Appendix

By Dr. Haitham Nabeel

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 Introduction

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Anatomy

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Introduction
• The importance of the vermiform appendix in surgery results primarily from its
propensity for inflammation, which results in the clinical syndrome known as
acute appendicitis.
• Acute appendicitis is the most common cause of an ‘acute abdomen’ in young
adults
• Appendicitis is sufficiently common that appendicectomy (termed appendectomy
in North America) is the most frequently performed urgent abdominal operation
and is often the first major procedure performed by a surgeon in training.
• Aside from its tendancy to cause surgical pathology the appendix, long thought to
be a vistigial organ, may also have important roles in both immune function and
maintaining the gut microbiota.

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Anatomy
• It is a blind muscular tube with mucosal, submucosal, muscular and serosal layers.
• At birth, the appendix is short and broad at its junction with the caecum, but differential
growth of the caecum produces the typical tubular structure by about the age of 2
years.
• During childhood, continued growth of the caecum commonly rotates the appendix into
a retrocaecal but intraperitoneal position.
• In approximately one-quarter of cases, rotation of the appendix does not occur, resulting
in a pelvic, subcaecal or paracaecal position. Occasionally, the tip of the appendix
becomes extraperitoneal, lying behind the caecum or ascending colon.
• Rarely, the caecum does not migrate during development to its normal position in the
right lower quadrant of the abdomen. In these circumstances, the appendix can be
found near the gall bladder or, in the case of intestinal malrotation, in the left iliac fossa,
causing diagnostic difficulty if appendicitis develops

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Anatomy

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Anatomy

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Anatomy

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Anatomy

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Anatomy
• The position of the base of the appendix is constant, being found at the confluence of the
three taeniae coli of the caecum, which fuse to form the outer longitudinal muscle coat of
the appendix.
• The mesentery of the appendix or mesoappendix arises from the lower surface of the
mesentery or the terminal ileum and is itself subject to great variation. Sometimes, as much
as the distal one-third of the appendix is bereft of mesoappendix.
• Especially in childhood, the mesoappendix is so transparent that the contained blood vessels
can be seen. In many adults, it becomes laden with fat, which obscures these vessels.
• The appendicular artery, a branch of the lower division of the ileocolic artery, passes behind
the terminal ileum to enter the mesoappendix a short distance from the base of the
appendix. It then comes to lie in the free border of the mesoappendix. An accessory
appendicular artery may be present but, in most people, the appendicular artery is an ‘end-
artery’, thrombosis of which results in necrosis of the appendix

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Anatomy

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Anatomy

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Microscopic anatomy
• The appendix varies considerably in length and circumference. The average length is
between 7.5 and 10 cm.
• The lumen is irregular, being encroached on by multiple longitudinal folds of mucous
membrane lined by columnar cell intestinal mucosa of colonic type
• Crypts are present but are not numerous.
• In the base of the crypts lie argentaffin cells (Kulchitsky cells), which may give rise to
carcinoid tumours
• The appendix is the most frequent site for carcinoid tumours, which may present with
appendicitis due to occlusion of the appendiceal lumen.
• The submucosa contains numerous lymphatic aggregations or follicles.
• While no discernible change in immune function results from appendicectomy, the
prominence of lymphatic tissue in the appendix of young adults seems to be important in
the aetiology of appendicitis

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Normal vermiform
appendix
The narrow lumen is bounded by mucosa,
which may be arranged in folds. There is
usually abundant lymphoid tissue in the
mucosa, especially in younger individuals.
This may encroach on and further narrow the
lumen. The mucosa is bounded by a
relatively thin muscularis mucosa

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Acute appendicitis
• Acute appendicitis is relatively rare in infants and becomes increasingly
common in childhood and early adult life, reaching a peak incidence in
the teens and early 20s.
• After middle age, the risk of developing appendicitis is quite small.
• The incidence of appendicitis is equal among males and females before
puberty.
• In teenagers and young adults, the male–female ratio increases to 3:2 at
age 25; thereafter, the greater incidence in males declines.

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Acute appendicitis
• Aetiology
• There is no unifying hypothesis regarding the aetiology of acute appendicitis.
• Decreased dietary fibre and increased consumption of refined carbohydrates may be
important.
• As with colonic diverticulitis, the incidence of appendicitis is lowest in societies with a
high dietary fibre intake.
• In resource-poor countries that are adopting a more refined western-type diet, the
incidence continues to rise.
• This is in contrast to the dramatic decrease in the incidence of appendicitis in western
countries observed in the past 30 years.
• No reason has been established for these paradoxical changes; however, improved
hygiene and a change in the pattern of childhood gastrointestinal infection related to
the increased use of antibiotics may be responsible.

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Acute appendicitis

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Acute appendicitis

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Acute appendicitis
• Aetiology
• While appendicitis is clearly associated with bacterial proliferation within the
appendix, no single organism is responsible.
• A mixed growth of aerobic and anaerobic organisms is usual.
• The initiating event causing bacterial proliferation is controversial.
• Obstruction of the appendix lumen has been widely held to be important, and some
form of luminal obstruction, either by a faecolith or a stricture, is found in the majority
of cases.
• A faecolith (sometimes refered to as an appendicolith) is composed of inspissated
faecal material, calcium phosphates, bacteria and epithelial debris
• Rarely, a foreign body is incorporated into the mass.
• The incidental finding of a faecolith is a relative indication for prophylactic
appendicectomy or an interval appendicetomy in a patient treated conservatively
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Acute appendicitis
• Aetiology
• A fibrotic stricture of the appendix usually indicates previous
appendicitis that resolved without surgical intervention.
• Obstruction of the appendiceal orifice by tumour, particularly
carcinoma of the caecum, is an occasional cause of acute
appendicitis in middle-aged and elderly patients.
• Intestinal parasites, particularly Oxyuris vermicularis (pinworm),
can proliferate in the appendix and occlude the lumen.

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Acute appendicitis
• Pathology
• Obstruction of the appendiceal lumen seems to be essential for the
development of appendiceal gangrene and perforation.
• However, in many cases of early appendicitis, the appendix lumen is
patent despite the presence of mucosal inflammation and lymphoid
hyperplasia.
• Occasional clustering of cases among children and young adults suggests
an infective agent, possibly viral, which initiates an inflammatory response.
• Seasonal variation in the incidence is also observed, with more cases
occurring between May and August in northern Europe than at other
times of the year.

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Acute appendicitis
• Pathology
• Lymphoid hyperplasia narrows the lumen of the appendix, leading to luminal
obstruction.
• Once obstruction occurs, continued mucus secretion and inflammatory exudation
increase intraluminal pressure, obstructing lymphatic drainage.
• Oedema and mucosal ulceration develop with bacterial translocation to the
submucosa.
• Resolution may occur at this point either spontaneously or in response to antibiotic
therapy.
• If the condition progresses, further distension of the appendix may cause venous
obstruction and ischaemia of the appendix wall.
• With ischaemia, bacterial invasion occurs through the muscularis propria and
submucosa, producing acute appendicitis
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Acute appendicitis
• Pathology
• Finally, ischaemic necrosis of the appendix wall produces gangrenous appendicitis,
with free bacterial contamination of the peritoneal cavity.
• Alternatively, the greater omentum and loops of small bowel become adherent to
the inflamed appendix, walling off the spread of peritoneal contamination and
resulting in a phlegmonous mass or paracaecal abscess.
• Rarely, appendiceal inflammation resolves, leaving a distended mucus-filled organ
termed a mucocele of the appendix.
• It is the potential for diffuse peritonitis that is the great threat of acute
appendicitis.
• Peritonitis occurs as a result of free migration of bacteria through an ischaemic
appendicular wall, frank perforation of a gangrenous appendix or delayed
perforation of an appendix abscess.
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Acute appendicitis

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Acute appendicitis

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Acute appendicitis
• History
• The classical features of acute appendicitis begin with poorly localised colicky
abdominal pain.
• This is due to mid-gut visceral discomfort in response to appendiceal inflammation
and obstruction.
• The pain is frequently first noticed in the periumbilical region and is similar to, but less
intense than, the colic of small bowel obstruction.
• Central abdominal pain is associated with anorexia, nausea and usually one or two
episodes of vomiting that follow the onset of pain (Murphy).
• Anorexia is a useful and constant clinical feature, particularly in children.
• The patient often gives a history of similar discomfort that settled spontaneously.
• A family history is also useful as up to one-third of children with appendicitis have a
first-degree relative with a similar history.

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Acute appendicitis
• History
• With progressive inflammation of the appendix, the parietal
peritoneum in the right iliac fossa becomes irritated, producing
more intense, constant and localised somatic pain that begins to
predominate.
• Patients often report this as an abdominal pain that has shifted
and changed in character.
• Typically, coughing or sudden movement exacerbates the right
iliac fossa pain.

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Acute appendicitis

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 The classic visceral–somatic sequence of
pain is present in only about half of those
patients subsequently proven to have
acute appendicitis.

Clinical pearl!
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Acute appendicitis
• History
• Atypical presentations include pain that is predominantly somatic or visceral
and poorly localised.
• Atypical pain is more common in the elderly, in whom localization to the
right iliac fossa is unusual.
• An inflamed appendix in the pelvis may never produce somatic pain
involving the anterior abdominal wall, but may instead cause suprapubic
discomfort and tenesmus.
• In this circumstance, tenderness may be elicited only on rectal examination
and is the basis for the recommendation that a rectal examination should be
performed on every patient who presents with acute lower abdominal pain.

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Acute appendicitis
• History
• During the first 6 hours, there is rarely any alteration in temperature
or pulse rate.
• After that time, slight pyrexia (37.2–37.7ºC) with a corresponding
increase in the pulse rate to 80 or 90 is usual.
• However, in 20% of patients there is no pyrexia or tachycardia in the
early stages.
• In children, a temperature greater than 38.5ºC suggests other causes
(e.g. mesenteric adenitis)

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Acute appendicitis
• History
• Typically, two clinical syndromes of acute appendicitis can be
discerned, acute catarrhal (non-obstructive) appendicitis and acute
obstructive appendicitis, the latter characterised by a more acute
course.
• The onset of symptoms is abrupt and there may be generalised
abdominal pain from the start.
• The temperature may be normal and vomiting is common, so the
clinical picture may mimic acute intestinal obstruction.

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Acute appendicitis

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Acute appendicitis
• Signs
• The diagnosis of appendicitis rests more on thorough clinical examination of the abdomen
than on any aspect of the history or laboratory investigation.
• The cardinal features are those of an unwell patient with low-grade pyrexia, localised
abdominal tenderness, muscle guarding and rebound tenderness.
• Inspection of the abdomen may show limitation of respiratory movement in the lower
abdomen.
• The patient is then asked to point to where the pain began and where it moved (the
pointing sign).
• Gentle superficial palpation of the abdomen, beginning in the left iliac fossa and moving
anticlockwise to the right iliac fossa, will detect muscle guarding over the point of maximum
tenderness, classically McBurney’s point.
• Asking the patient to cough or gentle percussion over the site of maximum tenderness will
elicit rebound tenderness.

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Signs of appendicitis
- Tenderness, guarding, and rigidity in the
right lower quadrant (RLQ; red area)
- Tenderness and rebound tenderness at
McBurney point, which is located at the
junction of the lateral third and medial two-
thirds of a line drawn from the right anterior
superior iliac spine to the umbilicus
- Rovsing sign: RLQ pain elicited on deep
palpation of the LLQ

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Signs of appendicitis

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Signs of appendicitis

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Acute appendicitis
• Signs
• Deep palpation of the left iliac fossa may cause pain in the right iliac fossa,
Rovsing’s sign, which is helpful in supporting a clinical diagnosis of appendicitis.
• Occasionally, an inflamed appendix lies on the psoas muscle, and the patient, often
a young adult, will lie with the right hip flexed for pain relief (the psoas sign).
• Spasm of the obturator internus is sometimes demonstrable when the hip is flexed
and internally rotated.
• If an inflamed appendix is in contact with the obturator internus, this manoeuvre
will cause pain in the hypogastrium (the obturator test; Zachary Cope).
• Cutaneous hyperaesthesia may be demonstrable in the right iliac fossa, but is rarely
of diagnostic value.

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Acute appendicitis

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Acute appendicitis
• Special features, according to position of the appendix
• Retrocaecal
• Rigidity is often absent, and even application of deep pressure may fail to elicit
tenderness (silent appendix), the reason being that the caecum, distended with
gas, prevents the pressure exerted by the hand from reaching the inflamed
structure.
• However, deep tenderness is often present in the loin, and rigidity of the
quadratus lumborum may be in evidence.
• Psoas spasm, due to the inflamed appendix being in contact with that muscle,
may be sufficient to cause flexion of the hip joint.
• Hyperextension of the hip joint may induce abdominal pain when the degree
of psoas spasm is insufficient to cause flexion of the hip.
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Acute appendicitis

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Acute appendicitis
• Special features, according to position of the appendix
• Pelvic
• Occasionally, early diarrhoea results from an inflamed appendix being in contact with the
rectum.
• When the appendix liesentirely within the pelvis, there is usually complete absence of
abdominal rigidity, and often tenderness over McBurney’s point is also lacking.
• In some instances, deep tenderness can be made out just above and to the right of the
symphysis pubis.
• In either event, a rectal examination reveals tenderness in the rectovesical pouch or the pouch
of Douglas, especially on the right side.
• Spasm of the psoas and obturator internus muscles may be present when the appendix is in this
position.
• An inflamed appendix in contact with the bladder may cause frequency of micturition. This is
more common in children.

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Acute appendicitis
• Special features, according to position of the appendix
• Postileal
• In this case, the inflamed appendix lies behind the terminal ileum.
• It presents the greatest difficulty in diagnosis because the pain may
not shift, diarrhoea is a feature and marked retching may occur.
• Tenderness, if any, is ill defined, although it may be present
immediately to the right of the umbilicus.

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Acute appendicitis
• Special features, according to age
• Infants
• Appendicitis is relatively rare in infants under 36 months of age and,
for obvious reasons, the patient is unable to give a history.
• Because of this, diagnosis is often delayed, and thus the incidence of
perforation and postoperative morbidity is considerably higher than in
older children.
• Diffuse peritonitis can develop rapidly because of the underdeveloped
greater omentum, which is unable to give much assistance in localizing
the infection.

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Acute appendicitis
• Special features, according to age
• Children
• It is rare to find a child with appendicitis who has not vomited.
• Children with appendicitis usually have complete aversion to food.
• The elderly
• Gangrene and perforation occur much more frequently in elderly patients.
• Elderly patients with a lax abdominal wall or obesity may harbour a gangrenous
appendix with little evidence of it, and the clinical picture may simulate
subacute intestinal obstruction.
• These features, coupled with coincident medical conditions, produce a much
higher mortality for acute appendicitis in the elderly.

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Acute appendicitis
• Special features, according to age
• The obese
• Obesity can obscure and diminish all the local signs of acute appendicitis and the clinician may have to rely
on imaging to establish the diagnosis.
• Laparoscopy is particularly useful in the obese patient as it may obviate the need for a large abdominal
incision.
• Pregnancy
• Appendicitis is the most common extrauterine acute abdominal condition in pregnancy, with a frequency
of 1:1500–2000 pregnancies.
• Diagnosis is complicated by delay in presentation as early non-specific symptoms are often attributed to
the pregnancy.
• Obstetric teaching has been that the caecum and appendix are progressively pushed to the right upper
quadrant of the abdomen as pregnancy develops during the second and third trimesters. However, pain in
the right lower quadrant of the abdomen remains the cardinal feature of appendicitis in pregnancy.
• Fetal loss occurs in 3–5% of cases, increasing to 20% if perforation is found at operation.

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Acute appendicitis

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Acute appendicitis
• Children
• The diseases most commonly mistaken for acute appendicitis are acute gastroenteritis
and mesenteric lymphadenitis.
• In mesenteric lymphadenitis, the pain is colicky in nature and cervical lymph nodes
may be enlarged.
• It may be impossible to clinically distinguish Meckel’s diverticulitis from acute
appendicitis. The pain is similar; however, signs may be central or left sided.
Occasionally, there is a history of antecedent abdominal pain or intermittent lower
gastrointestinal bleeding.
• It is important to distinguish between acute appendicitis and intussusception.
Appendicitis is uncommon before the age of 2 years, whereas the median age for
intussusception is 18 months. A mass may be palpable in the right lower quadrant,
and the preferred treatment of intussusception is reduction by careful barium enema.

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Acute appendicitis
• Children
• Henoch–Schönlein purpura is often preceded by a sore throat or
respiratory infection. Abdominal pain can be severe and can be confused
with intussusception or appendicitis. There is nearly always an ecchymotic
rash, typically affecting the extensor surfaces of the limbs and on the
buttocks. The face is usually spared. The platelet count and bleeding time
are within normal limits. Microscopic haematuria is common.
• Lobar pneumonia and pleurisy, especially at the right base, may give rise to
right-sided abdominal pain and mimic appendicitis. Abdominal tenderness
is minimal, pyrexia is marked and chest examination may reveal a pleural
friction rub or altered breath sounds on auscultation. A chest radiograph is
diagnostic.
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Acute appendicitis
• Adults
• Terminal ileitis in its acute form may be clinically indistinguishable from acute
appendicitis unless a doughy mass of inflamed ileum can be felt. An antecedent history
of abdominal cramping, weight loss and diarrhoea suggests regional ileitis rather than
appendicitis. The ileitis may be non-specific, due to Crohn’s disease or Yersinia infection.
• Ureteric colic does not commonly cause diagnostic difficulty, as the character and
radiation of pain differs from that of appendicitis. Urinalysis should always be
performed, and the presence of red cells should prompt a supine abdominal radiograph.
Renal ultrasound or intravenous urogram is diagnostic.
• Right-sided acute pyelonephritis is accompanied and often preceded by increased
frequency of micturition. It may cause difficulty in diagnosis, especially in women. The
leading features are tenderness confined to the loin, fever (temperature 39ºC) and
possibly rigors and pyuria.

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Acute appendicitis
• Adults
• In perforated peptic ulcer, the duodenal contents pass along the paracolic gutter
to the right iliac fossa. As a rule, there is a history of dyspepsia and a very sudden
onset of pain that starts in the epigastrium and passes down the right paracolic
gutter. In appendicitis, the pain starts classically in the umbilical region. Rigidity
and tenderness in the right iliac fossa are present in both conditions but, in
perforated duodenal ulcer, the rigidity is usually greater in the right
hypochondrium. An erect chest radiograph will show gas under the diaphragm in
70% of patients. An abdominal computed tomography (CT) examination is
valuable when there is diagnostic difficulty.
• Testicular torsion in a teenage or young adult male is easily missed. Pain can be
referred to the right iliac fossa, and shyness on the part of the patient may lead
the unwary to suspect appendicitis unless the scrotum is examined in all cases.
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Acute appendicitis
• Adults
• Acute pancreatitis should be considered in the differential diagnosis of all
adults suspected of having acute appendicitis and, when appropriate,
should be excluded by serum or urinary amylase measurement.
• Rectus sheath haematoma is a relatively rare but easily missed
differential diagnosis. It usually presents with acute pain and localised
tenderness in the right iliac fossa, often after an episode of strenuous
physical exercise. Localised pain without gastrointestinal upset is the
rule. Occasionally, in an elderly patient, particularly one taking
anticoagulant therapy, a rectus sheath haematoma may present as a
mass and tenderness in the right iliac fossa after minor trauma.

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Acute appendicitis
• Adult female
• It is in women of childbearing age that pelvic disease most often mimics acute
appendicitis. A careful gynaecological history should be taken in all women with
suspected appendicitis, concentrating on menstrual cycle, vaginal discharge and
possible pregnancy. The most common diagnostic mimics are pelvic inflammatory
disease (PID), Mittelschmerz, torsion or haemorrhage of an ovarian cyst and ectopic
pregnancy.
• PELVIC INFLAMMATORY DISEASE
• PID comprises a spectrum of diseases that include salpingitis, endometritis and tubo-ovarian
sepsis. The incidence of these conditions is increasing, and the diagnosis should be considered
in every young adult female. Typically, the pain is lower than in appendicitis and is bilateral. A
history of vaginal discharge, dysmenorrhoea and burning pain on micturition is a helpful
differential diagnostic point. The physical findings include adenexal and cervical tenderness
on vaginal examination.

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Acute appendicitis
• Adult female
• MITTELSCHMERZ
• Midcycle rupture of a follicular cyst with bleeding produces lower
abdominal and pelvic pain, typically midcycle. Systemic upset is
rare, a pregnancy test is negative and symptoms usually subside
within hours. Occasionally, diagnostic laparoscopy is required.
Retrograde menstruation may cause similar symptoms.
• TORSION/HAEMORRHAGE OF AN OVARIAN CYST
• This can prove a difficult differential diagnosis. When suspected,
pelvic ultrasound and a gynaecological opinion should be sought.
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Acute appendicitis
• Adult female
• ECTOPIC PREGNANCY
• It is unlikely that a ruptured ectopic pregnancy, with its well-defined signs of
haemoperitoneum, will be mistaken for acute appendicitis, but the same cannot be said for
a rightsided tubal abortion or, still more, for a right-sided unruptured tubal pregnancy.
• In the latter, the signs are very similar to those of acute appendicitis except that the pain
commences on the right side and stays there. The pain is severe and continues unabated
until operation. Usually, there is a history of a missed menstrual period, and a urinary
pregnancy test may be positive.
• Severe pain is felt when the cervix is moved on vaginal examination. Signs of
intraperitoneal bleeding usually become apparent, and the patient should be questioned
specifically regarding referred pain in the shoulder.
• Pelvic ultrasonography should be carried out in all cases in which an ectopic pregnancy is a
possible diagnosis.

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Acute appendicitis
• Elderly
• DIVERTICULITIS
• In some patients with a long sigmoid loop, the colon lies to the right of the midline and it may be
impossible to differentiate between diverticulitis and appendicitis.
• Abdominal CT scanning is particularly useful in this setting and should be considered in the
management of all patients over the age of 60 years.
• INTESTINAL OBSTRUCTION
• The diagnosis of intestinal obstruction is usually clear; the subtlety lies in recognising acute
appendicitis as the occasional cause in the elderly
• CARCINOMA OF THE CAECUM
• When obstructed or locally perforated, carcinoma of the caecum may mimic or cause
obstructive appendicitis in adults.
• A history of antecedent discomfort, altered bowel habit or unexplained anaemia should raise
suspicion. A mass may be palpable and an abdominal CT scan diagnostic.

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Acute appendicitis
• Investigation
• The diagnosis of acute appendicitis is essentially clinical;
however, a decision to operate based on clinical suspicion alone
can lead to the removal of a normal appendix in 15–30% of cases.
• The premise that it is better to remove a normal appendix than to
delay diagnosis does not stand up to close scrutiny, particularly in
the elderly.
• A number of clinical and laboratory- based scoring systems have
been devised to assist diagnosis.
• The most widely used is the Alvarado score.
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Acute appendicitis

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Acute appendicitis
• Investigation
• A score of 7 or more is strongly predictive of acute appendicitis.
• In patients with an equivocal score (5–6), abdominal ultrasound or contrast-
enhanced CT examination further reduces the rate of negative appendicectomy.
• Abdominal ultrasound examination is more useful in children and thin adults,
particularly if gynaecological pathology is suspected, with a diagnostic accuracy in
excess of 90%
• Modern CT is both sensitive and specific (approximately 95%) in the diagnosis of
acute appendicitis and worldwide there has been a steady increase in its use for this
purpose.
• Contrast-enhanced standard dose CT is especially useful in patients in whom there
is diagnostic uncertainty, particularly older patients, where acute diverticulitis,
intestinal obstruction and neoplasm are likely differential diagnoses.
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Acute appendicitis
• Abdominal ultrasound
• Many institutions prefer ultrasound as the initial imaging
modality, reserving CT scans for inconclusive ultrasound findings.
• Supportive findings
• Distended appendix (diameter > 6 mm)
• Noncompressible, aperistaltic, distended appendix
• Target sign: concentric rings of hypo- and hyperechogenicity in the
axial/transverse section of the appendix
• Possible appendiceal fecalith: focal hyperechogenicity with posterior
acoustic shadowing

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Acute appendicitis
Ultrasound of the appendix (longitudinal
section of the right lower quadrant)
The appendix (green overlay) is
distinguishable from the hyperechoic
surroundings; it is dilated, with a diameter of
8.2 mm (physiological: ≤ 6 mm). Additionally,
the appendix is aperistaltic and
noncompressible when pressure is applied
with the transducer. These findings indicate
acute appendicitis (IA = right common iliac
artery; IV= right common iliac vein).

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Appendicitis with
target sign
Ultrasound of the appendix (axial view)
The diameter of the appendix is increased to
12.1 mm (normal ≤ 6 mm). The wall has
hyperechoic and hypoechoic layers due to
inflammation and resulting edema; because
of this appearance, this sign is termed target
sign.
These are characteristic features of acute
appendicitis.

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 While abdominal ultrasound can confirm
the diagnosis of acute appendicitis,
normal ultrasound findings do not
reliably rule out appendicitis.

Clinical pearl!
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Acute appendicitis
• CT abdomen with IV contrast
• Supportive findings
• Distended appendix (diameter > 6 mm)
• Edematous appendix with periappendiceal fat stranding
• Possible appendiceal fecalith: focal hyperdensity within the
appendiceal lumen
• Evidence of complications
• Additional considerations
• Consider low-dose CT scan (with IV contrast) to minimize radiation
exposure.
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Perforated
appendicitis due to
fecalith
CT abdomen (IV contrast; axial section)
There is distension of the appendix (green
overlay) with periappendiceal edema and
mesenteric fat stranding. A well-defined,
round, hyperdense lesion (black arrow),
characteristic of an appendiceal fecalith, is
seen at the proximal end of the appendiceal
lumen. A small pocket of extraluminal air (red
overlay) is also visible near the distal appendix.
These features indicate a perforated appendix
secondary to appendicitis caused by a fecalith.
Note: The air shadow (yellow overlay) adjacent
to the body of the appendix is likely intestinal
gas.

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Appendiceal abscess
Abdomen CT (IV and oral contrast; coronal
section)
The appendix (green overlay) is markedly
distended, as evidenced by its distinctly
visible hypodense lumen. A localized
hypodense fluid collection (hatched area)
with a well-defined hyperdense rim is visible
at the cecal end of the appendix, indicating a
periappendiceal abscess that is partially
compressing the bladder.

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 CT has been shown to reduce the rate of
negative appendicectomy without an
associated increased perforation rate (due to
delay in diagnosis) and may be cost-effective
due to shorter hospital stay.

Clinical pearl!
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Acute appendicitis

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Acute appendicitis
• Non-operative management
• While surgery remains the standard teaching, there is an emerging body of literature to
support a trial of conservative mangement in patients with uncomplicated (absence of
appendicolith, perforation or abscess) appendicitis.
• Treatment is bowel rest and intravenous antibiotics, often metronidazole and 3rd
generation cephalosprin. More recently, ertapenem has been used in this setting and has the
benefit of broad antimicrobial cover administered as a single daily dose.
• The available data indicate initial successful outcomes in more than 90% of patients with CT
confirmed appendicitis; however, approximately one-quarter of patients initially treated
conservatively will require surgery within 1 year for recurrent appendicitis.
• Subsequent surgery, if needed, tends to be uncomplicated. This approach may be considered
in the well patient with limited signs or those with high operative risk (multiple co-
morbidities). As with conservative treatment of an appendix mass, patients over the age of
40 should be followed up to ensure there is no underlying malignancy

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 PAIN: Pain
management, Antibiotics, Intravenous
fluid therapy, and NPO are part
of conservative management of
appendicitis.

Clinical pearl!
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Acute appendicitis
• Operative management
• The traditional treatment for acute appendicitis is appendicectomy.
• While there should be no unnecessary delay, all patients, particularly those most at
risk of serious morbidity, benefit by a short period of intensive preoperative
preparation.
• Intravenous fluids, sufficient to establish adequate urine output (catheterisation is
needed only in the very ill), and appropriate antibiotics should be given.
• There is ample evidence that in the absence of purulent peritonitis, a single
peroperative dose of antibiotics reduces the incidence of postoperative wound
infection.
• When peritonitis is suspected, therapeutic intravenous antibiotics to cover gram-
negative bacilli as well as anaerobic cocci should be given. Hyperpyrexia in children
should be treated with salicylates in addition to antibiotics and intravenous fluids
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 With appropriate use of intravenous fluids and parenteral
antibiotics, a policy of deferring appendicectomy after
midnight to the first case on the following morning does
not increase morbidity. However, when acute obstructive
appendicitis is recognised, operation should not be
deferred longer than it takes to optimise the patient’s
condition.

Clinical pearl!
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Acute appendicitis

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Acute appendicitis

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Acute appendicitis

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Acute appendicitis

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Acute appendicitis
• Problems encountered during appendicectomy
• A normal appendix is found
• This demands careful exclusion of other possible diagnoses, particularly terminal
ileitis, Meckel’s diverticulitis and tubal or ovarian causes in women. It is usual to
remove the appendix to avoid future diagnostic difficulties, even though the appendix
is macroscopically normal, particularly if a skin crease or gridiron incision has been
made.
• The appendix can not be found
• The caecum should be mobilised, and the taeniae coli should be traced to their
confluence on the caecum before the diagnosis of ‘absent appendix’ is made.
• An appendicular tumour is found
• Small tumours (under 2.0 cm in diameter) can be removed by appendicectomy; larger
tumours should be treated by a right hemicolectomy.

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Acute appendicitis
• Problems encountered during appendicectomy
• An appendix abscess is found and the appendix cannot
be removed easily
• This eventuality is rare in the era of modern diagnositic
imaging. Percutaneous drainage of the abscess and
intravenous antibiotic treatment is to be preferred. If found at
operation, the abscess should be drained and intravenous
antibiotics administered.
• Very rarely in the face of a frankly necrotic appendix, a
caecectomy or partial right hemicolectomy is required
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Acute appendicitis

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Complications after appendicectomy
• Wound infection
• Wound infection is the most common postoperative complication, occurring in 5–10% of
all patients.
• This usually presents with pain and erythema of the wound on the fourth or fifth
postoperative day, often soon after hospital discharge.
• Intra-abdominal abscess
• Approximately 8% of patients following appendectomy will develop a postoperative intra-
abdominal abscess. In an era of hospital discharge 24–48 hours following appendectomy,
patients should be advised prior to discharge that a spiking fever, malaise and anorexia
developing 5–7 days after operation is suggestive of an intraperitoneal collection and that
urgent medical advice should be obtained. Interloop, paracolic, pelvic and subphrenic sites
should be considered. Abdominal ultrasonography and CT scanning greatly facilitate
diagnosis and allow percutaneous drainage

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Intra-abdominal
abscess
(a) Rim enhancing collection in the right iliac
fossa, 1 week following open
appendicectomy for perforated appendicitis.
(b) Successful radiological drainage with
resolution of the abscess

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Acute appendicitis
• Ileus
• A period of adynamic ileus is to be expected after appendicectomy, and this may
last a number of days following removal of a gangrenous appendix.
• Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is
indicative of continuing intra-abdominal sepsis and should prompt further
investigation
• Respiratory
• In the absence of concurrent pulmonary disease, respiratory complications are rare
following appendicectomy
• Venous thrombosis and embolism
• These conditions are rare after appendicectomy, except in the elderly and in
women taking the oral contraceptive pill.

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Acute appendicitis
• Portal pyaemia (pylephlebitis)
• This is a rare but very serious complication of gangrenous appendicitis associated with high fever,
rigors and jaundice.
• It is caused by septicaemia in the portal venous system and leads to the development of
intrahepatic abscesses (often multiple).
• Treatment is with systemic antibiotics and percutaneous drainage of hepatic abscesses as
appropriate.
• Faecal fistula
• Leakage from the appendicular stump occurs rarely, but may follow if the encircling stitch has
been put in too deeply or if the caecal wall was involved by oedema or inflammation.
Occasionally, a fistula may result following appendicectomy in Crohn’s disease.
• Adhesive intestinal obstruction
• This is the most common late complication of appendicectomy. At operation, a single band
adhesion is often found to be responsible

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Acute appendicitis

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Acute appendicitis
• Management of an appendix mass
• If an appendix mass is present and the condition of the patient is
satisfactory, the standard treatment is the conservative Ochsner–
Sherren regime.
• This strategy is based on the premise that the inflammatory process is
already localised and that inadvertent surgery is difficult and may be
dangerous. It may be impossible to find the appendix and, occasionally,
a faecal fistula may form.
• For these reasons, it is wise to observe a non-operative programme
but to be prepared to operate should clinical deterioration occur.

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 Initial operative treatment of
appendiceal abscesses or
appendiceal phlegmons is associated with
a high risk of complications

Clinical pearl!
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Acute appendicitis
• Management of an appendix mass
• Careful recording of the patient’s condition and the extent of the mass should be made
and the abdomen regularly re-examined.
• It is helpful to mark the limits of the mass on the abdominal wall using a skin pencil.
• A contrast-enhanced CT examination of the abdomen should be performed and
antibiotic therapy instigated.
• An abscess, if present, should be drained radiologically.
• Temperature and pulse rate should be recorded 4-hourly and a fluid balance record
maintained.
• Clinical improvement is usually evident within 24–48 hours.
• Using this regime, approximately 90% of cases resolve without incident.
• Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn’s disease.

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Acute appendicitis
• Management of an appendix mass

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 Clinical deterioration or
evidence of peritonitis is an
indication for early laparotomy!

Clinical pearl!
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Acute appendicitis
• Management of an appendix mass
• The need for interval appendicectomy in this cohort is much debated.
The great majority of patients will not develop recurrent appendicitis;
however; recently published studies have identified higher than
expected rates of underlying appendiceal neoplasm in those patients
who do go on to interval appendicectomy, particularly those patients
over the age of 40. At the very least, follow-up CT should be
performed to ensure complete resolution of findings and patients
should undergo colonoscopy.

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Acute appendicitis
• Appendix abscess
• Failure of resolution of an appendix mass or continued spiking pyrexia
usually indicates that there is pus within the phlegmonous appendix mass.
Ultrasound or abdominal CT scan may identify an area suitable for the
insertion of a percutaneous drain. Rarely this is unsuccessful and laparotomy
though a midline incision is indicated.

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Appendiceal abscess
Abdomen CT (IV and oral contrast; coronal
section)
The appendix (green overlay) is markedly
distended, as evidenced by its distinctly
visible hypodense lumen. A localized
hypodense fluid collection (hatched area)
with a well-defined hyperdense rim is visible
at the cecal end of the appendix, indicating a
periappendiceal abscess that is partially
compressing the bladder.

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THANK YOU!

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