CHAPTER 76: THE VERMIFORM APPENDIX

Bailey & Love | Complete Study Guide for OT Students | 20-Mark Exam Preparation

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Written for OT students preparing for a 20-mark question. Each section = a potential question area.
Yellow = memory tricks. Blue = key facts. Red = critical warnings. Focus on UNDERSTANDING the
logic, not just memorizing.

SECTION 1: ANATOMY OF THE APPENDIX

What Is the Appendix?
 A small, blind-ended muscular tube arising from the caecum (start of large bowel)
 Present only in humans, certain apes, and the wombat
 Has 4 wall layers: mucosal, submucosal, muscular, and serosal
 Undeveloped distal end of the caecum - a vestigial organ
 Has IMMUNE function - contains lymphoid tissue; may protect gut microbiota

Size and Microscopic Structure

 Average length: 7.5-10 cm; lumen is narrow and irregular
 Rich in lymphoid tissue (especially in young people - important immune role)
 Kulchitsky cells in crypts - give rise to neuroendocrine tumours (NETs)
 Muscularis mucosa is thin; abundant lymphoid aggregates/follicles in submucosa

Positions of the Appendix

The appendix can lie in different positions - this changes the clinical presentation!
Position Frequency Clinical Significance
Retrocaecal 74% Most common; pain may be in
loin/back; psoas sign positive
Pelvic 21% Low pelvic pain; may mimic
gynaecological disease; rectal exam
key
Subcaecal 1.5% Unusual; hard to diagnose
Preileal 1% In front of small bowel; bowel
symptoms possible
Postileal 0.5% Diarrhoea common; ill-defined
tenderness

MEMORY TIP: Remember the Positions

74% Retro + 21% Pelvic = 95% of cases. Think 'RP 74-21'. Only 5% are rare positions. Retrocaecal is so
common, always consider it first.

Blood Supply
 Appendicular artery = branch of ileocolic artery (from lower division of superior mesenteric artery)
 It passes BEHIND the terminal ileum to reach the mesoappendix and then the appendix
 It is an END-ARTERY (no collateral circulation) - thrombosis causes total ischaemia = gangrene
 Accessory appendicular artery present in some patients
 4-6 lymphatics drain to ileocaecal lymph nodes

SECTION 2: ACUTE APPENDICITIS

Background
 Most common cause of 'acute abdomen' requiring surgery - paradigm for clinical teaching
 First described by Reginald Fitz (1886) - 'Perforating inflammation of the vermiform appendix'
 Charles McBurney described tenderness point (named McBurney's point)
 Lifetime risk: 8.6% males, 6.7% females; peak incidence in teens and early twenties
 Incidence has FALLEN in Western countries over last 30 years (improved hygiene, dietary changes)

Aetiology - What Causes It?

The KEY event is OBSTRUCTION OF THE APPENDIX LUMEN:
 Faecalith: Faecalith (inspissated faecal material + calcium phosphates) - most common; seen on CT
as radioopaque
 Lymphoid hyperplasia: Lymphoid hyperplasia - swollen lymph tissue narrows lumen; especially in
viral infections
 Stricture: Fibrous stricture from previous silent appendicitis that resolved
 Tumour: Tumour of caecum obstructing appendiceal orifice - consider in middle-aged/elderly
 Parasites: Enterobius vermicularis (pinworm) - can proliferate in appendix and occlude lumen
 Diet: Low dietary fibre (Western diet) associated with higher rates

Pathology - Step-by-Step Disease Progression

STEP 1 - Obstruction Lumen blocked -> mucus accumulates -> bacterial
overgrowth (aerobic + anaerobic mixed)
STEP 2 - Pressure rise Intraluminal pressure increases -> lymphoid
hyperplasia -> mucosal ulceration
STEP 3 - Bacterial invasion Bacteria invade mucosa and submucosa -> ACUTE
APPENDICITIS (inflamed wall)
STEP 4 - Venous obstruction Continued distension -> venous obstruction ->
ischaemia begins
STEP 5 - Gangrene Bacterial invasion of muscularis propria ->
GANGRENOUS APPENDICITIS (full-thickness necrosis)
STEP 6 - Perforation Necrotic wall perforates -> bacteria spill into
peritoneal cavity
STEP 7A - Contained Omentum + bowel walls off infection -> APPENDIX
MASS (palpable inflammatory lump)
STEP 7B - Free Perforation with free contamination -> GENERALISED
 PERITONITIS -> sepsis syndrome

Risk Factors for Perforation (Summary Box 76.1):

 Extremes of age (infants + elderly)

 Immunosuppression
 Diabetes mellitus
 Faecalith obstruction
 Pelvic appendix
 Previous abdominal surgery

SECTION 3: CLINICAL DIAGNOSIS

Classic Symptom Sequence
Appendicitis follows a CHARACTERISTIC sequence - knowing this order is key to diagnosis:
1st - Central pain Poorly localised, colicky, periumbilical pain
(visceral pain from distended appendix)
2nd - Anorexia Loss of appetite - almost ALWAYS present; very
useful clinical sign
3rd - Nausea/vomiting 1-2 episodes AFTER pain starts (key difference from
gastroenteritis!)
4th - Pain shifts Pain moves to RIGHT ILIAC FOSSA (RIF) as parietal
peritoneum becomes irritated
5th - Fever Low-grade (37.2-37.8 C); pulse 80-90/min in first 6
hours

MEMORY TIP: PAIN BEFORE VOMITING!

In appendicitis: PAIN comes first, then vomiting. In gastroenteritis: vomiting/diarrhoea usually comes
BEFORE abdominal pain settles. This one fact can help you differentiate them in an exam!

Signs on Examination
McBurney's Point Tenderness Maximum tenderness 1.5-2 inches from ASIS
toward umbilicus; THE classic sign
Rebound Tenderness Pain worse when hand suddenly released; indicates
peritoneal irritation
Muscle Guarding Involuntary rigidity of abdominal muscles over the
RIF
Rovsing's Sign Pressure on LEFT iliac fossa causes pain in RIGHT
iliac fossa (peritoneal spread)
Psoas Sign Pain on extension of right hip - suggests retrocaecal
appendix on psoas muscle
Obturator Sign Pain when right hip flexed + internally rotated -
suggests pelvic appendix
Pointing Sign Patient can point to where pain started and where it
moved (typical visceral-somatic shift)

Position-Specific Presentations
 Retrocaecal: Rigidity often absent (caecum covers inflamed area). Loin/back pain. Psoas sign +ve.
Silent appendix on palpation.
 Pelvic: Minimal abdominal rigidity. Rectal examination shows tenderness. May cause urinary
frequency. Low pelvic pain.
 Postileal: Diarrhoea common. Tenderness just to the right of umbilicus. Very difficult diagnosis.

Special Populations
 Infants: RARE in <3 months. Cannot give history. Perforation + morbidity MUCH higher. Diagnosis
always delayed.
 Elderly: Atypical presentation. Higher perforation. Think diverticulitis, colon cancer as differentials.
 Pregnancy: Most common non-obstetric surgical emergency in pregnancy. Appendix displaced
upward. Non-specific symptoms blamed on pregnancy. Fetal loss 3-5% (rises to 20%+ if perforated).

SECTION 4: DIFFERENTIAL DIAGNOSIS

Children Adult (male) Adult Female Elderly
Gastroenteritis Regional enteritis Mittelschmerz Diverticulitis
Mesenteric adenitis Ureteric colic Pelvic inflammatory Intestinal obstruction
disease
Meckel's diverticulitis Perforated peptic ulcer Pyelonephritis Colonic carcinoma
Intussusception Torsion of testis Ectopic pregnancy Torsion appendix
epiploicae
Henoch-Schonlein Pancreatitis Torsion of ovarian cyst Mesenteric infarction
purpura
Lobar pneumonia Rectus sheath Endometriosis Leaking aortic aneurysm
haematoma
Constipation Acute pancreatitis Ruptured ovarian cyst

MEMORY TIP: Top Differentials by Patient Type

Young male = ALWAYS examine the scrotum (testicular torsion!). Young female = ectopic pregnancy
(urine pregnancy test mandatory!). Child = mesenteric adenitis (most common mimic). Elderly =
diverticulitis or colon cancer.

SECTION 5: INVESTIGATIONS
Alvarado (MANTRELS) Score - Table 76.2
Score 7-10 = surgery. Score 5-6 = equivocal (get imaging). Score <5 = observe/discharge.
Category Feature Score
SYMPTOMS Migratory pain to RIF 1
SYMPTOMS Anorexia 1
SYMPTOMS Nausea and vomiting 1
SIGNS Tenderness in RIF 2
SIGNS Rebound tenderness 1
SIGNS Elevated temperature 1
LAB Leukocytosis (raised WBC) 2
LAB Shift to left (neutrophilia) 1
TOTAL 10

Preoperative Investigations (Summary Box 76.5):

 ROUTINE: Full blood count (WBC raised), Urinalysis

 SELECTIVE: Pregnancy test (ALL women of childbearing age!), U&E, CRP
 IMAGING 1st: Ultrasound - especially in children, thin adults, pregnant women; appendix >6mm
diameter suggests appendicitis
 IMAGING 2nd: CT scan - 90-95% accurate; gold standard in adults, obese, elderly, atypical
presentation
 MRI: Best in pregnancy - no radiation risk to fetus
 Low-dose CT protocol: Reduces radiation by up to 80% - use in young adults

SECTION 6: TREATMENT
A. Non-Operative Treatment (Antibiotics)
 Evidence shows IV antibiotics can successfully treat UNCOMPLICATED appendicitis (~85% initially)
 Regimen: Bowel rest + IV metronidazole + 3rd-generation cephalosporin
 25-46% of patients treated conservatively will need surgery within 1 year
 NOT suitable if: faecalith present, perforated, immunosuppressed, or high surgical risk
 Patients over 40: Need follow-up CT/colonoscopy to rule out underlying tumour

B. Appendix Mass - Ochsner-Sherren Conservative Regime

If patient presents LATE with a palpable mass (omentum + bowel walling off the appendix):
 Step 1: Admit, bowel rest, IV fluids, IV antibiotics (treat the infection first)
 Step 2: Mark the mass outline on abdominal skin with a pen - re-examine regularly
 Step 3: 4-hourly temperature and pulse recording
 Step 4: Contrast-enhanced CT to characterise mass and guide drainage if abscess
 Step 5: If abscess identified - radiological (ultrasound-guided) drainage preferred
 Step 6: 90% of masses resolve within 24-48 hours of starting treatment
 Step 7: INTERVAL appendicectomy 6-12 weeks later (especially >40 years old, to exclude
carcinoma)
STOP conservative treatment and operate if (Summary Box 76.6):

 Rising pulse rate

 Increasing or spreading abdominal pain
 Increasing size of the mass
 Clinical deterioration / peritonism develops

C. Operative Management - Appendicectomy

General Principles
 Standard definitive treatment for acute appendicitis
 Pre-op: IV fluids, single-dose perioperative antibiotics (reduces wound infection), VTE prophylaxis
 If peritonitis: therapeutic antibiotics covering Gram-negatives + anaerobes
 Safe to defer to next morning if stable (reduces risk of error with tired surgeon)
 Don't delay if: obstructive appendicitis, deteriorating, child, pregnant
Open Appendicectomy - Step by Step
 1. INCISION: Gridiron incision (McArthur) at right angles to line joining ASIS to umbilicus, centered
on McBurney's point. OR Lanz (transverse/skin crease) incision 2cm below umbilicus on
midclavicular-midinguinal line - better cosmesis.
 2. FIND CAECUM: Identify the taeniae coli (longitudinal muscle bands on large bowel surface) -
follow them to the base of the appendix.
 3. DELIVER APPENDIX: Gently break inflammatory adhesions with a finger. Turgid appendix may be
felt at base of caecum.
 4. DIVIDE MESOAPPENDIX: Clamp, divide, and ligate the mesoappendix - this controls the
appendicular artery.
 5. LIGATE BASE: Clamp appendix at its base, ligate with absorbable 2/0 suture, then cut between
clamps.
 6. BURY STUMP: Insert purse-string or Z-suture (absorbable 2/0 or 3/0) into caecal wall around
base; invaginate appendiceal stump into caecum; tie suture to bury stump.
 7. CLOSURE: Close layers. If contaminated peritoneum: leave skin open or close over a drain to
prevent wound infection.
Laparoscopic Appendicectomy - Steps
 1. POSITION: Patient supine, general anaesthetic. Camera port at umbilicus (open Hasson
technique). Two working ports: suprapubic and left lower quadrant.
 2. PNEUMOPERITONEUM: CO2 gas inflated into abdomen. Patient in Trendelenburg + right side up
to move small bowel away.
 3. IDENTIFY APPENDIX: Follow caecal taeniae to appendix base. Use laparoscopic tissue-holding
forceps.
 4. DIVIDE MESOAPPENDIX: Hook diathermy, scissors, or clip applier used to dissect and divide the
mesoappendix and appendicular artery.
 5. LIGATE BASE: Appendix base ligated with loop ligature (absorbable) or linear stapling device.
 6. REMOVE APPENDIX: Cut between ligatures. Place in a specimen bag. Remove through port.
 7. WASH OUT: Irrigate peritoneal cavity if contaminated.
 8. CLOSE: Absorbable sutures close fascial defects >5mm. Skin closed with subcuticular sutures.
Laparoscopic vs Open - Key Differences:
 Laparoscopic: Better cosmesis, lower wound infection rate, faster recovery, DIAGNOSTIC
advantage (can see ovaries, bowel, liver)
 Open: Cheaper, more widely available, preferred if adhesions/obesity prevent laparoscopy
 Stump: Routinely buried (invaginated) in OPEN surgery; NOT routinely invaginated
laparoscopically
 Both approaches: Same perforation rates, same long-term outcomes
 Pregnancy: Laparoscopic is SAFE in all trimesters (use Hasson technique)

SECTION 7: POSTOPERATIVE COMPLICATIONS

Complication Key Features Management
Wound Infection Most common (5-10%). Day 4-5 Open & drain wound + antibiotics
post-op. Pain + erythema at wound. (metronidazole + cephalosporin)
Intra-abdominal Abscess 8% of patients. Spiking fever + Ultrasound/CT guided
malaise 5-7 days post-op. percutaneous drainage + IV
antibiotics
Ileus Expected for 2 days post-op. NG tube, IV fluids; investigate if >5
Prolonged (>4-5 days) = ongoing days
sepsis.
Portal Pyaemia (Pylephlebitis) RARE but SERIOUS. High fever + IV antibiotics + drain hepatic
jaundice + rigors = liver abscesses. abscesses; high mortality
Faecal Fistula RARE. Stump leaks. Usually closes Conservative; may need re-
spontaneously. operation if persistent
Adhesive Obstruction Most common LATE complication. Laparoscopic adhesiolysis (divide
Colicky pain, distension, vomiting. the band)
Venous Thromboembolism RARE. DVT or pulmonary Prevention: LMWH + TED stockings
embolism. preoperatively
Respiratory RARE. Pneumonia, atelectasis. Adequate analgesia, physiotherapy,
early mobilisation

SECTION 8: NEOPLASMS OF THE APPENDIX

A. Neuroendocrine Tumours (NETs) / Carcinoids
 Most common appendix neoplasm - ~30% of all appendix tumours
 Usually found INCIDENTALLY at appendicectomy
 70% located at TIP of appendix; average age 40-50 years; slightly more common in females
 Diagnosed by immunohistochemistry: synaptophysin and chromogranin A staining
 Classified grade 1-3 by Ki-67 index and mitotic rate (grade 3 = aggressive)
 TREATMENT: Appendicectomy alone if <1cm + no serosal/mesoappendix invasion (essentially
curative!)
 If >2cm OR T3/T4 OR lymphovascular invasion: RIGHT HEMICOLECTOMY needed
 5-year survival: Early stage ~100%; Advanced disease <25%

B. Goblet Cell Carcinoma (GCC)

 Rare - <5% of appendix tumours. Show BOTH neuroendocrine AND glandular features
 NOT true NETs - classified as adenocarcinoma ex-GCC (Tang classification)
 More aggressive than NETs; treat LIKE appendix adenocarcinoma
 Treatment: Right hemicolectomy + careful staging

C. Epithelial Tumours - LAMN vs HAMN

 LAMN (Low-grade): Low-grade Appendiceal Mucinous Neoplasm: PUSHING invasion (no
destruction). Appendicectomy alone if <2cm with no adverse features.
 HAMN (High-grade): High-grade Appendiceal Mucinous Neoplasm: Infiltrative. Right
hemicolectomy + bilateral salpingo-oophorectomy (risk of ovarian seeding).
 Mucinous adenocarcinoma: Mucinous adenocarcinoma: Infiltrative invasion. High-grade. Treat
like colorectal cancer.
 Perforation: CRITICAL: If mucinous tumour PERFORATES -> mucin spreads through abdomen ->
Pseudomyxoma Peritonei (PMP)

D. Pseudomyxoma Peritonei (PMP) - The 'Jelly Belly'

PMP is a rare but deadly condition where the abdominal cavity fills with mucin (jelly-like material).
Almost always originates from a ruptured mucinous appendiceal tumour.
 Incidence: 3.2 cases per 1,000,000/year. Rare but important to know.
 Presentation: Slowly progressive abdominal distension, anorexia, bowel dysfunction, weight loss
 Characteristic finding: 'Omental cake' (omentum replaced by tumour + mucin) on CT/surgery
 Classification: 4 types from acellular mucin (best prognosis) to high-grade with signet ring cells
(worst)
 Without treatment: Invariably fatal due to bowel obstruction and malnutrition
Treatment: CRS + HIPEC (The Sugarbaker Procedure)
 Step 1 - CRS: CRS = Cytoreductive Surgery: Surgically remove ALL visible tumour + mucin. This
involves removing the peritoneum lining the abdomen, omentum, spleen, and sometimes other
organs (partial colectomy, hysterectomy, etc.).
 Step 2 - HIPEC: HIPEC = Hyperthermic Intraperitoneal Chemotherapy: After CRS, heated
chemotherapy solution (mitomycin C or oxaliplatin) is pumped through the abdominal cavity for 60-
90 minutes to kill remaining microscopic disease.
 Duration: Combined operation can take >10 hours. Requires specialist centre.
 Success rate: Complete cytoreduction achieved in ~75% of patients at expert centres (e.g.,
Basingstoke, UK - Moran's series of 1000+ patients)
 Mortality: Operative mortality <2% at experienced centres; major morbidity in 15%
 Survival: 5-year survival: 87% after complete cytoreduction; 70% at 10 years
 Systemic chemo: Systemic chemotherapy (FOLFOX/FOLFIRI) used for high-grade or unresectable
disease
 Follow-up: Follow-up: Tumour markers (CEA, CA-125, CA-19-9) + CT scan; surveillance for at least
10 years
MEMORY TIP: PMP in One Line

PMP = 'Jelly belly' from ruptured appendix mucinous tumour. Treatment = CRS (scoop out all the jelly +
tumour) + HIPEC (kill remaining cells with hot chemo). Without treatment = fatal. With expert
treatment = 87% 5-year survival.
SECTION 9: EXAM QUICK REVISION
Likely 20-Mark Essay Plan
Section Marks / Content
Introduction: Anatomy of appendix 2-3 marks: position, structure, blood supply,
positions
Aetiology + Pathology of acute appendicitis 3-4 marks: obstruction -> inflammation -> gangrene
-> perforation
Clinical Presentation: History + Examination 4-5 marks: symptom sequence, McBurney's, signs,
special positions
Differential Diagnosis 2-3 marks: age/sex-specific differentials
Investigations (Alvarado + imaging) 2 marks: blood tests, ultrasound, CT, Alvarado score
Treatment: Non-op + Appendicectomy (both 4-5 marks: antibiotics, open steps, laparoscopic
methods) steps, Ochsner-Sherren
Complications + Tumours (brief) 2-3 marks: wound infection, abscess, NETs, PMP
overview

Key Facts to Memorise

 Appendix most common position: RETROCAECAL (74%)
 Peak incidence: TEENS + EARLY TWENTIES
 Lifetime risk: 8.6% males, 6.7% females
 Alvarado score >=7 = operate; 5-6 = imaging; <5 = observe
 Appendicular artery = END ARTERY (no collaterals = gangrene if thrombosed)
 Pain BEFORE vomiting (vs. gastroenteritis where vomiting comes first)
 McBurney's point = 2/3 along line from umbilicus to ASIS
 Rovsing's sign = LIF pressure -> RIF pain
 Psoas sign = retrocaecal appendix (right hip extension causes pain)
 Obturator sign = pelvic appendix (right hip flex + internal rotation causes pain)
 Fetal loss in appendicitis: 3-5% uncomplicated; >20% if perforated
 Most common postoperative complication: WOUND INFECTION (5-10%)
 Most common late complication: ADHESIVE INTESTINAL OBSTRUCTION
 Most common appendix tumour: NET (carcinoid) - 30% of neoplasms
 NETs <1cm: appendicectomy alone curative; >2cm: right hemicolectomy
 PMP = mucinous 'jelly belly'; treatment = CRS + HIPEC; 87% 5-year survival

One-Sentence Summary of the Whole Chapter

The appendix (most often found retrocaecally, 74%) is a blind-ended tube prone to acute inflammation
when its lumen is obstructed, progressing from simple inflammation through gangrene to perforation
and peritonitis; clinical diagnosis rests on the characteristic central-to-RIF pain shift with anorexia and
the Alvarado score, confirmed by CT/ultrasound; treatment ranges from antibiotics alone
(uncomplicated) to emergency appendicectomy (open or laparoscopic), with the Ochsner-Sherren
regime for appendix masses; appendix tumours include NETs (most common, often cured by
appendicectomy alone), and mucinous neoplasms which can cause the rare but serious pseudomyxoma
peritonei, treated by CRS + HIPEC at specialist centres.
Study Guide from Bailey & Love Chapter 76 | For OT Students | Not a replacement for clinical judgment