33

The Appendix

• Development and anomalies • Faecal fistula

• Surgical anatomy • Neoplasm
• Mucocoele
• Acute appendicitis
• Valentino appendix
• Differential diagnosis
• Post-appendicectomy sepsis-case
• Complications report
• Appendicular mass • What is new?/Recent advances

Introduction DEVELOPMENT AND ANOMALIES

Acute appendicitis is the most common emergency encoun­
tered by the general surgeons. Men have slightly increased • Embryologically, the appendix and caecum develop as
incidence of acute appendicitis compared to women. Incidence outpouchings of the caudal limb of the midgut loop in the
is 11 per I 0,000 persons/year. Appendicectomy is a simple sixth week of human development. By the fifth month,
surgery, no doubt, but sometimes it can be very difficult and the appendix elongates into its vermiform shape, hence
disappointing-sometimes one may not be able to find the called vermiform appendix. At birth, the appendix is
appendix. Hence, appendicectomy should not be taken lightly. located at the tip of the caecum but due to unequal
The choice of surgery today is laparoscopic appendicectomy­ elongation of the lateral wall of the caecum, the adult
one advantage being one can look into all quadrants of the appendix typically originates from the posteromedial wall
abdomen-not to miss other causes such as perforated duode­ of the caecum, caudal to the ileocecal valve. A few
nal ulcer (see later Valentino appendix), etc. anomalies are given below:
1. Duplication of the appendix is one anomaly which is
Few historical events
further divided into following ways
• 1736: Claudius Amyand removed inflamed appendix from
the hernia sac of a boy. Type A: Single caecum-partial duplication
Type B: Single caecum and 2 separate appendices
• 1886: Reginald Fitz of Boston identified the appendix as
Type C: Double caecum with each one having one
the primary cause of the right lower quadrant inflammation. appendix (Figs 33.1 and 33.2)
He coined the word appendicitis.
2. Situs inversus: In this condition appendix is found on
• 1889: Charles McBurney suggested early laparotomy and the left side. Adds confusion in the diagnosis of acute
removal of the appendix. He also describe the McBumey appendicitis
point of maximum tenderness. 3. Subhepatic appendix: Tt happens in malrotation of the
• The first laparoscopic appendicectomy was described by gut. Patients with subhepatic appendicitis may complain
Kurt Semm. of pain in the right lower quadrant. A McBurney incision
• 2009: First transvaginal removal of the appendix by is usually given only to find no appendix in that location.
Santiaggo Horgan and Mark A. Talamini-a procedure Laparoscopy has the advantage of looking into all
called NOTES-Natural Orifice Transluminal, quadrants of the abdomen.
Endoscopic, Surgery (more details on page 1178). 4. Congenital absence of the appendix is rare.

824
 The Appendix 825

Fig. 33.1 A to C: Anomalies of the appendix (see text for details} Fig. 33.3: Positions of the appendix-see text for numbers

4. Subcaecal (6 o'clock)
5. Paracaecal
6. Subhepatic appendix is associated with subhepatic
caecum. It occurs due to malrotation of the gut (this
position is not depicted in the figure)

Layers of the appendix

• Mesoappendix is the continuation of mesentery of the ileum
above. It comes down carrying blood vessels in the meso­
appendix.
• Appendix has a serosa and a mucosa lined by columnar
epithelium (similar to intestinal mucosa) between which are
the circular and longitudinal muscle fibres.
• Submucosa has rich lymphoid follicles (lamina propria).
The lymphatic tissue decreases as age advances. Hence,
Fig. 33.2: Appendicular duplication and gangrene in one of the incidence of appendicitis is less after the age of 30
moieties years.
• Appendicular orifice is occasionally guarded by an
SURGICAL ANATOMY OF THE APPENDIX 1 indistinct semilunar fold of mucous membrane, known as
Valve of Gerlach.
• It is 8-10 cm long, may vary from 3 to 30 cm in length.
• It is situated 2 cm posteromedial to ileocaecal junction, at Blood supply of the appendix
the point of convergence of the three taeniae coli. • Appendicular artery is a branch of ileocolic artery.
• It is the primary cause of lower abdominal pain on the right Accessory appendicular artery ofSheshachalam (a branch
side. of posterior caecal artery) is a branch of ileocolic artery,
which runs in the mesoappendix (Fig. 33.4).
Positions of the appendix (Fig. 33.3)
• Veins follow the artery and end in the superior mesenteric
I. Retrocaecal in about 70% of patients (12 o'clock) vein, thus draining into portal vein. This is the reason for
2. Pelvic in 20% of cases (4 o'clock) development of pylephlebitis in cases of suppurative
3. Preileal and postileal (2 o'clock) appendicitis.
1 Appendix secretes immunoglobulins particularly IgA. So it is not considered as a vestigial organ anymore. However, appendicectomy is not
associated with any immunological compromise.
 826 Manipal Manual of Surgery

Surgical anatomy and significance

1. The area of the maximum tenderness in acute appen­
dicitis is called McBurney's, point - corresponds to the
site of appendix in vast majority of the cases.
2. Appendicular artery must be ligated in open or laparoscopic
method - to free mesoappendix.
3. Severe inflammation of the appendix can spread to portal
vein via ileocolic vein and can result in portal pyaemia, a
,.-----+a--1+- Appendicular very dangerous condition.
-----··
artery
4. Malrotation of the gut - appendix may be in subhepatic
region - to be kept in mind in cases wherein appendix is
not found in the right iliac fossa.

ACUTE APPENDICITIS
Fig. 33.4: Anatomy of the appendix
It is one of most common surgical emergencies encountered
by general surgeons. Sometimes acute appendicitis can be
dangerous (Key Box 33.1).
Surgical importance
• Suppurative appendicitis can give rise to pylephlebitis Definitions
(inflammation of portal venous radicles). • Acute appendicitis: Sudden appearance of signs and
Locating the appendix symptoms of appendicitis.
• Trace the taenia coli or trace ilea! loops at laparotomy. • Recurrent appendicitis: Recurrent attacks of acute
Taenia coli point to the base of the appendix. However, appendicitis-incidence is 15 to 25%.
• Grumbling appendicitis: Low grade recurrent bouts of
surface marking of the appendix is done as follows: Draw
a line from anterior superior iliac spine to the umbilicus. colics, vomiting with frequent admission, self-limiting
The junction of lateral 113rd and medial 2/3rds of this line cases.
• Simple appendicitis: If duration of symptoms is less than
indicates the location of appendix. This is the point of
maximum tenderness in appendicitis. This is called 48 hours or imaging does not show any abscess or
McBurney's point (Fig. 33.5). phlegmon.
• Complicated appendicitis: Acute appendicitis with
perforation or large abscess/phlegmon.
• Pseudoappendicitis: Acute ileitis mimics appendicitis
following Yersinia infection. It can also be due to Crohn's
disease.

MUMiilllllllWIIII�
WHY APPENDICITIS IS DANGEROUS?
• The appendix is a cul-de-sac (closed at one end) and can
be easily blocked
• The appendicular artery is an end-artery (gangrene can
occur fast)
• Inflammatory oedema causes easy and early thrombosis
of appendicular artery
Fig. 33.5: McBurney's point • The appendix has thin muscular coat. Hence, perforates
easily
• The lumen of the appendix is very narrow-1-3 mm in
diameter
Lymphatics • Closed loop obstruction: lntraluminal pressure builds up
• The lymphatic channels which are 4 to 6 in number drain as the appendicular mucosa secretes fluid resulting in
mucosal ischaemia. Slowly bacterial overgrowth and
into ileocolic nodes, ileocaecal nodes and appendicular
translocation occurs
nodes in mesoappendix.
 The Appendix 827

• Stump appendicitis: It is the inflammation and infection II. In obstructive cases

of appendicular stump, if a big stump is left behind (post­ • Symptoms are abrupt, vomiting is more, pain is more
operative cases). It may require stump appendicectomy. It and tenderness is more.
is important to ligate and divide at the base of the appendix • It is a more dangerous variety.
to avoid this complication (more so in laparoscopic
• Appendix looks inflamed, with congested blood vessels.
appendicectomy).
Tip especially looks more inflamed. As the inflammation
Aetiology is more severe, the outer aspect looks dull and purulent
exudates may be seen. Areas of blackening or green
1. Racial and dietary factors
colour indicates gangrene or necrosis with perforation.
• It is more common in white race than in coloured persons.
In acute inflammation neutrophils are dominant and in
Young males are affected more often.
cases of gangrenous appendicitis, vascular thrombosis
• It may be related to Westernisation of food-a diet rich
is a feature. The important pathological events can be
in meat precipitates appendicitis and a diet rich in fibre
summarised as follows--due to obstruction, the contents
(cellulose) protects the person from appendicitis.
get infected fast and the tension increases. The appendix
2. Familial susceptibility: It is related to having a long
becomes a closed loop, which results in septic thrombosis
retrocaecal appendix in which case the blood supply is
of vessels. Gangrene of appendix, perforation, peritonitis,
diminished to the distal portion and may precipitate
followed by a local abscess can occur (Fig. 33.6).
appendicitis.
3. Socioeconomic status: Appendicitis is common in middle • In children, greater omentum is very thin. Hence, it
class and rich people. The exact reasons are not known. cannot localise the infection. In adults, omentum is like
4. Obstructive theory: Obstruction to the lumen of the a fatty apron which localises the infection.
appendix due to faeco-liths, worms, ova, cysts of • ln aged patients, because of atherosclerosis, gangrene
Entamoeba causes obstructive appendicitis. It is seen only occurs very fast resulting in peritonitis. Obstruction is
in one-third cases. caused by faecoliths, worms and bands which cause
5. Nonobstructive theory: It is due to bacteria such as E. tenting. Obstructed appendicitis is one of the examples
coli, Enterococci, Proteus, Pseudomonas, Klebsiella and for closed loop obstruction. Other causes are volvulus,
anaerobes which produce diffuse inflammation of appendix carcinoma hepatic flexure, etc.
and cause appendicitis. This seems to be more common • Common bacteria encountered in acute appendicitis are
cause than obstruction. Bacteroides fragilis, Escherichia coli, Clostridium
perfringens, Streptococcus faecalis, Pseudomonas
Pathology aeruginosa, etc.
I. In nonobstructive cases (catarrhal appendicitis)
• Process of inflammation is slow and gradual. Clinical features
• A mild attack may completely resolve or mucosa! and The peak incidence is in the second and third decades. Very
submucosal oedema can occur (Key Box 33.2). uncommon before the age of two.
• Ulceration of the appendix results in slow bacterial
invasion of lymphoid tissue.
• Gangrene and perforation are rare.

............................. .
KEY BOX 33.2
Closed loop obstruction is caused by a faecolith

Swelling of the mucosa I and submucosal lymphoid tissue

NONOBSTRUCTIVE THEORY
IN ACUTE APPENDICITIS Secretion of fluid intraluminally
• This is seen in two-thirds of the cases. Hence, more
common than obstructive theory Rise in the intraluminal pressure
• Bacterial or viral infection is the cause
• It causes mucosal ulceration Mucosal ischaemia
• This is followed by bacterial invasion
• The decrease in the incidence of enteric fever in the Bacterial overgrowth, translocation
Western world has decreased incidence of acute
appendicitis-a support for infective theory Necrosis perforation
• In many cases of appendicitis, the appendix is not dilated
(against obstructive theory)
Fig. 33.6: Pathogenesis of appendicitis
 828 Manipal Manual of Surgery

Symptoms • Haematuria is uncommon and it is due to inflammatior

• Pain is severe, colicky type, initially felt in the umbilical of retrocaecal appendix which irritates the ureter in th{
region and it is due to distension of appendix. This is a retroperitoneum.
• Constipation is the usual feature, except in pre- and post­
visceral pain. After a few hours, the pain localises to the
right iliac fossa. It is a somatic pain which is due to ileal appendicitis, where they produce diarrhoea due tc
inflammation of parietal peritoneum. This is called shifting irritation of ileum.
pain of acute appendicitis (Fig. 33.7). This is called
Signs
migratory pain-most reliable symptom of acute
appendicitis. 1. Cough tenderness (Fig. 33.8) indicates inflammation of
• Normal appendix is mobile. So, the site of maximum pain parietal peritoneum. This is an important physical sign
which differentiates acute appendicitis from right-sided
and tenderness can vary.
ureteric colic.
• Vomiting occurs once or twice due to reflex pylorospasm.
2. Tenderness and rebound tenderness are present at
It contains stomach contents. However, it is never frequent McBurney's point. Rebound tenderness is called
such as in intestinal obstruction. Blumberg sign. It is due to inflammation of the parietal
• Appendicitis is unlikely in patients with normal appetite. peritoneum. This physical sign can be elicited in all cases
Usually patients have anorexia. of peritonitis.
• Fever is of low grade (around 100° F) and indicates bacterial 3. Guarding and rigidity are present in the right iliac fossa.
inflammation. However, guarding and rigidity of back muscles (erector
spinae) indicates retrocaecal appendicitis.
PEARLS OF WISDOM 4. Rovsing sign: Palpation of left iliac region of abdomen
produces pain in the right iliac region. It is because of
Painfirst, followed by vomiting and then by fever is called
displacement of colonic gas and small bowel coils
Murphy's 1 triad of symptoms of acute appendicitis
impinging upon the inflamed appendix (Fig. 33.9).
(Murphy's syndrome).
5. Hyperaesthesia in the Sherren's triangle (Fig. 33.10): It
is formed by anterior superior iliac spine, umbilicus

Fig. 33.7: Shifting pain (migratory pain)-most reliable symptom

Fig. 33.8: Cough tenderness (Dunphy's sign)

Pain in the ---,1---"-'la

right iliac fossa _osc,c;- Press
with hand

--+ ---1----
- Sherren's
triangle

Fig. 33.9: Rovsing sign

1Can you find out what is Murphy's sign and Murphy's punch test? Fig. 33.10: Hyperaesthesia in the Sherren's triangle
............
The Appendix 829

5. Abdominal ultrasound to rule out other causes including

gynaecological causes. Ultrasound can demonstrate a non­
� compressible, aperistaltic tubular organ with a thick wall.
VARIATIONS IN ACUTE APPENDICITIS
1. Retrocaecal: Silent (no rigidity in the right iliac fossa) It can be used to elicit probe tenderness (sensitivity of 85%,
2. Pelvic: Causes diarrhoea specificity 90%).
3. Postileal: Causes diarrhoea-called missed appendix
Advantages
4. Subhepatic: Manifests as pain in the right iliac fossa, very
difficult to remove from gridiron incision
• It is a simple bedside investigation
5. In pregnancy: The location of the pain is shifted higher
• Economical
up and laterally • Can confirm acute appendicitis in about 50% of the patients
• Appendicolith, pericaecal fluid collection or inflammation
can be diagnosed-indirect features of acute appendicitis
and pubic symphysis. It is due to irritation of lower • More sensitive and specific in children-thin abdominal
abdominal nerves. wall.
6. Cope's psoas test: Seen in retrocaecal appendicitis.
There will be irritation of psoas major which produces Disadvantages
flexion at the hip. If any attempt is made to extend the • It is operator-dependent
hip, it produces pain. • It is not a choice in fatty obese patient
7. Cope's obturator test: Seen in pelvic appendicitis due to • Gas within the dilated intestine may obscure the appendix
irritation of the obturator muscle. Flexion and medial
rotation produces pain. 6. CECT-Contrast Enhanced CT scan is the investiga­
tion of choice (sensitivity 90%, specificity 90%), specially
8. Features of generalised peritonitis are seen only when when diagnosis is not established or in unclassic cases. All
there is a rupture. Gangrene and perforation is more the findings mentioned in the ultrasound can also be defined
common in elderly patients because of atherosclerosis. In by CT scan (Fig. 33.11).
infants, omentum is very thin without much of fat. Hence,
diffuse peritonitis occurs very fast. Advantages
9. Rectal examination: There is tenderness in the right rectal • More objective
wall-differential tenderness. • Sensitivity and specificity is almost about 95%
10. Per vaginal examination: Presence of ovarian mass, • Helps to rule out carcinoma caecum, duodenal perforation,
tenderness on movement of cervix, adnexal tenderness acute pancreatitis, etc.
may suggest obstetric pathology.
• Signs and symptoms vary depending upon the location Disadvantages
(Key Box 33.3). • Pregnant woman-it is contraindicated
• In children-better to avoid it for the fear of radiation
Investigations exposure and risk of cancer developing at a later date
1. Total WBC count is almost always increased above l 0,000 • Expensive, long time for the contrast to reach the site
cells/mm3 , in most of the patients (95%). • Low fat, sensitivity is less
• A very high white blood cell count (> 20,000/mm3 )
suggests complicated appendicitis with gangrene or
perforation.
2. Urine examination is mainly to rule out urinary tract
infection, haernaturia and sometimes pyluria.
3. C-reactive protein is elevated in any inflammatory condition
such as appendicitis. Elevated in the first 12 hours of acute
inflammation very non-specific.
4. Plain X-ray abdomen erect is taken to rule out perforation
and intestinal obstruction. It may show dilated small bowel
loops in the right iliac fossa.

PEARLS OF WISDOM
Presence of faecolith is highly suggestive of acute
Fig. 33.11 : CT scan in acute appendicitis -
appendicitis in plain X-ray.
showing a faecolith
 Manipal Manual of Surgery

• Allergy to contrast and contrast nephropathy (dehydration, Surgical wisdom: Symptoms, signs (tenderness in
high creatinine, diabetics precipitating factors). McBurney point) with increased total counts, often you de
not need any imaging tests.
SCORING SYSTEM
To avoid negative appendicectomies, many scoring systems DIFFERENTIAL DIAGNOSIS OF
have been developed considering signs, symptoms and ACUTE APPENDICITIS
investigations. Most commonly used Alvarado scoring
system is given in Table 33.1. Innumerable conditions may mimic some signs of appendicitis.
Score less than 5 Not sure A few important conditions have been considered here.
Score 5-6 Compatible In children (Fig. 33.12A to D)
Score 6-9 Probable
Score more than 9 Confirmed A. Enterocolitis is common in children. It presents with severe
diarrhoea with blood and mucus in the stools.
• Even though Alvarado scoring is highly suggestive of
B. Meckel's diverticulitis can present with abdominal pain,
appendicitis, it is only a simple and cost-effective scoring
vomiting, fever-signs and symptoms are similar to acute
system. T his can be applied when sophisticated investiga­ appendicitis (difficult to differentiate clinically).
tions such as ultrasonography and CT scan are not available.
C. Worm ball is common in children in the developing
countries. However, features of intestinal obstruction will
be present.
Alvarado scoring system
D. Acute iliac/mesenteric lymphadenitis-non-shifting pain
Features Score and rebound tenderness are absent. It is viral in origin and
self-limiting. Neck nodes will give clue to the diagnosis.
Symptoms:
Migrating RlF pain
Anorexia
Nausea, vomiting
Signs:
Tenderness RIF 2
Rebound tenderness
A B
Elevated temperature
Laboratory:
Leucocytosis 2
Shift to left I
Total 10

C D

A 65-year-old lady was examined for feature of acute

Fig. 33.12A to D: In children (see text)
appendicitis of8 hours duration. On examination, she had
McBurney tenderness but a vague mass was palpable. It
In young adults (Fig. 33.13A to D)
is unusual for an appendicular mass to appear within 8
hours following appendicitis. Ovarian pathology was A. Right-sided ureteric colic: Haematuria, severe pain from
considered and gynaecological opinion was requested. It loin to groin, absence of cough tenderness help in excluding
was normal. CT scan was done. It revealed mucocoele of acute appendicitis.
the appendix (8 cm size). She underwent lower midline B. Amoebic typhlitis is associated with diarrhoea, blood in
laparotomy and it was removed. the stools and tenderness in left iliac fossa (Manson Barr's
amoebic point of tenderness).
CT scan gave a correct diagnosis and it guided the
treatment policy. C. Torsion of undescended testis: Absence of testis in the
scrotum clinches the diagnosis.
 The Appendix 831

D. Meckel's diverticulitis C. Acute cholecystitis can also present with features of acut�
E. Yersinia ileitis: Acute, self-limiting inflammation of appendicitis. However, it is common in elderly females.
the ileum caused by Yersinia pseudotuberculosis. D. Pain in the right iliac fossa and tenderness is due to dilateci
intestinal loop peristalsis as in ileocaecal tuberculosis 01
carcinoma caecum. Presence of an irregular, hard mass
suggest carcinoma caecum.

• In females (Fig. 33.15A to D)

A. Ruptured ectopic gestation: Missed periods, features of
haemorrhagic shock (pallor), extreme tenderness on
A B movement of cervix during per vaginal examination
clinches the diagnosis.
B. Pelvic inflammatory diseases:
• These are group of inflammatory conditions affecting
young women
• Tubo-ovarian sepsis, salphingitis and endometriosis are
grouped under this
• Pain is bilateral, fever is higher degree, no anorexia are
C D a few features
• Tenderness is present on both iliac fossae on deep
Fig. 33.13A to D: In adults (see text) palpation-no cough tenderness
• Vaginal discharge helps in the diagnosis
In middle age (Fig. 33.14A to D) • Chlamydia trachomatis and Neisseria gonorrhoeae
A. Acute pancreatitis: Inflammatory exudate collects and culture to be done.
gravitates in the right iliac fossa resulting in pain, guarding
and rigidity in the right iliac fossa. History of alcohol intake,
severe backache and tenderness in the epigastrium helps in
diagnosing acute pancreatitis.
B. Perforated duodenal ulcer can present with pain in the
right side of the abdomen due to similar causes mentioned
above. • •

A B

A B

• •
• •
C D
C D
Twisted ovaries
Fig. 33.14A to D: In middle age (see text) Fig. 33.15A to D: In females (see text)
 832 Manipal Manual of Surgery

C. Midmenstrual (mittelschmerz) rupture of ovarian follicle Few special situations

occurs about 14th to 16th day and can produce abdominal One should be careful and be firm in decision making of
pam. appendicectomy in these cases (Key Boxes 33.4 to 33.6).
D. Torsion of ovarian cyst produces very severe abdominal
pain with a mass.

PEARLS OF WISDOM
MHMI........,.�
ACQUIRED IMMUNODEFICIENCY
Any female patient with right-sided lower abdominal pain SYNDROME (AIDS) AND APPENDICITIS
• Incidence of acute appendicitis is more common in AIDS
should undergo a gynaecological examination to rule
patients-4 fold than non-AIDS patients
out the causes mentioned above, before subjecting to
• Pain is chronic than acute
appendicectomy. • Diarrhoea is more common
• Leukocytosis is not common
Systemic diseases • Delay in the presentation may be present especially
1. Pleurisy and pneumonia. patients with low CD count
2. Porphyria: Violent intestinal colic occurs due to spasm. It • Interestingly outcome or results are surprisingly good after
is precipitated by barbiturates. Urine is orange-coloured surgery
and when it is exposed to sunlight, the colour changes to
amber.
3. Pott's spine causes compression of nerve roots-radicular
pa111.
4. Preherpetic pain of 10th and 11th dorsal nerve is located • A 30-year-old lady was diagnosed to have acute
appendicitis w ith classical features-pain, fever,

.,.,........,.�
over the same area. Marked hyperaesthesia is present.
5. Purpura and bleeding disorders. vomiting and tenderness in the McBurney '.s point. A
gynaecological examination revealed pelvic infection.
An infected copper T was removed which was the cause
of abdominal pain.
CHILDREN AND ACUTE APPENDICITIS • A 22-year-old man underwent appendicectomy for right­
• Appendicitis is rare under 2 years of age because lymphatic sided abdominal pain. At laparotomy, appendix was
tissue is not yet developed by that time.
normal. However, it was removed. He continued to have
• Signs are not very well located.
abdominal pain. An ultrasound of the abdomen revealed
• Greater omentum is very thin. Perforation peritonitis is
torsion of the undescended testis. Nobody had examined
common.
• Hence, early surgery is recommended. his external genitalia!
• Open or laparoscopic method is followed. • A 36-year-old male who had previous history of
• Remember to rule out acute mesenteric lymphadenitis abdominal pain underwent appendicectomy for

•.,••........,.�
(viral), Yersinia ileitis and Meckel's diverticulitis. tenderness and rebound tenderness in the right iliac
fossa. Operative surgery notes said that the appendix
was slightly inflamed and seropurulentfluid was present
in the right iliac fossa. After 2-3 days, greenish fluid
(bile) started draining out through the tube. The
PREGNANCY AND ACUTE APPENDICITIS condition of the patient deteriorated and on
• Most common cause of abdominal pain and nonobstetric re-exploration this time, by midline incision revealed
emergency in pregnancy is acute appendicitis. perforated chronic duodenal ulcer!!
• Incidence may be 1 to 1.5/1000 pregnancies.
• Symptoms of nausea and vomiting are confused for
Complications of acute appendicitis
morning sickness.
• Migration of pain need not be present. Leukocytosis is seen 1. Rupture of appendix causes generalised peritonitis with
in pregnancy cases-it is normal occurrence. 10-20% mortality rate. The treatment involves emergency
• Tenderness is shifted because appendix is displayed laparotomy, appendicectomy and peritoneal wash followed
superiorly and laterally. by drainage of peritoneal cavity.
• Ultrasound is the investigation of choice.
• Treatment is by laparotomy and appendicectomy. 2. Appendicular mass (Figs 33.16 and 33.17)
• Foetal loss is 3% but with perforation, it is 30%.
• Following an attack of acute appendicitis, infection is
• Maternal mortality rate in perforated appendicitis is 4%.
sealed off by greater omentum, caecum, terminal ileum,
 The Appendix 833

CLINICAL NOTES
•
• A 60-year-old lady was diagnosed to have appendicular
mass and was undergoing conservative management.
On the fourth day, she developed features of early septic
shock. As the patient was not improving, laparotomy
was done. It was a case of volvulus of the caecum.

etc. which results in a tender, soft to firm mass in the

right iliac fossa.
• Presence of a mass is a contraindication for appendi­
cectomy because it is very difficult to remove appendix
from such a mass. An attempt to remove it may result in
a faecal fistula.
• It is treated by Ochsner and Sherren regime.
Fig. 33.16: Appendicular mass-tender, diffuse mass Aspiration with Ryle's tube to give rest to the gut.
Bowel care-purgatives should not be used (may
cause perforation).
Charts-temperature, pulse, respiration, diameter of
the mass. Swinging temperature, and increase in size
of mass indicates an appendicular abscess.
Drugs to cover all the organisms-gram-positive,
gram-negative and anaerobic organisms.
Exploratory laparotomy should not be done. However,
when the condition of the patient is not improving,
there is a suspicion of an abscess (Fig. 33.17) and
when doubtful of the diagnosis, exploration ts
indicated (see the clinical notes above).
Fluids (see Table 33.2)
Patient is kept nil orally for a few days. During this time,
intravenous fluids are given to correct dehydration.
After 3-4 days, the abdomen becomes soft, tenderness
Fig. 33.17: Appendicular abscess-once drained, fever touched decreases and once stools are passed, Ryle's tube is
the base removed. Clear oral fluids followed by soft diet is given.

Wisdom/mistakes/surprises for surgeon while conducting appendicectomy

Observes straw-coloured fluid Observes bile-coloured fluid Observes 'foul' fluid Observes haemorrhagic fluid

Completes appendicectomy Completes appendicectomy Completes appendicectomy Completes appendicectomy

Closes the wound Puts a drain Postoperative faecal fistula Ignores fluid
Realises 3 days later, it was acute Closes the wound Re-explores by midline Patient continues to have pain
pancreatitis Postoperative biliary fistula incision OBG consultation given
How could it have been avoided? Asks for contrast CT, realises Perforated Meckel's Twisted ovarian cyst
Serum amylase, lipase were not sent. duodenal ulcer perforation, diverticulum
Laparotomy and ovariectomy
A preoperative ultrasound was not done. explores, sutures the perforation Resection, anastomosis
Surgical wisdom: If these He had not done a simple chest Surgical wisdom: Surgeon Surgical wisdom: Surgeon
investigations were done before surgery, X-ray or plain X-ray abdomen had not examined the had not done ultrasound and
they could have helped the surgeon. erect preoperatively in this case terminal 2 feet ileum during gynaecological consultation
Luckily, the patient recovered from this appendicectomy was not requested before
unnecessary, avoidable surgery. surgery.
 834 Manipal Manual of Surgery

By one week, the patient is back to normal. After 6-8

weeks, patient is advised elective appendicectomy.

3. Perforated appendicitis
• Incidence is about 8-10%.
• More common in children and elderly patients.
• Delay in seeking medical treatment is the main factor.
• Other factors which precipitate perforation are diabetes
mellitus, AIDS, faecolith.
• The pain usually localises to the right lower quadrant if the
perforation has been walled off by surrounding intra­
abdominal structures including the omenturn.

.............
• Diffuse pain in cases of generalised peritonitis.
Fig. 33.19: Appendicular abscess is drained by extraperitoneal route
• Rigors and chills with fever of I 02° F (38.9 °C) or above.
• As a complication of perforation peritonitis, portal pyaemia
(pylephlebitis) can develop, it can be very dangerous.
• Emergency laparotomy, appendicectomy, drainage of pus, �
peritoneal lavage, antibiotics APPENDICULAR ABSCESS
• Mortality in these cases can be high. • Ultrasound/CT scan is done to assess the size and location
of abscess
4. Appendicular abscess (Fig. 33.18): If the infection is not • Abscess greater than 4-6 cm in size needs to be drained
controlled properly following an attack of appendicitis, an by guided percutaneous aspiration or drainage through
rectum or vagina
abscess can occur in relation to the appendix. They are (A)
• Ongoing inflammation may force a s urgeon to do
retrocaecal, (B) postileal and preileal, (C) pelvic, appendicectomy open/laparoscopic at the same admission
(D) subcaecal abscesses. Clinically, it presents with high­ • Those who improve require appendicectomy after 6 weeks
grade fever with chills and rigors and a tender boggy
swelling in the right iliac fossa or in the right lumbar region.
Pelvic abscess presents with diarrhoea. Diagnosis is by late C. Pelvic abscess is drained via the rectum (see page 647)
presentation to the hospital (3-4 days) and high-grade fever
D. Lumbar abscess (perinephric abscess) is drained through
with chills and rigors (Key Box 33.7).
a loin incision.
A. Retrocaecal abscess is drained by extraperitoneal
approach. An incision of 5 to 6 cm is made in the right iliac Preoperative resuscitation
fossa and all muscles are divided. However, perito-neum • Once diagnosis of acute appendicitis is suspected, the
is not opened. It is swept medially and pus is drained patient is admitted to the hospital.
outside. Appendicectomy is done at a later date (Fig. 33.19). • IV fluids-isotonic saline or Ringer lactate is given.
B. Preileal and postileal abscesses are drained by a • Electrolytes are corrected especially in late cases of acute
laparotomy. appendicitis/perforation peritonitis, etc.
• Ryle's tube is not necessary in simple appendicitis but is
definitely required in complicated cases (peritonitis).
• Second generation cephalosporins along with metro-
nidazole is given.
• Informed consent is taken.
Treatment
• Emergency appendicectomy: Emergency appendicectomy
is offered when patient comes within 24 to 48 hours of
abdominal pain. It is very impo1tant to rule out or detect a
mass, especially if a decision is made to operate around
2nd or 3rd day. If a mass is palpable, it is better not to
operate at that time (please refer to operative surgery,
appendicectomy). A few important steps are given here
(Figs 33.20 to 33.24).
• The appendix is identified by tracing Taenia coli which
Fig. 33.18: Appendicular abscess (see text for A to D) converges onto the base of the appendix. Mesoappendix is
 The Appendix 835

Fig. 33.21: Large faecolith resulting in acute appendicitis

Fig. 33.20: Emergency appendicectomy-base is crushed

Fig. 33.22: Inflamed appendix at surgery (Courtesy: Dr Prasad, Fig. 33.23: A ppendicular perforation with abscess­
S. Professor of Surgery, KMC, Manipal) appendicectomy could be done (Courtesy: Dr Annappa Kudva,
Professor of Surgery, KMC, Manipal)

TREATMENT OF APPENDICITIS

Simple/Early Delayed/Complicated
Late/Recovering
(within 48 hours) (perforation/abscess)

1st attack:
Appendicectomy Child/Pregnant/Adults Nonpregnant Give the choice to the
patient if he is willing
Ultrasound CT scan
Obese/
Elderly women 1. Laparoscopic interval
Large abscess 1----� Phlegmon
appendicectomy
2. Can advice appen­
Laparoscopic Laparoscopic/open Antibiotics + drainage Antibiotics dicectomy only when he
or she gets the second
attack also
Interval appendicectomy Interval appendicectomy

Fig. 33.24: Algorithm of treatment of appendicitis

 836 Manipal Manual of Surgery

divided in between ligatures. A purse-string suture is applied

all around the appendix in the caecum. The appendix is
divided in between ligatures, the stump is invaginated and
the purse string is tightened. The abdomen is closed in layers.
(see Chapter on operative surgery)
• Laparoscopic appendicectomy has become more
popular nowadays. Less postoperative pain, speedy
recovery. Benefit is maximum in obese, women and elderly
patients.

PEARLS OF WISDOM
When you trace Taenia coli and you are not getting
appendix, it means you are holding and tracing Taenia Fig. 33.25: Carcinoma colon with appendicitis
of the sigmoid colon. (It can be found on the right
side sometimes.)
to do incidental appendicectomy provided it can be removed
through same incision, without much difficulty.
Problems encountered during appendicectomy The patient should be stable to tolerate the procedure.
l. The incision is small: Location is higher up-never hesitate
to close the incision and a midline incision is given and do Contraindications for incidental appendicectomy
appendicectomy. An attempt to remove the appendix with • Crohn's of caecum
traction and limited exposure through McBurney incision • Radiation treatment of caecum
may result in faecal fistula. • Immunosuppression
2. Normal appendix is found: Remove the appendix. Other­ • Vascular grafted patient (aortoiliac, etc.)
wise it may cause confusion to the next surgeon when this • Chances of infection are high in this group of patients. The
patient presents with abdominal pain. However, look for result will be faecal fistula-difficult to treat.
Meckel 's diverticulitis, intestinal obstruction, stricture, etc.
3. Gangrenous appendix involving base: Problem one What to do if normal appendix is found at surgery?
can face here is that the purse string can be applied but • Nonnal white appendix is called Lily-white appendix.
invagination of the stump is not possible. Risk of faecal • It is removed because the 'scar' should not add confusion
fistula is also present. Appendicectomy, wash and a drain later to a doctor whether appendix was removed or not.
is kept. • However, examine:
4. Difficult to isolate the appendix which is gangrenous - Meckel's diverticulum
but pus is present: Limited ileocecectomy can be - Mesenteric lymph node enlargement
done. - Ovaries and fallopian tubes
5. The appendix cannot be found: First mobilise the caecum - Gall bladder for cholecystitis and pancreas for
and look for subcaecal or retrocaecal sites. Look also into pancreatitis.
preileal or postileal sites. Then mobilise the ascending colon • Rule out duodenal ulcer perforation.
also. Agenesis of the appendix is very rare. • Document the findings
6. Surprise findings of carcinoma caecum (Fig. 33.25): If
suspicion of a carcinoma is high, hemicolectomy should POST-APPENDICECTOMY FAECAL FISTULA
be done. Otherwise take a biopsy-do appendicectomy.
• It can occur after appendicectomy especially when gangrene
INCIDENTAL APPENDICECTOMY of the appendix extends to base of the caecum. It can also
occur if purse-string suture is not properly applied, injury
It means removal of normal appendix at laparotomy for another to the terminal ileum or caecum, etc. occurs.
condition. Examples: Laparotomy and ilea! resection for
• Discharge of faeculent contents or faecal matter after
stricture and anastomosis (can we do appendicectomy?).
Ovarian cyst: Torsion (right) ovary is removed. Can we appendicectomy suggests faecal fistula (Fig. 33.26 and Key
add appendicectomy? Box 33.8).
Since benefits of appendicitis/appendicectomy is more in • Usually discharge stops after a few days provided there is
young patients, if patient is under 30 years, it may be justifiable no distal obstruction.
 The Appendix 837

• Can present as acute appendicitis due to obstruction

caused by the tumour.
• Mucinous variety has better prognosis.
• Colonic variety should be treated by right hemicolec­
tomy.
3. Cystic neoplasm of the appendix
• Rare occurrence
• Simple cyst (non-neoplastic mucocoele) and mucinous
cystadenoma (like pancreatic).
• Can attain large size.
• Diagnosis is by ultrasound/CT scan.
• Appendicectomy is the treatment of choice.
• It can rupture into peritoneal cavity resulting in pseudo­
myxoma peritonei.
Fig. 33.26: This patient had faecal fistula which healed after two
weeks of conservative management

MHMIIIIIIIIIIMIIIII�
MUCOCOELE OF THE APPENDIX

Definition: It means accumulation of mucus within the lumen

FAECAL FISTULA-CAN OCCUR of the appendix.
• After drainage of appendicular abscess Causes: It can be a simple retention cyst due to blockage by
• After appendicectomy-if purse string sutures are not
foreign body or mucosa! hyperplasia. It can also be due to a
properly applied
• mucinous adenocarcinoma (Fig. 33.27).
If the caecum is also involved by inflammation
• If the cause of appendicitis is carcinoma
Pathology (Figs 33.28 to 33.31)
• If chronic diseases develop or are present-tuberculosis,
Crohn's or actinomycosis • The majority of epithelial tumours of the appendix are
• If appendicitis is associated with carcinoma caecum mucin rich, thus results in gross distension.
• Mucocoeles resulting from non-neoplastic occlusion
• Cases which do not respond to conservative treatment are (simple retention cysts) rarely exceed 2 cm in diameter.
managed by resection of the diseased portion of the caecum • Mucinous neoplasms of the appendix are by far the most
or ascending colon. common cause of mucocoeles.
• Mucocoeles larger than 2 cm are more likely to represent
benign neoplasms.
PEARLS OF WISDOM

The important causes for faecal fistula are carcinoma Diagnosis

caecum and ileocaecal tuberculosis in India and Crohn 's • It is impossible to differentiate clinically mucocoele of the
disease in the West. appendix and acute appendicitis when they present with
abdominal pain. If a mass is palpable, it can be confused
with appendicular mass.
NEOPLASM OF THE APPENDIX

1. Carcinoid tumour
• It is the most common neoplasm of the appendix, less
aggressive, majority are benign and cured with simple
appendicectomy (see Chapter 28 for more details).
• Goblet cell carcinoid tumour-it is more aggressive,
requires right hemicolectomy if the tumour is more than
2 cm, has more than 2 mitosis per high power field and
lymphovascular invasion, adenocarcinoma of the
appendix.
2. Carcinoma
• It is very rare.
• Often it is colonic type. Other type is mucinous adeno­ Fig. 33.27: Mucocoele of the appendix ( Courtesy: Dr Raghunath
carcmoma. Prabhu, KMC, Manipal)
 838 Manipal Manual of Surgery

Fig. 33.31: Mucocoele specimen

Fig. 33.28: Large mucocoele removed along with caecum and
terminal ileum Complications
1. Gross enlargement and can present as mass abdomen.
2. Rupture will result in pseudomyxoma peritonei (more
details are given in Chapter 27, Peritonitis).
3. Secondary infection: Can result in 'empyema' of the
appendix.

PEARLS OF WISDOM

Rule out adenocarcinoma of the base of the appendix

causing mucocoele.

Treatment: Appendicectomy

MISCELLANEOUS

VALENTINO APPENDIX
Fig. 33.29: Mucocoele ( Courtesy: Dr Rajesh Sisodia, KMC, • Rudolf Valentino was an Italian actor acting in Hollywood
Manipal) who was operated for right iliac fossa pain with features of
peritonitis in the early 20th century. Following a few days
of surgery, he died of sepsis. The actual disease was
perforated duodenal ulcer. This is a typical case scenario
that holds true even today. The contents gravitate down
along right paracolic gutter. The symptoms and signs mimic
appendicitis. CT scan is the investigation needed to rule
out other causes (see page 637).

POST-APPENDICECTOMY SEPSIS (A case report)

A 32-year-old man presented to casualty with septic shock
after 5 days after appendicectomy. It was a difficult
appendicectomy. Gangrene of the appendix was almost
involving the base.
Fig. 33.30: Appendicular tumour arising from the tip has been
On examination he was having paralytic ileus and jaundice.
removed-reported as c arcinoid ( Courtesy: Dr Raghunath Abdomen was distended-guarding was present, more in the
Prabhu, KMC, Manipal) right iliac fossa. He was admitted to the hospital.

• CT scan is the investigation of choice. The anatomic Investigations

relationship between the elongated cystic mass and the • Total counts were 20,000 cells/cu mm
caecum is usually more clear at CT scan than at ultrasound. • Urea:51, Cr: l .l
 The Appendix 839

• K: 3.2, Na: 129

• TB: 19 mg/DI, DB: 16.6, ALP: 167
• AST: 189 units, ALT: 100 units
Remarks: It showed he was in sepsis-counts were elevated,
urea was high-renal failure sets in slowly, increased bilirubin
levels-sepsis with cholestasis.
Plain X-ray chest revealed free gas under the diaphragm
(Fig. 33.32).
CT scan: Done after hydration-showed pneumoperitoneum
and liver cyst (incidental) and free fluid in the peritoneal cavity
(Fig. 33.33).

Conclusion
He was in sepsis. The reason was probably that the
appendicular base (stump) had given way.

Fig. 33.32: Free gas under the right dome of the diaphragm
Exploratory laparotomy
• Faecal peritonitis
• One litre of frank purulent pus in the peritoneal cavity.
• Gangrene oflateral wall ofcaecum with sloughing of caecal
wall.
• Appendix not seen-post-appendicectomy
• Ileum normal
• Cystic lesion on anterior surface of right lobe of liver
• Rest of viscera are normal

Procedure
• Limited resection of ileocecal segment and end-to-end ileo-
ascending single layer anastamosis
• Peritoneal lavage
• Drains in the pelvis and subhepatic space
• Skin not closed (wound infection is very common) Fig. 33.33: Free gas under the right dome of the diaphragm
pneumoperitoneum and liver cyst
Postoperative
6th postoperative day
• Patient had greenish discharge from the right DT
• Anastomotic leak and enterocutaneous fistula was suspected
• Patient was passing flatus
• RS: Basal crepitations
• Managed conservatively
• TPN was given for 5 days
• Discharge subsided by 5 days
8th postoperative day
• Breathlessness
• Fever
• Hypoxia: Sp02: 85%
• Chest X-ray-pneumonia (Fig. 33.34)
• Intubated, ventilated for 5 days, appropriate antibiotics
• By 20th day, he was discharged from the hospital-leak
had stopped. Fig. 33.34: Right lung pneumonia
 840 Manipal Manual of Surgery

• This case report has been given here for the following
WHAT IS NEW IN THIS CHAPTER?/ RECENT ADVANCES
message
1. Acute appendicitis can be dangerous • All topics have been updated with flowcharts and
2. Leak should be suspected if a patient who underwent coloured pictures.
appendicectomy does not improve in the postoperative • New algorithm of treatment of appendicitis and a
period. Wisdom Table 33.2 have been added.
3. High total count, increased bilirubin, oliguria suggest sepsis • Valentino appendix and neoplasms of the appendix have
4. CT scan is the best investigation in such cases. When in been added.
doubt reexplore. Danger lies in delay, not in resurgery.
• Multiple choice questions have been added.

INTERESTING 'MOST COMMON'

• Most common surgical emergency encountered by a general surgeon is acute appendicitis.

1• Most common emergency surgical operation is appendicectomy
• Most common nonobstetric surgical disease of the abdomen during pregnancy is acute appendicitis.
• Most significant symptom of acute appendicitis is migratory pain.
1• Most significant sign of acute appendicitis is rebound tenderness in the McBurney's point.
• Most prominent scoring system to diagnose acute appendicitis is Alvarado score.
• Most common anaerobic bacteria in acute appendicitis is Bacteroides fragilis and aerobic bacteria is Escherichia coli.
• Most common complication after appendicectomy is wound infection.
• Most common age group for acute appendicitis is below 40 years.
• Most common neoplasm of the appendix is carcinoid tumour.
• Most of the carcinoids are less than 1 cm in size.
 The Appendix 841

MULTIPLE CHOICE QUESTIONS

1. The most common position of the appendix is: 9. The most common cause of nonobstetric emergency
A. Subhepatic B. Subcaecal with abdominal pain in pregnancy is due to:
C. Retrocaecal D. Pelvic A. Acute appendicitis B. Acute cholecystitis
C. Acute gastritis D. Acute hepatitis
2. The incidence of appendicitis is less after 30 years
because: 10. Contraindications for incidental appendicectomy
include all of the following except:
A. The appendix undergoes involution
A. Crohn's of caecum
B. The lymphatic tissue in the appendix decreases B. Radiation treatment of the rectum
C. Most people would have had their appendices removed C. Immunocompetent individuals
D. The vascularity reduces D. Previous vascular reconstruction in the abdomen
3. The name Sheshachalam is associated with which of 11. The following statement is TRUE about appendicular
the following arteries? abscess:
A. Accessory appendicular artery A. Abscess greater than 4-6 cm in size needs to be drained
B. Appendicular artery by laparotomy
C. Ileocolic artery B. Appendicectomy must be done along with laparotomy
for appendicular abscess
D. Posterior caecal artery
C. Can present with diarrhoea
4. Appendicular orifice is occasionally guarded by an D. Conservative management is advised till inflammation
indistinct semilunar fold of mucous membrane called: settles down.
A. Valve of Gerlach B. Valve of Heister 12. Most common aerobic bacteria involved in acute
C. Valve of Kerckring D. Valve of Houston appendicitis is:
5. The most common scoring system used for appendicitis A. Samonel/a typhi B. Streptococcus
is scoring system. C. Escherichia coli B. Clostridium perfringens
A. Child-Pugh B. Furtado 13. The following statement is FALSE about occurrence of
C. Murray D. Alvarado faecal fistula following appendicectomy:
A. Faecal fistula can occur if the cause of appendicitis is
6. Palpation of left iliac region of abdomen produces pain carcmoma caecum
in the right iliac region in appendicitis because of:
B. Faecal fistula can occur if chronic diseases such as
A. Sympathetic reaction tuberculosis is present
B. Displacement of colonic gas and small bowel coils C. Faecal fistula can occur if purse string sutures are not
C. Sigmoid colon is also affected applied properly
D. Ileocolic reflex D. It is always due to actinomycosis
7. Cope's psoas test is positive in: 14. The most reliable symptom of acute appendicitis is:
A. Fever B. Migratory pain
A. Retrocaecal appendicitis
C. Right iliac fossa pain D. Vomiting
B. Pelvic appendicitis
15. Appendicular perforation is common because of the
C. Preileal appendicitis following reasons except:
D. Subcaecal appendicitis A. Appendix is a cul-de-sac
8. Rebound tenderness in acute appendicitis is called: B. It has blood supply with profuse collaterals
A. McBurney's sign B. Blumberg's sign C. It has a narrow lumen
C. Rovsing's sign D. Sherren's sign D. The muscle coat of appendix is thin

ANSWERS
1 C 2 B 3 A 4 A 5 D 6 B 7 A 8 B 9 A 10 C
11 C 12 C 13 D 14 B 15 B