DR .

Krishna Kumar Mallick

M.B.B.S.(Gold Medalist), M.S.(Gen.Surg.), F.C.G.P.(India), F.S.A.S.M.S.(Delhi) M.R.S.H.(London).

INTRODUCTION
Acute inflammation of appendix is called acute

appendicitis Most common cause of acute abdomen

EMBRYOLOGY
Develops as a protuberance off the terminal portion of

caecum in the 8th week of intrauterine life. Differential growth of caecum displaces appendix medially

ANATOMY
Blind muscular tube arising from the caecum around 2

cm from the ileo caecal junction Variable length: average 7.5 to 10 cm

POSITION
The position of the base of the appendix is constant At the confluence of the three taeniae coli which fuse to form the outer longitudinal muscle coat. The position of the appendix with reference to the tip

are
Retrocaecal - most common Pelvic Paracaecal

Subcaecal
Preileal Postileal

( 74 % ) (21 % ) (2% ) (1.5 % ) (1 % ) (0.5 % )

Positions of Appendix

MESOAPPENDIX
Mesentery of the appendix Arises from the lower surface of the mesentery. Tip of the appendix is devoid of mesoappendix

Transparent in children ; fat laden in adults.

Carries the appendicular artery and lymphatics.

Mesoappendix

BLOOD SUPPLY
Receives blood supply from the Appendicular Artery
It is an end artery Branch of lower division of ilio colic artery Passes behind the terminal ileum to enter the

mesoappendix Lies in the free border of the meso appendix Accessory appendicular artery is a branch of posterior caecal artery

HISTOLOGY
Layers Mucosa Submucosa Muscularis propria Serosa Mucosa contains abundant lymphoid follicles

ETIOLOGY OF APPENDICITIS
Appendix is a frequent site of infection called as

ABDOMINAL TONSIL Infection lymphoid hyperplasia luminal obstruction Obstruction of the appendiceal orifice by
Fecolith

Inspissated faecal matter , Ca PO4 , bacteria , epithelial debris

Stricture
Ca caecum ( tumour obstructing the orifice) Intestinal parasite ( Oxyuris vermicularis ) Rarely a foreign body

ETIOLOGY OF APPENDICTIS
Organisms responsible are E . Coli Pseudomonas aureginosa Klebsiella sp. Bactroids fragilis Fusobactrium sp. Streptococcus sp. Enterococcus sp . Clostidium sp.
G-ve aerobic bacilli G-ve anerobic bacilli G +ve cocci G +ve bacilli

PATHOLOGY
Luminal obstruction
Mucus secretion / inflammatory exudate Increased intraluminal pressure Obstruction of lymphatic drainage Edema & mucosal ulceration Bacterial translocation to the submucosa Further distension with venous obstruction Ischemia with bacterial invasion into Ms. Propria & submucosa Acute appendicitis

PATHOLOGY
Ischemic necrosis of the appendix wall produces

gangrenous appendicitis with free bacterial contamination of the peritoneal cavity Alternatively, greater omentum and loops of small bowel become adherent to the inflammed appendix, walling of the spread of peritoneal contamination, forming phlegmonous mass which may become a paracaecal abscess. Rarely inflammation resolves leaving a mucus filled distended mucocele of the appendix

CLINICAL FEATURES
Diagnosis of appendix is made clinically
Two clinical syndromes of acute appendicitis Acute catarrhal (non-obstructive) Acute obstructive

ACUTE OBSTRUCTIVE
Acute onset of periumbilical colic due to midgut visceral

discomfort in response to appendiceal inflammation Anorexia useful constant clinical feature Nausea & vomiting due to reflex pylorospasm

Contd.
With progressive inflammation , parietal peritoneum

in the right iliac fossa gets irritated . Intense , constant , localized somatic pain in right iliac fossa.
Exacerbated by coughing & sudden movt.
Pain is atypical and poorly localized in elderly

Contd.
Slight pyrexia ( 37.2 37.7 C ) after 6 hrs with increase

in pulse rate In children temp > 38.5 C suggests some other cause eg; mesenteric adenitis

ACUTE CATARRHAL
Much more acute course
Abrupt onset of symptoms Generalized abdominal pain from the start Temperature may be normal Vomiting is common Clinical picture may mimic acute intestinal

obstruction More rapid progression to perforation - hence the need for urgent surgical intervention

SIGNS
Low grade pyrexia
Pointing sign Tenderness in the Mc Burneys point with guarding Cough tenderness Rebound tenderness Rovsings sign Psoas sign Obturator sign Cutaneous hyperaesthesia in the right iliac fossa

SPECIAL FEATURES
Retrocaecal Even deep pressure may fail to elicit tenderness Rigidity is often absent Psoas spasm due to inflammed appendix flexion of hip; hyperextension of hip causes abdominal pain Pelvic Early diarrhoea Abdominal rigidity may be completely absent Deep tenderness just above and to the right of symphysis pubis Spasm of psoas 7 obturator internus Frequency of micturition Per rectal examn tenderness in right side if pouch of Doughlas

SPECIAL FEATURES
Post ileal Presents with greatest difficulty in diagnosing Pain may not shift Diarrhoea Marked retching Tenderness if any is ill defined

DIFFERENTIAL DIAGNOSIS
CHILDREN Gastroenteritis Mesenteric adenitis Meckels diverticulum Intussusception Henoch-schonlein purpura Lobar pneumonia ELDERLY Diverticulitis Intestinal obstruction Colonic carcinoma Torsion appendix epiploicae Mesenteric infarction Leaking aortic aneurysm

DIFFERENTIAL DIAGNOSIS
ADULT/Male-Female Regional enteritis Ureteric colic Perforated peptic ulcer Torsion of testis Pancreatitis Rectus sheath hematoma ADULT FEMALE Mittelshmerz Pelvic inflammatory disease Colonic carcinoma Torsion appendix epiploicae Mesenteric infarction Leaking aortic aneurysm

SPECIAL SITUATIONS
INFANTS
Appendicitis is rare under 36 months of age Diagnosis is delayed since pt cannot give history hence

there is higher incidence of perforation Diffuse peritonitis is common due to under developed greater omentum and immune system CHILDERN Always asso. with vomiting Usually have complete aversion to food

SPECIAL SITUATIONS
THE ELDERLY Gangrene & perforation occur more frequently due to

atherosclerosis and defective omental function Commonly presents as subacute intestinal obstruction Higher mortality due to comorbid illness THE OBESE All local signs are obscured Technical difficulty of operating in obese Wiser to go for midline incision Laparoscopy obviates large abdominal incision

SPECIAL SITUATIONS
PREGNANCY
Most common extrauterine acute abdominal condition

in pregnancy Frequency - 1 : 1500 1 : 2000 pregnancies Delay in presentation due to non specific symptoms attributed to pregnancy Caecum & appendix are progressively pushed up to the right upper quadrant during 2nd and 3rd trimester Fetal loss 3 to 5 % ; 20 % if perforation has occurred

INVESTIGATIONS
Diagnosis of appendicitis is essentially clinical
However decision to operate based on clinical evidence

alone can lead to removal of normal appendix in 15 20 % The most widely used score is ALVARADO score

The Alvarado (MANTRELS) score

Symptoms
Migratory RIF pain Anorexia Nausea & vomitting

score
1 1 1

Signs Tenderness ( RIF )

Rbound tenderness Elevated temperature

2
1 1

Laboratory Leucocytosis
Shift to left (Arneths Count)

2
1

Total

10

INVESTIGATIONS
A score of seven or more is strongly predictive of acute

appendicitis In patients with equivocal score ( 5 6 ) , abdominal USG or contrast CT further reduces the rate of negative appendicectomy

INVESTIGATIONS
ROUTINE
Full blood count Polymorphonuclear leucocytosis Shift to left Urinalysis

SELECTIVE
Pregnancy test Urea & electrolyte

Supine abdominal radiography

USG of abdomen & pelvis Contrast enhanced CT of abdomen

SUPINE ABDOMINAL X RAY

Calcified appendicolith Right lower quadrant mass

Caecal ileus
Loss of right psoas shadow Distortion of right flank stripe

Pneumoperitoneum if perforated

USG ABDOMEN
Aperistaltic, non-compressible blind ending tubular

appendiform structure in the right iliac fossa with diameter measuring > 6 mm Probe tenderness

CT ABDOMEN
UNCOMPLICATED Periappendiceal inflmn Pericaecal inflmn Thickened appendiceal wall Thickened medial caecal wall Thickened wall of distal ileum Thickened anterior renal & lateral conal fascia appendicolith COMPLICATED Peritonitis Phlegmon Abcess

TREATMENT
Treatment for acute appendicitis is appendicectomy
Short period of intensive preoperative preparation I V fluids to establish adequate urine output Appropriate antibiotics Treat hyperpyrexia Ensure that bladder is empty before surgery

Incisions for appendicectomy

Gridiron incision

Transverse (Lanz) incision

Rutherford Morrison incision

When identification of appendix is difficult, the

gridiron incision can be converted into a muscle cutting incision known as Rutherford Morrison incision

APPENDICECTOMY
Anesthesia Position

spinal / general supine with wedge

beneath RIF
Incision Gridiron Skin & s .c tissue incised . External oblique aponeurosis incised along the line of

skin incision. Internal oblique & Tr. abdominis ms split across their fibres Peritoneum opened medially

APPENDICECTOMY
Caecum identified by taeniae coli
Appendix base is identified by tracing the taeniae coli Mesoappendix serially clamped , cut & ligated till the

base of the appendix Base of appendix crushed ( unless base is inflammed) Crushed portion is ligated using absorbable suture Base of appendix is inverted by z suture or purse string suture Wound closed in layers

POST OP COMPLICATIONS
Wound infection
Intra abdominal abcess Ileus Respiratory complications Venous thrombosis & embolism Portal pyemia ( pylephlebitis ) Fecal fistula Adhesive intestinal obstruction

Appendicitis - Complications
Appendix mass Appendix abcess Perforative peritonitis Pelvic abscess

APPENDIX MASS
Formed by sealing of infection by omentum along with

caecum & terminal ileum Tender , soft to firm mass in RIF MASS is a contraindication for surgery Management is conservative ;OCSHNER SHERRENS regimen

Ocshner Sherrens Regimen

Nil per oral
I V fluids Parentral antibiotics 4th hourly temperature & pulse chart Input output chart Marking limits of mass with skin pencil Clinical improvement is usually evident within 24 48

hours Interval appendicectomy after 6 8 weeks

Ocshner Sherrens Regimen

Clinical improvement is assessed by the following: Pulse rate becomes normal Fever subsides Mass decreases in size Criteria for stopping conservative management Rising pulse rate Persistent or increasing pain Increase in size of mass Fluctuation Clinical deterioration or evidence of peritonitis is an

indication for early laparotomy

Appendix abscess
Failure of resolution of appendix mass or continued

spiking pyrexia usually indicates pus in the phlegmonous appendix mass TREATMENT
Extraperitoneal drainage of abscess

PELVIC ABCESS
Occasional complication Irrespective of position of appendix Symptoms Spiking pyrexia Pelvic discomfort Loose stools Tenesmus Per Rectal examination Boggy mass anterior to rectum Treatment Trans rectal drainage under GA

Pelvic Abscess

Perforative peritonitis
Common in children and elderly
Signs: Sepsis Guarding and rigidity Liver dullness may be obliterated Plain X-Ray abdomen erect may show air under the right hemi-diaphragm Treatment: Emergency appendicectomy

CARRY HOME MESSAGE

Appendicitis is the commonest acute abdominal

condition Commonest position - retrocaecal Diagnosis is made clinically Commonly presents as subacute intestinal obstruction in elderly Appendicectomy is the treatment of choice Appendix mass is managed conservatively Appendix abscess is treated by trans rectal drainage under anaesthesia