APPENCITIS

Introduction

– appendicitis is inflammation of the vermiform appendix

due to an obstruction
– it’s most common between puberty and age 30
– In the United States, 250,000 cases of appendicitis are
reported annually, representing 1 million patient-days of
admission.
– Man : Woman = 3:2
 Definition

• Appendicitis is an
inflammation of the
appendix, which is the small,
finger-shaped pouch
attached to the beginning of
the large intestine on the
lower-right side of the
abdomen. Appendicitis is a
medical emergency, and if
left untreated, the appendix
may rupture and cause a
potentially fatal infection.
 Etiology Appendicitis
lumen
is caused by obstruction of the appendiceal

Obstruction :
•Corpus
Alienum
•Stricture

Lymphoid Hyperplasia

Fecolith

Infection :
•E.Coli
•Streptococcus
Epidemiology
Anatomy
• The appendix is a wormlike
extension of the cecum and. The
average length of the appendix is 8-
10 cm (ranging from 2-20 cm)
• The appendix runs into a serosal
sheet of the peritoneum called the
mesoappendix, within which
courses the appendicular artery,
which is derived from the ileocolic
artery
 Anatomy

– The appendix has a retroperitoneal location in 65% of patients and may

descend into the iliac fossa in 31%. In fact, many individuals may have an
appendix located in the retroperitoneal space; in the pelvis; or behind
the terminal ileum, cecum, ascending colon, or liver
 Histology

• Interior muscle layer is circular.

• Beneath these layers lies the
submucosal layer, which contains
lymphoepithelial tissue. The
mucosa consists of columnar
epithelium with few glandular
elements and neuroendocrine
argentaffin cells.
Symptoms

– Periumbilical Pain/Epigastric pain (Visceral Pain) →Right

Lower Quadrant (RLQ) Pain
– Anorexia
– Nausea Vomitting
– Diarrhea
– Constipation
Physical Examination

– General : Pain, Fever, Flexi of articulatio Coxae Dextra

– Auscultation : Bowel Sounds Increased or Decreased
– Palpation : Rebound Tenderness, Rovsing sign, Rigidity,
Guarding
– Percussion : Pain
 Rovsing Sign
McBurney’s Sign

Psoas Sign Obturator Sign

Workup

– White Blood Cell (WBC) Count (>10,500)

– Ultrasonography
– Appendicogram
– CT Scan
Ultrasonography
Appendicogram

Non Filling
CT Scan
Stages
No Stage Explanation

1. Early Stage obstruction of the appendiceal lumen leads to mucosal

edema, mucosal ulceration, bacterial diapedesis, appendiceal
distention due to accumulated fluid, and increasing
intraluminal pressure. The patient perceives mild visceral
periumbilical or epigastric pain, which usually lasts 4-6 hours
2. Suppurative Transmural spread of bacteria causes acute suppurative
appendicitis. When the inflamed serosa of the appendix
comes in contact with the parietal peritoneum, patients
typically experience the classic shift of pain from the
periumbilicus to the right lower abdominal quadrant (RLQ),
which is continuous and more severe than the early visceral
pain.
No Stage Explanation
3. Gangrenous Intramural venous and arterial thromboses ensue

4. Perforated Persisting tissue ischemia results in appendiceal infarction and

perforation. Perforation can cause localized or generalized
peritonitis.
5 Phlegmonous/Abcess An inflamed or perforated appendix can be walled off by the
adjacent greater omentum or small-bowel loops

6 Spontaneusly Resolving If the obstruction of the appendiceal lumen is relieved, acute

appendicitis may resolve spontaneously

7 Recurrent The diagnosis is accepted as such if the patient underwent similar

occurrences of RLQ pain at different times that, after
appendectomy, were histopathologically proven to be the result of
an inflamed appendix.

8 Chronic (1) the patient has a history of RLQ pain of at least 3 weeks’
duration without an alternative diagnosis; (2) after appendectomy,
the patient experiences complete relief of symptoms; (3)
histopathologically, the symptoms were proven to be the result of
chronic active inflammation of the appendiceal wall or fibrosis of
the appendix.
Diagnosis
Treatment
Conservative :
• Bed rest : Fowler Position
• Antibiotics (Broad Spectrum)
 Penicillins (Ampicillin/Sulbactam)
 Cephalosporins (Ceftriaxone, Cefipime)
 Aminoglycosides (Gentamicin)
 Carbapenem (Meropenem)
 Fluoroquinolones (Ciprofloxacin, Levofloxacin)
 Anti-Infective Agents (Metronidazole)
• Analgesics
Indications Of Surgery

– Consider an appendectomy for patients with a history of

persistent abdominal pain, fever, and clinical signs
of localized or diffuse peritonitis, especially if leukocytosis
is present.
– If the clinical picture is unclear, a short period (4-6 h) of
watchful waiting and a computed tomography (CT)
scan may improve diagnostic accuracy and help to hasten
the diagnosis
Open
Appendectomy
Conclusion

– Appendicitis means inflammation of the appendix. It is thought that

appendicitis begins when the opening from the appendix into the
cecum becomes blocked. Historically, the diagnosis of appendicitis has
been made based on clinical findings. Diagnostic imaging has been
used primarily to evaluate patients who have an atypical clinical
presentation. Over the past several years, improvements in imaging
technology have contributed to an increase in diagnostic accuracy in
these patients. Early and accurate diagnosis of appendicitis can
decrease patient morbidity and hospital costs by reducing the delay in
diagnosis of appendicitis and its associated complications, as well as
by avoiding inpatient observation prior to surgery in patients who
present with atypical symptoms.
References

• Craig S. Appendicitis Treatment & Management..

• Stengel JW, Webb EM, Poder L, et al. Acute appendicitis: clinical outcome in
patients with an initial false-positive CT diagnosis. Radiology 2010; 256:119.
• Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site
infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect
Control Hosp Epidemiol 1999; 20:250.
• Spirt MJ. Complicated intra-abdominal infections: a focus on appendicitis and
diverticulitis. Postgrad Med 2010; 122:39.
• Eriksson S, Tisell A, Granström L. Ultrasonographic findings after conservative
treatment of acute appendicitis and open appendicectomy. Acta Radiol 1995;
36:173.
• Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy:
outcomes comparison based on a large administrative database. Ann Surg 2004;
239:43.