acute appendicitis &

peritonitis

DONE BY:HOZAN BURHAN

GROUP 19-01
 Anatomy of appendix
The appendix or vermiform appendix is a muscular structure attached to the large
intestine in the human body. It is a narrow tube. The appendix extends from the
lower end of the cecum, a pouch-like structure in the large intestine.
The diameter of the appendix usually ranges from 7 to 8 mm and its length
ranges between 2 and 20 cm, with an average length of 9 cm. The appendix is
usually located at the lower right side of the abdomen. The appendix is made of
inner mucosa layer just like the rest of the digestive tract and is also known as the
vermix or the cecal appendix.
IT’S A VESTIGEAL OF HUMAN BODY (means no function in human body )
  Appendicitis 
• Appendicitis is an acute inflammation
of the inner lining of the appendix. It is
the most common cause of acute
surgery and most often occurs
between 10 and 30 years of age.
• The abdomen is most tender at
McBurney’s point – one third of the
distance from the right anterior
superior iliac spine to the umbilicus.
This corresponds to the location of the
base of the appendix
 • Infection, possibly stomach
infection that has traveled to the
site of appendix.

Risk • Obstruction such as a hard piece

of stool getting trapped in the

factor 
appendix leading to infection of the
appendix.  

• Previous abdominal surgery

 CAUSES
• Acute appendicitis seems to be the end result of a primary obstruction of
the appendix. FAECOLITH
 • Once this obstruction occurs, the appendix becomes filled with mucus and swells.
This continued production of mucus leads to increased pressures within the lumen and
the walls of the appendix. 
• The increased pressure results in thrombosis and occlusion of the small vessels, and
stasis of lymphatic flow.​
 1-Appendiceal fecalith and fecal stasis( A layered buildup of
calcium salts and fecal debris around a piece of fecal material
within the appendix)

2-Lymphoid tissue hyperplasia(The appendix contains

lymphoid (immune system) tissue that can become inflamed
Common as a result of infection or inflammatory bowel disease (IBD) 

cause  3. Parasites • Examples: Schistosomes species, pinworms,

Strongyloides

4-neoplasia(eg.carcinoid btumor,adenocarcinoma)
pathophysiology
 Clinical presentation
•Periumbilical pain that later migrates to the right lowe quadrant (RLQ)
•Anorexia
•Nausea/vomiting
•Fever
•Indigestion
•Diarrhea
•Constipation
•Generalized malaise
 Diagnosis
•History
1-Duration of symptoms: typically 24–48 hours
2-Abdominal pain :
-Sudden onset 
-Constant, becoming progressively worse
-Exacerbated by movement
3-Anorexia,Nausea diarrhea /constipation may or may not be present
•dults (eliminate other causes): History of inflammatory bowel
disease.History of  colorectal cancer/previous  colonoscopy
•Reproductive/sexually transmitted diseases in women (rule
out pelvic inflammatory disease ,ectopic pregnancy
• Physical exam 
​
General:
• Low-grade fever up to 38.3°C 
•High fever may indicate late appendicitis/necrosis /perforation
•Signs of dehydration if prolonged vomiting/ anorexia:
•Tachycardia 
•Orthostatic hypotension 
•Decreased urinary output
•Abdominal exam:  
•RLQ tenderness  
•Localized rebound tenderness (peritoneal irritation)  
•Signs:  
•McBurney’s point tenderness: maximal tenderness at 3.8–5.0 cm  from anterior iliac spine on
a straight line to the umbilicus  
•Rovsing’s sign: pain in the RLQ with palpation of the left lower quadrant  
•Psoas sign: RLQ pain with passive hip extension (characteristic of retrocecal appendix) 
• Obturator sign: RLQ pain with internal hip rotation with a flexed knee (pelvic appendix) 
• Generalized peritonitis suggests perforation. 
        Laboratory studies

• Complete blood count (CBC): leukocytosis with a left shift 

• Inflammatory markers: ↑ erythrocyte sedimentation rate (ESR), C-reactive protein
(CRP)
•  Chemistry may show dehydration pattern: low K (potassium), low Na (sodium),
metabolic alkalosis 
• Urinalysis: may show mild pyuria due to proximity of the right ureter 
• Pregnancy test: Perform on all females of reproductive age.
•  Alvarado score
• Appendicitis inflammatory response score Air score
Appendicitis inflammatory
response score (AIR Score) Alvarado score (MANTRELS)
Characteristics Score Characteristics Score
Vomiting 1
Symptoms Migration of pain to RLQ 1
RLQ pain 1
Symptoms Anorexia 1
Mild 1

Rebound tendern Moderate 2

Nausea and/or vomiting 1
Physical examina ess
tion Strong 3 Tenderness in RLQ 2
Temperature ≥ 38.5°C (101.3°F) 1 Rebound pain 1
Physical examination
10,000/mm3–
1 Elevated temperature >
14,999/mm3 1
Leukocytosis 37.3°C (99.1°F)
≥ 15,000/mm3 2
Laboratory 70–84% 1 Leukocytosis (>
2
parameters PMN 10,000/mm3)
≥ 85% 2 Laboratory parameters
10–49 mg/L 1 Shift to the left (≥ 75%  1
CRP neutrophils)
≥ 50 mg/L 2

•Likelihood of appendicitis≤ 4: Low

•Likelihood of appendicitis ≤ 4: Low  [16]
•5–8: Moderate •5–6: Moderate
•≥ 9: High •≥ 7: High  [16]
• Imaging
•  Imaging is not required for diagnosis if the Alvarado score is very low (< 3) or high (> 7).
• Computed tomography (CT) scan:
• Findings of appendicitis: 
• Appendiceal diameter > 6 mm (0.24 in) with occluded lumen 
• Appendiceal wall thickening  > 2 mm (0.08 in) 
• Appendiceal wall enhancement
• Ultrasound (US):
• Signs of appendicitis:
•  Non-compressible appendix 
• Appendix diameter > 6 cm (2.4 in) 
• Focal pain with pressure from US probe
•  Increased echogenicity of surrounding fat
• Magnetic resonance imaging (MRI):
Management
 Initial management
•  Intravenous fluid resuscitation (hydrate and replace electrolytes)
• NPO (nothing by mouth)
•  Analgesia
• Nausea control
 Case study
a 24-year-old female who presented to the accident & emergency department  with a four-hour history of right
lower quadrant (RLQ) abdominal pain. The pain originated in the umbilical region, radiating diffusely across the
lower abdomen and subsequently localised to the RLQ. The pain was of sudden onset, sharp and colicky with
progressing intensity. Over the counter, oral co-codamol 500mg (a combination analgesic of codeine phosphate and
acetaminophen) was taken before presenting to A&E, which did not alleviate the pain. The pain was exacerbated by
lifting the right leg and relieved by leaning forwards. Severity was rated eight on a scale of one to 10, with one
being no pain and 10 being the most pain possible. This episode had not been preceded by previous abdominal
pain, and she denied nausea or vomiting. She opened her bowels post-onset of the pain with no changes to the
consistency of the stools and absence of blood or mucus. She denied urinary or infective symptoms. Past medical
and surgical history was nil of note. Drug history included the oral contraceptive pill with no known drug allergies.
There was no relevant family history. The patient did not smoke, reported alcohol consumption occasionally, and
denied recreational drug use.
1-what disease can you think of?
2-what is the survery plan?
3-what is the treatment plan?
 Peritonitis
Peritonitis refers to the inflammation of the peritoneum , which is the inner membrane that lines the abdominal cavity
and abdominal organs. Peritonitis is typically caused by an infection involving gastrointestinal or pelvic organs, and it can
be life threatening if left untreated

Can peritonitis lead to sepsis?

A potential complication of peritonitis is sepsis, which results from the spread of
infection throughout the body. Sepsis refers to the body s extreme response to such an
infection and can potentially lead to organ damage and failure. If not treated
immediately, sepsis can be fatal.
 What causes peritonitis?
• Depending on its cause, peritonitis can be classified into two
main types of peritonitis: spontaneous bacterial peritonitis and
secondary peritonitis.
1-Spontaneous bacterial peritonitis is usually a complication of
liver or kidney failure, resulting in fluid buildup in the abdominal
cavity (also known as ascites )Spontaneous bacterial peritonitis is
the development of an infection of the ascitic fluid in
the peritoneum, with no identifiable source of the infection.
2-Secondary peritonitis is typically the result of a ruptured organ
in the abdomen, which can allow bacteria to enter the peritoneal
cavity. Secondary peritonitis most often occurs as a complication
of gastrointestinal disorders, such as appendicitis , pancreatitis, a
ruptured stomach ulcer, or a perforated colon.
Common symptoms of peritonitis include:
 abdominal discomfort,
nausea and vomiting
loss of appetite
 Diarrhea
constipation, 
fever, fatigue, and confusion.
 Early stage peritonitis will often present as dull, generalized pain in the abdomen,
later stage peritonitis may cause more severe, localized abdominal pain. If
undergoing peritoneal dialysis  cloudy dialysis fluid can also be a sign of peritonitis.
 Peritonitis
• Peritonitis refers to the inflammation of the peritoneum , which is the inner membrane that lines the abdominal cavity and abdominal
organs. Peritonitis is typically caused by an infection involving gastrointestinal or pelvic organs, and it can be life threatening if left
untreated..
• Clinical features:
• fever,
• bloating,
• constipation,
• arterial hypotension, tachycardia,
• flattened abdominal muscles,
• symptoms of peritoneal irritation,
• diffuse abdominal pain,
• vomiting, nausea,
• pale gray skin,
• confusion,
• dry tongue

• Pain is first localized in the right iliac region, then quickly spreads throughout the abdomen. The Shchetkin-Blumberg symptom is expressed
in all parts of the abdomen, but gradually its severity weakens. On auscultation of the abdomen, no bowel sounds are heard. Gas and stool
retention is noted.
 How do you diagnose peritonitis?

• Several tests can be performed in order to diagnose peritonitis. Firstly, a

physical examination and review of medical history can reveal underlying
conditions or medical procedures that may have caused peritonitis. A
blood test may be taken to check for high white blood cell counts or the
presence of bacteria. A peritoneal fluid analysis can also be performed to
determine if there is infection or inflammation. Finally, imaging studies,
such as X-rays or CT scans, can show perforation or other trauma in
the gastrointestinal tract.
 Treatment
1- Surgery(laparotomy) is to correct any gross anatomical
damage that may have caused peritonitis

2-General:
Antibiotics are usually administered intravenously, but
they may also be infused directly into
the peritoneum.Example:Ampicillin. 
- correction of homeostasis disorders (intensive
therapy with respiratory support, maintenance of
hemodynamics, control and replacement of
kidney function);
- extracorporeal detoxification;
- adequate nutritional and metabolic support;
- modulation of the anti-inflammatory response.