APPENDIX

ANATOMY:
The appendix is a 7.5-10 cm blind muscular tube that comes from the posterior medial wall
of the cecum and completes its growth by 2 years of life. The appendix rotates and it becomes
retrocecal in majority of the cases (65%) but there is a variation in this rotation and the
appendix can be:
The appendix positions The various appendix positions illustrated
Retrocecal (65%)
Pelvic (30%)
Para cecal (2%)
Sub cecal (2%)
Preileal (1%)
Postileal (0.5%)
Sub hepatic (<0.1%)

 The base of the appendix is at the confluence of 3 taeniae coli (tinea libera + tinea
omentalis + tinea mesocolica) and this can be used to find the appendix with a light
tug of the tinea coli.

 The mesentery is from the mesentery of the terminal ileum, sometime as much as the
distal 1/3 is lacking mesoappendix (transparent in children, fatty in adults).

 The blood supply: superior mesenteric artery=> ileocolic artery=> appendicular

artery. This is behind the terminal ileus to enter the mesoappendix which is the
appendix’s mesentery.

 Lymphatics: 4-6 lymphatic channels is in the mesoappendix that empties into the
ileocecal lymph nodes.

 The appendix is made up of 4 layers histologically being the:

o Mucosa:
 which is columnar epithelium with crypts that secrete mucous (the base
of the cells have argentaffin cells that give rise to carcinoid tumors).
 There is also lymphoid tissue that has WBC embedded in their
fibrocellular reticulum that congregates to give the lymphoid follicles.
o Submucosa: which consists of lymphoid tissues in the lamina propria
o Muscularis: The outer longitudinal and inner circular muscular layers.
o Serosal covers and protects the appendix.
  The function are as follows: immunological function + Maintain gut biota +
Ulcerative colitis protective.

ACUTE APPENDICITIS:
This is inflammation of the appendix due to obstruction of the lumen and is the most common
cause of acute abdomen in young adults with the peak incidence at age 20 and reduced after
middle age.
Uncomplicated appendicitis: appendicitis with no evidence of an appendiceal fecalith, an
appendiceal tumor, or complications, such as perforation, gangrene, abscess, or mass.

Etiology:
The etiology is due to obstruction of the lumen of the appendix with the main cause being:
 Lymphoid tissue hyperplasia is most common in children and young adults [when
lymphoid tissue is maturing it can be physiological or pathological]. 60%
 Fecalith: most common in adults (35%)
 Neoplasm in patients >50years
 Stricture in appendix that was inflamed but healed without surgical intervention.
 Parasitic infiltration (uncommon).

Pathophysiology:
1. Obstruction → ↑ secretions (mucous + gut flora trapped in the appendix =>
proliferates and stimulates inflammation => edema) → ↑ intraluminal pressure →
compression of lymphatics → edema + mucosal ulceration.
2. Ulceration → translocation to submucosa
3. Edema → compression of veins then arterioles → ischemia → translocation to other
layers of appendix (signs of appendicitis).
4. Ischemia → Necrosis → gangrene can lead to either:
 a. Perforations and spread causing generalized peritonitis.
b. Inflamed appendix walled off by bowel and mesentery (phlegmon)/ perf in the
wall causing a paracecal abscess.
c. Appendicitis resolves leaving a mucous filled appendix called mucocele.
Risk factors:
 Extreme of ages in infants and elderly
 Immunosuppression in diabetes mellitus
 Fecalith obstruction
 Pelvic appendix
 Previous abdominal surgery

History & Physical:

 Migratory abdominal pain first periumbilical (poorly localized + colicky due to
midgut viscera innervation) that then localizes at McBurney’s point in the RLQ 12-
24h after onset. (Due to parietal peritoneum irritation). If the patient indicates this, it
is known as the pointing sign.
 Anorexia
 Nausea/vomiting
 DRE: can illicit tenderness if the appendix is pelvic (30%) otherwise it’s RLQ pain.
 Fevers can be present.
 Rovsing sign (pain in RLQ on palpation of LLQ of the abdomen)
 Obturator sign pain elicited when (hip flexed and internally rotated)
 Guarding over McBurney’s point
 Rebound tenderness at umbilicus.
 Psoas sign (patient lies with right hip flexed for relief)
 Hamburger sign (patient doesn’t want to eat favorite food).
Cardinal signs: low fever + McBurney’s tenderness + Guarding + rebound tenderness.
Retrocecal Pelvic Postileal
Absent rigidity Diarrhea due to contact with the No pain shift.
(distended cecum rectum.
prevents contact with Diarrhea
inflamed appendix) DRE can illicit tenderness.
Tenderness elicited is ill
Psoas sign because No McBurney’s tenderness but defined.
contact with the above pubic symphysis.
muscle.
Contact with bladder causes
urinary frequency especially in
children. Or tenesmus.

obturator signs present

Differential diagnosis:
Children Adults
Acute gastritis Perforated PUD (Valentino’s sign)
Intussusception Ectopic pregnancy
Meckel’s diverticulum IBD
Mesenteric adenitis Endometrial carcinoma
Endometrial cyst.
Torsion of testis
Colon carcinoma

Management:
 Initiate the ABCDE approach to begin the stabilization of the patient while screening
for signs of peritonitis.
 Begin supportive care for the patient [NPO → IV fluids → analgesic → antiemetics]
 Apply risk stratification scores to determine the likely hood of the patient having
appendicitis.
The risk stratification score determines the next approach of the patient depending on the
likelihood of appendicitis. The main one used is the modified ALVARADO score. Which is
shown below.
Criteria MANTRELS (Criteria used) Score
Symptoms Migratory pain to RLQ 1
Anorexia 1
Nausea 1
Signs Tenderness in RLQ 2
Rebound pain 1
Elevated temperature 1
Labs Leukocytosis 2
Shift of neutrophils to left 1
Alvarado of <4: with nonspecific signs [check for other pathology]/ with specific sign [check
the exam], a score of 5-6 is a moderate assumption of appendicitis and a score of more than 7
is highly suggestive of appendicitis.
Diagnosis tools:
1. Labs:
a. CBC: Leukocytosis and Left shift of neutrophils.
b. C-reactive protein elevated with inflammation.
c. BMP: Increase creatinine and electrolyte imbalance in vomiting and diarrhea
d. Beta-hCG to rule out pregnancy and ectopic pregnancy.

2. Imaging:
a. Pregnant women and children would be an Ultrasound. There would be a
distended appendix >6mm and target sign present (hyperechoic layer then
hypoechoic edema layer the hyperechoic mucosa).
 Distension: Targetsign:

b. CT scan incores 5-6 this shows dialted appendix >6mm, and an edmatous
appendix with periappendicular fat.

c. Ehanced CT: if diagnosis is uncertain to rule out diverticulitis, Small bowel

obstruction, large bowel obstruction and enlarged appendix with free fluid.

Treatment:
Conservative management Operative management
1. Bowel rest- NPO the patient, add 1. Prep for surgery
fluids to the patient. a. IV catheter
2. Antibiotics coverage- Metronidazole b. Antibiotics
and 3rd gen cephalosporins 2. Appendectomy-
3. Check for malignancy if the patient  Gridiron incision
is >40 years  ID and remove the appendix by
4. Stop when the patient is stable. clamping and ligating
mesoappendix
 Suture with 2-0, 3-0 absorbable
suture.
If the appendix is not found then tug tinea
coli, and if there is a tumor >2cm a right
hemicolectomy should be done.

If there is an abscess percutaneous drainage

is done with the addition of IV antibiotics
and a right hemicolectomy if necrotic.
Complications of Acute appendicitis:
 Appendiceal phlegmon: an ill-defined mass of inflammatory periappendiceal tissue
with RLQ pain and the treatment is conservative or interval appendectomy.

 Appendiceal abscess: pus and necrotic tissue around the inflamed appendix following
a perforated appendix. It manifests as an acutely ill patient with RLQ pain. If it’s less
than 4cm antibiotics should be enough if not it is treated with percutaneous drainage
or an appendectomy.

 Gangrene appendicitis: necrosis of the appendiceal wall manifests as acutely ill

patient with RLQ pain and treated with emergency appendectomy and IV antibiotics.

 Perforated appendix: rupture of the appendix presents as peritonitis that then localizes
to conceal the perforation that then presents as an appendiceal mass or abscess later.
The treatment is emergency appendectomy and IV antibiotics.

 Pylephlebitis: septic thrombosis of the portal vein and there is bacteremia and filling
defect in the portal vein. The treatment is broad spectrum antibiotics.

 Mucocele of the appendix is a descriptive term that refers to dilation of the

appendiceal lumen as a result of mucin accumulation and is based on the gross or
macroscopic appearance of the appendix. Mucocele formation is most commonly
caused by epithelial proliferation, either benign or malignant.

Exam tips
 Alvarado scoring system.
 Natural history of appendicitis.
 The complications of appendicitis.
 Antibiotics vs surgery (we practice surgery).
 Don’t do interval appendectomy (Older patients Tx with Ab and then scope then do
appendectomy to send to histopathology).

Neoplasms of the appendix

Heading Notes
Introduction Neoplasm of the appendix is an uncontrolled autonomous cell-proliferation which can
occur in the appendix as a benign or malignant tumor. It is present in 1% of appendectomy
specimens.

Carcinoid Small, slow growing neuroendocrine tumors that arise from the argentaffin cells at the base
tumors of crypts.
 Low grade well differentiated with benign behaviour (10-30%).
 Well differentiated endocrine carcinoma with low malignant behaviour (50-80%).
 High grade, poorly differentiated with high malignant behaviour (1-3%).

Pathophysiology
Carcinoid tumors arise from amine precursor uptake and decarboxylation cells typically in
the GI tract these would be your enterochromaffin cells (argentaffin cells).
 GI tract (60%) + Pancreas (15%) + lungs (10%) + thyroid medullary/adrenal: PCC.

 Gives rise to serotonin secretion which can reach systemic circulation via liver
metastasis this is in midgut carcinoid tumors as foregut tumors can directly enter
systemic circulation via absorption. => carcinoid syndrome + Carcinoid heart
disease + pellagra.

RULE OF 1/3:
 1/3: are associated with multiple locations.
 1/3 are associated with another malignancy.
 1/3 end up metastasizing.

Clinical features:
1. Typically asymptomatic: because the hormones secreted are metabolized with first
past mechanism of the liver. If it is symptomatic, it can be by local tumor growth or
metastasis to the liver itself.

2. Carcinoid syndrome:
a. Diarrhea: >3 Bowel movements OR water content >75% OR quantity of
>200-250g/day. This is via the stimulation of mucosa to secrete mucous; it
also increases peristalsis and decreases absorption within the GI tract.

b. Cutaneous facial flushing: vasoconstrictor of cutaneous arteries, it also

occurs episodically as the serotonin isn’t always hyper secreted.

c. Dyspnea and wheezing: via bronchoconstriction => bronchospasms =>

wheezing.

d. Palpitations.

e. Abdominal pain (recurrent appendicitis/ subacute)

3. Carcinoid heart disease:

a. Endocardial fibrosis specific deposits at the valves (tricuspid + Pulmonic)
 via the serotonin receptors in the valves.
b. Right side heart failure: left side spared as the lungs metabolize vasoactive
substances via monoamine oxidases. But stasis in the right-side leads to
heart failure.
c. Pulmonary stenosis due to tricuspid regurgitation.

Diagnosis:
 Clinical biochemistry: if carcinoid tumor is suspected.
o Increased 5-hydroxyinodoleactic acid in 24h urine collection (byproduct of
serotonin metabolism).
o Serum serotonin levels.

 Imaging:
o CT of abdomen and pelvis
o Somatostatin receptor scintigraphy (shows active tumors and areas of Mets).
o MRI: for liver Mets.

 Biopsy: Histology (rosettes with chromatin) + immunohistochemistry (Test for

neuroendocrine origin).

Treatment:
 If <2cm then an appendectomy is done.
 If >2cm or with lymph node involvement, then a right hemicolectomy is indicated.
 If inoperable then
o somatostatin analogs Inhibit the release of splanchnic vasodilatory
hormones.
o tryptophan hydroxylase- An enzyme that hydroxylates tryptophan to produce
5-hydroxytryptophan, a rate limiting step for serotonin secretion. (For
diarrhea)

Epithelial carcinoma of the appendix.

Introduction Neoplasms of the epithelial cells of the appendix are classified using the Carr
classification of comparing their secretions and cytological atypia.
 Adenomas (benign)
 Serrated polyps
 Adenocarcinoma
o Non-mucinous adenocarcinoma
o Mucinous neoplasm/ mucinous cystadenocarcinoma (low grade, high
grade, mucinous adenocarcinoma)
o Adenocarcinoma with signet ring cells >50%.
 Signet ring carcinoma.

Pseudomyxom A rare condition classified by Peritoneal tumor deposits, mucinous ascites omental cake
a peritonei and tumor deposits in females. Typically, by the perforation of a mucinous appendiceal
tumor. The patients present with:
 Massive abdominal distension.
 Anorexia.
 Symptoms of bowel dysfunction.

The risk of developing it is practically 30-50% following the removal of an appendix

with mucinous adenocarcinoma. It is classified by cytological atypia.
 Low grade mucinous carcinoma peritonei
 High grade mucinous carcinoma peritonei
 High grade mucinous carcinoma peritonei with signet ring cells.

Spreads via: perforation => free floating epithelial mucinous tumor cells => fixation
then further secretion of mucinous material => gross progressive distension of abdomen
+ abdominal pain + bowel dysfunction.

Treatment Treatment:
 Without PMP there is cytology and low grade there is colonoscopy to ensure no
type of Metz to other tissue over a 5year period.

 High grade with extra appendicular cells right hemicolectomy + reginal

peritonectomy + sapling -oophorectomy.