Appendicitis

R.Nandinii
Group K1
Anatomy
• a blind muscular tube with mucosal, submucosal,
muscular and serosal layers
• At birth, appendix is short and broad at its junction
with the caecum, but differential growth of the
caecum  typical tubular structure by about the age
of 2 years
• During childhood, continued growth of the caecum
commonly rotates the appendix into a retrocaecal but
intraperitoneal position
• Position of the base of the appendix is constant, being
found at the confluence of the three taeniae coli of the
caecum, which fuse to form the outer longitudinal
muscle coat of the appendix.

Source: Bailey & Loves Short Practice of Surgery 25th ed

Various positions of the appendix:

• Mesentery of the appendix or mesoappendix

arises from the lower surface of the mesentery
or the terminal ileum and is itself subject to
great variation
• Vascularisation Appendicular artery, a
branch of the lower division of the ileocolic
artery, passes behind the terminal ileum to
enter the mesoappendix a short distance from
the base of the appendix

Source: Bailey & Loves Short Practice of Surgery 25th ed

Definition:
• An inflammation of the vermiform appendix

Aetiology:
• No unifying hypothesis
• Decreased dietary fibre and increased consumption of refined
carbohydrates
• Obstruction of the appendix lumen
– Fecolith (composed of inspissated faecal material, calcium
phosphates, bacteria, epithelial debris, rarely a foreign body)
– Tumour (carcinoma of caecum)
– Intestinal parasites (Oxyuris/Enterobius vermicularis – pinworm)
Source: Bailey & Loves Short Practice of Surgery 25th ed
PATHOPHYSIOLOGY
Risk Factors for Perforation of The Appendix

Source: Bailey & Loves Short Practice of Surgery 25th ed

Clinical Manifestations

Source: Bailey & Loves Short Practice of Surgery 25th ed

Special Features Based On
Appendix Locations

Source: Bailey & Loves Short Practice of Surgery 25th ed

Differential Diagnosis

Source: Bailey & Loves Short Practice of Surgery 25th ed

Investigation

Source: Bailey & Loves Short Practice of Surgery 25th ed

 Diagnostic Scoring

• Diagnosis is essentially clinical;

• HOWEVER a decision to operate based on clinical suspicion
only can lead to the removal of a normal appendix.
• A number of clinical and laboratory-based scoring systems
have been devised to assist diagnosis.
• The most widely used is Alvarado score.

Source: Bailey & Loves Short Practice of Surgery 25th ed

 The Alvarado (MANTRELS) Score
Score
Symptoms
•Migratory RIF pain 1
•Anorexia 1
•Nausea and vomiting 1
Signs
•Tenderness (RIF) 2
•Rebound tenderness 1
•Elevated temperature 1
Laboratory
•Leucocytosis 2
•Shift to the left (segmented neutrophils) 1
TOTAL 10

• < 5 is strongly against a diagnosis of appendicitis

• 7 or more is strongly predictive of acute appendicitis
• In patients with an equivocal score of 5 or 6, abdominal USG or
contrast-enhanced CT scan is used to further reduce the rate of
negative appendicectomy
Source: Bailey & Loves Short Practice of Surgery 25th ed
 CT Scan images of Appendicitis:
1. enlarged appendix 2. appendiceal wall thickening

Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acute
appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.
 CT Scan images of Appendicitis

3. appendicolith 4.periappendiceal fat stranding

Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings for diagnosing acute
appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-582.
 Treatment

• Intravenous fluids
• to establish adequate urine output

• Appropriate 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

• Salicylates
• Appendicectomy

Source: Bailey & Loves Short Practice of Surgery 25th ed

Appendicectomy

• Conventional Appendicectomy
• Laparoscopic Appendicectomy
• Postoperative Complications

Source: Bailey & Loves Short Practice of Surgery 25th ed

 Conventional Appendicectomy

2/3
1/3
2 cm

Gridiron incision : right angles Lanz incision : 2 cm below the

to a line joining the ASIS to the umbilicus centred on the mid-
umbilicus. Centred on clavicular-midinguinal line
McBurney’s point
 Conventional Appendicectomy
• Caecum is identified
• Base of mesoappendix is clamped in artery forceps, divided, and ligated
• The freed appendix is crushed near its junction with the caecum in artery forceps,
which is removed and reapplied just distal to the crushed portion
• An absorbable ligature is tied around the crushed portion close to the caecum
• The appendix is amputated between the artery forceps and the ligature
• An absorbable purse-string or ‘Z’ suture may then be inserted into the caecum
about 1.25 cm from the base
• The stump of the appendix is invaginated while the purse-string or ‘Z’ suture is tied,
thus burying the appendix stump

Source: Bailey & Loves Short Practice of Surgery 25th ed

Source: Bailey & Loves Short Practice of Surgery 25th ed
 Laparoscopic appendicectomy
• The placement of operating ports may vary according to operator preference and
previous abdominal scars.
• The operator stands to the patient’s left and faces a video monitor placed at the
patient’s right foot.
• A moderate Trendelenburg tilt of the operating table
• The appendix is identify & controlled using a laparoscopic tissue-holding forceps.
• By elevating the appendix, the mesoappendix is displayed
• A dissecting forceps is used to create a window in the mesoappendix to allow the
appendicular vessels to be coagulated or ligated using a clip applicator.
• The appendix, free of its mesentery, can be ligated at its base with an absorbable
loop ligature,divided, & removed through one of the operating ports.
• It is not usual to invert the stump of the appendix
• A single absorbable suture is used to close the linea alba at the umbilicus, and the
small skin incisions may be closed with subcuticular sutures.
• Patients who undergo laparoscopic appendicectomy are likely to have less
postoperative pain & to be discharged from hospital and return to activities of daily
living sooner than those who have undergone open appendicectomy.
Source: Bailey & Loves Short Practice of Surgery 25th ed
Source: Bailey & Loves Short Practice of Surgery 25th ed
 Problems Encountered During
Appendicectomy
Problems
A normal appendix is found
The appendix cannot be found
An appendicular tumour is found
An appendix abscess is found and
the appendix cannot be removed
easily
Management
Demands careful exclusion of other possible
diagnosis
Remove the appendix to avoid future diagnostic
difficulties
Caecum should be mobilised, and the taeniae
coli should be traced to their confluence on the
caecum before the diagnosis of ‘absent
appendix’ is made
Small tumours (< 2.0 cm in diameter) can be
removed by appendicectomy
Larger tumours should be treated by a right
hemicolectomy
Should be treated by local peritoneal toilet,
drainage of an abscess and intravenous
antibiotics
Source: Bailey & Loves Short Practice of Surgery 25th ed
 Appendix mass
• If an appendix mass is present & the condition of the patient is
satisfactory, the standard treatment is the conservative
• Careful recording of the patient’s condition and the extent of the mass
should be made and the abdomen regularly re-examined.
• mark the limits of the mass using a skin pencil.
• Temperature and pulse rate should be recorded 4- hourly and a fluid
balance record maintained
• A contrast-enhanced CT examination of the abdomen should be
performed and antibiotic therapy instigated.
• An abscess, if present, should be drained radiologically.
• Clinical deterioration or evidence of peritonitis is an indication for early
laparotomy.
• Clinical improvement is usually evident within 24–48 hours
Source: Bailey & Loves Short Practice of Surgery 25th ed
Criteria for stopping conservative treatment of
an appendix mass

• A rising pulse rate

• Increasing or spreading abdominal pain
• Increasing size of the mass

Source: Bailey & Loves Short Practice of Surgery 25th ed

 Postoperative Complications
• Wound infection
• Intra-abdominal abscess
• Adhesive intestinal obstruction
• Rare
• Ileus
• Respiratory – pneumonitis or collapse
• Venous thrombosis and embolism
• Portal pyaemia (pylephlebitis)
• Faecal fistula

Source: Bailey & Loves Short Practice of Surgery 25th ed

Other causes of acute
appendicitis

• Recurrent Acute Appendicitis

• Neoplasms of the Appendix
 Recurrent Acute Appendicitis
• Widely known but unfavourable
• Not uncommon for patients to attribute such attacks
to ‘biliousness’ or dyspepsia
• Attacks vary in intensity and may occur every few
months
• Through history, patient might have had milder but
similar attacks of pain showing fibrotic appendix
indicative of previous inflammation
• Chronic appendicitis, per se, does not exist; however,
there is evidence of altered neuroimmune function in
the myenteric nerves of patients with so called
recurrent appendicitis (Büchler)
Source: Bailey & Loves Short Practice of Surgery 25th ed
Excised appendix showing the point of luminal
obstruction with distal fibrosis

Source: Bailey & Loves Short Practice of Surgery 25th ed

Neoplasms Of The Appendix

Source: Bailey & Loves Short Practice of Surgery 25th ed