ACUTE ABDOMEN

Dr. Abdulelah Shugaa Addin

Consultant general Surgery

ACUTE APENDICITIS *
Incidence:

1) It is the commonest cause of acute abdomen and the commonest surgical emergency and more in
males.
2) It usually occurs between 15-30 years.
3) Rare in old age due to atrophy of the lymphoid tissue and fibrosis of the appendix with complete
obliteration of the lumen.
4) Rare in children below 5 years due to short wide lumen of the appendix obstruction and stasis does
not occur.
5) Appendicitis is more common in citizens than in the farmers due to high protein and low fibers
diet.

*Aetiology:
A)Predisposing Factors:
[Link]: (most important predisposing factor).
 It is usually due to faecolith (hard faeces) or swelling of lymphoid follicles in response to viral
infection.
 It may be due to adhesions, kinking, parasites, foreign body, undigested seeds, adhesions or tumors
of appendix or caecum.
[Link] factors:
A narrow lumen & its wall is rich in lymphoid follicles.
3. Septic focus from which organisms are carried to the lymphoid follicles of the appendix.
4. Diet:
High protein and low fibers diet predisposes to constipation , stasis all over the colon & liability of
faecolith formation .
B) Route of infection: Usually from the lumen and rarely blood or lymphatic spread.
C) Organisms :
Usually E. Coli , strept. faecalis and viridians or Cl. Welchii
. * Pathology: 2 types are known.
A) Acute obstructive appendicitis:(more common , 2/3 of cases).
• Obstruction of the lumen of the appendix → stasis → overgrowth of normal bacterial flora → spread of
bacteria to mucosa.
• This usually produce rapidly progressive severe inflammation , gangrene & perforation are rapid &
common.
The condition progress rapidly as follows:
[Link] inflammation affect mucosa only → mucocele of the appendix. If the condition is untreated
→ spread of inflammation to the wall of the appendix leading to the following
[Link] inflammation → formation of multiple abscesses in the wall of the appendix and pus in the
lumen → pyocele or empyaema of the appendix. If the condition is untreated , the condition usually
progress to the followings.
[Link] inflammation: Gangrene uaually occurs at the tip of the appendix ( where appendicular
vessels are close to the wall of the appendix ) or the site of obstruction (pressure necrosis ).
B)Acute Non-obstructive Appendicitis :(Less common,1/3 of cases )
 Produce mild slowly progressive inflammation
 Usually catarrhal inflammation rarely progress to suppuration or gangrene.

* Fate & Complications:

1) In non-obstructive type only , acute inflammation may resolve spontaneously and
becomes recurrent subacute appendicitis but usually recurrent acute attacks occurs .
2) Appendicular Mass:
♣ Mechanism: In non obstructive type → gives time for the greater omemtum , caecum ,
loops of intestine and adhesions to surround the inflamed appendix on the 3 rd day after the
onset of the condition
.♣ Fate of Appendicular Mass:
[Link] it resolves within few weeks.
[Link] inside the mass → appendicular abscess.
3) Perforation:
♣ More common in young below 5 years (thin wall) and elderly ( atherosclerosis ) .
♣ Sudden perforation with poor general resistance → generalized peritonitis which is more
common in the obstructive type.
♣ Gradual perforation inside an appendicular mass → appendicular abscess (localized
peritonitis).

▪ Fate of Appendicular Abscess: The abscess may point on the abdominal wall, rectum,
vagina or brust into the generalized peritoneal cavity → generalized peritonitis.
Subphrenic abscess may occur .
4) Local spread of infection with irritation of the uterus , uterine tube , ovaries, bladder,
ureter, rectum , ileum , psoas major & obturator internus muscles etc …..
5) Rarely Pylephlebitis : It is a septic thrombophlebitis of portal vein or one of its
tributaries ( ileo-colic V. in case of retro-ileal appendix ) → portal pyaemia , pyogenic liver
abscesses, high fever with chills , jaundice & portal hypertension.
A. Symptoms:
1. A history of recent constipation or similar attacks are common.
2. Pain: ( main presentation )
 Nature: Colicky or dull aching .
 Onset: Rapid.
 It is aggravated by movements or cough
 . • Site:
 ▪ At first: Pain is generalized abdominal and most marked periambilical (both
appendix and umbilicus are supplied by the 10th thoracic segment of the spinal cord
and the appendix is part of midgut ).
♣ Distension of appendix → visceral Pain, which is illdefined and diffuse .
▪ After 6-10 hours pain becomes sharper and localizes in the right iliac fossa (spead of
inflammation to serosa → irritation of parietal peritoneum i.e. somatic pain which is
localized and sharp).
[Link] is always present and usually occurs before pain . If the patient feel hunger
and want to eat , one should think of another diagnosis .
[Link] nearly always present and appears after pain [Link] in 75% of patients
,occurs once or twice only & if persistant , it indicates complications.
▪ Vomiting always occur after pain .
▪ If vomiting precedes pain , one should think of another diagnosis .
6. Constipation is common but diarrhea may be present .
B. Examination:
a. General Examination:
1. Temperature rises gradually to 380C, a higher temperature indicates complications or
other diagnosis . ▪ Appendicitis never start by rigor or temperature higher than 40oC .
2.
Tachycardia is slight. Marked tachycardia indicates complications or other diagnosis .
Abdominal Examination:
1. Localized tenderness & rebound tenderness in the McBurney’s point ( which is the
commonest site for the base of the appendix . It is the junction between medial 2/3 & lateral
1/3 of a line between umbilicus & right ASIS) or elsewhere, as determined by the position
of the appendix.
2. Cough tenderness: on coughing, pain becomes sharp & localized to the site of appendix.
3. Rigidity , guarding & limitation of abdominal wall movements with respiration over the
position of the appendix occurs in advanced stage with perforation & peritonitis .
▪ 1, 2 & 3, indicate involvement of the overlying parietal
Rovsing’s sign: pressure on the left iliac fossa causes pain in the right iliac fossa due
to displacement of gases from the pelvic colon to the appendix.
Hyperaesthesia in the sheren’s triangle (between the umbilicus, right A.S.I.S. & symphysis
pubis), rarely present in early cases due to strectch of the serous coat. (irritation of spinal
segment supplying both areas).
6. P-R or P-V exam. to exclude gynaecological causes of acute abdomen & show tenderness
or mass & tenderness in the right side , in pelvic appendicitis.
*Atypical forms of acute appendicitis: 1. Retrocaecal Appendix: (75%) ▪ Tenderness &
rigidity in the Rt. Iliac fossa is usually minimal.
▪ Deep tenderness can be elicited in the loin with rigidity.
▪ If the appendix lies in contact with the ureter → ureteric colic.
▪ Irritation of psoas major muscle → psoas spasm → flexion of the hip joint & abdominal
pain of its hyperextension (psoas sign)
. Pelvic Appendix: (20%)
▪ Pain may be felt in the pelvis.
▪ Deep tenderness can be elicited on P-R & P-V examination
▪ Irritation of the surrounding structures: 1. Right obturator internus muscle → spasm →
lateral rotation of the hip with abdominal pain on medial pain on medial rotation (obturator
sign).

Appendicitis with pregnancy:

 ▪ Pain is displaced upwards as pregnancy progress.
 ▪ Localization by the omentum is less efficient.
 ▪ The condition is usually misdiagnosed as pyelitis
 ▪ If perforation occurs, there is a high chance of abortion or
premature labour.

Appendicitis in infants & young children

is more serious as perforation occurs in 80% of cases because difficult
examination of children , thin wall , greater omentum is not well developed
& the case may be misdiagnosed as gastroenteritis.
Appendicitis in elderly:
perforation is common due to weak immunity & atherosclerosis → early
thrombosis & gangrene.

Ultrasound findings in acute appendicitis

 Blind ended loop

 Non compressible
 Edematous wall
 Increased diameter 7mm or more
 Reactive regional lymph nodes
 Inflamed mesenteric fat and omentum and adjacent bowel loops
 Free fluid collection
 Appendicolith leading to obstruction
 Complications including appendicular mass, perforated appendix or
appendicular abscess