Introduction

Anatomy

Etiology

Risk Factors

Pathophys

Clinical Manifestation

Differntial Diag

Investigation

Management

INTRODUCTION

 The appendix is a blind muscular tube arising from the posteromedial wall of the caecum
below the ileocaecal orifice
 Appendicitis is inflammation of the vermiform appendix.
 The most common surgical emergency disease affecting the abdomen, especially in
adolescents and young adults between the ages of 10 and 20 years
 Male to Female ratio 1.4:1

ANATOMY:

 Development: The appendix appears during the fifth month of gestation, and several
lymphoid follicles are scattered in its mucosa. Such follicles increase in number when
individuals are aged 8-20 years.
 Appendix develops from midgut loop . Other derivatives of it are small intestine including
most of duodenum, ascending colon, cecum and right 2/3 of transverse colon
 During 6th week, the midgut elongates into the umbilical cord resulting in the formation of
cranial and caudal limbs.
 Caudal limb give rise to cecal diverticulum, the primodium of cecum and appendix. Appendix
is a small diverticulum from cecum, as the ascending colon elongates appendix elongates
and can be positioned in different positions
 Rotation of midgut to 90 degrees counterclockwise around the axis of superior mesenteric
artery and further 180 degree rotation counterclock wise to occupy right side of the
abdomen.
 As the proximal portion of the colon elongates, the cecum and the appendix descend on the
right side of the abdomen. The position of the appendix can be variable
 Retrocecal appendix: behind the cecum
 Retroco1ic appendix: behind the ascending colon
 Pelvic appendix: appendix descends into the pelvis
 The appendix grows in length, so that at birth, it is long and worm-shaped, or vermiform
 After birth, the cecal wall grows unequally and the appendix comes to lie on its medial side
  THE CECUM AND APPENDIX
o The cecal diverticulum (bud of cecum which forms in the midgut) appears in week
6 and is the primordium of the cecum and the vermiform appendix
o During week 5 of development the midgut loops ventrally herniating to the
umbilical cord this creates most of the resulting length of the interstines. It forms
cranial and caudal limbs
 The diverticulum is seen as a conical pouch on the antimesenteric border of
the caudal limb of the midgut loop just beyond the apex of the loop
 The distal end of the blind sac does not grow as fast, thus the appendix,
which is a vestige of the incomplete development of the cecum, develops
 As the proximal portion of the colon elongates, the cecum and the
appendix descend on the right side of the abdomen. The position of the
appendix can be variable
 Retrocecal appendix: behind the cecum
 Retroco1ic appendix: behind the ascending colon
 Pelvic appendix: appendix descends into the pelvis
 The appendix grows in length, so that at birth, it is long and worm-shaped,
or vermiform
 After birth, the cecal wall grows unequally and the appendix comes to lie
on its medial side

 Size: The average length of the appendix is 8-10 cm (range 2-20 cm) with a diameter of 6mm
or less
 Location: The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal
ileum, either in a dorsomedial location (most common) from the cecal fundus, directly
beside the ileal orifice, or as a funnel-shaped opening (2-3% of patients). The appendix has a
retroperitoneal location in 65% of patients and may descend into the iliac fossa in 31%. In
fact, many individuals may have an appendix located in the retroperitoneal space; in the
pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Thus, the course of the
appendix, the position of its tip, and the difference in appendiceal position considerably
changes clinical findings, accounting for the nonspecific signs and symptoms of appendicitis.
 the exact point on the abdomen at which tenderness was
maximal in cases of acute appendicitis--the point now known
as "McBurney's point."
 McBurney point is defined as a point that lies one-third of the distance
laterally on a line drawn from the umbilicus to the right anterior superior
iliac spine. Classically, it corresponds to the location of the base of the
appendix

Etiology:

 obstruction of the appendiceal lumen by:

 Lymphoid hyperplasia 2° IBD or infection (more common during childhood and in
young adults)
 Fecalith (calcium salts and fecal debris) - elders
  Parasites
 Tumors
 Foreign material
 Crohn disease or other rare causes, e.g. stricture, tumor, parasite

 A layered buildup of calcium salts and fecal debris around a piece of fecal material within
appendix
 Lymphoid tissue in the appendix can be inflamed as a result of infection or IBD CMV, EBV,
HIV, Yersinia enterocolitica, Helicobacter pylori, and Giardia lamblia
 Enterobius, Ascaris, Giardia and Entamoeba histolytica.
 Schistosomes species, pinworms, strongyloides stercoralis
 Neuroendocrine tumors of the appendix

It has been suggested that the peak in the development of lymphoid tissue which occurs
during adolescence leads to an increased liability of the appendix to obstruct, and so
accounts for the high incidence of the disease.

 There is no particular pattern regarding the etiology of appendicitis

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 is composed of inspissated faecal material, calcium
phosphates, bacteria and epithelial debris (Fig. 67.5). Rarely, a foreign
body is incorporated into the mass. The incidental finding of
a faecolith is a relative indication for prophylactic appendicectomy previous appendicitis that resolved without surgical intervention

Etiology
Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal
obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD) or infections
(more common during childhood and in young adults), fecal stasis and fecaliths (more common in
elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and
neoplasms.
Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated
fecal material located within the appendix. Lymphoid hyperplasia is associated with various
inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory
infections, measles, and mononucleosis.
Obstruction of the appendiceal lumen has less commonly been associated with bacteria
(Yersinia species, adenovirus, cytomegalovirus,
actinomycosis, Mycobacteria species, Histoplasma species), parasites (eg, Schistosomes species,
pinworms, Strongyloides stercoralis), foreign material (eg, shotgun pellet, intrauterine device, tongue
stud, activated charcoal), tuberculosis, and tumors.

Pathophysiology:

Clinical manifestation:
Symptoms:
  Abdominal pain
(Begin at Periumbilical or epigastric region radiating to
RLQ )
 Anorexia 74-78
 Vomiting 50% of cases.
 Nausea is present in 61-92% of patients;
 Diarrhea or constipation is noted in as many as 18% of
patients and should not be used to discard the
possibility of appendicitis.
 PHx of gastroenterologic, genitourinary, and
pneumologic conditions, as well as consider gynecologic
history in female patients.
 An inflamed appendix near the urinary bladder or ureter can cause
irritative voiding symptoms and hematuria or pyuria.
 Cystitis in male patients is rare in the absence of instrumentation.
Consider the possibility of an inflamed pelvic appendix in male
patients with apparent cystitis.
 Acute urinary retention

Signs:
 RLQ tenderness is present in 96% of patients,
 rebound tenderness,
 pain on percussion,
 rigidity, and guarding

Physical Examination:
 The Rovsing sign
 The obturator sign
 The psoas sign
 The Dunphy sign
  A careful physical examination, not limited to the abdomen, must be
performed in any patient with suspected appendicitis. Gastrointestinal
(GI), genitourinary, and pulmonary systems must be studied
 There is no evidence in the medical literature that the digital rectal
examination (DRE) provides useful information in the evaluation of
patients with suspected appendicitis; however, failure to perform a
rectal examination is frequently cited in successful malpractice claims

The classic history of anorexia and periumbilical pain followed by nausea,

right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
Nausea is present in 61-92% of patients; anorexia is present in 74-78% of
patients. vomiting occurs, it nearly always follows the onset of pain.
Vomiting that precedes pain is suggestive of intestinal obstruction, and the
diagnosis of appendicitis should be reconsidered. Diarrhea or constipation
is noted in as many as 18% of patients and should not be used to discard
the possibility of appendicitis.
This pain migration is the most discriminating feature of the patient's history, with a
sensitivity and specificity of approximately 80%, a positive likelihood ratio of 3.18,
and a negative likelihood ratio of 0.5. [1] Patients usually lie down, flex their hips, and
draw their knees up to reduce movements and to avoid worsening their pain. Later, a
worsening progressive pain along with vomiting, nausea, and anorexia are described
by the patient. Usually, a fever is not present at this stage.
The duration of symptoms is less than 48 hours in approximately 80% of adults but
tends to be longer in elderly persons and in those with perforation.

In addition to recording the history of the abdominal pain, obtain a complete

summary of the recent personal history surrounding gastroenterologic,
genitourinary, and pneumologic conditions, as well as consider gynecologic
history in female patients. An inflamed appendix near the urinary bladder or
ureter can cause irritative voiding symptoms and hematuria or pyuria.
Cystitis in male patients is rare in the absence of instrumentation. Consider
the possibility of an inflamed pelvic appendix in male patients with apparent
cystitis. Also consider the possibility of appendicitis in pediatric or adult
patients who present with acute urinary retention.
A careful physical examination, not limited to the abdomen, must be
performed in any patient with suspected appendicitis. Gastrointestinal (GI),
genitourinary, and pulmonary systems must be studied. Male infants and
children occasionally present with an inflamed hemiscrotum due to
migration of an inflamed appendix or pus through a patent processus
vaginalis. This is often initially misdiagnosed as acute testicular torsion. In
addition, perform a rectal examination in any patient with an unclear clinical
picture, and perform a pelvic examination in all women with abdominal
pain.