The vermiform appendix

SURGICAL ANATOMY

It is located at the terminal end of the caecum where three taeniae join, about
2 cm below the ileocaecal orifice.

Usually, around 5-10 cm in size but can be varible. Size of its lumen is that of
matchstick. Diameter of appendix is 3-8 mm; diameter of lumen is 1-3 mm
(matchstick).

Mesoappendix is extension of the mesentery contains appendicular artery, a

branch of ileocolic artery. Often an accessory appendicular artery (of
Seshachalam) may be present. Thrombosis of these vessels leads to
gangrenous appendicitis.

Most common position is retrocaecal (75%). Next common is pelvic (21%).

Other sites are:

Preileal—rarest (1%) , Postileal , Paracaecal , Subcaecal
 On table demonstration of mesoappendix with appendicular
artery. Note the appendix (A); mesoappendix (B); caecum (C); ileum
(D); taenia (E).
Different anatomical positions of the appendix.
 ACUTE APPENDICITIS
Aetiology

It is common in young males (& females).

It is common in white races.
Fibre rich diet prevents appendicitis. Less fibre diet increases chance of
appendicitis.
Viral infection may cause mucosal oedema and inflammation which later
gets infected by bacteria causing appendicitis.
Obstruction of the lumen of appendix causing obstructive appendicitis.
Blockage occurs due to—faecoliths, stricture, foreign body, round
worm or threadworm.
Adhesions and kinking—carcinoma caecum near the base, ileocaecal
Crohn’s disease.
Distal colonic obstruction.
Abuse of purgatives.
Faecolith is the most common cause.
Organisms:
E. coli (85%), enterococci, (30%), streptococci, Anaerobic streptococci,
Cl. Welchii , bacteroides.

Pathogenesis

Acute inflammation of the mucus membrane with secondary infection without

obstruction causes acute non-obstructive appendicitis. It may lead into resolution,
fibrosis, recurrent appendicitis or eventual obstructive appendicitis.

Luminal obstruction by faecolith, lymphoid hyperplasia, pinworm (oxyuris

vermicularis), other worms, foreign body, carcinoma/Crohn‘s disease → mucus and
inflammatory fluid collects inside the lumen → increases intraluminal pressure →
leads to blockage of lymphatic and venous drainage → resulting in increased
oedema of mucosa and wall → causes mucosal ulceration and ischaemia →
bacterial translocation → bacterial spread through submucosa and muscularis
propria → acute obstructive appendicitis → thrombosis of appendicular artery →
ischaemic necrosis of full thickness of the wall of the appendix → gangrene of the
appendix → perforation at the tip or at the base → peritonitis.
After perforation → localisation by greater omentum and dilated ileum occurs →
with suppuration and pus inside forming appendicular abscess.

In severe acute appendicitis → localisation can occur by omentum and dilated ileum
without pus inside → forming appendicular mass.

Acute appendicitis with blockage at the opening of the lumen → inflammation rarely
subsides → mucus collects inside the lumen of the appendix resulting in its
enlargement → Mucocele of the appendix.

McBurney’s point is junction

of lateral 1/3rd and medial
2/3rd of spinoumbilical line.

McBurney’s/Gridiron’s/McA
rthur’s incision is
perpendicular to this line in
this point.
 Clinical Features
It is rare before the age of two, common in children and other age groups.

Pain: It is the earliest symptom. Visceral pain starts around the umbilicus due to
distension of appendix, later after few hours, somatic pain occurs in right iliac fossa
due to irritation of parietal peritoneum due to infl a med appendix.

Pain eventually becomes severe and diffuse which signifies spread of infection into
the general peritoneal cavity.

Vomiting: Due to reflex pylorospasm.

Murphy’s triad
 Pain , Vomiting , Temperature

Constipation is the usual feature but diarrhoea can occur if appendix is in postileal or
pelvic positions.

Fever, tachycardia, foetor oris are other features.

Urinary frequency: Infl amed appendix may come in contact with bladder and can
cause bladder irritation.
Tenderness and rebound tenderness at McBurney’s point in right iliac fossa (release
sign—Blumberg’s sign) are typical.

Rovsing’s sign: On pressing left iliac fossa, pain occurs in right iliac fossa which is due
to shift of bowel loops which irritates the parietal peritoneum.

Often infection gets localised by omentum, dilated ileum and parietal peritoneum
leading to appendicular mass. Often suppuration occurs in the localised area resulting
in appendicular abscess.

Acute appendicitis in infancy:

Even though it is rare, when it occurs, it has got 80%
chances of perforation with high mortality (50%).

Acute appendicitis in children:

Here localisation is not present, and so peritonitis
occurs early.It requires early surgery. Dehydration, septicaemia are common.

In elderly:
Gangrene and perforation are common. Because of lax abdominal wall,
localisation is poor and so peritonitis sets in early.
In pregnancy:

 Incidence is 1 in 2,000 pregnancies. It is more common in 1st and 2nd trimesters.

 Appendix shifts to upper abdomen. So pain is higher and more lateral.
 Rebound tenderness and guarding may not be evident.
 TC will be very high with neutrophilia.
 Risk of premature labour is 15%.
 Foetal death in early appendicitis is 5% but becomes 29% once appendix perforates
in pregnancy.
 After 6 months, maternal mortality increases by 10 times than usual and also leads
to premature labour.
 Appendicitis is the most common non-gynaecologic surgical emergency during
pregnancy.
 Incidence of perforation is highest in 3rd trimester.
 Surgery is the treatment.
 Differential diagnosis
 Perforated peptic ulcer
 Ruptured or twisted ovarian cyst
 Acute cholecystitis
 Right ureteric colic
 Enterocolitis
 Right acute pyelonephritis
 Mesenteric lymphadenitis
 Acute pancreatitis
 Meckel’s diverticulitis
 Salpingitis
 Ectopic gestation—ruptured
 Differential diagnosis in children

 Meckel’s diverticulitis
 Acute colitis
 Acute iliac lymphadenitis
 Intussusception
 Roundworm colic

Differential diagnosis in females

 Ruptured ectopic gestation

 Mittelschmerz rupture of ovarian follicle during midmenstrual period
 Ovarian cyst torsion
 Salpingo-oophoritis

Differential diagnosis in elderly

 Acute diverticulitis
 Carcinoma caecum—acute features
 Mesenteric ischaemia
 Sequelae of acute appendicitis

o Resorption
o Relapse and recurrent appendicitis
o Appendicular mass
o Appendicular abscess
o Perforation—has got 20% mortality
o Peritonitis, septicaemia
oIntestinal obstruction due to obstructive ileus, inflammatory adhesion, formation of
band between appendix and omentum or between appendix and small bow
 Investigations

Total leucocyte count is increased.

Ultrasound is done to rule out other conditions like ureteric stone, pancreatitis, ovarian
cyst, ectopic pregnancy and also to confirm appendicular mass or abscess.

Laparoscopy is the most useful method.

Contrast CT scan is very much useful when diagnosis is difficult especially in old
people.

Dilated appendix; dilated lumen; thickened wall; non filling of the lumen by contrast or
air; peri-appendicular fluid collection; presence of mass/abscess/associated pathology
like carcinoma can be identified.

It has 95% sensitivity and specificity with 95% accuracy.

Plain X-ray may show faecolith on the right side; very much nonspecific.

X-ray is useful to rule out DU perforation, intestinal obstruction, ureteric stone.

 Alvarado scoring for appendicitis (1986):
Score
1. Migrating pain 1
2. Anorexia 1
3. Nausea and vomiting 1
4. Tenderness in right iliac fossa 2
5. Rebound tenderness 1
6. Elevated temperature 1
7. Leucocytosis with count more than 10,000 2
8. Shift to left with neutrophilia in peripheral smear 1

Total score 10

Score less than 5: Not sure.

Score between 5-6: Compatible.
Score between 6-9: Probable.
Score more than 9: Confirmed.
US showing dilated noncompressible appendix
 Treatment
Surgery-Appendicectomy

Approaches

1. Gridiron incision: Incision is placed perpendicular to the right spinoumbilical

line at the McBurney’s point (i.e. at the junction of lateral one-third and medial
two-third of spinoumbilical line).

2. Rutherford Morison’s muscle cutting incision.

3. Lanz crease incision