I.

SURGICAL ANATOMY OF THE CECAL APPENDIX

Cecal appendix (vermiform)

it is a rudimentary diverticular organ attached to the cecum, cylindrical in shape and with a length
from approximately 6-10 cm (extreme variations 2-20 cm).

Histologically, the appendicular wall presents all the characteristic elements of the colon.
including the Meissner and Auerbach nerve plexuses; by the age of 15-25 there is
rich mucosal and submucosal lymphoid tissue (around 200 lymphatic follicles producing
immunoglobulin, from where the name "abdominal tonsil" given to the appendix comes from), which
then it spontaneously evolves.

The appendix presents 5 typical locations in relation to the cecum in order.

the frequencies are:
retrocecal-retrocolic (free or fixed)
pelvic (descendant)
subcecal (oriented downwards and to the right)
ileocecal or mesocecal (oriented upwards and to the left)
anterior of ileum
ileocecal or posterior mesenteric of the ileum.

The vermiform appendage originates at the posteromedial surface of the cecum at

approximately 1.7 cm from the ileocecal valve;
The base of the appendix is located at the junction of the 3 cecal tenae.

fixed retrocecal appendix

The mesentery of the appendix is derived from the posterior leaflet of the mesentery of the ileum.
terminal and attaches to the base of the appendix and to the cecum, containing the appendicular artery;
Sometimes in women, it continues with the Clado appendiculoovarian ligament.

The appendicular artery comes from the ileocolic artery (terminal branch of the SMA), from a branch.
ileal from the ileocolic artery or from a cecal artery; it is usually singular, but can also be
double. In addition to the appendicular artery, the base of the appendix may be irrigated by a small
the ram of the anterior or posterior cecal artery.
translatedText
1
 ileocecal
ram colic
ram ileal
superior mesenteric
posterior cecum
[Link]
anterior cecal

vascular fold of the cecum

superior ileocecal recess

ileocecal fold
ileon terminal
inferior ileocecal recess
mesoappendix

appendicular

parieto-space-
right colic
folds
slip
external iliac vessels
retroperitoneal

recess retrocecal

ileocecal region

free tenon (anterior)

ileocecal valve

ileon terminal

the opening of the vermiform appendix

frenulum

free time

appendix
worm-shaped

2
II. APPENDICITIS

A. ACUTE APPENDICITIS
is the most common abdominal emergency, affecting one in 500-600 individuals.
Maximum incidence in the age decades 2-3;
before puberty sex ratio = 1, after puberty ♂ : ♀ = 2:1 up to 25-30 years old, when
the report becomes unified again
There is no racial predisposition, but it seems that the incidence is higher in societies with
diet mainly based on meat consumption.

ETIOPATHOGENESIS
There are 2 etiopathogenetic theories:

1. Enterogenous theory: determining factor = obstruction of the appendicular lumen through

coprolite, through a foreign body (cherry pit, etc.), through an intestinal worm (of
ascariasis), through lymphoid hyperplasia (common in young people), through fibrous scar
consecutive to a previous inflammatory flare-up or from compacted barium coming from
previous explorations.
Pathogenic sequence: obstruction stabilization with appendicular distension and stimulation
free nerve endings that produce a vague diffuse sensation of pain and cramps in
mesogastrium and lower epigastrium the accentuation of distension through rapid multiplication
intraluminal bacterial, with disturbances in venous and lymphatic circulation and triggering
through reflex path of nausea, vomiting, alongside the intensification of pain (colicky) which
localized in the right iliac fossa arterial circulation disorders with lesions of
parietal gangrene and perforation.
Fever, tachycardia, and leukocytosis develop as a consequence of the absorption of products of
tissue necrosis and bacterial toxins.
2. Hematogenous theory: justifies the occurrence of appendicitis in the absence of a luminal obstruction by
blood dissemination during an upper respiratory tract infection or
Eruptive febrile. In this case, the evolution is usually less severe.
Bacteriology: Bacteroides fragilis, Escherichia coli, Peptostreptococcus, Pseudomonas, etc.

PATHOLOGICAL ANATOMY
Appendicular suffering goes through 3 stages of morphopathological evolution:

1. Acute catarrhal (congestive) appendicitis: swollen, congested appendix with drawing

vascular evident, red-violet color; on section thickened, hyperemic mucosa,
with areas of superficial ulceration; microscopic areas of mucosal necrosis.
2. Flegmonous acute appendicitis (suppurative, purulent): appendix greatly enlarged in size,

3
 in tension and very brittle (must be handled with great care as it can break)
with often uneven caliber, serous with a lost sheen, the tip of the appendix thicker;
in the periapendicular area there is often a cloudy peritoneal reaction fluid
opalescent; appendicular infiltrate and friable; appendix possibly adherent to the organs
vein (false membrane); after the appendectomy, the content is observed
purulent (appendicular empyema); microscopic examination shows the destruction of lymphatic follicles
with their transformation into small abscesses.
3. Acute gangrenous appendicitis (necrotic-hemorrhagic): appendiceal wall with areas
devitalized with a flaccid appearance and brown color ("withered leaf"); intense meso
edematous and hyperemic, often with thrombosed vessels due to sepsis; presence of fluid
intensely fetid and hyperseptic in the peritoneum; properly performed bacteriological examination
reveals
in most cases the presence of anaerobic germs (Clostridium perfringens,
Bacilus funduliformis alongside coliform bacteria and streptococcus.

Evolving modalities of gangrenous appendicitis:

perforation in the large peritoneal cavity, with the onset of generalized peritonitis
The peritoneal cavity contains fetid pus and gases that are expelled under pressure in
the moment of opening the cavity;
if the progression of the necrotizing process is slower (moderately virulent germs
and
good reactivity of the body), the small intestine near the cecum and the large
the omentum must block the inflammatory process, causing localized peritonitis
(circumscribed, blocked), initially by slightly stable adhesions, then taking
form
of the appendicular skeleton;
purulent transformation of the central area of the chest with the formation of an abscess
appendicular; spontaneous amputation of the appendix with its loss can occur.

4
TABLOU CLINIC
It depends on the age of the patient (young child, adult, elderly), on the anatomical position of
the appendix (retrocecal, subhepatic, mesocecal, pelvic) and the anatomoclinical form
(plastron, abscess formed, purulent or septic diffuse peritonitis, shape
pseudotumoral.
The classic clinical table (appendix in normal position) presents:

a) Symptoms:
1. Abdominal pain = major symptom that changes character over time
the time since the onset of the condition: initially it has a colicky character and is located in
epigastric and periumbilical, agitating the patient, so that after 4-6 hours it localizes in
right iliac fossa and become continuous, forcing the patient to avoid
any
movements. The initial pseudo-obstructive character thus gives way to a peritoneal pain.
2. Early established anorexia (lack of appetite).
3. Nausea and vomiting (75% of cases): follow the pain; they are reflex, irritative, initially.
food and then biliary.
4. Modification of the usual transit rhythm: constipation is especially noted (the stopping
(gaseous transit), but it can also be diarrhea.

b) Signs:
1. Fever (slight thermal rise): it is a rare phenomenon at first, not exceeding 38°C; it has
greater significance in the case of complications.
[Link] or slightly accelerated pulse.
3. Antalgic attitude: attempts at deep breaths or coughing are followed by pain.
at the level of the right iliac fossa, sometimes with a tendency to immobilize the abdominal wall
then to bring the hands to the level of the painful area; a characteristic face is observed
the patient suffering and the tendency not to change position, most commonly consisting of
in a dorsal position with the right thigh flexed over the pelvis.
4. Cutaneous hyperesthesia = excessive sensitivity of the skin of the right iliac fossa to
gentle pinching of the skin between the thumb and index.
5. Rovsing's sign: gentle palpation with the open palm in the left iliac fossa and flank
The left side sometimes produces pain in the contralateral iliac fossa (due to pushing)
retrograde from the gas column in the colon to the cecal area, as well as movement
abdominal wall imprint.
6. Pain on superficial and deep palpation of the lower right abdominal quadrant,
more pronounced in the possible projection area of the affected appendix (point
McBurney's point is located at the union of the lateral 1/3 and medial 2/3 of the line that connects the iliac spine.
upper right quadrant with the umbilicus). Palpation of the epigastrium, initial site of the pain
in acute appendicitis, no further discoveries will be made after a few hours from the onset.

5
7. Signs of peritoneal irritation: initially there is noted local muscle guarding for pain relief.
in the right iliac fossa (can be gently defeated by highlighting the area of
maximum sensitivity), with a positive Blumberg maneuver (pain occurring upon decompression
sudden pain after deep palpation of the area); during evolution, a contracture may occur
true, often extending to the entire abdominal wall (certain peritoneal involvement).
8. The psoas sign (Jaworski-Lapinski maneuver): the patient lying on their back
it is requested to raise the extended right lower limb towards the zenith, while the left palm of
the explorer presses the right iliac fossa; the cecal-appendicular area is compressed
between the examiner's hand and the psoas put under tension, generating pain.
9. Abdominal auscultation finds the rarity or even disappearance of sounds related to
intestinal peristalsis.
10. Rectal touch: it may reveal a painful Douglas, the presence of a laterally localized tumor.
right or, in more advanced cases, liquid collections located in the cul-de-sac
Douglas.
11. Vaginal touch: may exclude suffering of the internal genital organs (element
important in the formulation of the differential diagnosis of acute appendicitis in women.

Classic, the local symptoms form Dieulafoy's painful triad: spontaneous pain and
provoked, localized muscle defense, skin hyperesthesia in the right iliac fossa.

6
PARACLINICAL EXPLORATIONS

1. Biochemical probe: moderate leukocytosis (10,000-18,000/mm)3), with predominance

moderate of polymorphonuclears; increase to over 20,000/mm3this is usually a sign
of the abscess or perforation of the organ.

In 20-30% of cases, the disease progresses with normal or very low leukocyte counts.
raised, which should not lead to expectation in front of a firm clinical picture!
2. Urinalysis exam: in situations where the appendix is located nearby
the ureter or the bladder may show the onset of pyuria or hematuria
discrete (useful in differential diagnosis with certain urinary disorders).
[Link] abdominal X-ray: does not provide additional information, except for
cases when pneumoperitoneum occurs following organ perforation; sometimes it
One can observe the coprolith responsible for the luminal obstruction. Important for
exclusion of intestinal occlusion (frequent differential diagnosis). In late presentations
but the patient with appendicitis may show hydroaeric levels at the level of the cecum
and
the last ileal loops.
4. Baritat enema (irrigography): it can be useful in patients with uncertain diagnosis (especially in
children); it is done with great gentleness, without prior preparation of the colon and without
external manipulations under pressure (it is known that the principle of preoperative preparation through
Enema is contraindicated in cases of acute appendicitis due to the risk of perforation.
iatrogenic with peritonitis); in acute appendicitis, the appendix is found to be not filled with Ba.
and mass effect present in the medial and inferior area of the cecum (filling defect).
5. Chest X-ray: excludes suffering from the lower right lung field.
6. Abdominal ultrasound: in trained hands, it visualizes in 86% of cases.
Inflamed appendices reduce the rate of unnecessary appendectomies to 7% and decrease
timing the intervention under 6 hours in 98% of cases. It is difficult to execute due to
possible intestinal pneumatisms.
7. The leukocyte test marked with Tc99min colloidal albumin solution: useful for children,
allowing visualization of the inflamed appendix.
8. Laparoscopy: mainly used to differentiate a gynecological condition from
an appendectomy; in the case of discovering an inflamed appendix, it is performed
laparoscopic appendectomy.

7
DIFFERENTIAL DIAGNOSIS
1. Acute mesenteric lymphadenitis (especially in children): usually follows a
infections
recent upper respiratory infections, especially of viral origin; presentation
unsystematic digestive; possible generalized lymphadenopathy and lymphocytosis
relative. Attitude = armed expectation.
2. Acute gastroenteritis (viral, salmonella, or rickettsial): diffuse abdominal pain
intense in the form of cramps, changes in the frequency and appearance of stools.
3. Male genital conditions: acute epididymitis, seminal vesiculitis, torsion of
testicle.
4. Meckel's diverticulitis: similar clinical picture, surgical sanction.
Ileocecal invagination: more frequent in individuals under 2 years old; between painful episodes there is
clinical calm; after a few hours the patient emits a mucoid bloody stool;
this
preferred reduction of intussusception through barium enema (completely contraindicated in appendicitis
sharp).
6. Regional enteritis (ileocecal Crohn's disease): presence of diarrhea and rarity of anorexia.
Nausea and vomiting guide the diagnosis.
7. Perforated peptic ulcer: simulates appendicitis especially if the content
gastroduodenal exteriorization through perforation advances through the right parietocolic sulcus
through the right iliac fossa, while the perforation is walled off by the neighboring organs;
The anamnesis and simple abdominal X-ray can help in guiding the diagnosis.
(sometimes intraoperative).
Perforated cecal neoplasm.
9. Urinary tract infections (right pyelonephritis, etc.): positive Giordano maneuver,
eventual urinary syndrome present (pyuria, pollakiuria, dysuria).
10. Right ureteral lithiasis: it can simulate a retrocecal appendix; the lithiasis is
suggested by the descending irradiation of pain (in the labia, scrotum, penis), by the presence of
of hematuria and the absence of fever and leukocytosis.
11. Primitive peritonitis (pneumococcus, gonococcus, chlamydia, etc.): high fever from the onset;
diagnostic pus by peritoneal aspiration.
[Link] conditions (acute right anexitis, ruptured Graaf follicle at ovulation,
right twisted ovarian cyst, ruptured ectopic pregnancy): complete genital examination
and very carefully directs the diagnosis.
13. Acute cholecystitis: possible confusion in the case of an appendix with an ascending course
subhepatic; surgical treatment.

8
CLINICAL FORMS
1. Appendicitis in small children (up to 3 years): history taking is practically impossible, reports
subjective of the parents, difficult and poor physical exam in the context of the agitated child who
cry; to note the marked physical asthenia, abdominal bloating, diarrhea, occurred in
the course of flu, angina, or gastroenteritis. Maximum attention to diagnoses
possible differentiations! The combination of C-reactive protein (CRP) with leukocytosis and ESR
increased allows the diagnosis of appendicitis in 96% of cases in children. The attitude of
this surgical intervention in doubtful situations.
Appendicitis in the elderly: due to weaker reactivity, the initial clinical picture is
attenuate, the illness remaining unidentified until its complication manifested through forms
pseudo-occlusive or pseudo-tumoral, leading to increased postoperative mortality;
a differential diagnosis is made with ascending colon cancer or cecal distension
with/without diastatic perforation during the course of left colon obstructive cancer;
Irigography can help in diagnosis; surgical intervention required by the evolution
the occlusive syndrome clarifies the diagnosis.
[Link] in pregnancy:in the first months of pregnancy, against the background of a clinical syndrome more
a little atypical, it can be interpreted as an ectopic pregnancy, as a threat of miscarriage or
with pyelonephritis; in the last months of pregnancy the clinical picture is even more confusing,
muscle contraction may be absent, replaced by painful uterine contraction of
the right side. Diagnostic errors are dangerous, hindering the surgical decision
savior.
4. Appendicitis with abnormal location:
retrocecal appendicitis: poor digestive symptoms and abdominal physical examination;
the lumbar region is carefully examined (palpation with the patient in the left lateral decubitus position),
excluding a perinephric phlegmon or certifying the evolution towards a plasm or abscess
consecutive to a perforation of the appendix located just subphrenic;
mesenteric appendicitis (of the promontory): the importance of rectal or vaginal examination;
the agglutination of the small intestinal loops by the inflamed appendix explains the evolution under
form of an obstructive enteral syndrome with fever from the beginning;
pelvic appendicitis: often interpreted as salpingitis, a phlegmon of the ligament
acute evolution of a sigmoid diverticulosis or a urinary condition; it
it notes the absence of abdominal symptoms, which gives way to some sufferings
bladder (dysuria, tenesmus) or rectal (pain followed by repeated purulent discharge);
painful rectal touch; in the absence of intervention, it can progress to the formation of pelvic abscesses
they can open spontaneously in the rectum, or more rarely in the vagina or urinary bladder.

5. Form with diffuse purulent peritonitis: it is the result of an appendicular inflammatory attack
often interrupted by a brief period of silence; most often raises the issue
differential diagnosis with ulcer perforation; it is recommended to initially practice
a right iliac fossa celiotomy, which in the case of excluding appendiceal pathology
(normal appendix, bilious content of the peritoneal cavity) will serve for the placement of a tube
child in Douglas. The confusion can be eliminated to the same extent in the case of a

9
 vesicular or salpingian perforations.
6. In the form of diffuse septic peritonitis: signs of general intoxication dominate a picture.
clinic where abdominal participation is modest. More common in children and adults
pulled.
7. Appendicitis in patients with AIDS / HIV infection: classical clinical picture, usual without
leukocytosis; diagnostic laparoscopy with appendectomy through this route, without increase
of morbidity or mortality.

10
EVOLUTION AND COMPLICATIONS

1. Favorable evolution (rare): remission in the presence of intestinal rest, possibly with
symptomatic treatment and associated antibiotic; however, it remains as chronic appendicitis, which
can reactivate at any time, often presenting in a more severe, complicated form.
2. Unfavorable evolution (frequent):
a) Serious general complications: septicemia (frequently with Bacillus funduliformis),
piles caused by multiple hepatic abscesses.
b) Local complications:
gangrenous appendicitis with perforation and localized or generalized peritonitis;

- localized plastic peritonitis ("appendicular plastron"): occurs 24-72 hours after onset
crises and is accompanied by pain and vomiting that later calm down, making way for
refractory constipation and anorexia; the temperature rises to 38-39°C, the pulse remains rapid,
Palpation of the tumor mass is painful, as it is poorly defined and
seeming to catch in fixation and the anterior abdominal wall; the appendicular plastron can
returns progressively (spontaneously or under antimicrobial treatment) in 2-3 weeks,
appendectomy can be performed 2-3 months later;

appendicular abscess: when the infectious signs of a mass amplify (fever

oscillating fever accompanied by chills, anorexia becomes complete, leukocytosis
grows up to around 20,000/mm3), indicate the central softening of the formation with
the formation of an abscess; in the absence of surgical drainage, it can lead to rupture
spontaneous skin abscess (more rarely in the cecum or rectum), with the appearance of a purulent discharge
and the fever is reduced; during the intervention the appendix is removed only if it is provided
spontaneously in the operator field, any maneuver performed for the purpose of discovering it being
complex and dangerous; otherwise, the appendectomy will be attempted after 6 months, when it may be
only an appendicular remnant discovered as a result of spontaneous amputation during the course of abscess formation.
the plastron (the excision of the residual appendage is mandatory, as leaving it in place can be
starting point of some new severe acute inflammatory accidents;

generalized peritonitis "in 2 stages" (peritonitis that occurs as a result of a perforation

produced by an incompletely healed appendicular inflammatory process during effort
especially after the administration of a purgative) or 'in 3 stages' (fistulization of a
appendicular abscess in the peritoneum, exceptionally rare and particularly severe.

________________________________________________________________________________________________________________
11
TREATMENT
The treatment of acute appendicitis is surgical. The use of antibiotic therapy and the pouch
Applying ice to the iliac fossa in diagnosed acute appendicitis cannot stop the progression.
for serious complications of acute peritoneal process.
The recognition of suffering in the first 48 hours of evolution must be followed by desancţiunea
emergency surgery, whether it occurs in infants, children, the elderly, or women
pregnant, the only sanction being appendectomy and drainage of the cavity
peritoneal. We can talk about an armed expectation only in situations of doubt.
diagnoses, when purgatives and evacuant enemas are prohibited until exclusion
acute appendicular pathology.
In cases of diffuse appendicular peritonitis, the operation can be delayed for a few hours for
allows the medical measures for correcting subsequent hydroelectrolytic disorders
losses of intraperitoneal fluids and in the 'third sector Randall' represented
of dilated and immobile intestinal loops.
There are still discussions regarding the approach to the appendicular plaster, going from
immediate surgical intervention until timing and medical treatment (diet,
ice pack, broad-spectrum antibiotic therapy) under continuous clinical monitoring
paraclinical; most prefer the last option described, undergoing surgery after 2-3
Monday for a "cold" appendectomy.
The surgical treatment consists of approaching the right iliac fossa through an incision.
(performed almost horizontally along the direction of the Langer skin folds), McBurney (oblique) or
Jalaguier (transrectal vertical), with the appendectomy performed in an anterograde manner
(from the top to the bottom) or retrograde with the separate ligation of the appendicular artery, possibly
with superimposed ligatures of the mesentery, or in a subserosal manner, followed by obstruction

appendicular diverticulitis in the cecal bursa (provided that

the tissue should not be very infiltrated or cartilaginous) and possibly
mesoplasty. Peritoneal drainage is required by quality
peritoneal secretion and possible bleeding. Closure
the abdominal wall is done anatomically (layer by layer) with
catgut, except for the situation of diffuse purulent peritonitis
When is monoplan suture with catgut recommended? blockage of the appendicular stump
Soft tissue and loose closure of the skin plan with sparse threads of in cecal bursitis

nylon; in these cases one can also opt for secondary suturing of the skin or even
of the wounds.

Postoperative complications:
a) Precocious:
-parietal abscess: requires immediate opening of the wound and its treatment.

Immediate

12
- Residual intra-abdominal abscess: febrile evolution, with leukocytosis and diarrhea.
accompanied by tenesmus against the background of a often painful distended abdomen; localized more
ales in the cul-de-sac Douglas (detected through rectal touch), being resolved the most
often through evacuative rectotomy; however, they can also be localized between the intestinal loops or
subphrenic, a situation in which diagnosis and treatment pose particular problems;
-Intestinal obstruction: it can be functional (possible postoperative paralytic ileus present)
until the 5th or 6th postoperative day, which is resolved by placing a suction
gastric continues and the establishment of medical measures for resuming transit, with avoidance
of an operator trauma useless) or mechanical (with initial colicky pains following
hyperperistalsis trying to overcome the obstacle, requiring celiotomy
exploratory).
c) Delayed:
fecal fistula: it is indicated by the appearance of a specific secretion at the level of the drain
due to the dehiscent wound, occurring under conditions of ligature disunion of the stump or of
decubitus lesions caused by the prolonged maintenance of a rigid drainage tube; the most
often has a benign evolution, with spontaneous closure in the absence of reintervention; lack of
spontaneous closure suggests the existence of an obstruction downstream (colon tumor)
undiagnosed preoperatively that becomes occlusive), or the presence of a pericecal abscess
due to a foreign body (usually a forgotten compress), and necessitates reintervention.

The prognosis is generally good, with the USA recording an operative mortality rate.
0.2/105in 1986.

B. CHRONIC APPENDICITIS
a set of micro- and macroscopic lesions resulting from an inflammatory process
appendicular acute of moderate intensity, which in the absence of surgical intervention has
evolve towards resolution.
It represents a latent appendicular condition that explains part of the suffering of the type
dyspeptic and can worsen at any time, most often generating a complication of
acute appendicitis (especially in children). This justifies the countless appendectomies.
execute "at the reception".

PATHOLOGICAL ANATOMY
partial or total adherence to cec
- covered by multiple membranes (Jackson) or even being intramural (located in the wall
of the eye
it can be retrocecal, ascending, renal-fixed or hepatobiliary, laterocecal external or
intern, aderent la ileon, mezenter, epiploon, sigmoid, anexă
it is often twisted, curved

________________________________________________________________________________________________________________
13
 The so-called Jackson membranes represent a membranous wave that can
completely covers the ascendant and represents the witness of an inflammatory epiploic
atrophy.
Macroscopic can be:
- thickened, vascularized, with infiltrated mesentery occupied by lymph nodes more or less
slightly bulky
- mic, sclerosis, filiform, with stenosis areas or uniform caliber, with thickened meso.
When it is very small, it can be a witness to a previous acute crisis that has
spontaneous amputation of the organ
In some cases, however, the external appearance may be normal, only the examination
histopathological being the one that confirms the lesion
- in the case of discovering a giant appendix, either very long (20-25 cm), or
very voluminous, it is spoken of as a mega appendix.

The histopathological examination is most often dominated by atrophic processes affecting

mucosa, submucosa, and muscular. Appendicular lesions may be associated with lesions of
neighborhood, especially cecal diseases (typhlitis, ileitis) and epiploitis, but also distantly affected
the liver and the urinary system. Following the inflammation of the lymphatic appendage, it is also described
retractile mezenteritis that can induce distant suffering such as periduodenitis with
chronic duodenal subvascular stage. Thus, consecutively to the lymphatic spread of the suffering.
appendiceal inflammations are explained by the classic and frequent 'flirt' between the appendix and the ovary.

CLINIC
Symptom
intermittent or continuous spontaneous right iliac pain occurring every 5-6 hours
postprandial
aggravated by effort or digestion, accompanied by various digestive disturbances (indigestion with
food poisoning
states of fatigue or persistent chronic asthenia.
Physical examination:
Rovsing sign present
pain caused by deep palpation at the level of the appendicular points (the point
McBurney = the union of 1/3 lateral and 2/3 medial of the spinal-umbilical line, the point
Morris = the union of 2/3 lateral with 1/3 medial of the same line, the Lanz point = the union of 1/3
killed with 2/3 left of the bipinous line
triangular painful zone of Jacobovicidin in the right iliac fossa
the absence of defense and contracture is noted, allowing for the palpation of a sensitive mass of
stanza.

PARACLINICAL EXPLORATIONS

Blood formula: leukocytosis with mononucleosis.

14
2. Radiographic/graphic examinations = monitoring of a barium transit from the stomach to the cecum, with
the detection of the following radiological arguments:
the stopping of the baritated column at the lower knee of the duodenum (periduodenitis)
secondary)
prolonged ileal stasis
palpation under the area of the cecoappendicular zone with pain production
easy injection of the appendix with contrast material 5-6 hours after ingestion (test
Czeppa).

TREATMENT

It consists of the 'cold' appendectomy, which is especially supported in children, taking into account
smaller surgical risk, almost spectacular consecutive improvement of some
digestive sufferings that seem serious and difficult to treat at first glance, as well as definitive removal
the risk of developing acute appendicitis with all its complications. In
the case of the adult should be approached with more caution, only after elimination
preliminary to the suffering of neighboring organs, taking into account possible accidents
postoperative (risk/benefit ratio) between pulmonary embolism and bridge occlusion.

III. APPENDICEAL TUMORS

They are rare.

CLASSIFICATION:

A. Benign tumors:
1. Inflammatory pseudotumors (fibroblastic appendicitis).
2. Appendicular endometriosis.
B. Benign tumors with malignant potential:
Appendiceal carcinoid.
2. Villous appendiceal tumor (papillary or adenomatous).
Benign appendiceal mucocele.
C. Malignant tumors:
Appendiceal adenocarcinoma.
2. Appendicular sarcomas (fibroblastoma, lymphocytoma, lymphoblastoma).
3. Malignant appendiceal mucocoele (pseudomyxoma).

I. APPENDICEAL CARCINOID (ARGENTAFIN)

the most common appendicular tumor (90% of appendicular tumors), the appendix
being the most common localization for carcinoid (75-90% of carcinoids).

15
It is more commonly found on the female, being located in most cases (70%) towards the tip.
of the organ, which gives it the particular appearance of a "drumstick"; the maximum incidence is
the 4-5 years of life.

The origin of the tumor is in the Kulchitsky cells located at the bottom of the Lieberkühn glands;
The habit is small, firm in consistency, well-defined, and yellow-brown in color.
composed of cells that exhibit fine argentaffin, sideraffin or chromaffin granulations.
In the case of appendicular localization, malignancy is only rarely found (2.9% of cases),
the tumoral secretion of 5-HO-tryptamine is rarely sufficient to develop
the carcinoid syndrome revealing characteristics of metastatic ileal carcinoid manifested by
"flash" facial
Hypertension
paroxysmal tachycardia
diarrhea.
The preoperative diagnosis is exceptional, the symptoms being attributed to a
acute appendicitis. From a therapeutic point of view, appendectomy is sufficient.
except in cases with basal appendicular localization, when hemicolectomy is required
right.

II. APPENDICULAR ADENOCARCINOMA

This is similar macro- and microscopically to colon adenocarcinoma. It is diagnosed

usually intraoperative, evolving asymptomatically for a long time; it can sometimes be discovered
irrigographic (lacunary image, stenosis). The treatment consists of right hemicolectomy.
(in case of suspected degeneration due to a simple hardened area or of
the presence of adenopathies in the appendicular mesentery necessitates an enlarged appendectomy
the complete elevation of the entire appendicular mesentery with the interested lymph nodes, with
the epiploon eventually adherent and with the cecal bottom, followed by re-intervention for performing
right hemicolectomy in the case of neoplastic invasion detected during examination
histopathological; hemicolectomy can be performed from the outset if the tumor is
evidence or if the extemporaneous histopathological examination affirms it.

III. APPENDICULAR MUCOCELE

unique or multiple cystic dilatation of the appendix, which has a mucoid content.

There are two histopathological types:

mucocelbenign: consists of the intraluminal accumulation of mucus secreted by the cells

caliciform from the appendicular wall upstream of an obstruction, usually aseptic,
the lumen of the organ; as it increases in volume, the tumor may become palpable,
deforming the check, a demonstrable irrigographic aspect; treatment = appendectomy;
- mucinous malignancy (1 case out of 9): in fact, it is a grade of mucous papillary adenocarcinoma.
________________________________________________________________________________________________________________
16
The mucus now contains mucous cells that can disseminate spontaneously or consecutively.
therapeutic manipulations in the peritoneal cavity, causing the appearance of pseudo-
peritoneal mixoma ("gelatinous disease of the peritoneum").

17
The treatment of malignant mucocele consists of appendectomy (in localized forms) or
in right hemicolectomy (in situations with cecum or invaded ileum), with extraction as much as possible
possible efficiency of the gelatinous substance in the case of peritoneal pseudomyxoma and
intraperitoneal injection of trypsin as prophylaxis for gelatinous recurrences.
There can be synchronous presence of mucinous ovarian and appendiceal tumors, a situation
which is treated by appendectomy, bilateral oophorectomy (in case of involvement
bilateral ovaries) and hysterectomy.

________________________________________________________________________________________________________________
18
IV. PARTICULAR APPENDICULAR CONDITIONS
Appendiceal diverticulum.
Appendicular intussusception.
[Link] torsion.
They are rare.

________________________________________________________________________________________________________________
19