Dr.

EHAB TOTAH

DEFINITION
Sudden inflammation of the
appendix usually
caused by obstruction of the
lumen

Epidemiology
. Accounts for 2% of all hospital admissions
. 7-12% of population
. M>F
. The incidence of appendectomy appears to
be declining due to more accurate
preoperative diagnosis.
. Despite newer imaging techniques, acute
appendicitis can be very difficult to
diagnose.
. Age mainly affecting the adolescence age
group

Surgical anatomy
Origin 2.5 cm below ileocecal valve from
postero medial aspect of cecum
Taenia coli coalesce
Length usually 5-10 cm (1-25cm)
Blood supply appendiceal artery (end artery) ileocolic SMA
.The appendix has an immunological function
particularly IgA secretion.

SURGYCAL ANATOMY-POSITION

Pathophysiology
.Acute appendicitis is thought to begin
with obstruction of the lumen
Obstruction can result from:
Submucosal lymphoid hyperplasia
Faecolith / faecal stasis
Inspissated barium
Vegetable/fruit seeds
Worms (Entrobius vermicularis
Tumors of cecum/appendix

Pathophysiology
. Mucosal secretions continue to increase

intraluminal pressure
. Eventually the pressure exceeds
capillary perfusion pressure and
. venous and lymphatic drainage are
obstructed.
. With vascular compromise , epithelial
mucosa breaks down and bacterial
invasion by bowel flora occurs.

Pathophysiology
.Increased pressure also leads to arterial stasis
and tissue infarction
.End result is perforation and spillage of infected
appendiceal contents into the peritoneum
.Initial luminal distention triggers visceral
afferent pain fibers, which enter at the 10th
thoracic vertebral level.
.This pain is generally vague and poorly localized.
.Pain is typically felt in the periumbilical or
epigastric area.

Pathophysiology
.As inflammation continues, the serosa and
adjacent structures become inflamed
.This triggers somatic pain fibers,
innervating the peritoneal structures.
.Typically causing pain in the RLQ
.The change in stimulation form visceral to
somatic pain fibers explains the classic
migration of pain in the periumbilical
area to the RLQ seen with acute
appendicitis.

Pathophysiology
.Exceptions exist in the classic presentation due to
anatomic variability of the appendix position .
.Appendix can be retrocecal causing the pain to
localize to the right flank
.In pregnancy, the appendix can be shifted and patients
can present with RUQ pain.
In some males, retroileal appendicitis can irritate the
ureter and cause testicular pain.
.Pelvic appendix may irritate the bladder or rectum
causing suprapubic pain, pain with urination, or
feeling the need to defecate
.Multiple anatomic variations explain the difficulty in
diagnosing appendicitis

Clinical Features - Symptoms

Typical periumbilical/epigastric pain
that shifts to RIF (50%).
Afebrile/low grade fever (high in perf.)
Anorexia
Nausea
Constipation/Diarrhea
RIF tenderness Guarding
Percussion tenderness (rebound)
Tachycardia

Clinical Features Special Signs

McBurneys Point: just below the middle of a
line connecting the umbilicus and the ASIS
Rebound tenderness sign: Pain upon sudden
release of pressure over the McBurneys Point
Rovsings

LLQ

Psoass

sign: pain in RLQ with palpation to

Sign :place patient in L lateral decubitus

and extend R leg at the hip. If there is pain with

sign is positive this movement, then the
Obturator

test :passively flex the RT hip and

knee and internally rotate the hip. If there is

increased pain then the sign is positive

Pointing sign

Differential diagnosis
GIT
Gastroenteritis
Mesenteric adenitis
-Meckles diverticulitis
-Terminal ileitis
Acute typhlitis
Ca Cecum

Differential diagnosis
Gynae
Salpingitis
Ectopic gestation
Rt. Ovarian torsion
Ruptured ovarian follicle .

Urinary tract
Renal colic
Pyelonephritis
Testicular torsion

Investigations
CBC: the WBC is of limited value.
Sensitivity of an elevated WBC is 7090%, but
specificity is very low.
UA: abnormal UA results are found
in 19-40%
Abnormalities include: pyuria,
hematuria, bacteruria

Investigation
.Imaging studies: include X-rays,
US, CT
.X-rays of abd. are abnormal in
24-95%
.Abnormal findings include:
fecalith, appendiceal gas, localized
paralytic ileus, and free air

Abdominal X-ray

Ultrasound finding
.Thickened wall >3
mm
.Diameter >6 or 7
mm
Noncompressible
Appendolith
Free fluid
Abscess

CT finding:
variable degree of distension (diameter 640mm)
wall thickness of 13 mm.
periappendiceal inflammatory mass
Thickening and enhancement with
intravenous contrast - adjacent wall of the
cecum or ileum

CT finding:

Scoring system:)Alvarado Score)

Feature

Score

Abdominal pain that migrates to the

RIF
Anorexia

Nausea/vomiting

Tenderness in RIF

Rebound tenderness

Temperature > 37.3

WBC >10,000/L

Left shift

Special populations:
.Very young, very old, pregnant,
and HIV patients present
atypically and often have
delayed diagnosis
.High index of suspicion is
needed in the these groups to
get an accurate diagnosis

Diagnosis
.Acute appendicitis should be
suspected in anyone with epigastric,
periumbilical, right flank, or right
sided abd pain who has not had an
appendectomy.

Treatment
.Appendectomy is the standard of
Care.
.Patients should
be NPO, given IVF,
)
and preoperative antibiotics .
.Antibiotics are most effective when
given preoperatively and they
decrease post-op .infections and
abscess formation

Post op:
1.IV fluids till oral fluids are
tolerated
2. Antiemetic
3.Analgesia
4.Early ambulation
5. Home once oral diet tolerated

complications:
.Death is rare

Perforated appendix - ~30%

complication rate
Wound infection +/-dehiscence
Intra-abdominal abscess
Cecal fistulas

 Small bowel obstruction

(adhesions) (esp. after perf.)
Ileus
Stump appendicitis (ass with
long appendiceal stump)

Follow up:
Most are discharged within 48hrs

Normal activities within few weeks

(earlier for
LA)
Routine outpatient review is not
common
practice
1% have appendiceal tumors carcinoid
Tumors >1cm consider rt
hemicolectomy

Thank you