Acute Appendicitis
Dr TT
Outline
• Introduction
• Epidemiology
• Types
• Pathogenesis
• Clinical Diagnosis
• Management
• Complications
• Take-Home Message
• References
Introduction
• Most common cause of acute abdomen in young adults
• Anatomy-a worm-shaped, blind-ending tube
that arises from the posteromedial wall of the caecum 2 cm
below the ileocaecal valve
It varies in length from 2 to 25 cm,
but is most commonly 6–9 cm long
On the external surface of the bowel,
the base of the appendix is found at
the point of convergence of the three taeniae coli of the caecum
Epidemiology
• It is common in - White races - Young males
• uncommon in patients below the age of 2 and above the age of 65
•·· Fibre rich diet prevents appendicitis.
Less fibre diet increases chance of appendicitis
• Viral infection ( Measles, CMV)
• Obstruction of the lumen ( 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
• ?Seasonal variation (May,August), familial 30%
• A faecolith (sometimes refered to as an appendicolith) is composed of
inspissated faecal material, calcium phosphates, bacteria and
epithelial debris
Types
• Catarrhal or Non-obstructive 1/3
• Obstructive 2/3
• Recurrent appendicitis- Repeated attacks of nonobstructive appendicitis
leads to fibrosis, adhesions causing recurrent appendicitis
• Subacute appendicitis - milder form of acute appendicitis
• Stump appendicitis is retained long stump of appendix after commonly
laparoscopic appendicectomy.
Pathogenesis
• Following obstruction, the wall of the appendix becomes inflamed,
commencing in the mucosa and spreading to involve the submucosal,
muscular and serosal layers. A fibrinopurulent exudate forms on the
serosal surface and extends to any adjacent peritoneal surface.
Perforation is usually at the site of impaction of a faecolith before any
adhesions have formed. Within 12–24 hours, the appendix distal to
the site of obstruction becomes inflamed and subsequently
gangrenous
• the nonobstructive or catarrhal type (one-third of cases),
inflammation of the wall of the appendix causes venous congestion,
which may compromise arterial inflow, especially in the distal
appendix where the artery lies in a subperitoneal position, leading to
ischaemia, infarction and gangrene near the tip of the appendix.
Organisms from the lumen of the appendix enter the submucosa
through an ischaemic ulcer, causing liquefaction of the wall and
ultimately perforation
• As a result of the transmural inflammation, small bowel and omentum
adhere to the appendix, creating a localised area of sepsis. If left
untreated, this may progress to form an appendix mass or even an
abscess. If perforation occurs early in the clinical course, the inflamed
area will not have had time to be walled off, and generalised
peritonitis follows
Risk factors for perforation of the appendix
• Extremes of age
• Immunosuppression
• Diabetes mellitus
• Faecolith obstruction
• Pelvic appendix
• Previous abdominal surgery
Clinical Diagnosis
History
Pain
• Shifting Pain -begin with poorly localised colicky abdominal pain, first
noticed in the periumbilical region – visceral pain in response to
appendiceal inflammation and obstruction later after few hours,
somatic pain occurs in right iliac fossa due to irritation of parietal
peritoneum due to inflamed appendix
• -An inflamed appendix in the pelvis may never produce somatic pain
involving the anterior abdominal wall, but may instead cause
suprapubic discomfort and tenesmus and tenderness may be elicited
only on rectal examination
Anorexia, Nausea, Vomiting
• 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
• 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.
Temperature
• 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)
• Obstructive type > catarrhal type
more acute course
• Constipation is the usual feature but diarrhoea can occur if appendix
is in postileal or pelvic positions
• Urinary frequency: Inflamed appendix may come in contact with
bladder and can cause bladder irritation
Examination
• looks unwell, is flushed and has a dry, furred tongue with a foetor
• Temp is usually only mildly elevated (37.3–38.5°C) and there is often a
tachycardia
• Classically, the area of maximal tenderness is over McBurney’s point, with
guarding and rebound (percussion) tenderness (release sign-Blumberg's sign)
(Dumphy's cough tenderness sign)
• Palpation in the left iliac fossa may reproduce the pain in the right iliac fossa
(Rovsing’s sign)
• painful to extend the right hip owing to irritation of the psoas muscle (psoas
stretch sign)
• or internal rotation (in case of pelvic appendix - obturator test)
• Hyperaesthesia in 'Sherren's triangle’(formed by anterosuperior iliac
spine, umbilicus, pubic symphysis)
• If the acutely inflamed appendix lies within the pelvis, when
tenderness may be elicited with PR finger
• In women a vaginal examination is extremely useful in helping to
differentiate acute appendicitis from acute gynaecological disorders
Special features, according to position of the appendix
• Retrocaecal - (silent appendix)-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.
• Pelvic - early diarrhoea, frequency of micturition, abd tenderness may be absent,
tender on DRE, Spasm of the psoas and obturator internus muscles may be present,
common in children
• Postileal -greatest difficulty in diagnosis, pain not shift, diarrhoea is a feature and
marked retching, Tenderness, if any, is ill defined, immediately to the right of the
umbilicus.
Special features, according to age
• Acute appendicitis in infancy: rare, when it occurs, it has got 80%
chances of perforation with high mortality (50%)
• Acute appendicitis in children: rare to find a child with appendicitis
who has not vomited, usually have complete aversion to food.
poor localisation 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: more common in 1st and 2nd trimesters, 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%. Fetal 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. Incidence of perforation is highest in 3rd trimester.
Surgery is the treatment.
• In obese: obscure local signs, have to rely on imaging for diagnosis.
Laparoscopy particularly useful – can avoid larger incision
Management
• Inv for diagnosis
Alvarado score
-A score of 7 or more is
strongly predictive of acute appendicitis
• an equivocal score (5–6), abdominal ultrasound or contrast-enhanced
CT examination further reduces the rate of negative appendicectomy
• Other scoring systems- RIPASA, Anderson, Tzanakis
• USG- more useful for children and thin adults. Useful to exclude gynae
pathology, diagnosis accuracy – 90%
• CT- both sensitive and specific, 95% accuracy, 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, risk of radiation exposure
• C-reactive protein, even though nonspecific increases in acute phase
• LFT?
Treatment
• NOM
• Emergency Appendicectomy –open or laparoscopic
Non-operative management
• a trial of conservative mangement in patients with uncomplicated (absence
of appendicolith, perforation or abscess) appendicitis
• bowel rest and intravenous antibiotics, often metronidazole and 3rd
generation cephalosprin
• Ertapenem- more recently use, single daily dose
• 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
• patients over the age of 40 should be followed up to ensure there is no
underlying malignancy
Operative management
• The traditional treatment for acute appendicitis is appendicectomy
• no unnecessary delay- particularly 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
• 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
• minimally invasive approach, the rate of wound infection is lower
(when compared with open surgery) and, contrary to initial concerns,
the incidence of postoperative pelvic collection does not appear to be
increased
CONVENTIONAL APPENDICECTOMY
Exposure better, extension is easier-medial
• If better access is required, it is possible to convert the gridiron to a
Rutherford Morison incision
• Right lower paramedian incision/lower midline incision-- when in
doubt or when there is diffuse peritonitis
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Methods to be adopted in special
circumstances
• Odematous caecum- burying the stump not advised- purse string
suture would cut through it
• Base of appendix inflamed- should not be crushed, but ligated close
to caecal wall just to occlude the lumen of appendix, after which
appendix s/b amputated and invaginated
• Gangrenous appendix- no crushing nor ligation, two stitches close to
the base of gangrenous appendix , amputate it flushed to caecal wall,
then stitches are tied, second layer- seromuscular suture
• Alternative option- resect the appendix with a cuff of healthy caecum
with single firing of linear stapler
Retrograde appendicectomy
• When retrocaecal and adherent, to divide the base btw artery forceps
first
• Then artery ligation, stump buried, body of appendix removed by
gentle traction of caecum
• Occasionally, lat peritoneal attachments needs to be divided
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Laparoscopic appendicectomy
• Role in diagnosis of suspected
appendicitis in women of child
bearing age
• Port sites may vary according to
preference or prev: abd: incisions
• Pneumoperitoneum made via
infraumbilical open approach-
camera port
• Two working ports- suprapubic port,
left lower quadrant port
• Alternative- Single incision laparoscopic surgery (SILS)
• Position- Trendelenburg tilt with elevation of right side
Problems encountered
• Normal appendix- check other pathology, appendicectomy
• Cannot be found- mobilized caecum, trace taenia coli, check left side
perhaps- situs inversus, absent appendix diagnosis finally
• Appendicular tumour- <2cm, tip – appendicectomy , >2cm, base- Rt
hemicolectomy
• Appendicular abscess and cannot remove easily- preop- percutaneous drain
and antibiotics. Intraop- drainage of abscess and IV antibiotics, frankly
necrotic appendix- caecostomy tube or partial rt hemicolectomy considered
• Appendicitis complicating Crohn’s d/s- preop- conservative Rx, intraop-if
base healthy-appendicectomy , risk of faecal fistula
• Appendix abscess- failure of conservative Rx of appendicular mass or
continuing spiking fever- percutaneous drain USG or CT guided <
laparotomy with lower midline approach
• Pelvic abscess- spiking fever, even after discharge, loose motion or
tenesmus may +, tender boggy mass anterior to rectum at the level of
peritoneal reflection via DRE- Rx- radiologically guided percutaneous
drainage or transrectal drainage under GA
• Appendicular mass- Ochsner-Sherren Regime f/b interval
appendicectomy ( debatable)
Misc
• Appendicular artery which is an end artery can undergo infective
thrombosis and can cause gangrene and perforation
• Negative appendicectomy-incidence is 30%
• Claudius Amyand (1736) did first appendicectomy
• Chronic appendicitis' earlier this term was not used, but is presently
accepted terminology; few attacks of recurrent appendicitis will lead
into chronic appendicitis. It presents with episodic often vague
discomfort with colicky pain in RIF, anorexia, malaise, pain with
movement and is often called as grumbling appendicitis. TC, US, CT
scan may be normal in these patients
• Incidental appendicectomy- removal of normal appendix during other
operation eg, hysterectomy, Ladd’s procedure in intestinal
malrotation, On table colonic lavage
Take Home Message
References
• Bailey and Love’s Short Practice of Surgery , 27th edition
• Principles and practice of Surgery, 7th edition
• SRB’s Manual of Surgery, 6th edition
