Acute appendicitis

Dr. B. C. Shrestha
BMCTH
 VERMIFORM
APPENDIX
• The body of appendix is kinked on itself where the free border of
mesoappendix ends, hence it is coiled like worm and is named the
vermiform

• It is a blind-ended muscular tube attached to the posteromedial wall

of caecum, about 2cm below ileocaecal junction

• Suspended by peritoneal fold, MESOAPPENDIX

• Devoid of taenia coli, sacculations and appendices epiploicae

MESOAPPENDIX

• Short, triangular and variable

• Extends the whole length of appendix

• The breadth of mesoappendix usually falls short of length of appendix

• Appendicular vessels pass through free margin of mesoappendix

MEASUREMENTS

• 7 - 10 cm in length but can range from 2 - 20 cm

• Diameter of the appendix is 3 - 5 mm

• Diameter of lumen is 1 - 2 mm
PARTS OF APPENDIX

A) Base

B) Body

C) Tip
BASE

• Attached to posteromedial wall of caecum about 2 m below the

ileocaecal junction

• All taenia of caecum converge to the base and serve as a guide for the
identification of the appendix.
BODY

• Narrow , tubular and contains a canal which opens into the caecum

• The caecal opening is guarded by an incomplete mucous fold called

as, "THE VALVE OF GERLACH”
TIP

• Least vascular and is directed in various direction

 Anatomical
position
BLOOD SUPPLY

• Appendicular artery - branch Of inferior division of ileocolic artery

• Recurrent branches supplies base of appendix and anastomose with

posterior caecal artery.

• End artery

• Accessory artery
NERVE SUPPLY

• Parasympathetic: VAGUS

• Sympathetic: T10 segment of spinal cord.

LYMPHATIC DRAINAGE

• six or more lymphatic channels drain into superior mesenteric lymph

nodes via ilea-colic nodes
 ACUTE APPENDICITIS
• Importance in surgery results only from its propensity for inflammation

• Results in the clinical syndrome known as acute appendicitis

• Most common cause of an ‘acute abdomen’ in young adults

• Most frequently performed urgent abdominal operation

• first major procedure performed by a surgeon in training

• Diagnosis of appendicitis remains essentially clinical

• Rare in infants

• Becomes increasingly common in childhood and early adult life

• Peak incidence in the teens and early 20s

• After middle age, the risk of developing appendicitis is quite small

• Incidence is equal among males and females before puberty

 Aetiology
• Decreased dietary fibre

• Increased consumption of refined carbohydrates

• Non obstructive (catarrhal) - associated with bacterial proliferation within

the appendix (aerobic and anaerobic organisms)

• Obstructive - by a faecolith or a stricture or foreign body

• A faecolith is composed of inspissated faecal material, calcium
phosphates, bacteria and epithelial debris
• Tumour, particularly carcinoma of the caecum

• Intestinal parasites, particularly Oxyuris vermicularis (pinworm)

Obstruction
Perforation
Risk factors for perforation of the appendix

■ Extremes of age
■ Immunosuppression
■ Diabetes mellitus
■ Faecolith obstruction
■ Previous abdominal surgery
 Symptoms of appendicitis

■ Peri-umbilical colic

■ Pain shifts to the right iliac fossa

■ Anorexia

■ Nausea and vomiting

 Signs

• Low-grade pyrexia

• Localised abdominal tenderness

• Muscle guarding

• Rebound tenderness
Signs to elicit in appendicitis
■ Pointing sign
■ Rovsing’s sign
■ Psoas sign
■ Obturator sign
Psoas sign
Pointing sign
patient is asked to point to where the pain began and where it moved

Rovsing’s sign
Deep palpation of LIF may cause pain in RIF
 Obturator sign
The hip is flexed and internally rotated. If an inflamed appendix is in contact
with the obturator internus, this cause pain in the hypogastrium
 Special features, according to position of
the appendix
Retrocaecal
• Rigidity is absent

• Deep pressure may fail to elicit tenderness (silent appendix) due to

caecum, distended with gas, prevents the pressure exerted by the hand
from reaching the inflamed structure

• Psoas spasm, due to the inflamed appendix cause flexion of the hip joint

• Hyperextension of the hip joint may induce abdominal pain

Pelvic

• Contact with the rectum results early diarrhoea

• Absence of abdominal rigidity and tenderness

• Rectal examination reveals tenderness in the rectovesical pouch

• Contact with the bladder may cause frequency of micturition

Postileal

• Difficulty in diagnosis

• Pain may not shift

 Special features, according
to age
Infants

• Rare

• Unable to give a history

• Delayed incidence of perforation is higher

• Diffuse peritonitis can develop rapidly because of the underdeveloped

greater omentum
Children

• Rare to find a child who has not vomited

• Usually have complete aversion to food

Elderly

• Gangrene and perforation occur much more frequently

• Clinical picture may simulate subacute intestinal obstruction

Obesity

• Obscure and diminish all the local signs

• Laparoscopy is particularly useful in the obese

Pregnancy

• Most common extrauterine acute abdominal condition in pregnancy,

with a frequency of 1:1500–2000 pregnancies

• 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
 Differential
diagnosis
Children

• Mistaken for acute gastroenteritis and mesenteric lymphadenitis

• In mesenteric lymphadenitis, the pain is colicky in nature and cervical
lymph nodes may be enlarged
• Uncommon before the age of 2 years, whereas the median age for
intussusception is 18 months
• Lobar pneumonia and pleurisy, especially at the right base may give rise to
right-sided abdominal pain and mimic appendicitis
Adults

Terminal ileitis

• Doughy mass of inflamed ileum can be felt

• Abdominal cramping, weight loss and diarrhoea suggests regional
ileitis

Ureteric colic
• Radiation of pain differs
Perforated peptic ulcer
• History of dyspepsia
• Sudden onset of pain that starts in the epigastrium and passes down the right
paracolic gutter
• An erect chest radiograph will show gas under the diaphragm in 70% of pts

Testicular torsion in a teenage or young adult male is easily missed

Rectus sheath haematoma

• Acute pain and localised tenderness in the right iliac fossa, often after an
episode of strenuous physical exercise
• Anticoagulant therapy, a rectus sheath haematoma may present as a mass
and tenderness in the right iliac fossa after minor trauma
 Adult female
PID

• Include salpingitis, endometritis and tubo-ovarian sepsis

• Pain is lower than in appendicitis and is bilateral
• Vaginal discharge, dysmenorrhoea and burning pain on micturition is a
helpful differential diagnostic point
• Physical findings include adenexal and cervical tenderness on vaginal
examination
Mittelschmerz
• Midcycle rupture of a follicular cyst with bleeding produces lower
abdominal and pelvic pain
• Symptoms usually subside within hours

Torsion/haemorrhage of an ovarian cyst

Ectopic pregnancy
• Pain is severe and continues unabated
• History of a missed menstrual period, and a urinary pregnancy test may be
positive
• Signs of intraperitoneal bleeding usually become apparent
Sigmoid diverticulitis
• Long sigmoid loop, the colon lies to the right of the midline

Intestinal obstruction

Carcinoma of the caecum

• A mass may be palpable
 Diagnosis

• Essentially clinical

• Decision to operate based on clinical suspicion alone can lead to the

removal of a normal appendix in 15–30% of cases

• A number of clinical and laboratory-based scoring systems have been

devised to assist diagnosis

• Most widely used is the Alvarado score

 Alvarado (MANTRELS)
score
 Tzanakis scoring
system
• Presence of right lower abdominal tenderness – 4 pts
• Rebound tenderness – 3 pts
• Lab. Findings : WBC more than 12000 – 2 pts
• USG finding positive – 6 pts

Total 15 pts

More than 8 – diagnostic of acute appendicitis

 Treatment

• Treatment – appendicectomy

• IVF - sufficient to establish adequate urine output

• Appropriate antibiotics
 Indications of
Appendectomy

• Acute Appendicitis

• Recurrent Appendicitis

• Mucocele of Appendix
 Appendicectomy
• Claudius Amyand successfully removed an acutely inflamed appendix from
the hernial sac of a boy in 1736

• The first surgeon to perform deliberate appendicectomy for acute appendicitis

was Lawson Tait in May 1880. The patient recovered; however, the case was
not reported until 1890

• Thomas Morton was the first to diagnose appendicitis, drain the abscess and
remove the appendix with recovery, publishing his findings in 1887

• The first recorded operation for an appendix abscess was by Henry Hancock in
1848
Conventional appendicectomy

• Widely used gridiron incision

Gridiron:
• A frame of cross-beams to support a ship during repairs
• Gridiron incision (described first by McArthur)
• Mc Burney’s point
Rutherford Morison incision

• By cutting the internal oblique and transversus muscles in the line of the
incision

Transverse skin crease - Lanz incision

• Made approximately 2cm below the umbilicus centred on the mid
clavicular–mid inguinal line
Drainage of the peritoneal cavity

Laparoscopic appendicectomy
More beneficial than open
 Problems encountered during
appendicectomy
A normal appendix
• Demands careful exclusion of terminal ileitis, Meckel’s diverticulitis and tubal or ovarian causes in
women
• It is usual to remove the appendix to avoid future diagnostic difficulties

The appendix cannot be found

An appendicular tumour
• Is found Small tumours (under 2.0cm in diameter) can be removed by appendicectomy; larger tumours
should be treated by a right hemicolectomy

An appendix abscess
• Appendix cannot be removed easily
• Should be treated by local peritoneal toilet, drainage of abscess and intravenous antibiotics
• Caecectomy or partial right hemicolectomy is required
Appendicitis complicating Crohn’s disease
• Providing that the caecal wall is healthy at the base of the appendix,
appendicectomy can be performed
• Rarely, the appendix is involved with the Crohn’s disease. In this situation, a
conservative approach may be warranted, and a trial of intravenous
corticosteroids and systemic antibiotics can be used

Appendix abscess
• Suitable for the insertion of a percutaneous drain
• Unsuccessful, laparotomy though a midline incision is indicated
Pelvic abscess
• Treatment is transrectal drainage under general anaesthetic

Postoperative complications
• Wound infection - 4th ‘n 5th POD
• Intra-abdominal abscess - 5–7 days after operation
• Ileus
• Respiratory
• Venous thrombosis and embolism

• Portal pyaemia (pylephlebitis) - associated with high fever, rigors and

jaundice. Caused by septicaemia in the portal venous system and leads to
the development of intrahepatic abscesses

• Faecal fistula

• Adhesive intestinal obstruction - late complication