( 13 pages)

Anatomy: It is a warm shaped tube containing large amount of lymphoid tissue. Length 8-13 cm. It has a complete peritoneal covering called Mesoappendix. The base is attached to the posteriomedial surface of the cecum, about 1 inch below the iliocecal junction and this coincides with Mc Burneys point N.B. the base is easily identified by following the tenia coli at the point of convergence. The other end is freely moving and usually found in Retrocecal 74% (most common / give localized inflammation bcoz cecum is covered with peritoneum from front and both 2 sides) Pelvic 21% Postileal 5% Subcecal 1.5% Preileal 1% The Blood Supply of the appendix is by appendicular artery a branch of the posterior cecal artery which is a branch of iliocecal Iliocecal artery posterior cecal artery appendicular artery Venous drainage through appendicular vein to the posterior cecal vein Appendiclar vein posterior cecal vein Lymphatic drainage through one or two nodes lying in the mesoappendix into mesenteric nodes superior mesenteric nodes Nerve Supply is derived from sympathetic and parasympathetic (vagus) nerves from the superior mesenteric plexus

 Afferent fiber conducting visceral pain of appendix enter through the 10th thoracic segment (this explains the referred pain at the umbilical level) Acute appendicitis It is the most common surgical emergency, more common in the western countries d/t their diet. Appendicitis is a disease of young adults and children but can occur in elderly patient. Peak age of the disease is 15 years (adolescence). Types of appendicitis
Causes: Obstructed Faecolith (the commonest). Appendicitis Foreign body. E.g. fruit seeds Kink from inflame adhesion. Lymphoid hyperplasia within the wall. Lesion in the cecum e.g. carcinoma. Warm (rare). Coarse (according to presence Bacteria)

Non Obstructed Appendicitis

causes: Direct infection of lymphoid follicle from appendicular lumen. Hematogenous. E.g. strept (rare)

Present Bacteria proliferate in the Obstructed appendix and Invade the wall that was Damaged by pressure necrosis

absent Mucocele: Due to continues Secretion of mucous from goblet cells

Inflammation

Bacteria are: E.coli 85% Bacteroid. Pseudomonas Inflammation: Normal flora of the

May resolve. If not treated within 12 hours progressive infection and obstruction which lead to impairment of blood supply gangrene If perforation has occurred the outcome depend on the ability of the omentum to contain the infection A-If adequate omentum there will be: Appendicular mass. Appendicular abscess B- if the omentum is not adequate there will be Generalized peritonitis

History Taking
Age: can occur at all, but more common in the adolescence age group. Sex: same incidence. Symptoms: 1) Pain: the main symptom. Site: it starts central pain around the umbilicus (visceral pain) and it is a referred pain

because the visceral innervation of the appendix comes from the10th thoracic spinal segment, the corresponding dermatome encircle the abdomen at the umbilicus. This central pain will shift to the right iliac fossa RIF after few hours, to 2-3 days and then it is Somatic pain (d/t irritation of the inflamed appendix to the sensitive parietal peritoneum). Onset: gradual and then becomes sudden. Severity: sever. Pattern: Colicy pain obstructed appendix. Constant painnon obst appendix. Duration: usually few hours but it can be 2-3 days. Progression: increases with time. Relieving: by bending the leg to the abdomen(flexion) or by lying down Association: with other symptoms:

2) vomiting: vomiting after the onset of pain because vomiting before pain suggests gastroenteritis. 3) constipation: majority of cases state that they have been constipated for few days before the attack of pain. 4) diarrhea: few of the patients especially when it is pelvic appendicitis (d/t irritation to the rectum) 5) anorexia 6) low grade fever: (37.2 37.7 C ) if higher fever think about complicated appendicitis ( by peritonitis and abscess)

in the Hx you have to exclude other GIT symptoms. symptoms of DDx.

Physical Examination
General examination: pale (esp. in children) tachycardia ( d/t spread of infection) low grade fever tongue: white and furred with foetor oris ( bad breath) Neck: palpate glands and look at the tonsils to exclude mesenteric adenitis Chest: Examine the lung for right basal pneumonia Abdomen: inspection: normal, the abdomen is slowly moving with respiration due to pain. palpation: right iliac fossa is tender with or without guarding (voluntary contraction of abdominal muscle when palpate) Rebound tenderness : +ve in McBurneys point. Signs: Rovsings Sign: Pain in the Right iliac fossa RIF d/t pressing or palpating the Left iliac fossa LIF. Because either - transmission of air Or: - by pressing on the left side you are moving the intestine to touch the inflammewd organ Psoas Sign:
6

Pain when extending the right hip joint d/t spasm of the psoas muscle. So, you observe hip flexing slightly by patient to decrease the pain. Obturaror internus sign: Pain with passive internal rotation of the flexed Rt. Thigh it indicates inflammation overlying the muscle. Blumbergs sign: Pressing and releasing suddenly in LIF feels pain in the RIF [ crossed rebound tenderness] Straight leg raising sign: +ve with retrocecal appendix. Rectal Examination; Tenderness ( in the pelvic position, or when there is pus in Douglas Pouch). DDx: (according to the location of pain) I - RIF pain & tenderness A) Intra abdominal diseases: Mesenteric adenitis: Especially in children following upper respiratory tract infection URTI. It looks like appendicitis in their symptoms. You must ask about previous Hx of URTI tonsillitis or enlarged L.N. Meckels diverticulitis: Often indistinguishable from appendicitis, you have to look for Meckles when you do appendectomy. Acute crohn ileitis:
7

II- Central abd. Colic

(Discussed below)

 Affect young adult & usually there is Hx of recurrent pain. Mass of inflamed ilieum can be felt. Acute cholecystitis: Sometimes pain of inflamed Gall bladder descends into RIF. Murphys sigh (+ve in cholecystitis). Vomiting & jaundice may be present. Perforated peptic ulcer: Hx. Of dyspepsia. Sudden pain on epigastrium shifted to RIF. Gas under diaphragm on X-ray. Pancreatitis: (rare) Diffuse abd. Pain & sometimes central or RIF pain. Associated with copious vomiting & back pain. B) The urinary tract diseases: Renal colic & acute pyelonephritis: You should ask about hematuria or loin pain which radiate to the groin region. Ask if there is any change in (color / frequent / volume) of urine. Testicular torsion or undescended testis: Very rare. C) Gynecological diseases (females): Acute salpingitis: Hx of vaginal discharge, menstrual irregularities and dysmenorrhea or dysuria. Hx of contact with venereal dis. On PR or PV examination, enlarged fallopian tubes may be palpable. Confirm Dx by Laparoscopy Ectopic pregnancy:
8

 Hx. Of missed period. Pain on constant site. Sever pain. N.B. In female pt you should ask about: Mid cycle pain: (esp. in youngs) d/t rupture of ovarian follicle o Pain o Bleeding Ectopic pregnancy (missed period) D) Chest: Pneumonia and pleurisy: Rt basal pneumonia. Associated with tachycardia and cheat pain. Chest examination added sound and friction rub. Chest X-ray may be helpful.

II- DDx of Central abd pain: In the early stages of appendicitis may suggest: Gastroenteritis: Nausea, vomiting and diarrhea proceeds the pain. Intestinal obstruction: High level obstruction characterized by profuse vomiting and little abdominal distension. Low level obstruction causes mark distention & late onset vomiting. On X-ray you will see fluid level. Noisy bowel sounds.

Investigation: 1) CBC: leukocytosis esp. neutrophils. 2) Urine Analysis: to exclude urinary tract disease Pyourea may indicate Rt.pyelonephritis. 3) Plain X-ray: Related to appendicitis: May show faecolith in RIF. Loss of Rt psoas shadow. Others to exclude: Acute intestinal obstruction. Peptic ulcer perforation. Uretric stone. 4) U.S: To exclude or verify: Ovarian pathology. Or mesenteric adenitis. Or carcinoma of the cecum. Or appendicular mass. 5) Laparoscopy: In doubtful diagnosis. Management: A. Direct operative management: If you doubt it is appendicitis or not you can admit the patient for few hours: If still fever then operate. If it improves dont operate & he may not have appendicitis. If the patient did not under go appendectomy there will be: 1. He may improve give him antibiotics.

10

2. in some cases there will be adhesions of the omentum and adjacent viscera to the inflamed appendix and then there will be formation of Appendicular mass. Localized abscess. To differentiate between the two, do U.S. & treat both of them by antibiotic if it is: Mass: will improve, mass will decrease in size, fever will decrease [can be treated by antibiotics alone] Abscess: will not improve(confirm by U.S) [need drainage under ultrasonograpgy guidance] Pramedian incision: N.B: we Dont operate and remove the mass b/c there will be It is a vertical inflammation around the whole area & you may injure the bile or incision lying blood vessels or renal strucrure. parallel to the mid B. Appendectomy: line just 1.25-2.5 cm Types Commonly 2.5 cm of incisions: below the umbilicus and just above the Lanz incision: Grid Iron incision: pubis. Advantage: Transverse incision made When the Dx is certain, Done when the Dx is approximately 2 cm an incision is made aright doubt and you should below the umbilicus angle to a line joining the operate. centered in the superior iliac spine to the It gives a good access midclavicular line. umbilicus. Its center to the pelvic organs in The external oblique being the line at females. aponeurosis,internal McBurneys point It can extend upward oblique and transverses Has less to deal with a muscles are split in the postoperative perforated duodenal direction. complication ulcer or other Superficial intraabdominal The exposure is circumflex artery pathology. better and extension usually need ligation if needed is easier Disadvantage: Recently this Give limited access to incision became so retrocecal appendix. popular and it is High incidence of performed in most of infection. the patients. High Chance of 11 incisiona hernia May injure the bladder.

* You can do Laparoscopic appendectomy Complications: Complications of the operations: 1. Bleeding. 2. wound infection: anaerobic bacteria (flagyl) gram ve bacteria (gentamycine) gram +ve bacteria (ampicilline) 3. residual abscess: local. Pelvic.(common) Paracolic. 4. Intestinal obstruction from adhesions. 5. Incisional hernia ( esp. Para median incision) 6. Rt. Inguinal hernia (following the grid iron incision) Complications of the appendicitis: 1. localized peritonitis or generalized after perforation: symptoms include: generalized abdominal pain.
12

 Nausea and vomiting. Sweating and sometimes rigors. With pyrexia. 2. appendicular mass: pt. present with Hx. Of 4-5 days abd. Pain with localized mass in the RIF. No signs of general peritonitis. Conservative ttt( 80% will resolve) : Antibiotic: Anaerobesflagyl. G-ve gentamycine. G +ve ampicillin. Analgesia. Observe vital signs. The remaining 20% : Deterioration. Abscess formation. No change. 3. appendicular abscess: Need drainage. May give pelvic abscess or portal pyemia through ilio colic vein. N.B: In 20% of the cases the appendix is found to be normal You look for other causes and remove the appendix as prophylaxis. DDx of a mass in the RIF: 1. appendicular mass or abscess. 2. carcinoma of the cecum : not tender. Blood in stool. Deterioration in health over month Pt. usually old. Signs of metastasis e.g. to the liver [ enlarged/ tender] 3. Crohns disease:
13

4. 5. 6. 7. 8. 9.

Diarrhea. Wt. loss. Abdominal pain, rectal bleeding. Occult blood in stool. Increased ESR. Ovarian carcinoma. Iliocecal T.B. Iliac L.N enlargement. Iliac artery aneurysm. psoas abscess. distended gall bladder.

14