4th Year MBBS,

Jinnah Medical College, Peshawar

ACUTE APPENDICITIS

Lecture By:
Dr. Shahid Hasnain Siddiqui
Assistant Professor Pathology
ACUTE APPENDICITIS
• Acute inflammation of the vermiform appendix not attributable
to distinct inflammatory disorders, such as idiopathic inflammatory
bowel disease.

• Existence of chronic appendicitis is disputed; may represent recurrent

acute appendicitis.

• Acute appendicitis is most common in adolescents and young adults

but may occur in any age group.

• The lifetime risk for appendicitis is 7%.

ACUTE APPENDICITIS
• Males are affected slightly more often than females.

• Despite the prevalence of acute appendicitis, the diagnosis can be

difficult to confirm preoperatively.

• The condition may be confused with:

• Mesenteric lymphadenitis
• Acute salpingitis
• Ectopic pregnancy
• Mittelschmerz (pain associated with ovulation), and
• Meckel diverticulitis.
PATHOGENESIS
• The most common mechanism is obstruction of the lumen from
various etiologic factors that leads to increased intraluminal
pressure.

• This presses upon the blood vessels to produce ischemic injury.

• Ischemic injury and stasis of luminal contents, favor bacterial

proliferation.

• This triggers inflammatory responses including tissue edema and

neutrophilic infiltration of the lumen, muscular wall, and peri-
appendiceal soft tissues.
PATHOGENESIS
The common causes of appendicitis are as under:

A. Obstructive:
1. Fecolith (stone like mass of stool)
2. Calculi
3. Foreign body
4. Tumor
5. Worms (especially Enterobius vermicularis)
6. Diffuse lymphoid hyperplasia, especially in children.
PATHOGENESIS
B. Non-obstructive:

1. Hematogenous spread of generalized infection

2. Vascular occlusion

3. Inappropriate diet lacking roughage.

MORPHOLOGY (GROSS)
• Appendix may appear grossly normal when inflammation is limited to
the mucosa and submucosa.

• Appendix appears swollen and erythematous when inflammation

extends into the muscularis propria.

• When the serosa is affected, a purulent exudate appears.

• Cut surface may show hyperemia or intraluminal or intramural

abscess.

• Appendiceal wall may be completely necrotic in gangrenous

appendicitis. Perforation occurs in severe cases.
 Typical acute appendicitis with
———————————fibrinopurulent exudate on the
surface.
Cut surface of acute appendicitis
showing mucosal ulceration and
hyperemia.
MICROSCOPY
• Although mucosal neutrophils and focal superficial ulceration are
often present, these findings are not specific.

• Diagnosis of acute appendicitis requires neutrophilic infiltration of

the muscularis propria.

• Process may be divided into acute focal, acute suppurative,

gangrenous and perforative:

• Early lesions display mucosal erosions and scattered crypt abscesses.

MICROSCOPY
• Later, the inflammation extends into the lamina propria and
collections of neutrophils are also seen in the lumen

• In more severe cases, focal abscesses may form within the wall
(acute suppurative appendicitis).

• These may even progress to large areas of hemorrhagic ulceration

and gangrenous necrosis that extend to the serosa, creating acute
gangrenous appendicitis.

• This is often followed by rupture and suppurative peritonitis.

 Marked Neutrophilic
Infiltration of Appendiceal
Wall
 Marked Neutrophilic
Infiltration of Appendiceal
Wall
 Acute inflammation
extends through the
Appendiceal wall to the
periappendiceal soft
tissue.
CLINICAL FEATURES
• Typically, early acute appendicitis produces periumbilical pain that
then moves to the right lower quadrant, followed by nausea,
vomiting, low-grade fever.

• Elevated TLC is classically present but up to 33% of patients with

acute appendicitis will present with a normal WBC count.

• Elevated C reactive protein (CRP), elevated erythrocyte

sedimentation rate (ESR)
CLINICAL FEATURES
• A classic physical finding is McBurney sign, deep tenderness noted
at a location two-thirds of the distance from the umbilicus to the right
anterior superior iliac spine (McBurney point).

• These signs and symptoms, however, are often absent, creating

difficulty in clinical diagnosis.

• Imaging studies such as CT scanning are helpful in narrowing the

differential diagnosis.
Tenderness here implies a
Positive McBurney sign
TREATMENT
• While in the emergency department, the patient must be kept NBM
and hydrated intravenously with crystalloids.

• Antibiotics should be administered intravenously as per the surgeon

• Appendectomy is the gold standard treatment

o Laparoscopic appendectomy is preferred over the open
approach
 THANK YOU!
ANY QUESTIONS..