ACUTE

APPENDICITIS
Presented By:
Zeeshan Mahmood 20100
Vinay Kumar Singh 20094
Vijay Mandloi 20093
Yasho Vardhan Mishra 20097
SURGICAL ANATOMY

 It is 8–10 cm long, may vary from 3 to 30 cm in length.

 It is situated 2 cm posteromedial to ileocaecal junction,
at the point of convergence of the three taeniae coli.
 It is the primary cause of lower abdominal pain on the
right side.
 Positions of the Appendix
 Retrocaecal
 Pelvic
 Preileal And Postileal
 Subcaecal
 Paracaecal
 Subhepatic Appendix
LAYERS OF APPENDIX

 Mesoappendix is the continuation of mesentery of the ileum

above. It comes down carrying blood vessels in the
mesoappendix.
 Appendix has a serosa and a mucosa lined by columnar
epithelium (similar to intestinal mucosa) between which are
the circular and longitudinal muscle fibers.
 Submucosa has rich lymphoid follicles (lamina propria). The
lymphatic tissue decreases as age advances. Hence,
incidence of appendicitis is less after the age of 30 years.
 Appendicular orifice is occasionally guarded by an indistinct
semilunar fold of mucous membrane, known as valve of
Gerlach.
BLOOD SUPPLY

 Appendicular artery is a branch of ileocolic

artery.
 Accessory appendicular artery of
Seshachalam (a branch of posterior caecal
artery) is a branch of ileocolic artery, which
runs in the mesoappendix
LOCATION AND ITS SIGNIFICANCE

 Surgical Anatomy and Significance

 1. The area of the maximum tenderness in acute
appendicitis is called McBurney’s point—corresponds
to the site of appendix in vast majority of the cases. This
is the site selected for incision in open method.
 2. Appendicular artery must be ligated in open or
laparoscopic method—to free mesoappendix.
 3. Severe inflammation of the appendix can spread to
portal vein via ileocolic vein and can result in portal
pyemia, a very dangerous condition.
 4. Malrotation of the gut—appendix may be in
subhepatic region—to be kept in mind in cases wherein
appendix is not found in the right iliac fossa
ACUTE APPENDICITIS

 It is one of the most common surgical emergencies encountered by general surgeons.

Sometimes acute appendicitis can be dangerous
 Acute appendicitis: Sudden appearance of signs and symptoms of appendicitis.
 Recurrent appendicitis: Recurrent attacks of acute appendicitis—incidence is 15 to 25%.
 Grumbling appendicitis: Low grade recurrent bouts of colics, vomiting with frequent
admission, self limiting cases.
 Simple appendicitis: If duration of symptoms is less than 48 hours or imaging does not
show any abscess or phlegmon.
 Complicated appendicitis: Acute appendicitis with perforation or large abscess/phlegmon.
 Pseudoappendicitis: Acute ileitis mimics appendicitis following Yersinia infection. It can
also be due to Crohn’s disease
AETIOLOGY

 Racial and dietary factors: It is more common in white race than in coloured
persons
 Familial susceptibility: It is related to having a long retrocaecal appendix in
which case the blood supply is diminished to the distal portion and may
precipitate appendicitis
 Socioeconomic status: Appendicitis is common in middle class and rich people.
The exact reasons are not known.
 Obstructive theory: Obstruction to the lumen of the appendix due to faecoliths,
worms, ova and cysts.
 Non-obstructive theory: It is due to bacteria such as E. coli, enterococci,
Proteus, Pseudomonas, Klebsiella and anaerobes which produce diffuse
inflammation of appendix and cause appendicitis.
PATHOGENESIS
 PATHOLOGY - NON OBSTRUCTIVE
CASES

 Process of inflammation is slow and

gradual.
 A mild attack may completely
resolve or mucosal and submucosal
oedema can occur
 Ulceration of the appendix results in
slow bacterial invasion of lymphoid
tissue.
 Gangrene and perforation are rare
PATHOLOGY - OBSTRUCTIVE CASES

 Symptoms are abrupt, vomiting is more, pain is more and tenderness is more. It
is a more dangerous variety.
 The important pathological events can be summarised as follows—
 Due to obstruction, the contents get infected fast and the tension increases.
 The appendix becomes a closed loop, which results in septic thrombosis of vessels.
 Gangrene of appendix, perforation, peritonitis, followed by a local abscess can occur
 In children, greater omentum is very thin, it cannot localise the infection. In
adults, omentum is like a fatty apron which localises the infection. In aged
patients, because of atherosclerosis, gangrene occurs very fast resulting in
peritonitis.
 Common bacteria encountered in acute appendicitis are Bacteroides fragilis,
Escherichia coli, Clostridium perfringens, Streptococcus faecalis,
Pseudomonas aeruginosa, etc
CLINICAL FEATURES

 Pain is severe, colicky type, initially felt in the

umbilical region and it is due to distension of
appendix. This is a visceral pain.
 After a few hours, the pain localizes to the
right iliac fossa. It is a somatic pain which is
due to inflammation of parietal peritoneum.
 This type of pain is called shifting pain of
acute appendicitis or migratory pain— most
reliable symptom of acute appendicitis
 Vomiting occurs once or twice due to reflex
pylorospasm. It contains stomach contents.
 Appendicitis is unlikely in patients with normal
appetite. Usually, patients have anorexia.
 Fever is of low grade (around 100°F) and
indicates bacterial inflammation.
 Pain first, followed by vomiting and then by
fever is called Murphy’s triad of symptoms of
acute appendicitis (Murphy’s syndrome).
 Haematuria is uncommon and due to
inflammation of retrocaecal appendix which
irritates the ureter in the retroperitoneum.
 Constipation is the usual feature, except in
pre- and post-ileal appendicitis, where they
produce diarrhoea due to irritation of ileum
SIGNS

 Cough tenderness (Dunphy’s sign) indicates inflammation of parietal peritoneum.

 Tenderness and rebound tenderness are present at McBurney’s point. Rebound tenderness is
called Blumberg sign
 Guarding and rigidity are present in the right iliac fossa.
 Rovsing sign: Palpation of left iliac region of abdomen produces pain in the right iliac region
 Hyperaesthesia in the Sherren’s triangle
 Cope’s psoas test: Seen in retrocaecal appendicitis. There will be irritation of psoas major
which produces flexion at the hip. If any attempt is made to extend the hip, it produces pain. 7.
 Cope’s obturator test: Seen in pelvic appendicitis due to irritation of the obturator muscle.
Flexion and medial rotation produces pain.
 Features of generalised peritonitis are seen only when there is a rupture
 Rectal examination: There is tenderness in the right rectal wall—differential tenderness
INVESTIGATIONS

 Total WBC count is almost always increased above 10,000

cells/mm3 , in most of the patients (95%).
 Urine examination is mainly to rule out urinary tract infection,
haematuria and sometimes pyuria.
 C-reactive protein is elevated in any inflammatory condition
such as appendicitis. Elevated in the first 12 hours of acute
inflammation is very non-specific.
 Plain X-ray abdomen erect is taken to rule out perforation and
intestinal obstruction.
 Abdominal ultrasound to rule out other causes
including gynaecological causes.
 Pregnancy testing is mandatory in women of
childbearing age.
 CECT: Contrast enhanced CT scan is the
investigation of choice (sensitivity of 90 to 100%,
specificity of 90%), specially when diagnosis is
not established or in atypical cases
 MRI: Ideal in pregnant women.
SCORING SYSTEM
 DIFFERENTIAL DIAGNOSIS

 In Children :-  In Young Adults :-  In Middle Age:-

 Enterocolitis  Right-sided Ureteric Colic  Acute Pancreatitis
 Meckel’s Diverticulitis  Amoebic Typhlitis  Perforated Duodenal Ulcer
 Worm Ball  Torsion Of Undescended Testis  Acute Cholecystitis
 Acute Iliac lymphadenitis  Meckel’s Diverticulitis  Ileocaecal Tuberculosis
 Mesenteric Lymphadenitis  Yersinia Ileitis  Carcinoma Caecum.
COMPLICATIONS

 Rupture of Appendix
 The treatment involves emergency laparotomy
appendicectomy and peritoneal wash followed by
drainage of peritoneal cavity
 Perforated Appendicitis
 The pain usually localises to the right lower quadrant
 It can also give rise to generalised peritonitis and septic
shock
 Rigors and chills with fever of 102°F (38.9°C) or above.
•
 As a complication of perforation peritonitis, portal
pyaemia (pylephlebitis) can develop, it can be very
dangerous.
 Emergency laparotomy, appendicectomy, drainage of
pus, peritoneal lavage, and antibiotics are main
principles
 Appendicular Mass
 Following an attack of acute appendicitis, infection is sealed off by greater omentum,
caecum, terminal ileum, etc. which results in a tender, soft to firm mass in the right iliac
fossa
 It is treated by Ochsner and Sherren regime.
 – Aspiration with Ryle’s tube to give rest to the gut, if vomiting is present.
 – Bowel care—purgatives should not be used (may cause perforation).
 – Charts—temperature, pulse, respiration, diameter of the mass. Swinging temperature, and increase
in size of mass indicates an appendicular abscess.
 – Drugs to cover all the organisms—gram-positive, gram-negative and anaerobic organisms.
 – Exploratory laparotomy should not be done.
 – Fluids

 After 6–8 weeks, patient is advised elective appendicectomy.

 Presence of a mass is a contraindication for appendicectomy

 Appendicular Abscess
 They are (A) retrocaecal, (B) postileal and preileal, (C) pelvic, (D) subcaecal abscesses.
 Clinically, it presents with high-grade fever with chills and rigors and a tender boggy swelling
in the right iliac fossa or in the right lumbar region
TREATMENT

 Preoperative Resuscitation
 Once diagnosis of acute appendicitis is suspected, the patient is admitted to the hospital.
 IV fluids—isotonic saline or Ringer lactate is given.
 Electrolytes are corrected especially in late cases of acute appendicitis/perforation peritonitis,
etc.
 Ryle’s tube is not necessary in simple appendicitis but is definitely required in complicated
cases (peritonitis).
 Second generation cephalosporins along with metronidazole is given.
 Informed consent is taken.
 Definitive management is removal of appendix or appendicectomy
 Laparoscopic appendicectomy
 It has become more popular nowadays because of less postoperative pain, speedy recovery.
 3 ports
 Infraumblical
 Left iliac fossa
 Suprapubic
 Steps
 Locate the appendix at junction of 3 taenia coli
 Ligate the appendicular artery and bare the appendix
 Crush the base
 Transfix the base
 Cut the appendix
 Opening closed in layers
 Emergency appendicectomy
 Emergency appendicectomy is offered when patient comes within 24 to 48 hours of
abdominal pain.
 The appendix is identified by tracing Taenia coli which converges onto the base of the
appendix.
 Mesoappendix is divided in between ligatures.
 A purse-string suture is applied all around the appendix in the caecum.
 The appendix is divided in between ligatures, the stump is invaginated and the purse-string is
tightened.
 The abdomen is closed in layers.
 Incidental Appendicectomy
 It means removal of normal appendix at laparotomy for another condition.
 Open Appendectomy
 Types of incison given
 Structures encountered from superficial to
deep are skin , superfacial fascia, external
oblique aponeurosis, muscles ,pre
peritoneal fat and peritoneum.
ALGORITHM OF TREATMENT OF
APPENDICITIS
PROBLEMS ENCOUNTERED DURING
APPENDICECTOMY

 The incision is small. ( can be enlarged upto 2 to 3 cm)

 Normal appendix is found: Look for Meckel’s diverticulitis, intestinal obstruction, stricture,
etc.
 Gangrenous appendix involving base.
 Difficult to isolate the appendix which is gangrenous but pus is present.(limited
ilieocecectomy)
 The appendix cannot be found.
 Surprise findings of carcinoma caecum. (hemicolectomy)
COMPLICATIONS FOLLOWING
APENDICECTOMY

 Bleeding from appendicular artery

 Wound infection
 Injury to right iliohypogastric nerve
 Portal pyaemia
 Pelvic abcess
 Stump appendicitis
THANK YOU