Appendicitis
Objective
History
Anatomy & Anomaly
Acute Appendicitis(Causes, Pathology, C/F, Inv & M/n)
D/D of Acute Appendicitis
Appendicular Lump & malignancy ( Carcinoid tumor)
Appendectomy & Complications
History
In 1492,Leonardo da Vinci first depicted the appendix in
anatomic drawings
In 1521, Jacopo Beregari da Capri, a professor of anatomy in
Bologna, identified the appendix as an anatomic structure.
In 1710, Phillipe Verheyen coined the term appendix
vermiformis.
The first recorded successful appendectomy was in 1735 by
Claudius Amyand
Kurt Semm, ( German gynecologist) did first laparoscopic
appendectomy on May 30, 1980.
Anatomy
Position of the Appendix
Position of Appendix
Position Incidence
Retrocecal 74% Commonest postion
Pelvic 21% 2nd Commonest position
Pre-ileal 1%
Post- ileal 0.5%
Paracaecal 2%
1.5%
Promontoric( Subileal
/subcaecal)
In Situs Inversus Viscerum: Appendix in LIF
Size of the Appendix
Range : 2- 20 cm
Average: 11 cm
Diameter: 7-8 mm
The longest appendix measured
26cm, Safranco August (Croatia)
Zagreb, Croatia, on 26 August 2006.
Anatomy:
Origin – Postero-medial wall of the caecum
( 2 cm below the ileocaecal orifice)
Appendicular orifice: Guarded by an
indistinct semilunar fold of mucous
membrane k/as Valve of Gerlach.
Mesoappendix: peritoneum – lower
surface of the mesentery of the terminal
ileum.
Colon and teniae
coli.
Tenia libera: red.
Tenia mesocolica:
blue.
Tenia omentalis:
green.
Appendicular Artery- Lower Division of
Ileo-colic artery
Appendicular artery in mesoappendix
Thrombosis of Appendicular
artery(as it is an end artery) -
Gangrenous appendicitis
Venous Drainage & Nerve Supply
Appendicular Vein
Ileocolic vein Portal Vein
Superior Mesenteric vein
Sympathetic Nerves- Derived 4m T9-T10
( Celiac Plexus)
Para Sympathetic Nerves- Vagus
Lymphatic & KULTSCHITZSKY Cells
8-15 lymphatic vessels - mesoappendix
Ileocolic Node ( Sup & Inf group)
Ileocolic Nodes SMN Celiac
nodes
In the base of the crypts lie argentaffin cells
(Kultschitzsky cells) which may give rise to
carcinoid tumours .
The submucosa contains numerous
lymphatic aggregations or follicles.
Wallbridge Anomaly: A,B1,B2,C
Wallbridge Anomaly
1. Type A anomaly. Single cecum and a partial
duplication of the appendix with a single base.
2. Type B1 anomaly. Two completely separate
appendices arise from a single cecum.
3. Type B2 anomaly. The second appendix is
usually found arising from the taenia coli of the
wall of the cecum.
4. Type C anomaly. Double cecum, each with
its own appendix,
In the study of clinical cases of
appendectomy, there was a doubling in only
two cases per 50,000 studies (0.004%). The
first case described in 1892, and nowadays
only one hundred such anomalies have been
reported.
Several authors have presented
classifications to describe anatomical
variations. The first classification was
developed by Cave, supplemented in 1962 by
Wallbridge.
In addition, a variation of the horseshoe-
shaped appendix has been described. And
even the patient has three vermiform
processes (Tinckler L.F., "Triple appendix
vermiformis - a unique case", 1968).
In 1966 G. Mauzels described a case of
appendicitis in a child whose second process
was not verified. After 5 months, the need for
a second appendectomy arose, as
inflammation developed in the second
appendix.
So, with a very low probability, a patient with
a history of appendectomy may have a second
appendicitis!
Jose Roberto Alves, PubMed, Appendicitis in double cecal appendix:
case report, aug 2014.
White arrow: distal ileum, black arrow - process with slight
inflammation. The green arrow indicates a pronounced inflamed
vermiform appendix.
Predisposing Factors:Appendicitis
Age: 20-30 years( peack incidence in early
20s)
Socio-economic condition: High profile( Low
fibre)
Lymphoid hyperplasia of the appendix
Fibrosis of the appendix cos of previous
damage
Causes of appendicitis:
Obstructive causes- faecolith or stricture
Bacterial proliferation : mixed growth commonest is
streptococci & [Link].
Intestinal parasites – Oxyuris Vermicularis(pin worm)
Tumour( C-r of the Caecum) in elderly & middle age.
Fibrotic stricture of the appendix
Composition of Faecolith:
Bacteria
Calcium phosphate
Epithelial Debris
Inspissated fecal material
Foreign bodies ( Rarely)
Pathology: Obstructive & Non obstructive
Obstructive- Primarily
- Acute appendicitis
- Gangrenous appendicitis
- Phlegmonous mass/paracaecal abscess
- Mucocele of the appendix
- Rupture of appendix
Obstruction:
Mucus + Inflammatory exudation
Increases intraluminal P Obstructing
lymphatic drainage
Edema+ [Link]+ Bacterial
Translocation to the submuosa.
Venous obstruction( cos of further distension)
Ischemia Bacterial Invasion Acute
Append.
Inflamed Appendix
Perforation- If Fever > 38°С(102°F)
& WBC> 18,000
If Ischemia continue
Necrosis of the appendicular wall
Gangrenous appendicitis
Perforation with free bacterial
contamination of the peritoneal cavity
Gangrenous appendix.
Phlegmonous Mass/Paracaecal abscess
Greater omentum & loops of small bowel
become adherent to the inflamed appendix
Walling off the spread of peritoneal
contamination
Phlegmonous Mass / Paracaecal abscess
Phlegmonous appendicitis
Appendicular inflammation-resolves-
distended mucus filled organ-
Mucocele of appendix
Peritonitis ??? If perforation??
Extreme of Age
Immunosuppression
Diabetes Mellitus
Faecolith obstruction
Pelvic appendix
Previous Abdominal surgery
C/F- Symptoms
PAIN: Initially Periumbilical region ( midgut
visceral discomfort) in response to A.I &
obstruction.
:Pain shift to right iliac fossa(RIF) :
Parietal peritoneum irritated and
inflamed.
ANOREXIA
NAUSEA/VOMITTING
Clinical Sign
Pyrexia: Low grade after 6 hours
Tenderness (localized) in the RIF
Muscle guarding
Rebound Tenderness/ BLUMBERG’S Sign
Foul breath.
Tachycardia: Perforation, Gangrene & Peritonitis
Sign to elicit in Appendicitis
Rovsing’s Sign
Psoas Sign
Obturator Sign:
Obturator Sign
Dunphy’s Sign: Any movement
( Coughing) causes Pain.
Hyperesthesia in Sherren’s
Localized tenderness at Mc
Burney’s Point
Mc Burney’s Point -Tenderness
Investigation:
TLC- Raised: 10000 to 18000 ( Neutrophils
>75%). If TLC >18000 perforation.
Abdominal X-Ray: exclude other pathologies.
USG: Especially if clinical Dx is equivocal.
CT: Especially in Adult patient with equivocal
history , physical examination & lab findings.
Pregnancy test: In reproductive age group
ALVARADO SCORING SYSTEM
SYMPTOMS SCORE
Migratory RIF Pain 1
Anorexia 1
Nausea/Vomiting 1
SIGN
Tenderness in RIF 2
Rebound tenderness in RIF 1
Elevated Temperature 1
Laboratory Findings
Leucocytosis 2
Shift to the left of neutrophils 1
Total 10
Interpretation of ALVARADO Score.
Aggregate 7-10 Strongly
s score predictive
of
Appendicit
is
Aggregates 5-6 Equivocal CT &
score USG
helpful in
making Dx.
Aggregates 1-4 Appendiciti
score s can be
ruled out
Treatment of Acute Appendicitis
Absolute bed rest & NPO
IV Fluids Supplements.
Analgesics
Antibiotics
Appendectomy ( within 24 hours ASAP)
Indications of Appendectomy
Acute Appendicitis
Recurrent Appendicitis
Mucocele of Appendix
Carcinoma confined to the mucosa.
Incision in Appendectomy.
Gridiron and Lanz incisions : Muscle-
splitting incisions .They differ in the
orientation of the skin incision alone.
BIKNI INCISION: Modified Lanze incision
slightly lower
Rutherford Morison : The gridiron incision
can be more readily extended laterally into an
oblique, curvilinear muscle-cutting incision:
Grid Iron
Lanze Incision
Modified Lanze
Gridiron/ Lanze & Modified Lanze:
Muscles splitting & Cut the Peritoneum
Follow the taneia coli to reach up to the
appendix
Appendicular artery in the Mesoappendix
Identified the base of the appendix
to Ligate
Ligate the base of the
appendix.
After crushing the base, cut the appendix
Invaginating the stump
Z-Suture to invaginate the stump
Buried Appendicular stump
Remember the steps in Appendectomy
Pre-Op( NPO, Shaving, consent, PAC, Draping)
Incision- Gridiron(McBurney), Rutherford
Incision, Bikney Incision
Follow the taenia coli to find the appendix
Ligate the Appendicular artery in mesoappendix
Crush the base of the appendix
Appendectomy
Ligate the base of the appendix( absorbable
suture)
Appendix is divided distal to the ligature.
Clean the stump with betadine or simple spirt
Take purse string around the caecal wall to buried
the stump.
Close the wound in layers.
Complication of Appendectomy
Wound Infection
Intra-abdominal abscess
Ileus
Respiratory complication like pneumonia
DVT & Embolism
Portal Pyemia
Adhesive Intestinal Obstruction
Fecal Fistula
Ritcher’s Hernia
Appendicular
Lump(Periappendicular infiltrate)
Appendicular Lump- on 3rd day.
Appendix
Edematous Caecum
Terminal Ileum
Omentum ( Greater Omentum)
Loop of Intestine
Ascending Colon
Adjacent Peritoneum
Presentation of Appendicular Lump
Usually on 3rd day of attack of appendicitis.
Lump in RIF
Rigidity over the lump
Tenderness
Fever/ Increase pulse.
Appendicular Lump- Don’t Operate
Severe adhesion/ Difficult to separate the
part.
Bloody and dangerous to operate
Chance of Fecal fistula
Max chance of iatrogenic injury
OCHSNER- SHERREN REGIMEN.
Ist mark the size of the swelling for further
assessment
NPO & IV Fluid supplements
Antibiotics, Analgesics
Temp, Pulse( 4 hourly) & Fluid record
charting .
Allow oral liquid on subsequent days.
OCHSNER- SHERREN REGIMEN
If more vomiting- antiemetic &/+ PPI
If size of the lump decreases – continue the
same.
After 6-8 weeks = Interval Appendectomy
Prognosis: 90% success rate for this regimen.
Failure to this regimen: suspect Crohn’s &
Cancer????
When to stop conservative t/t in
Lump
CRITERIA FOR STOPPAGE OF CONSERVATIVE
TREATMENT IN APPEDICULAR LUMP
RISING PULSE RATE
RISING TEMPERATURE
INCREASING or SPREADING ABDOMINAL PAIN
INCREASING SIZE OF MASS
VOMITING or COPIOUS GASTRIC ASPIRATE
D/D of Appendicular Lump
Hypertrophic Ileo- caecal Tuberculosis
Carcinoma of the Caecum
Crohn’s Disease
Actinomycosis
Twisted ovarian cyst in female
Right sided iliac lymphadenitis
Parametritis
Appendicular Malignancy
Mucinous Adenocarcinoma - MC neoplasm of 38%
appendix
Adenocarcinoma 26%
Carcinoid Tumour 17%
Goblet Cell Carcinoma 15%
Signet – ring cell carcinoma 4%
Carcinoid tumor of Appendix
Neuroendocrine tumor
Origin- Argentaffin cells ( KULCHITSKY
Cells of crypts of Lieberkuhn)
Contains sustentacular cells that express S-
100
distal third i.e tip of the appendix
T/T 4 Carcinoid tumor of Appendix
TOC- Appendectomy
Right hemicolectomy is indicated when-
- Tumor is > 2 cm in size.
- Involves the base of the appendix.
- Involves the caecal wall or mesoappendix.
- Lymph nodes are involved.
D/D of Acute Appendicitis:
In Adult In Female
Terminal Ileitis Ruptured Ectopic Pregnancy
Ureteric colic Torsion/Rupture of an Ovarian
cyst
Right sided pyelonephritis Salpingitis( Right sided)
Perforated peptic ulcer Endometriosis
Torsion of Testes Mittelschmerz ( Painful
Ovulation)
Acute Pancreatitis
Rectus Sheath Hematoma
D/D of Acute Appendicitis:
In Children In Elderly
Gastroenteritis Sigmoid diverticulitis
Meckele’s Diverticultitis Intestinal obstruction
Intussusception Carcinoma of the caecum
Lobar Pneumonia
Henoch- shchonlein Purpura
Mesenteric adenitits
Home Message
Appendicitis is common surgical emergency
in 20-30 years age group
Commonest cause is Faecolith
Pain in RIF, N/V, Anorexia with findings of
Tenderness in RIF, increase temp &
Leucocytosis usually confirm the Dx
Appendectomy should be performed ASAP
Home Message
Ochsner- sherren regimen is the gold standard
t/t for Appendicular lump
Interval Appendectomy after 4-6 weeks is the
preferred Surgical steps in Appendicular Lump
Commonest site 4 Carcinoid tumor is the tip of
the Appendix
Appendectomy is the TOC for Carcinoid tumor of
appendix
Thank you!