APPENCICITIS
A REVIEW BY
DR. MH LAIQUE
HOUSE OFFICER
PIMS
ANATOMY OF APPENDIX
• It is a blind muscular tube with mucosal, submucosal, muscular and serosal
layers. Morphologically, it is the undeveloped distal end of the large caecum
found in many lower animals.
• At birth, the appendix is short and broad at its junction with the caecum
• but differential growth of the caecum produces the typical tubular structure
by about the age of 2 years
• The position of the base of the appendix is constant, being found at the
confluence of the three taeniae coli of the caecum,
Anatomy
Blood supply of appendix
The appendix
receives blood
from the
appendicular
artery, which is
a branch of the
ileocolic artery
Position of APPENDIX
• During childhood, continued growth of the caecum commonly rotates
the appendix into a retrocecal but intraperitoneal position
• In approximately one-quarter of cases, rotation of the appendix does
not occur, resulting in a pelvic, subcaecal or paracaecal position
• Occasionally, the tip of the appendix becomes extraperitoneal, lying
behind the caecum or ascending colon
Acute Appendicitis
• “Acute appendicitis is acute inflammation and infection of the
vermiform appendix”
• The incidence of appendicitis seems to have risen greatly with up
to 16% of the population undergoing appendicectomy
• Acute appendicitis is relatively rare in infants and becomes
increasingly common in childhood and early adult life, reaching
a peak incidence in the teens and early 20s
ETIOLOGY OF ACUTE APPENDICITIS
• No unifying hypothesis regarding the etiology of acute appendicitis.
• Decreased dietary fiber and increased consumption of refined
carbohydrates may be important
• While appendicitis is clearly associated with bacterial proliferation within
the appendix, no single organism is responsible. A mixed growth of
aerobic and anaerobic organisms is usual.
• Obstruction of the appendix lumen has been widely held to be important
PATHOLOGY
• “Obstruction of the appendiceal lumen seems to be essential for the
development of appendiceal gangrene and perforation”.
• However, in many cases of early appendicitis, the appendix lumen is
patent despite the presence of mucosal inflammation and lymphoid
hyperplasia.
• Lymphoid hyperplasia narrows the lumen of the appendix, leading to
luminal obstruction. Once obstruction occurs, continued mucus
secretion and inflammatory exudation increase intraluminal pressure,
obstructing lymphatic drainage. Oedema and mucosal ulceration
develop with bacterial translocation to the submucosa
• Resolution may occur at this point either spontaneously or in
response to antibiotic therapy.
• If the condition progresses, further distension of the appendix
may cause venous obstruction and ischemia of the appendix
wall.
• With ischemia , bacterial invasion occurs through the muscularis
propria and submucosa, producing acute appendicitis
• Finally, ischemic necrosis of the appendix wall produces
gangrenous appendicitis, with free bacterial contamination of the
peritoneal cavity
• Alternatively, the greater momentum 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 para-cecal abscess.
Clinical diagnosis
• The classical features of acute appendicitis begin with poorly localized
colicky abdominal pain The pain is frequently first noticed in the
periumbilical region.
• Central abdominal pain is associated with anorexia, nausea and usually
one or two episodes of vomiting that follow the onset of pain .
• Anorexia is a useful and constant clinical feature
Symptoms of appendicitis
• Periumbilical colic
• Pain shifting to the right iliac fossa
• Anorexia
• Nausea
Clinical signs in appendicitis
• Pyrexia
• Localized tenderness in the right iliac fossa
• Muscle guarding
• Rebound tenderness
Signs to elicit in appendicitis
• Pointing sign
• Rovsing’s sign
• Psoas sign
• Obturator sign
Differential Diagnosis:
Investigations
• The diagnosis of acute
appendicitis is essentially
clinical
A number of clinical and
laboratory-based scoring
systems have been devised
to assist diagnosis. The
most widely used is the
Alvarado score
INTERPRETATION:
• A score of 7 or more is strongly predictive of acute appendicitis.
• In patients with an equivocal score (5–6), abdominal ultrasound or contrast-enhanced
CT examination further reduces the rate of negative appendicectomy.
• Abdominal ultrasound examination is more useful in children and thin adults,
particularly if gynaecological pathology is suspected, with a diagnostic accuracy in
excess of 90%
Preoperative investigations in
appendicitis:
Routine:
• Full blood count Urinalysis
• Selective Pregnancy test
• Urea and electrolytes Supine abdominal radiograph
• Ultrasound of the abdomen/pelvis
• Contrast-enhanced abdomen and pelvic computed tomography scan
• Consider low-dose protocol in young
TREATMENT:
NON-OPERATIVE MANAGEMENT:
• “ surgery remains the standard teaching”
• A trial of conservative management in patients with uncomplicated (absence of
appendicolith, perforation or abscess) appendicitis must be done.
• Treatment is bowel rest and intravenous antibiotics, often metronidazole and 3rd
generation cephalosprin.
approximately one-quarter of patients initially treated conservatively will require
surgery within 1 year for recurrent appendicitis
• Subsequent surgery, if needed, tends to be uncomplicate
OPERATIVE MANAGEMENT:
• traditional treatment for acute appendicitis is appendicectomy .
• Treatment include intravenous fluids, sufficient to establish adequate urine output
(catheterization is needed only in the very ill), and appropriate antibiotics should be given.
• There is ample evidence that in the absence of purulent peritonitis, a single preoperative
dose of antibiotics reduces the incidence of postoperative wound infection.
• When peritonitis is suspected, therapeutic intravenous antibiotics to cover gram-negative
bacilli as well as anaerobic cocci should be given.
PROCEDURE OF CONVENTIONAL
APPENDECTOMY:
INCISIONs:
• The incision that is widely used for appendicectomy is the so-called gridiron incision The gridiron incision
(described first by McArthur) is made at right angles to a line joining the anterior superior iliac spine to the
umbilicus, its center being along the line at McBurney’s point .
• a transverse skin crease (Lanz) incision has become more popular, as the exposure is better and
extension, when needed, is easier. is made approximately 2 cm below the umbilicus centered on the
midclavicular–mid-inguinal line
• When the diagnosis is in doubt, particularly in the presence of intestinal obstruction, a lower midline
abdominal incision is to be preferred over a right lower paramedian incision
• Rutherford Morison’s incision is useful if the appendix is para- or retrocecal and fixed
PROCEDURE:
• Incise the aponeurosis of external oblique along the line of fibers.
• The external oblique and transverse oblique are spread apart by
scissors.
• These muscles are held apart by two Richardson retractors.
• The peritonium is divided obliquely.
• Mobilize the cecum and deliver it into the wound
• Identify the appendix by dollowing the tania coli
• Identify mesoappendix then clamp and divide the mesoappendix
along with the appendicular artery after ligating it.
• Crush the base of appendix for few minutes then tied,
• Hemostasis is secured and peritonium is closed
• External oblique aponeurosis is closed using vicryl , akin closed .
Postoperative complications
• Wound infection
• Intra-abdominal abscess
• Ileus
• Faecal fistula
• Portal pyaemia (pylephlebitis)
•
Adhesive intestinal obstruction
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