APPENDICITIS

Made by: MADHURPREET KAUR

INTRODUCTION
 Vermiform Appendix is considered to be a vestigeal
organ in humans.
 Its importance in surgery results only from its
propensity for inflammation, which results in
clinical syndrome called Acute Appendicitis.
ANATOMY
 Vermiform Appendix is a blind muscular tube with
mucosal, submucosal,muscular and serosal layers.
 Morphologically, it is the underdeveloped distal
end of large caecum found in many lower animals.
 At birth, the appendix is short and broad at its
junction with caecum, but differential growth of the
caecum produces the typical tubular structure by
the age of two years.
 During childhood, continued growth of the caecum
commonly rotates the appendix into retrocaecal but
intraperitoneal position(74%)
 In some cases, rotation of appendix does not occurs,
leading to pelvic(21%), paracaecal(2%),
subcaecal(1.5%) or postileal(0.5%) position.
 The position of the base of the appendix is constant,
being found at the confluence of three taenia coli of
the caecum which fuse to form outer longitudinal
muscle coat of the appendix.
 The mesentry of the appendix arises from the lower
surface of the mesentry or the terminal ileum.
 This, mesoappendix is so transparent in the
childhood, that the contained blood vessels can be
seen, in adults, it becomes laden with fat, which
obscures these vessels.
Microscopic Anatomy
Acute Appendicitis
 Acute inflammation of the appendix is termed as
appendicitis.
 Rare in infants, increasingly common in childhood
and early adult life, reaching peak incidence in early
20s. After Early age, the risk of appendicitis is quite
small.
 Incidence is equal in both males and females before
puberty, however, in teens and young adults, the male-
female ratio reaches 3:2 at the age of 25, male
incidence thereafter declines.
Aetiology
 There is no unifying hypothesis regarding the
aetiology of acute appendicitis.
 Decreased dietary fibre and Increased consumption
of carbohydrates may be important, as incidence is
low in societies having increased intake of fibre.
 While appendicitis is clearly associated with
bacterial proliferation within the appendix, no
single organism is responsible.
 Initiating event causing bacterial proliferation in majority of the cases
is found to be luminal obstruction.
 Luminal obstruction canbe due to:
1. a faecolith (faecal material, calcium phosphates, bacteria and
epithelial debris) or
2. a stricture, which is found in majority of the cases
3. Rarely, a foreign body is incorporated into the mass.
4. Tumor particularly carcinoma of caecum is occasional cause of
obstruction and acute appendicitis in middle aged and elderly
people.
5. Intestinal parasites, eg. Oxyuris vermicularis can occlude the lumen.
 Yet, in many cases of early appendicitis, the
appendix lumen is patent despite mucosal
inflammation and lymphoid hyperplasia, possibly
due to viral infection.
 Here lymphoid hyperplasia obstructs the lumen
leading to luminal obstruction.
Pathology
 Once luminal obstruction occurs, following
changes are observed:
o Increased mucus secretion and inflammatory
exudation
o Increased intraluminal pressure and causing
lymphatic obstruction.
o Oedema and mucosal ulceration occurs with
bacterial translocation to the submucosa.
o Further distention of the appendix may cause
venous obstruction and ischaemia of the appendix
wall
o With ischaemia, bacterial invasion occurs through
the muscualris propria and submucosa, producing
acute appendicitis.
o Finally, ischaemic necrosis of the appendix wall
produces gangrenous appendix with free bacterial
contamination of the peritoneal cavity.
o Alternatively , the greater omentum and loops of
the small bowel become adherent to the inflamed
appendix, waling off the spread of the peritoneal
contamination, resulting in paraceacal abscess
o Diffuse peritonitis is the great threat of acute
appendicitis, which may occur due to bacterial
migration through ischaemic appendicular wall or
through perforation in paracaecal abscess.
Risk factor for perforation of appendix

 Extremes of age
 Immunosuppression
 DM
 Faecolith obstruction
 Pelvic appendix
 Previous abdominal surgery
CLINICAL DIAGNOSIS
 HISTORY:
 Age: childhood and early adult life
 Pain: periumblical colic, shifting to righ iliac fossa
 Anorexia
 Nausea
 Vomiting: 1-2 episodes that follow the onset of
pain
Pain
 poorly localised colicky abdominal pain.
 pain is first noticed in the periumblical region and is similar
to, but less intense than, the colic of small bowel obstruction.
 With progressive inflammation of the appendix, parietal
peritoneum gets irritated, producing more intense, constant,
localised somatic pain in the right iliac fossa.
 Typically, coughing or sudden movement exacerbates the
right iliac fossa pain.
 Inflamed apendix in the pelvis never produces somatic pain in
the anterior abdominal wall, rather presents with suprapubic
discomfort and tenesmus.
GENERAL PHYSICAL EXAMINATION

 After approx 6hours, slight raise in body temp,

upto 37.2-37.7 degree celcius. In some cases this
may not be observed. In children,Temp above 38.5
degree celcius suggests other causes.
 Increase in pulse rate to 80-90 is usual in this.
PALPATION
 Hyperaesthesia of the sherren’s triangle
 Tenderness:
 site-in the right iliac fossa with maximum at the
McBurney’s point. Appendicular tenderness can be
best elicited with patient in left lateral position as it
shifts the viscera towards the left exposing the the
appendix for direct palpation.
 Degree and extent of tenderness- will indicate about
the severity of the disease
 Spread of tenderness-tenderness over the left iliac
fossa indicated spreading peritonitis
 Rovsing’s sign: pressure on the left iliac fossa will
elicit tenderness in the right iliac fossa. This is due
to the fact that the coils of the ileum shift slightly to
the right ,thus, pressing on the inflamed appendix.
 Muscle guarding: Involunatry muscle contraction
in response to pain, which occurs due to muscle
contraction in that area to splint that area in an
effort to minimize pain through limitation of
motion.
 Rebound tenderness: Blumberg’s sign/release sign.
It is a sign of peritonitis due to inflamed organ
underneath it. In the presence of abdominal
guarding, this test may not be necessary.
 In this, the suspected area is palpated, with each
expiration the hand on the abdomen is gradually
pressed down as the circumstances may allow, the
hand is now suddenly withdrawn completely,
 This abrupt removal will cause the abdominal
muscle to spring back in its original place, the
patient will immediately cry out or atleast wince in
pain. This is due to the face that the parietal
peritoneum which has already been inflamed
because of the underlying inflamed organ also
springs back along wih the abdominal musculature.
 Cope’s psoas test: pain in the psoas major muscle
on hyperextension of the right hip joint in
retrocaecal appendicitis.
 Obturator test: internal rotation of the hip joint will
elicit pain in the obturator internus in pelvic
appendicitis.
 In case of post ileal appendicitis, pain may not shift
, diarrhoea is present, and marked retching occurs.
Tenderness if present, may be ill defined, although
it maybe present immediately to the right of
umblicus.
Rectal examination
 No case of acute abdomial examination is complete
without digital examination of rectum
 The right wall may be tender in pelvic appendicitis
which may not show tenderness over the anterior
abdominal wall.
DIFFERENTIAL DIAGNOSIS
Investigations
 The diagnosis is essentially clinical. The decision
to operate on clinical suspicion alone can lead to
removal of normal appendix in 15-30% cases.
 However, the premise is that is better to remove a
normal appendix than to delay diagnosis,
particularly in elderly.
The Alvarado score
A score of 7 or more is strongly suggestive of acute appendicitis.
 In patient with equivocal score of 5-6,
 Abdominal ultrasound
 CECT
Treatment
 The traditional treatment of aute appendicitis is
appendicectomy.
 A trial of conservative management is tried in those
having non obstructive appendicitis, which
includes- bowel rest, iv antibiotics and usually
metronidazole or third generation cephalosporins.
 The available data indicates successful outcomes in
80-90% patients.
 With regard to appendicectomy, there is perception
that emergency, often out of hours, operation is
essential to prevent the increased morbidity and
mortality.
Pre-operative investigations
 Routine- CBC, Urinalysis
 Selective-
o pregnancy test
o Urea and electrolytes
o Supine abdominal radiograph
o Ultrasound in abdomen/pelvis
o CECT abdomen and pelvis
Intensive preoperative preparation
 Intravenous fluids sufficient to establish adequate urine
output(catheterisation is seen only in very ill patients)
 Appropriate antibiotics: single preop dose of antibiotics
reduces the incidence of post op wound infection
 When peritonitis suspected, therapeutics iv antibiotics
to cover gram negative bacilli and anerobic cocci
should be given.
 Hyperpyrexia in children should be treated with
salicylates.
Appendicectomy
 Conventional: gridiron incision
 Rutherford morison’s incision: In this, the internal
oblique and transversus muscle is cut along the line
of gridiron incision.
 This is useful in para or retrocaecal appendix and
fixed.
Problems encountered during appendicectomy

 A normal appendix is found- careful exclusion of other

possible diagnoses, particularly- meckel’s diverticulitis and
tubal or ovarian causes in women.
 The appendix is not found- caecum should be mobilised,
taenia coli should be traced to their confluences on the
caecum.
 An appendicular tumor is found-small tumors(d=2cm) can
be renoved by appendicectomy, large tumors to be removed
by hemicolectomy.
 An appendix abcess is found and appendix cannot be
removed easily
Post operative complications
 Wound infection
 Intra abdominal mass
 Ileus- adynamic ileus with fever persisting for more
than 4-5 days is indicative of intra abdominal
sepsis.
 Adhesive intestinal obstruction