APPENDIX

ACUTE APPENDICITIS

Incidence:

- rare in infants, increasingly common in childhood and early adult life, peak incidence in
the teens and early 20s.
- before puberty males = females.
- In teenagers and young adults the male–female ratio 3:2
- Thereafter, the greater incidence in males declines.
 Aetiology
No definite cause
1-Decreased dietary fibre and increased consumption of refined carbohydrates (low fiber diet)
2-Bacterial proliferation within the appendix,
no single organism is responsible(mixed growth of aerobic and anaerobic organisms ).
3- Obstruction of the appendix lumen
- Lymphoid hyperplasia
- faecolith (composed of inspissated faecal material,
calcium phosphates, bacteria and epithelial debris
- stricture
- foreign body(rare)
- tumour, particularly carcinoma of the caecum(middle age and elderly)
- Intestinal parasites, particularly Oxyuris vermicularis
 Pathology
- Lymphoid hyperplasia narrows the lumen luminal obstruction.
- Continued mucus secretion and inflammatory exudation increase intraluminal pressure
obstructing lymphatic drainageOedema
- Mucosal ulceration
- Bacterial translocation to the submucosa.
Resolution may occur (spontaneously/antibiotic therapy).
or
Condition progresses,more distension venous obstruction & wall ischaemia
bacterial invasion through the muscularis propria and submucosa, producing
acute appendicitis.
Ischaemic necrosis  gangrenous appendicitisfree bacterial contamination of
the peritoneal cavity(peritonitis).
• Alternatively, the greater omentum and loops of small bowel become adherent to the
inflamed appendix, walling off the spread of peritoneal contamination, and resulting in a
phlegmonous mass or paracaecal abscess.

Rarely, appendiceal inflammation resolves, leaving a distended mucus-filled

organ termed a ‘mucocoele’ of the appendix .
Diffuse peritonitis is the great threat of acute appendicitis, it ocuurs as a result of:
- free migration of bacteria through an ischaemic appendicular wall
- frank perforation of a gangrenous appendix
- delayed perforation of an appendix abscess.

Factors that promote this process include:

- extremes of age
- immunosuppression
- diabetes mellitus
- faecolith obstruction of the appendix lumen
- free-lying pelvic appendix
- previous abdominal surgery

In these situations, a rapidly deteriorating clinical course is accompanied by signs of diffuse peritonitis and systemic
sepsis syndrome.
 CLINICAL DIAGNOSIS
History
PAIN
-poorly localised, colicky abdominal pain(midgut visceral discomfort in response to appendiceal
inflammation and obstruction).
-The pain in periumbilical region.
- Central abdominal pain + anorexia, nausea and usually one or two episodes of vomiting that follow the
onset of pain.
With progressive inflammation of the appendix:
Shifting of pain: from central abdominal pain to right iliac fossa(irritation of RIF parietal peritoneum) visceral
to somatic pain which is :
- more intense
- constant
- localised to right iliac fossa

Typically, coughing or sudden movement exacerbates the right iliac fossa pain.
ANOREXIA
-constant clinical feature, particularly in children.
Family history
1/3 of children with appendicitis have a first-degree relative with a similar history .
One half of acute appendicitis classic visceral–somatic sequence of pain .

Signs
Temperature and pulse rate:
- After 6 hours, slight pyrexia (37.2–37.7°C) with a corresponding increase in the pulse rate to 80 or 90
is usual.
-Changes of greater magnitude may indicate complications.
- Unwell patient with low-grade pyrexia
- Inspection of the abdomen limitation of respiratory movement in the lower abdomen.
- localised abdominal tenderness maximum at McBurney’s point.
- Muscle guarding
- Rebound tenderness

Asking the patient to cough or gentle percussion over the site of maximum tenderness will elicit
rebound tenderness .
- Pointing sign: The patient is asked to point to where the pain began and where it moved .
- Rovsing’s sign: Deep palpation of the left iliac fossa may cause pain
in the right iliac fossa.
- Psoas sign : passive extension of hip or active flexion of hip against
resistance pain. The patient will lie with the right hip flexed for
pain relief .
- Obturator sign : hip flexion and internal rotation cause pain in the
hypogastrium (the obturator test).
-Cutaneous hyperaesthesia may be demonstrable
in the right iliac fossa
Two clinical syndromes of acute appendicitis:
1- acute catarrhal (non-obstructive) appendicitis
2- acute obstructive appendicitis:
-more acute course(abrupt)
-generalised abdominal pain from the start.
- Temperature normal
- vomiting common.
Special features, according to position of the appendix

1-Retrocaecal appendicitis
- Rigidity is often absent
- Application of deep pressure may fail to elicit
tenderness (silent appendix)
-Deep tenderness is often present in the loin, and
rigidity of the quadratus lumborum.
-Psoas spasm leading to flexion of the hip joint.
Hyperextension of the hip joint may induce abdominal
pain (Psoas sign +ve).
2-Pelvic appendicitis
- More common in children
- Early diarrhoea (inflamed appendix in contact with the rectum).
- Complete absence of abdominal rigidity
- Tenderness over McBurney’s point is also lacking.
- Deep tenderness can be made out just above and to the right of the symphysis pubis.
- Rectal examination reveals tenderness in the rectovesical pouch or the pouch of Douglas, especially on
the right
side.
- +ve psoas and obturator signs.
- Frequency of micturition (inflamed appendix in contact with the bladder).
3-Postileal appendicitis
The inflamed appendix lies behind the terminal
Ileum(difficult to diagnose)
- Pain may not shift
- Diarrhea is a feature
- Marked retching
- Tenderness, if any, is ill defined, although it may be
present immediately to the right of the umbilicus.
SPECIAL FEATURES, ACCORDING TO AGE
Infants
- Rare in infants under 36 months of age.
- The patient is unable to give a history. Diagnosis is
often delayed.
- Higher incidence of perforation and postoperative
morbidity than older children.
- Diffuse peritonitis can develop rapidly because of the
underdeveloped greater omentum.
Children
- Vomiting is more common.
The elderly
- Gangrene and perforation occur much more frequently .
- The abdominal clinical picture is not obvious even in the presence of gangrenous appendicitis (lax abdominal walls or obesity)
- Clinical picture may simulate subacute intestinal obstruction.
- Higher mortality
(coincident medical conditions plus the previous factors)

The obese
- Obesity can obscure and diminish all the local signs of acute
appendicitis.
- Midline abdominal incision
(Delay in diagnosis + technical difficulty of operating in the obese)
- Laparoscopy is particularly useful in the obese.
Pregnancy
Appendicitis is the most common extrauterine acute abdominal condition in pregnancy.
- Delay in presentation (early non-specific symptoms are often attributed to the pregnancy).
- The physiologic leukocytosis of pregnancy (high as 16,000 cells/mm3).
Obstetric teaching has been that the caecum and appendix are progressively pushed to the right upper
quadrant of the abdomen as pregnancy develops during the second and
third trimesters.
- Pain in the right lower quadrant of the abdomen remains the cardinal feature of appendicitis in
pregnancy.
- Fetal loss occurs in 3–5 per cent of cases, increasing to 20 per cent if perforation is found at
operation.
Adult female
pelvic disease in women of childbearing age most often mimics acute appendicitis.
A careful gynaecological history should be taken in all women with suspected appendicitis,
concentrating on:
- menstrual cycle
- vaginal discharge
- possible pregnancy .
The most common diagnostic mimics are
pelvic inflammatory disease (PID), Mittelschmerz, torsion or haemorrhage of an ovarian cyst and
ectopic pregnancy.
1-Pelvic inflammatory disease
(salpingitis, endometritis and tubo-ovarian sepsis)
- The pain is lower than in appendicitis and is bilateral.
- history of vaginal discharge, dysmenorrhoea and dysurea .
- vaginal examination  adnexal and cervical tenderness .
- High vaginal swab & culture Chlamydia trachomatis and Neisseria gonorrhoeae.
- gynaecologist opinion should be obtained.
- Transvaginal ultrasound
- diagnostic laparoscopy
2- Mittelschmerz
Midcycle rupture of a follicular cyst with bleeding produces lower abdominal and pelvic
pain, typically midcycle.
- No systemic upset
- Pregnancy test is negative
- Symptoms usually subside within hours.
Occasionally, diagnostic laparoscopy is required. Retrograde menstruation may cause
similar symptoms.
3- Torsion/haemorrhage of an ovarian cyst
(difficult differential diagnosis)
pelvic ultrasound and a gynaecological opinion should be sought.
If encountered at operation untwisting of the involved adnexa and ovarian cystectomy
should be performed.
4- Ectopic pregnancy
- Ectopic preg.  signs of haemoperitoneum
-right-sided tubal abortion or
right-sided unruptured tubal pregnancy.

Right-sided unruptured tubal pregnancy :

- pain commences on the right side and stays there.
- pain is severe.
- history of a missed menstrual period
- Signs of intraperitoneal bleeding with referred pain in the shoulder.
- cervical excitation test positive
- urinary pregnancy test may be positive.
- Pelvic ultrasonography.
Elderly
1- Diverticulitis
Abdominal CT scanning is particularly useful and should be considered in the management of
all patients over the age of 60 years.
Right-sided diverticulitis is unusual and may be clinically indistinguishable from appendicitis.
2-Intestinal obstruction

In elderly, occasionally, it may be difficult to differentiate IO from acute appendicitis

3-Carcinoma of the caecum

-Carcinoma of the caecum when obstructed or locally perforated, may mimic or cause
obstructive appendicitis in adults.
-history of antecedent discomfort, altered bowel habit or unexplained anaemia.
- mass may be palpable and an abdominal CT scan
diagnostic.
Rare differential diagnoses
1-Preherpetic pain of the right 10th and 11th dorsal nerves.
- no shift of pain
- marked hyperaesthesia.
- no intestinal upset, no rigidity.
The herpetic eruption may be delayed for 3–8 hours.

2-Tabetic crises.
3-Spinal conditions include tuberculosis of the spine, metastatic carcinoma,
osteoporotic vertebral collapse and multiple myeloma.
4-porphyria and diabetes mellitus
5-Typhlitis or leukaemic ileocaecal syndrome
Investigation
The diagnosis of acute appendicitis is essentially clinical
• Routine
Full blood count WBC > 10,000
Urinalysis hematuria/ pyuria due to irritation of nearby ureter/ urinary bladder
• Selective
Pregnancy test
Urea and electrolytes
Supine abdominal radiograph
Ultrasound of the abdomen/pelvis
Contrast-enhanced abdomen and pelvic computed tomography scan
ALVARADO SCORE
Alvarado score:
A score of 7 or more is strongly predictive of acute appendicitis
- Equivocal score (5–6)abdominal ultrasound or contrast-enhanced CT examination .
Abdominal ultrasound is useful in:
- children and thin adults
- if gynaecological pathology is suspected, with a diagnostic accuracy >90 %.
Contrast-enhanced CT scan is most useful in:
- diagnostic uncertainty+older patients
- acute diverticulitis, intestinal obstruction and neoplasm suspected.
Treatment
The traditional treatment for acute appendicitis is appendicectomy.

Some research the conservative management in non-obstructive appendicitis including :

1- bowel rest(NPO)
2- intravenous antibiotics, usually metranidazole and third-generation cephalosporin
conservative management  80-90% successful, 15 recurrence within one year.
patients over the age of 40 should be followed up to ensure there is no underlying malignancy
 Appendicectomy:
- no unnecessary delay
- short period of intensive preoperative preparation:
1- NPO
2- Intravenous fluids
(catheterisation is needed only in the very ill)
3- IV antibiotics
In the absence of purulent peritonitis give single preoperative dose of antibiotics .
When peritonitis is suspected, therapeutic intravenous antibiotics to cover Gram negative bacilli,
as well as anaerobic cocci, should be given.
 Appendicectomy
- general anaesthetic
- patient supine on the operating table.
- When a laparoscopic technique is to be used, the bladder must be empty

(ensure that the patient has voided before leaving the ward).
palpated for a mass prior to preparing the entire abdomen with an antiseptic solution.(mass  conservative)
Draping of the abdomen
Incisions used:
1- The gridiron incision(most common)
2- Rutherford Morison incision(muscle cutting)
3- Transverse skin crease (Lanz) incision
4- lower midline abdominal incision( doubtful diagnosis)
1-The caecum is identified by the presence of taeniae coli and is
withdrawn.
2- Appendix may be felt at the base
of the caecum.
3- Inflammatory adhesions must be gently broken with a finger, the
appendix delivered into the wound.
4- Mesoappendix devided between ligature, the base of appendix
ligated and divided.
5- Purse-string to invaginates the stump of the appendix(?????)
Laparoscopic appendicectomy
Laparoscopy is diagnostic tool(esp. in female) and therapeutic.
Used more in:
• Female (child bearing age)
• in obese patients
• early pregnancy
Advantages:
• less postoperative pain
• Early discharge from hospital
• Early return to daily activities
 PROBLEMS ENCOUNTERED DURING
APPENDICECTOMY

1-A normal appendix is found

- exclude other possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis and tubal or
ovarian causes in women.
- remove the appendix (avoid future diagnostic difficulties)
2-The appendix cannot be found.
The caecum should be mobilised, and the taeniae coli should be traced to their confluence on the
caecum before the diagnosis of ‘absent appendix’ is made.
3-An appendicular tumour is found.
Small tumours (under 2.0 cm in diameter) can be removed by appendicectomy.
Larger: right hemicolectomy
4- An appendix abscess is found and the appendix cannot be removed easily.
Preoperatively diagnosed abscessPercutaneous drainage of the abscess and intravenous
antibiotic .
At operationdraine the abscess +intravenous antibiotics.
Frankly necrotic appendix(very rarely)  caecectomy or partial right hemicolectomy .
 Appendix abscess
Failure of resolution of an appendix mass or continued spiking pyrexia usually indicates that
there is pus within the phlegmonous appendix mass.
Treatment :
Ultrasound or abdominal CT scan percutaneous drain.
If unsuccessful  laparotomy through a midline incision is indicated.
Pelvic abscess
- an occasional complication of acute appendicitis.
- Presented with spiking pyrexia several days after appendicitis

- Pelvic pressure or discomfort

- loose stool or tenesmus is common.
- Rectal examination  mass in the pelvis.

Pelvic ultrasound or CT scan confirm.

Treatment:
- Radiologically guided percutaneous drainage
- Transrectal drainage under general anaesthetic.
 POSTOPERATIVE COMPLICATIONS

1- Wound infection
most common postoperative complication
usually presents with pain and erythema of the wound on
the 4th or 5th postoperative day.

Treatment: wound drainage + antibiotics.

2- Intra-abdominal abscess
presented with spiking fever, malaise and anorexia developing 5–7 days after operation .
Sites of collection:
Interloop, paracolic, pelvic and subphrenic

Abdominal ultrasonography and CT scanning diagnostic and allow percutaneous drainage.

Laparotomy in intra-abdominal sepsis without localised collection.
3- slipped ligature
internal bleeding, hypotension, tacchycardia reoperate
4- Ileus
Ileus persisting for more than 4 or 5 days + fevercontinuing intra-abdominal sepsis investigation.
5- Respiratory
- rare
- Adequate postoperative analgesia and physiotherapy reduce the incidence.
6- Venous thrombosis and embolism
- rare after appendicectomy
- more in elderly and in women taking the oral contraceptive pill and prophylactic measures should
be considered.
7- Portal pyaemia (pylephlebitis)
- rare
- complication of gangrenous appendicitis
- high fever, rigors and jaundice.
- caused by septicaemia in the portal venous system  intrahepatic abscesses (multiple).
Treatment: systemic antibiotics + percutaneous drainage of hepatic abscesses.
screen for underlying thrombophilia
8- Faecal fistula
- Rare
- leakage from appendicular stump.
- More in appendicectomy in Crohn’s disease.
Treatment: Conservative management with low-residue enteral nutrition.
9- Adhesive intestinal obstruction
This is the most common late complication of appendicectomy.
 MANAGEMENT OF AN APPENDIX MASS
Conservative Ochsner–Sherren regimen;
A nonoperative programme but to be prepared to operate should clinical deterioration occur . This
includes:
Careful recording of the patient’s condition
1- Temperature and pulse rate should be recorded 4-hourly
2- Fluid balance record
3- The abdomen regularly reexamined.
4- The extent of the mass should be made (mark the limits of the mass on the abdominal wall using a
skin pencil)
5- A contrast-enhanced CT examination of the abdomen
6- Antibiotic
7- An abscess, if present, should be drained radiologically.
Criteria for stopping conservative treatment of an
appendix mass
_ A rising pulse rate
_ Increasing or spreading abdominal pain
_ Increasing size of the mass

Clinical deterioration or evidence of peritonitis is an indication for early laparotomy.

If the mass resolve, Patients over the age of 40 should have colonoscopy and follow-up imaging to
ensure resolution and exclude appendicular or colonic malignancy.
 Recurrent acute appendicitis
- not uncommon
- attacks vary in intensity and may occur every few months.
- majority of cases ends in severe acute appendicitis.
The appendix in these cases shows fibrosis indicative of previous inflammation.
Neoplasms of the appendix
 1-Carcinoid tumours
- arise in argentaffin tissue (Kulchitsky cells of the crypts of
Lieberkühn)
- most common in the vermiform appendix.
- appendix removed because of symptoms of subacute or
recurrent appendicitis.
-frequently in the distal third of the
appendix.
-moderately hard , yellow tumour
-the intact mucosa .
-Microscopicallycharacteristic
pattern using immunohistochemical
stain for chromogranin B .
-rarely gives rise to metastases.
Treatment:
- Appendectomy .
- Right hemicolectomy is indicated if:
- caecal wall involvement .
- 2 or more in size.
- Involved lymph nodes.

2- Goblet cell carcinoid tumour

3- Primary adenocarcinoma of the appendix
extremely rare, presented as appendicitis
treated by right hemicolectomy
Mucinous cystadenoma
- A mucin-secreting adenoma of the appendix
- rupture into the peritoneal cavity , seeding it with mucus secreting cells.
- delayed presentation with gross abdominal distension as a result of pseudomyxoma peritoneii, which may
mimic ascites .
Treatment
radical resection of all involved parietal peritoneal
surfaces and aggressive intraperitoneal chemotherapy.
Thank you