APPENDIX
Anatomy
• It is the undeveloped distal end of cecum and is found only in humans some apes and
wombat.
• It is blind ending tube containing all the layers of intestine.
• In almost 75% people its retrocecal in position due to continued growth of cecum rotates
the appendix into this position. In 25% this rotation does not take place and appendix may
be one of the different positions as shown in the fig.
• If gut rotation is incomplete during development or in case of situs-inverses appendix can
found near GB, LIF or LHC.
• It is 7.5 to 10cm long. Mucosa is large gut, contain crypts where argentafin cells are present
which can cause carcinoid tumor.
Acute Appendicitis
• Reginald Fitz 1886 first paper on perforating infl. Of vermiform appen.
• Charles McBurney: clinical manifestation of acute app. And showed the
McBurney’s point
• A life time risk of 8.6% in males and 6.7% in female is there.
• Peek incidence in teens and early twenties, rare in infants and after middle
age.
• In teen agers and young adults the M to F ratio is 3:2 at age 25.
Etiology
• Decreased use of fibrous diet and increase consumption of refined CH.
• In paradox there is a dramatic decrease in appendicitis in western countries
probably due to better hygiene and use of antibiotics.
• Obstruction of the appendix lumen and proliferation of bacteria both
anaerobes and aerobes is important. The obstruction is commonly caused by
lymphoid follicles, faecolith, worms, seeds and stricture.
• Rarely a tumor like a caecal ca or carcinoid may block the lumen of app.
Pathology
• Luminal obstruction
• Mucosal hyperplasia causing narrowing of the lumen
• Frequent occurrence of acute app. In children and young adults suggest an infective
cause probably viral causing inflammation
• High incidence in spring and autumn suggest an allergic element also
• Continued secretion of mucus increases intra-luminal pressure causing lymphatic
obstruction and bacterial translocation to submucosa and mucosal ulceration. Can
resolve spontaneously or in response antibiotics at this stage.
• Progression can lead to venous obstruction and ischemia of app wall
Ischemia leads to bacterial invasion occurs through muscular layer and submucosa
leading to acute app.
• Ischemic necrosis will lead to gangrenous appendicitis leading bacterial
contamination of peritoneal cavity.
• Adhesions of omentum and gut loops will form a phlegmonous mass.
• Perforation of the appendix will lead to a para-cecal abscess.
• Sometime inflammation resolve and leaves behind a mucocele
• In immunocompromised patients like in extreme of ages, in n
immunosuppression, diabetes, feacolith obstruction, free-lying pelvic app.,
previous surgery causing a fixed omentum can lead a life threatening
generalized peritonitis.
Clinical Presentation
• History: poorly localized colicky abd pain
• Anorexia, nausea and vomiting
• A family Hx is useful
• Changing pain character and migration to RIF
• Exacerbation of pain in response coughing and movement
• A pelvic appendix will cause suprapubic pain tender on DRE
• After 6 hours pyrexia, increased pulse
• Acute catarrhal( non obstructive ) and obstructive appendicitis
Signs
• Thorough clinical examination of abd. is more important than Hx and lab.
• Pyrexia, localized tenderness in the RIF, muscle guarding, rebound
tenderness, pain on coughing and gentle percussion.
• Pointing sign, Rovsing’s sign, Psoas sign, Obturator sign ( Zachary Cope )
and tenderness on DRE.
Special features according to position of app.
• Retrocaecal app: absent rigidity, barely tender, tender loin, rigidity of
quadratus lumborum, positive psoas sign.
• Pelvic app: early diarrhea, frequency, absent tenderness and guarding in RIF,
tender hypogastrium, tender DRE in pouch of Douglas and positive psoas
sign.
• Postileal: pain may not shift, diarrhea, marked retching, ill defined tenderness
slightly medial close to umbilicus.
Special features, according to age
• Infants: rare below 36 months, Hx. Is not possible and delayed diagnosis leads to
generalized peritonitis (underdeveloped omentum)
• Children: vomiting always and complete anorexia.
• The Elderly: gangrene and perforation, less tenderness and guarding, feature of
subacute obstruction, mortality rate is high (co-morbid)
• The obese: decreased local signs, delayed Dx, difficult surgery better done
laparoscopically.
• Pregnancy: 1:1500 to 2000 pregnancies, delayed Dx., pain RIF is there though
appendix pushed up, fetal loss in 3-5% up-to 20% in perforation.
Differential diagnosis
• Children: acute gastro-enteritis
• mesenteric adenitis
• Meckel’s diverticulitis
• Intussusception
• Henoch-Schonlen purpura
• Lobar pneumonia
• Adults: Regional enteritis
• Ureteric colic
• Perforated DU
• Torsion of testis
• Pancreatitis
• Rectus sheath hematoma
• Amoebic typhlitis
• Adult female: Mittelschmerz
• pelvic inflammatory disease
• Pyelonephritis
• Ectopic pregnancy
• Torsion/ rupture of the ovarian cyst
• Endometriosis
• Salpingitis
• Elderly: diverticulitis
• Intestinal obstruction
• Colonic carcinoma
• Torsion of the appendix epiploicae
• Mesenteric infarction
• Leaking aortic aneurysm.
Investigations
• Mainly clinical
• On clinical suspicion only 15-30% normal appendix are removed
• Alvarado scoring system: which includes
• Symptoms: MAN( migratory pain, anorexia, nausea and vomiting)
• Signs: TRP ( tenderness, rebound tenderness, pyrexia)
• Laboratory: ( leukocytosis, shift to the left )
• (1+1+1 ) and ( 2+1+1 ) and ( 2+1 )
• A score of 7 and above strongly suggest appendicitis
• Contrast enhanced CT and u/s abdomen can further reduce neg. app.
Treatment
• Conservative treatment with injectable metronidazole and third generation
cephalosporin can be successful in up-to 80 to 90% but with 15% recurrence rate
with in one year.
• Pre-operative single dose of metro and 3rd gen ceph reduces the risk of wound
infection perforated cases.
• Appendicectomy:
• Conventional appendecectomy
• Retrograde appenndicectomy
• Laparoscopic appendecectomy
Problems encountered during appendectomy
• Appendix found normal
• Appendix can not be found
• An appendicular tumor is found
• An appendicular abscess is found and appendix can not be removed easily
• Appendicitis complicating Crohn’s disease
• Appendix abscess
• Pelvic abscess
• Appendix mass ( Ochsner-sherren ) regimn
Postoperative complications
• Wound infection in 5 to 10%
• Intra-abdominal abscess can occur in 8 % cases
• Ileus
• RTI
• DVT
• Portal pyaemia ( Pylephlebitis )
• Faecal fistula
• Adhesive intestinal obstruction
Neoplasms of the appendix
• Carcinoid tumor (argentaffinoma) Kulchitsky cells of lieberkuhn
• Found in every 300 to 400 appendectomies
• Goblet cell carcinoid tumor
• Primary adenocarcinoma
• Mucinous cystadenoma: rupture can lead to pseudomyxoma pertoneii