‫بسم الله الرحمن‬

‫الرحيم‬

APPENDICITIS
[Link] farah
Lecturer at HAU ,SKYU ,CU ,AAIUand FU

14/9/2019
 FORMAT
• Definition
• A historical perspective
• Epidemiology
• Aetiology
• Classification
• Pathophysiology
• Clinical presentation
• Differential Diagnosis
• Work up
• Treatment
• Complications
 DEFINITION
• Appendicitis refers to inflammation
of the vermix appendix

• Appendicitis is one of the most

common causes of acute abdomen
worldwide
 SURGICAL ANATOMY
• The appendix
is a blind
ended tube
connected to
the caecum,
from which it
develops
embryological
ly
 Size and location
• The appendix averages 10 cm in
length but can range from 2 to 20 cm
• The diameter of the appendix is
usually between 7 and 8 mm
• The appendix is located in the lower
right quadrant of the abdomen (RIF)
• Its position within the abdomen
corresponds to a point on the surface
known as McBurney's point, which
lies two thirds of the way along a line
drawn from the umbilicus to the
anterior superior iliac spine
• While the base of the appendix is at
a fairly constant location the location
of the tip of the appendix can vary
 Positions of the appendix
• Retro-caecal (75%)
• Para-caecal (1%)
• Sub-caecal (1.5%)
• Pre-ileal (1%)
• Post-ileal (0.1%)
• Pelvic (21%)
 Blood supply
• Arterial supply
– Appendicular artery which is a branch of
ileo-colic artery, enters the
mesoappendix a short distance from the
base of the appendix
• Venous drainage
– Appendicular vein  ileocolic vein 
superior mesenteric vein  portal
veinous drainage
 A HISTORICAL PERSPECTIVE
• First described by Reginald Fitz
in 1886 who also was the first to
advocate appendicectomy as the
cure

• In 1889 Charles McBurney

described the clinical findings of
acute appendicitis including the
point of maximum tenderness in
RIF which bears his name
 EPIDEMIOLOGY
• Incidence:
– The incidence is higher in developed
countries and in developing countries
which are adopting a more refined
western type diet
– Incidence of appendicitis is lower in
cultures with a higher intake of dietary
fiber
 EPIDEMIOLOGY [cont’d]
• Mortality/Morbidity:
– The overall mortality rate of 0.2-0.8% is
attributable to complications of the disease
rather than to surgical intervention
– Mortality rate rises above 20% in patients older
than 70 years, primarily because of diagnostic
and therapeutic delay
– Perforation rate is higher among patients
younger than 18 years and patients older than
50 years, possibly because of delays in
diagnosis
– Appendiceal perforation is associated with an
increase in morbidity and mortality rates
 EPIDEMIOLOGY [cont’d]
• Sex:
– The incidence of appendicitis is
approximately 1.4 times greater in men
than in women

– The incidence of primary appendectomy

is approximately equal in both sexes
 EPIDEMIOLOGY [cont’d]
• Age:
– Appendicitis may occur at all ages, but is
most commonly seen in the 2nd and 3rd
decades of life
– The incidence of appendicitis gradually
rises from birth, peaks in the late teen
years, and gradually declines in the
geriatric years
– Although rare, neonatal and even
prenatal appendicitis have been
reported in literature
– The emergency physician must maintain
 AETIOLOGY
• Etiological factors for appendicitis
include:-
– Appendiceal luminal obstruction
– Diet
– Social status
– Familial susceptibility
 Appendiceal luminal obstruction
• Luminal causes
– Feacolith
– Lymphoid follicle hyperplasia
– Worms e.g. ascaris
– Foreign body
• In the wall
– Stricture
– Neoplasms
• Outside the wall
– Adhesions
– kinks
 Diet
• Low intake of dietary fiber is
associated with increased incidence
of appendicitis
• Dietary fiber is thought to decrease
the viscosity of feces, decrease bowel
transit time, and discourage
formation of fecaliths that
predispose individuals to
obstructions of the appendiceal
lumen
 Familial tendency
• Appendicitis tends to run in
certain families may be due to
peculiar position of the organ
which predisposes to infection
 CLASSIFICATION
• Clinical classification
• Pathological classification
 Clinical classification
• Acute appendicitis
• Subacute appendicitis
• Recurrent appendicitis
• Chronic appendicitis
 Pathological classification
• Obstructive appendicitis
• Non-obstructive appendicitis
 PATHOPHYSIOLOGY

• Two types:-
– Obstructive appendictis
– Non-obstructive appendicitis
 Obstructive appendicitis
• Luminal obstruction and mucus
production result in increased
intraluminal pressure
• Bacteria trapped within the appendiceal
lumen begin to multiply, and the
appendix becomes distended
• Luminal distention stimulates visceral
nerve endings concerned with pain
[visceral pain]
• This produce dull aching pain felt
periumbilically according to nerve supply
of the appendix (T10)  referred pain
• Venous congestion and edema follow next,
and by 12 hours after onset, the
 Obstructive appendicitis[ cont]

• Peritoneal irritation then develops

• If the obstruction is left untreated,
arterial blood flow to the appendix
is compromised, and this leads to
tissue ischemia and necrosis
• This stimulates parietal nerve
endings shift of pain to the RIF
• Full thickness necrosis of the
appendiceal wall leads to
perforation with the release of
 Obstructive appendicitis [cont]
• Depending on the duration of the
disease process, either a localized
walled-off abscess or mass occurs, or
if the pathologic process has
advanced rapidly, the perforation is
free in the peritoneal cavity and
generalized peritonitis occurs
• The commonest bacterial growth
from inflamed appendices include
Escherichia coli, Kleblesiella spp.,
Proteus spp and Bacteroids
 Non-obstructive appendicitis
• This is less dangerous type
• Inflammation commences in the mucous
membrane or in the lymphoid follicles and
gradually spread to the submucosa
• As there is no obstruction there is not much
distension, but when the serosa is involved
localizing peritonitis develops and the patient
c/o RIF pain
• Such inflammation terminates either by:-
– Suppuration
– Gangrene
– Fibrosis
– Resolution
• Many of the sub-acute appendicitis, recurrent
appendicitis and chronic appendicitis develop
 CLINICAL PRESENTATION
• History: classic symptoms include:-
– Periumbilical pain [visceral pain] which
shifts and localize to the RIF [parietal
or somatic pain]
– Periumbilical pain is colicky in nature
in obstructive type and is dull aching
and constant in non-obstructive type
– RIF pain is sharp intense and well
localized to the RIF
– Anorexia- 92%
– Nausea & Vomiting- 78%
• particularly difficult to diagnose in the extremes of
age and in pregnancy .
• In pregnant women, the pain localizes
to the area of the appendix, which
rises as the pregnancy progresses.
• The pain is typically described as
crampy or gassy and may be confused
with that of indigestion .
 CLINICAL PRESENTATION [cont’d]
• Physical examination
– Pyrexia-is present in only 21% of patients
– RIF tenderness
– Muscle guarding
– Rebound tenderness-in the RLQ due to local
peritonitis
– Special test to elicit in appendicitis
• Pointing sign ,hamburgers sign –no need
feeding
• Rovsing’s sign [RIF pain with palpation of
the LIF ]
• Psoas sign [RIF tenderness with internal
rotation of the flexed right hip while pts lying
left side ]
 DIFFERENTIAL DIAGNOSIS
• Abdominal disorders
• Gynecological disorders
• Retroperitoneal disorders
• Thoracic disorders
• Others
 Abdominal disorders
• Acute cholecytitis
• Perforated peptic ulcers
• Entecolitis
• Intestinal obstruction
• Carcinoma caecum
• Crohn’s diseases
• Amoebic colitis
• Meckel’s diverticulitis
• Acute pancreatitis
 Gynecological disorders
• PID
• Ectopic pregnancy ®
• Twisted ovarian cyst ®
• Ruptured ovarian follicles ®
 Retroperitoneal disorders
• Right ureteric colic
• Right sided acute pyelonephritis
• Right sided testicular torsion
• Retroperitoneal haematoma
 Thoracic disorders
• Basal pneumonia
• Pleurisy
 Miscellaneous
• Henoch-Schoenlein purpura
• Porphyria
• Diabetic abdomen
 WORK UP
• Lab investigations
– Complete blood cell count
• Leucocytosis- typically in the 10,000– 16,000/mm3
range
• Neutrophilia greater than 75%
– C-reactive protein test
– Urinalysis – some RBCs as a result of ureteral
irritation.
 WORK UP [cont’d]
• Imaging investigations
– Abdominal radiography
• The kidneys-ureters-bladder (KUB) view is
typically used
• Visualization of an appendicolith in a
patient with symptoms consistent with
appendicitis is highly suggestive of
appendicitis, but this occurs in fewer than
10% of cases
• The consensus in the literature is that plain
radiographs are insensitive, nonspecific,
and is not cost-effective
 has a sensitivity of 75%–89% and a specificity of 86%–100%
when performed by an experienced sonographer
 WORK UP [cont’d]
• Abdominal Ultrasonography
– An outer diameter of greater than 6
mm, noncompressibility, lack of
peristalsis, or periappendiceal fluid
collection characterizes an inflamed
appendix
– The normal appendix is not
visualized
– It’s noninvasive, short acquisition
time, lack of radiation exposure,
and potential for diagnosis of other
causes of abdominal pain,
particularly in the subset of women
 WORK UP [cont’d]
• Computed tomography
– Abdominal CT has become the most important
imaging study in the evaluation of patients with
atypical presentations of appendicitis
– Advantages of CT scanning include
• Sensitivity and accuracy compared with
those of other imaging techniques
• Readily available
• Noninvasive
• potential to reveal alternative diagnoses
– Disadvantages
• lengthy acquisition time if oral contrast is
used
• patient discomfort if rectal contrast is used
• Exposure to radiation
 DIAGNOSTIC SCORING SYSTEM
• Various scoring systems have been devised
to aid diagnosis of appendicitis
• Although many diagnostic scores have been
advocated, most are complex and difficult to
implement in the clinical situation
• The Alvarado score, is a simple scoring
system that can be instituted easily
• The Classic Alvarado score [1986] is based
on three symptoms, three signs and two
laboratory findings and has a total score of
10
 Classic Alvarado Score [1986]
Features Score
Symptoms
• Migratory RIF pain
1
• Anorexia
1
• Nausea & vomiting 1
Signs
• Pyrexia
1
• Tenderness RIF
1
• Rebound tenderness RIF
2
Lab investigations
• Leucocytosis
2
• left shift of neutrophil maturation
1
 Diagnostic Scoring System [cont]
• Kalan et al [1994] omitted one lab
parameter [left shift of neutrophil
maturation] which is not routinely
available in many laboratories, and
produced a modified score which
have only one lab findings
• A modified Alvarado score [1994] is
based on three symptoms, three
signs and one laboratory findings
[total score of 9]
• MAS is commonly used
 Modified Alvarado Score [1994]
Features Score
Symptoms
Migratory RIF pain
Anorexia 1
Nausea & vomiting 1
1

Signs
Pyrexia
Tenderness RIF 1
Rebound tenderness RIF 1
2
Lab investigation 2
leucocytosis

Total 9
 MASS- interpretation
• A score of 1-4:[ discharging group]
The diagnosis of acute appendicitis
is unlikely
• A score of 5-6: [observing group]
Probable to have appendicitis but
not convincing to have urgent
appendicectomy
• A score of 7-9:[emergency group]
Regarded as probable to have
acute appendicitis and needs
 TREATMENT
• The treatment of appendicitis is
appendicectomy
• Appendicectomy can be elective,
emergency or interval
• Two types of appendicectomy:-
– Conventional open appendicectomy
– Laparoscopic appendicectomy
 Preoperative care
• Iv fluid
• Analgesics
• Preoperative antibiotics with
broad spectrum antibiotics
• Check Hb, blood grouping and
crossmatching
• Shaving
• Written informed consent
• Pre-anaesthetic visit
• preoperative antibiotics (eg amoxicillin +
gentamicin + metronidazole) infective
complication
 Intraoperative care
• Open appendicectomy
– Incisions
• Grid-iron sss
• Rurtherford Morrison’s
• Lanz’s [transverse skin crease]
• SUMI when the diagnosis is not clear
• Rt lower paramedian
• Midline incision
 Intraoperative care cont’d
• Appendiceal locations of the tip
– Retrocaecal appendix [74%]
– Pelvic appendix [21%]- the tip hangs in the
pelvic brim
– Subcaecal appendix [1.5%]
– Splenic appendix [0.5-1%]- either pre- or post-
ileal i.e anterior or posterior to the terminal ileum
– Paracaecal appendix [2%]
– Paracolic appendix [1%]-either to the right or
left of ascending colon, the tip in the
extraperitoneal tissue
• Location of the base-is constant, being
found at confluence of 3 taeniae coli of the
cecum which fuse to form the outer
Open appendicectomy
 Laparoscopic appendicectomy
• External view
Internal view
Removed appendix
 Post operative care
• Iv fluids
• Analgesics
• Antibiotics
• Monitor-
• Vital signs
• Discharge home in 2-3 days
postoperatively
 COMPLICATIONS
• Complications of acute
appendicitis
• Postoperative complications
 i. Complications of acute appendicitis

• Appendicular mass
• Appendicular abscess
• Recurrent appendicitis
• Perforation peritonitis
 Treatment of complications

• Appendicular abscess
• Appendicular mass
• Peritonitis
• Recurrent appendicitis
 [Link] mass

• Use conservative Ochsner-Sherren

regime
– Iv fluid
– NGT
– Analgesics
– Antibiotics –parenteral
– Mark the limits of the mass on the
abdominal wall using a skin pencil
– Monitor- vital sign, size of the mass,
input/output chart
– Clinical improvement is expected in
 Appendicular mass [cont]

• Criteria for stoping OSR

– Increased pulse rate
– Increasing or spreading abdominal
pain
– Increasing the size of the mass
– Vomiting or increasing gastric
contents
 [Link] Abscess
• I&D
• Antibiotics
 [Link] appendicitis
• Elective appendicectomy
 [Link] complications
• Wound infections
• Intrabdominal abscess
• Paralytic ileus
• Feacal fistula
• Adhesive intestinal obstruction
• Portal pyaemia due to septicemia in the
portal venous system
• Respiratory complications
• DVT-embolism
• RIH due to damage to iliohypogastric /
ilioinguinal nerves
• Incisional hernia