Appendicitis

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 History
 Used to be called perityphlitis (500 years
ago)  cecum abnormality was believed
as etiology
 Amyand, 1735  first successful
appendectomy
 Morton, 1887  first appendectomy in US
 McBurney, 1889  appendectomy before
perforation, McBurney point
 Introduction
 Most common acute surgical
condition of the abdomen
 Incidence 1 : 1000 children per year.
 Risk for appendicitis is 9% for men and
7% for women
 1/3 patients < 18 years of age
 The peak of incidence  11 and 12y
 Embryology and Anatomy

 Embryology : continuation of cecum, appendix

rotates on the posteromedial of cecum about 2
cm below ileocecal valve (late childhood)
 Length  0.3-33 cm, average 8 cm
 Diameter 5-10 mm
 Blood supply  appendical branch of ileocolic
artery  end artery
 Base of appendix  junction of three taenia
coli  landmark
 Lymph follicles  2 weeks after
birth, the amount of lymphoid tissue
increases throughout puberty,
remains steady for the next decade,
and then begins a steady decrease
with age
 >60 years, virtually no lymphoid
tissue remains within the
appendixcomplete obliteration of
the appendiceal lumen is common.
 Function
 Appendix is a immunologic organ
which produce immunoglobulin A
Anatomy
 Pathogenesis

 Appendicitis  luminal obstruction

followed by infection
 Cause of obstruction  not always clear
• Fecalith
• Hypertrophy lymphoid follicles
• Parasitic infection
• Enteric and systemic infection
• Cystic fibrosis
• Tumor
• Foreign bodies
• Trauma
 Pathogenesis

Obstruction  intraluminal pressure

increase (appendix distention) venous
congestion  arterial obstruction 
ischemic  necrosis  perforation
 Presentation
 Initially, describe mild GI symptoms
 Anorexia
 Nausea
 Vomiting
 Fever, tachycardia, leukocytosis
 Periumbilical pain  pain in
McBurney’s point.
 Diagnosis : symptoms
 Mild GIT symptoms before acute pain
 Nausea and vomiting
 Deep, dull, poorly localized pain (T10
dermatom)
 McBurney’s point (mostly, not
always)
 Urinary frequency, testicular pain,
dysuria, urinary retention
 Fever, tachycardia, leukocytosis
 Diagnosis : symptoms
 Patient movement and position
 Constipation (unusual), diarrhea
(more common)
 Signs of perforation :
• Temperature higher than 38.6°C
• Leukosit > 14.000/mm3
• More generalized peritoneal sign
 Diagnosis : Physical examination
 Location of abdominal pain
 Tenderness
 Rebound tenderness
 Rovsign’s sign  peritoneal irritation
 Psoas sign  retrocecal appendicitis
 Obturator sign retrocecal
appendicitis
 Local muscular rigidity
 Diagnosis : Laboratory studies
 Leukocytosis, left-shifted lekocyte
count
 Female : Pregnancy test
 Neutrophyl-lymphocyte ratio > 3.5
 C-reactive protein
 Appendicitis scoring system : PAS
score, MANTREL score, etc
 Diagnosis : Radiologic studies
 Plain radiography
 Appendicogram
 USG appendix
 CT scan
 Laparoscopic
 Differential diagnosis
 Urinary tract
• Hydronephrosis
 Appendix
• Pyelonephritis
• Appendical tumor, carcinoid tumor
• Ureteral or renal calculus
• Appendical mucocele
• Wilm’s tumor
• Crohn’s disease
 Uterus, ovary
 Cecum and colon
• Ectopic pregnancy
• Cecal carcinoma
• Ovarian torsion
• Diverticulitis
• Ruptured ovarian cyst
• Crohn’s disease
• Salphingitis
• Intestinal obstruction
• Tubo-ovarian abcess
• Stercoral ulcer
 Other
• typhlitis
• CMV infection
 Hepatobiliary
• Diabetic ketoacidosis
• Cholecystitis
• Kawasaki disease
• Hepatitis
• Henoch-schonlein disease
• cholangitis
• Burkitt’s lymphoma
 Small intestine
• Omental torsion
• Adenitis
• Rectus sheath hematoma
• Duodenal ulcer
• Omental torsion
• Gastroenteritis
• Pancreatitis
• Intestinal obstruction
• Parasitic infection
• Intussuseption
• Pleuritis
• Meckel’s diverticulitis
• Pneumonia
• Tuberculosis
• Psoas abcess
• Typhoid perforation
• Torsion of appendix epiploica
 Treatment
 Antibiotics
• Gold standard for complicated
appendicitis  10 days of iv ampicillin,
gentamicin, and clindamycin or
metronidazol; cefotaxime/ ceftriaxone +
Metronidazole
• Early appendicitis  perioperative
antibiotics, till 48 hours
 Appendectomy  Standard Open
 Laparoscopic App
 Palpable abdominal mass
 Still controversial
 Options :
• Immediate appendectomy
• IV antibiotic till leukocytes reduced and
afebrile for 24 h  appendectomy
• Drained percutaneously  with/without
interval appendectomy
• Conservative management 
appendectomy after 8-12 weeks
 Post operation treatment
 Maintain hydration and nutritional
status
 Early immobilization  shorter
hospitalization duration
 Early feeding
 Antibiotic
 Complications
 Wound infection
 Intra-abdominal abcess
 Postoperative intestinal obstruction
 Prolonged ileus
 Enterocutaneous fistula
 Sepsis  MOF
 Tubal infertility