planet from the
actually a cold place” Sun. We all live here”
 Discussion
summary
Images reveal large amounts of
data, so remember: use an image
instead of a long text. Your
audience will appreciate it
 Comparison

Group Test 01 Test 021 Test 03

A
B
C
D
Awesome
words
 Diagnosis

Mercury Venus Mars

Mercury is the closest Venus is the second Despite being red,
planet to the Sun planet from the Sun Mars is a cold place

Jupiter Saturn Neptune

Jupiter is the biggest Saturn is composed of Neptune is the farthest
planet of them all hydrogen and helium planet from the Sun
 Treatment
Surgery
Mercury is the closest planet to
the Sun and the smallest one in
the Solar System—it’s only a bit
larger than the Moon
Antibiotics
Venus has a beautiful name and
is the second planet from the
Sun. It’s hot and has a
poisonous atmosphere
 Patient monitoring
Week 01 Week 02 Week 03 Week 04
Despite being red, Venus is the second Jupiter is the biggest Mercury is the closest
Mars is a cold place planet from the Sun planet of them all planet to the Sun

20% 20% 40% 40%

Earth Earth Earth Earth

40% 20% 60% 80%

Mars Mars Mars Mars

A picture is worth
a thousand words
Contraindications & indications

Venus has a beautiful name and is

Venus the second planet from the Sun

Despite being red, Mars is actually

Mars a cold place full of iron oxide dust

Mercury is the closest planet from

Mercury the Sun and the smallest one

It’s the third planet from the Sun

Earth and the only one that harbors life

Jupiter is a gas giant and the

Jupiter biggest planet in the Solar System
 Outcome & Postoperative Course
@ Jooo, delete ra the contents you don’t want to report on

● Appendectomy is a relatively safe procedure with an extremely

low mortality rate (less than 1%).
● The commonest adverse events include soft tissue infections,
either superficial or deep (including abscesses).
● Patients with uncomplicated appendicitis do not require further
antibiotics after an appendectomy, while patients with perforated
appendicitis are treated with 3 to 7 days of antibiotics (4 days
from the STOP-IT trial).
 Outcome & Postoperative Course

● Patients with wound infections can be managed with simple

wound opening and packing, and delayed primary closure has
not been shown to be beneficial.
● In laparoscopic cases, these are usually the periumbilical ports.
● Patients with deep space abscesses are managed with
percutaneous drainage and antibiotics.
● Fistulas (appendicocutaneous or appendicovesicular) are
managed conservatively as the first step.
● Bowel obstructions and infertility are infrequent but reported.
 Outcome & Postoperative Course

STUMP APPENDICITIS

● An uncommon complication after surgery is the development of appendicitis

in an incompletely excised appendiceal stump (greater than 0.5 cm stump
length).
● Optimal management requires re-excision of the appendiceal base, but
diagnosis can be difficult and requires careful assessment of the patient’s
history, physical exam, and imaging studies.
● Use of the “appendiceal critical view” (appendix placed at 10 o’clock, taenia
coli/libera at 3 o’clock, and terminal ileum at 6 o’clock) and identification of
where the taeniae coli merge and disappear is paramount to identifying and
ligating the base of the appendix during the initial operation
 Outcome & Postoperative Course

APPENDICEAL NEOPLASMS

● The incidence of appendiceal neoplasms is estimated at around 1% of all

appendectomy specimens, although the true incidence of appendiceal
neoplasms is not known.
● Neoplasms that occur in the appendix are predominantly
gastroenteropancreatic neuroendocrine tumors (or GEP-NETs, previously
called carcinoids), mucinous neoplasms, or adenocarcinomas.
● Almost one-third of the neoplasms of the appendix present with acute
appendicitis, while the others are often incidentally detected or are detected
after regional spread of disease
 Outcome & Postoperative Course
Gastroenteropancreatic Neuroendocrine
Tumors (GEP-NETs or Carcinoid)
● Appendiceal carcinoid tumors are submucosal rubbery masses that are detected
incidentally on the appendix.
● Carcinoid tumors of the appendix are relatively indolent but can develop nodal or
hepatic metastases. Infrequently, these can be associated with a carcinoid syndrome
if there are hepatic metastases (2.9%).
● Upon incidental findings of a suspected carcinoid, the surgeon must evaluate the
nodal basin along the ileocolic pedicle and also examine the liver for any signs of
metastases.
● For lesions that are less than 1 cm (95% of all lesions), a negative margin
appendectomy is adequate.
● For tumors 2 cm or larger, a right hemicolectomy is recommended.
● For lesions 1 to 2 cm in size, there is no consensus on a completion colectomy. A right
colectomy is often performed for mesenteric invasion, enlarged nodes, or positive or
unclear margins. Measurement of serum chromogranin A is recommended.
 Outcome & Postoperative Course

Goblet Cell Carcinomas

● These lesions were mistakenly called goblet cell carcinoids, implying a rather indolent
biology, while goblet cell carcinomas are adenocarcinoid with both adenocarcinoma
and neuroendocrine features.
● Such lesions carry a worse prognosis than carcinoids but slightly better than
adenocarcinomas. There is a high risk of peritoneal recurrence in such cases.
● For incidentally detected lesions, a systematic surveillance of the peritoneum must be
performed, and a peritoneal cancer index score must be documented if disease is
present.
● In the absence of metastatic disease, a right hemicolectomy is generally appropriate,
although some advocate for a right colectomy only for tumors 2 cm or larger.
 Outcome & Postoperative Course

Lymphoma

● Appendiceal lymphomas are rare (1%–3% of lymphomas, usually non-Hodgkin’s) and

difficult to diagnose preoperatively (appendiceal diameter can be 2.5 cm or larger).
● Management includes an appendectomy in most cases.
 Outcome & Postoperative Course
Adenocarcinoma
● Primary adenocarcinoma of the appendix is a rare neoplasm with three major
histologic subtypes: mucinous adenocarcinoma, colonic adenocarcinoma, and
adenocarcinoid.
● The most common mode of presentation for appendiceal carcinoma is acute
appendicitis.
● Patients also may present with ascites or a palpable mass, or the neoplasm may be
discovered during an operative procedure for an unrelated cause.
● The recommended treatment for all patients with adenocarcinoma of the appendix is
● a formal right hemicolectomy.
● Appendiceal adenocarcinomas have a propensity for early perforation, although they
are not clearly associated with a worsened prognosis.
● Overall 5-year survival is 55% and varies with stage and grade.
● Patients with appendiceal adenocarcinoma are at significant risk for both synchronous
and metachronous neoplasms, approximately half of which will originate from the
gastrointestinal tract.
 Outcome & Postoperative Course
Appendiceal Mucoceles and Mucinous Neoplasms of the Appendix
● The term appendiceal mucocele broadly describes a mucus-filled appendix that could be secondary to
neoplastic or nonneoplastic pathologies (mucosal hyperplasia, simple or retention cysts, mucinous
cystadenomas, mucinous cystadenocarcinoma).
● On cross-sectional imaging, a low attenuation, round, well encapsulated cystic mass in the right or
quadrant is often encountered, and features such as wall irregularity and soft tissue thickening are
suggestive of a neoplastic process.
● It is important to carefully assess for the presence of ascites, peritoneal disease, and scalloping of the
liver surface on imaging upon initial evaluation.
● A reliable diagnosis cannot be established using imaging alone, and it is recommended that surgical
excision without capsular disruption is undertaken.
● The importance of careful handling of a mucocele and the avoidance of rupture cannot be
overemphasized because the intraperitoneal spread of neoplastic cells at subsequent development of
pseudomyxoma peritonei are nearly certain in cases of adenocarcinoma.
● When suspecting a mucinous neoplasm of the appendix, it is imperative to systematically examine the
peritoneum and document a peritoneal cancer index score if mucin is present. Biopsies to examine the
content of epithelial cell, neoplastic cells, and mucin can be helpful.
 Outcome & Postoperative Course
Pseudomyxoma Peritonei Syndrome

● Patients with appendiceal mucinous neoplasms develop peritoneal dissemination leading to

pseudomyxoma peritonei (PMP) syndrome. This can occur in gastric, ovarian, pancreatic, and colorectal
primary tumors as well.
● Patients with this syndrome can have varied prognosis ranging from curative to palliative.
● Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the
standard of care for patients with PMP syndrome from appendiceal primaries.
● Early detection and management of limited peritoneal disease is favorable and preferred as opposed to
extensive intraperitoneal mucin development.
● The surgical technique involves parietal and visceral peritonectomies, and intraperitoneal administration
of heated (42oC [108oF]) chemotherapy (usually mitomycin) in the abdomen. Previously considered a
morbid surgery, high volume centers and standardized practices have made the morbidity and mortality
similar to any major open GI procedure. This technique can also be performed laparoscopically
● when the disease is detected early and is low volume.
 Post-prevention

Good food Antibiotics Drink water Get rest

Mercury is the closest Neptune is the Venus has a beautiful Despite being red,
planet to the Sun and farthest planet from name and is the Mars is actually a cold
the smallest in the the Sun. It's also the second planet from place. It’s full of iron
Solar System fourth-largest object the Sun oxide dust
 Case timeline

Venus has very high Earth is the only

temperatures planet with life

Day 02 Day 04

Day 01 Day 03 Day 05

Mercury is the Mars is actually Jupiter is the
smallest planet a cold place biggest planet
150,000
Big numbers catch your audience’s attention
9h 55m 23s
is Jupiter's rotation period

333,000
Earths is the Sun’s mass

386,000 km
is the distance between Earth and the Moon
 Higher incidence

40% 60%

Venus Mercury
It has a beautiful name Mercury is the closest
and is the second planet from the Sun
planet from the Sun and the smallest one
 Conclusions
Earth is the third planet from the Sun and
the only one that harbors life in the Solar
System. This is where we all live
 References
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publication. Publisher
● AUTHOR (YEAR). Title of the
publication. Publisher
● AUTHOR (YEAR). Title of the
publication. Publisher
● AUTHOR (YEAR). Title of the
publication. Publisher
● AUTHOR (YEAR). Title of the
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● AUTHOR (YEAR). Title of the
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