APPENDICITIS
BY
[Link] JETHVA
ASSISTANT PROFESSOR
DEPT. OF SURGERY
SURGICAL ANATOMY
• It is located at the terminal end of the caecum where three taeniae
join, about 2 cm below the ileocaecal orifice.
• Usually, around 5–10 cm in size but can be variable. Size of its
lumen is that of matchstick.
• Diameter of appendix is 3–8 mm; diameter of lumen is 1–3 mm
(matchstick).
• Most common position is retrocaecal (75%). Next common is
pelvic (21%).
Other sites are:
•Preileal (anterior)—rare (1%)
•Postileal (splenic)—rarest
•Paracaecal
•subcaecal –2%
•subhepatic
ACUTE APPENDICITIS
•It is common in young males.
•It is common in white races.
•Fibre rich diet prevents appendicitis. Less fibre diet increases chance
of appendicitis.
•It is common in May and August—seasonal variation— often called
as epidemic appendicitis.
•Viral infection may cause mucosal oedema and inflammation which
later gets infected by bacteria causing appendicitis.
•Family history may be relevant in 30% of appendicitis in children with
appendicitis occurring in first degree relatives.
•Obstruction of the lumen of appendix causing obstructive
appendicitis.
Blockage occurs due to—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.
•Faecolith is the most common cause.
•Organisms:
E. coli (85%), enterococci, (30%), streptococci, Anaerobic
streptococci, Cl. welchii, bacteroides.
•Pseudoappendicitis is appendicitis due to acute ileitis following
Yersinia infection. It is often due to Crohn’s disease.
Pathogenesis
•Acute inflammation of the mucus membrane with secondary
infection without obstruction causes acute nonobstructive
appendicitis.
•It may lead into resolution, fibrosis, recurrent appendicitis or eventual
obstructive appendicitis.
Luminal obstruction by faecolith, lymphoid hyperplasia, pinworm
(oxyuris vermicularis), other worms, foreign body, carcinoma/Crohn‘s
disease
mucus and inflammatory fluid collects inside the lumen
increases intraluminal pressure
leads to blockage of lymphatic and venous drainage → resulting in
increased oedema of mucosa and wall → causes mucosal ulceration
and ischaemia →bacterial translocation → bacterial spread through
submucosa and muscularis propria → acute obstructive appendicitis
thrombosis of appendicular artery → ischaemic necrosis of full
thickness of the wall of the appendix → gangrene of the appendix →
perforation at the tip or at the base → peritonitis.
After perforation → localisation by greater omentum and dilated
ileum occurs → with suppuration and pus inside forming
appendicular abscess.
In severe acute appendicitis → localisation can occur by omentum
and dilated ileum without pus inside → forming appendicular mass.
Acute appendicitis with blockage at the opening of the lumen →
inflammation rarely subsides → mucus collects inside the lumen of
the appendix resulting in its enlargement → Mucocele of the
appendix.
Types
1. Acute nonobstructive appendicitis (catarrhal) (mucosal appendicitis):
Inflammation of mucous membrane occurs with redness, oedema and
haemorrhages which may go for following courses:
Resolution
Ulceration
Fibrosis
Suppuration
Recurrent appendicitis
Gangrene—rare initially in nonobstructive type but later can occur,Peritonitis
2. Acute obstructive appendicitis: Here pus collects in the blocked
lumen of appendix which is blackish, gangrenous, oedematous and
rapidly progresses leading to perforation either at the tip or at the base
of appendix. This leads to peritonitis, formation of appendicular
abscess or pelvic abscess. Most often, there will be thrombosis of the
appendicular artery.
3. Recurrent appendicitis: Repeated attacks of nonobstructive
appendicitis leads to fibrosis, adhesions causing recurrent
appendicitis.
4. Subacute appendicitis is milder form of acute appendicitis.
5. Stump appendicitis is retained long stump of appendix after
commonly laparoscopic appendicitomy
Clinical Features
•It is rare before the age of two, common in children and other age
groups.
•Pain: It is the earliest symptom. Visceral pain starts around the
umbilicus due to distension of appendix, later after few hours,
somatic pain occurs in right iliac fossa due to irritation of parietal
peritoneum due to inflamed appendix. Pain eventually becomes
severe and diffuse which signifies spread of infection into the general
peritoneal cavity
Vomiting: due to reflex pylorospasm.
Murphy’s triad - Pain—first, Vomiting—next, Temperature—last
Constipation is the usual feature but diarrhoea can occur if appendix
is in postileal or pelvic positions.
Fever, tachycardia, foetor oris are other features.
Urinary frequency: Inflamed appendix may come in contact with
bladder and can cause bladder irritation.
•Tenderness and rebound tenderness at McBurney’s point in right
iliac fossa (release sign—Blumberg’s sign) are typical.
•Rovsing’s sign: On pressing left iliac fossa, pain occurs in right iliac
fossa which is due to shift of bowel loops whichirritates the parietal
peritoneum.
•Hyperextension (in case of retrocaecal appendix—Cope’s psoas test)
or internal rotation (in case of pelvic appendix—obturator test) of
right hip causes pain in right iliac fossa due to irritation of psoas
muscle and obturator internus muscle respectively.
•Baldwing’s test is positive in retrocaecal appendix—when legs are
lifted off the bed with knee extended, the patient complains of pain
while pressing over the flanks.
•P/R examination shows tenderness in right side of the rectum.
•Hyperaesthesia in ‘Sherren’s triangle’. This triangle is formed by
anterosuperior iliac spine, umbilicus, pubic symphysis.
Differential diagnosis
• Perforated peptic ulcer
•Ruptured or twisted ovarian cyst
•Acute cholecystitis
•Right ureteric colic
•Enterocolitis
•Right acute pyelonephritis
•Mesenteric lymphadenitis
•Lobar pneumonia
•Crohn’s disease
•Acute pancreatitis
•Meckel’s diverticulitis
•Acute crisis of porphyria
•Salpingitis
•Diabetic abdomen
•Ectopic gestation—ruptured
•Typhlitis
Sequelae of acute appendicitis
•Resorption
•Relapse and recurrent appendicitis
•Appendicular mass
•Appendicular abscess
• Perforation—has got 20% mortality
•Peritonitis, septicaemia
•Portal pyaemia
•Intestinal obstruction due to obstructive ileus, inflammatory
adhesion, formation of band between appendix and omentum or
between appendix and small bowel
Investigations
•Total leucocyte count is increased.
•Ultrasound is done to rule out other conditions like ureteric stone,
pancreatitis, ovarian cyst, ectopic pregnancy and also to confirm
appendicular mass or abscess.
•Laparoscopy is the most useful method
•Contrast CT scan
•C-reactive protein
•MRI
•X-ray
Treatment
Surgery-Appendicectomy
Approaches
1. Gridiron incision: Incision is placed perpendicular to the right
spinoumbilical line at the McBurney’s point (i.e. at the junction of
lateral one-third and medial two-third of spinoumbilical line).
(Gridiron is a frame of cross beams to support a ship during repairs.
This incision was first described by McArthur).
2. Rutherford Morison’s muscle cutting incision (Muscles are cut
upwards and laterally).
3. Lanz crease incision centering at McBurney’s point—
cosmetically better.
4. Right lower paramedian incision/lower midline incision—when
in doubt or when there is diffuse peritonitis.
5. Laparoscopic approach: Becoming popular and better.
6. Fowler-Weir approach by cutting muscle medially over the rectus
Thank you