APPENDICITIS

Dr.sigid djuniawan, spB

Anatomy and physiology of
appendix
The appendix is a slender, worm-shaped
pouch, averaging 5—10cm in length, that
protrudes from the top of the colon in the
lower right abdomen
 Location
• McBurney’s point:one-third of the way
from the anterior,superior iliac spine to the
umbilicus.
• Pelvis and right ilac fossa appendix
• Anterior or posterior ileum appendix
• Retrocaceal appendix
• Right lateral caceal appendix
Retrocaceal appendix
 Supply & nerve
• Appendix artery: a final artery ,from
ileocolic artery
• Appendix vein : portal vein

• sympathetic nerve :celiac plexus and

lesser splanchnic nerve T10,T11
 Acute appendicitis
Appendicitis is a
common cause
of abdominal
pain

life-threatening condition because of systemic

sepsis (systemic inflammatory response
syndrome/SIRS leading to multiple organ failure)
following rupture and abscess formation
 Etiology

• Obstruction:
anatomy :wormed-shaped
narrow
plenty of lymph glands
mechanical reason:
food residue, ascarid,
tumor,etc.
 Etiology
• Gastrointestial disease

• Bacteria invasion:
all kinds of G- bacilus
 Pathology
Four type:
• Acute simple appendicitis
• Acute purulent appendicitis
• Perforation and gangrenous
• Appendiceal abscess
Acute simple appendicitis
Acute purulent appendicitis
Perforation and gangrenous
Gangrenous

Perforation
Appendiceal abscess
 Results
• Inflammation disappear
• Inflammation localization
• Inflammation diffusion
 Clinical manifestation
symptoms :
• abdominal pain :
Periumbilical or epigastric pain that
migrates to right lower quadrant
Pain becomes persistent and well
localized. It worsens with moving,
breathing deeply, coughing, sneezing,
walking, or being touched
 Symptoms :
• Gastrointestinal symptoms:
Anorexia, nausea, and vomiting
occur after the onset of pain
Constipation
Diarrhea
bladder and rectum stimulus
symptoms
 Symptoms
• General symptoms :
tired ,headach
fever
Rapid pulse
• SIRS (systemic inflammatory response
syndrome)
 Signs
• Tenderness in the right lower abdomen,
usually about a third of the distance from
the navel to the top of the hip bone
peritoneal irritation sign : muscular rigidity
Blumberg sign
bowel sounds disappear
 Others
• Rovsing’s sign:pain in the right lower
quadrant upon palpation of the left
lower quadrant.
• Psoas sign :pain on active elevation of
the legs
• The obturator sign: pain on internal
and external rotation of the hip
• Rectal exam & vaginal exam
 Lab test
• Mild to moderately elevated WBC with
left shift is typical but rarely may be
normal, range of 11000-17000/mm3
over 20000/ mm3 perforation
• UA may show ketonuria or a few RBCs
or WBCs
• pregnancy test (women only)
 Lab test
• B-us
• X-ray
• Diagnostic abdominal puncture
 Diagnosis
• Periumbilical or epigastric pain
that migrates to right lower
quadrant
• Tenderness in the right lower
abdomen, usually about a third of
the distance from the navel to the
top of the hip bone
 Differential diagnosis
Two type :
A: required surgery
B: not required surgery
 Differential diagnosis
Required surgery:
• Perforation of gastointestinal tract
ulcer,tumor, diverticulitis
• obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsion
• Meckel diverticulitis
• Tumor
 Differential diagnosis
Not required surgery
• Pelvic inflammation
• Mesenteric adenitis:at exploration a
normal appendix and enlarged lymph
nodes in the mesentery
• Viral & bacterial gastroenteritis
• Pneumonia, pleurisy
 Treatment
• Early operation:
surgical removal(appendectomy)
• Acute simple appendicitis: appendectomy
• Acute purulent and gangrenous
appendicitis:
appendectomy and/or drainage
 Treatment
Appendiceal abscess:
• if local in right low quadrant
antibiotic therapy and general treatment
• if infection diffusion
incision and drainage
 Treatment
Operation
• Incision :
incision over the point of maximal
tenderness,generally at McBurny point
true McBurney’s incision
tansvers skin incision
3—6cm long
 Incision

• McBurney’s
incision
 Incision

• tansvers
skin
incision
 Treatment
Operation
• Process:
The taenia of
the colon are
followed to the
base of the
appendix
 Treatment
Operation
• Process:
Mesoappendix is
divided
between
clamps and
ligated
 Treatment

Operation
• Process:
The base of
appendix is
divided and
ligated 0.5cm from
caceum and
inverted using a
purse-string
a

b c
 Treatment
• Suspected case: not definite.
Admit the patient to hospital for further
observation 12-24hrs
Operation
exploration incision
 Treatment
Antibiotic thearpy:
• Acute simple appendicitis
• Contraindication of operation
• Appendiceal abscess
 Treatment
Antibiotic thearpy
antibiotics: broadspectrum antibiotics
ampicillin-sulbactam
gentamycin triad drugs
metronidazol
3rd generation cefotides
 Treatment
• New method :
laparoscopy appendectomy
 Complication
Acute appendicitis:
• Abdomen abscess
• Inter or extra fistula
• Phylephlebitis
 Complication
Operation :
• Incision infection
• Peritonitis and abdomen abscess
• Bleeding
• Stool fistula
• Stump infection
• Adhesive intestinal obstruction
 Appendicitis in neonate
• Seldom
• Non-specific clinical manifestation
Anorexia, nausea, and vomiting diarrhea
dehydration
• Difficult in early diagnosis
• High rate of perforation
• High mortality
 Appendicitis in neonate
Diagnosis &Treatment
• Carefully physical exam

• Early operation
 Appendicitis in child
• Quick onset and severe
high fever and vomiting present early
• Non-typical tenderness at right low
quadrant
• High rate of perforation
• High mortality
• More complication
 Appendicitis in child
Treatment:
• Early operation
• Transfusion and correct dehydration
• Broadspectrum antibiotics
 Appendicitis in pregnancy
Uterus enlargement

appendix displaced Without

elevation of
superiorly adherent
abdominal
blanket of
wall
omentum
Tenderness
site upper shift Inconspicuous of
tenderness
rebound tenderness Peritonitis
muscular rigidity diffusion
 Appendicitis in pregnancy
Treatment :
• Operation :appendectomy
• To late pregancy :early operation
• Superior Incision
• No drainage
• Broadspectrum antibiotics
• Parturient with perforation :
cesarean section and appendectomy
 Appendictis in the elderly
• Less well-defined symptoms and signs
• Severe pathologic type
• Error diagnosis easily
• High rate of perforation
• Pay attention to tumor
 Chronic appendicitis
• Etiology and pathology
• Clinic feature and diagnosis
right low quadrant pain
local tenderness
x-ray
• Treat
appendectomy