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2008/2009

THE VERMIFORM APPENDIX

Acute appendicitis (AA) is the most common
.cause of an: acute abdomen" in young adults
;ANATOMY
Its a blind muscular tube with mucosa,
submucosa, muscular & serosal layer. During
childhood, continued growth of the caecum
commonly rotates the appendix into a retrocaecal
intraperitoneal position(74%).In 25% of cases,
rotation doesnt occur,
resulting in a
pelvic(21%),
subcaecal(1.5%), or
paracaecal(2%)
position, it also may
be preileal(1%) or
postileal(0.5%).Rarely it can be found near the
.gall bladder or in the LIF(situs inversus)
The appendicular artery is a branch of the lower
division of the ileocolic artery. It's an "end artery",
thrombosis of which results in necrosis of the
.appendix (gangrenous appendicitis)

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Lymphatic drainage of the appendix empty into
.ileocaecal LN

MICROSCOPIC ANATOMY
Appendix varies in length& circumference. The
length is 7.5-10 cm.Lumen has multiple
longitudinal folds of mucous membrane lined by
columnar cells (colonic mucosa). Crypts are
present, in its base lie argentaffin cells which may
give rise to carcinoid tumour. The submucosa
contains numerous lymphatic aggregations or
.follicles

ACUTE APPENDICITIS
It is relatively rare in infants, common in
childhood& early adult life. Peak incidence in the
teens & early 20s. Low incidence after middle
age. Incidence is equal among males& females
before puberty, but in teenagers &young adults,
.the M;F ratio rise to 3;2

AETIOLOGY
As with diverticulitis, the incidence of
appendicitis is lowest in societies with a high
dietary fiber intake. In developing countries that
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are adopting a more refined carbohydrates,
western type diet, the incidence continues to rise,
although dramatic decrease in the incidence in
Western countries. However improved hygiens
.may be responsible
A mixed growth of aerobic & anaerobic organisms
.is usual in appendices
Obstruction of the appendix lumen held to be
important which is either by faecolith or stricture.
Occasionally obstruction of the appendiceal
orifice by tumour ex. Carcinoma of the caecum is
an occasional cause of AA in middle age &
elderly. Intestinal parasites (oxyuris vermicularis
.can occlude the lumen

PATHOLOGY
Obstruction of the lumen is essential for
development of the appendiceal gangrene
&perforation. Yet in many early appendicitis, the
lumen is patent despite the presence of mucosal
inflammation &lymphoid hyperplasia. An
.infective agent, possibly viral may be implicated
Lymphoid hyperplasia narrows the lumen of the
appendix leading to luminal obstruction. Mucous
secretion& inflammatory exudation increase
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intraluminal pressure with lymphatic obstruction.
Oedema&mucosal ulceration develop with
.bacterial translocation to the submucosa
At this point resolution may occur spontaneously
.or by antibiotics
If the condition progresses, further distension of
the appendix causes venous obstruction&
ischaemia of the appendix wall. Bacterial invasion
occur through muscularis propria& submucosa,
producing AA. Finally ischaemic necrosis of the
wall produces gangrenous appendicitis, with
.bacterial contamination of the peritoneal cavity
Alternatively the greater omentum & loops of
small bowel adherent to the inflamed appendix,
walling off the spread of peritoneal contamination
resulting in a phlegmonous mass or paracaecal
.abscess
Peritonitis occurs as a result of free migration of
the bacteria through an ischemic appendicular
wall, through frank perforation of a gangrenous
appendix or delayed perforation of an appendix
.abscess

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 :Risk factors for perforation of the appendix
Extreme of age, Immunosuppresion, DM. Fecolith
obstruction, Pelvic appendix, previous abdominal
surgery that limit the greater omentum function
CLINICAL DIAGNOSIS
HISTORY
Periumbilical pain, it is poorly localised and -1
colicky (visceral pain)
Anorexia, nausea& usually one or two episodes -2
.of vomiting
With progressive inflammation, the parietal -3
peritoneum in the RIF become irritated producing
more intense, constant& localized somatic pain.
Typically coughing or sudden movement
exacerbates the R.I.F pain .This visceral-somatic
sequence of pain is present in 50% of AA. Atypical
pain is more common in the elderly in whom
.localization to the RIF is unusual
During first 6hrs there is no change in temp. Or -4
PR .After that pyrexia (37.2-37.8C) with increase in
.PR> to 80 or 90 is usual
Typically 2 clinical types of AA.Acute catarrhal
(non obstructive) &acute obstructive type. The
latter characterized by much more acute course.
Once recognized, urgent surgical intervention is
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required because of the more rapid progression to
.perforation

:SIGNS
The diagnosis of AA rests on clinical examination
than on any aspect of the history or Lab.
.Investigation
Low grade pyrexia. 2- Localised abdominal -1
tenderness on the RIF. 3- Muscle guarding &
Rebound tenderness. 4- May be limitation of
.respiratory movement in the lower abdomen
The patient can point where the pain begun& -5
where it moved (Pointing sign). 6- Deep
palpation of the LIF may cause pain in the RIF
(Rovsing sign). 7- Occasionally inflamed
appendix lies on the psoas muscle& patient will
lie with the Rt hip flexed for pain relief (Psoas
sign). 8- If inflamed appendix is in contact with
obturator internus, so when hip is flexed&
internally rotated, the patient will experienced
.pain in the hypogastrium (Obturator sign)

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SPECIAL FEATURES ACCORDING TO
:POSITION OF THE APPENDIX
:RETROCAECAL
.Rigidity is often absent -1
Deep pressure may fail to elicit tenderness the -2
reason being that the caecum distended with gas,
prevents the pressure exerted by the hand from
.reaching the inflamed structure
However deep tenderness in the loin& rigidity -3
.of quadratus lumborum may be present
Psoas spasm with flexion of the hip joint, -4
hyperextension of hip joint may induce abdominal
.pain

:PELVIC
Early diarrhea occasionally occurs when -1
.inflamed appendix being in contact with rectum
Complete absence of rigidity& often no -2
.tenderness over Mc Burney point
Deep tenderness can be made out just above & -3
.to the Rt of the symphysis pubis
Rectal examination (PR) reveals tenderness in -4
.the rectovesical pouch or pouch of Douglas
Spasm of psoas or obturator internus muscles -5
.may be present
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When appendix in contact with the bladder may -6
.cause frequency of micturition

:POSTILEAL
Appendix lies behind the terminal ileum, it
presents the greatest difficulty in diagnosis
:because
The pain may not shift. 2- Diarrhea is a feature. -1
.3- Marked retching may occur
Tenderness is ill defined; it may be present to -4
.the RT of umbilicus

SPECIAL FEATURES ACCORDING TO AGE

:INFANTS
Appendicitis is rare in infants under 36 months -1
.of age
Diagnosis is often delayed & thus the incidence -2
of perforation& postoperative morbidity is high
.than in older children
Diffuse peritonitis can develop rapidly due to -3
underdeveloped greater omentum which is unable
.to give much assistance in localising the infection

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:CHILDREN
Rare to find a child with AA who has not -1
.vomited
Usually complete aversion to food. -2
.3- They dont sleep during the attack
Bowel sounds are completely absent in the -4
.early stages

:THE ELDERLY
Gangrene& perforation occur much more
frequently in elderly. Lax abdominal wall or
obesity gives little evidence of it &clinical picture
may simulate subacute IO. These features,
coupled with concident medical condition produce
.a high mortality in the elderly

:THE OBESE
Obesity can obscure& diminish all the local signs
of AA. Delay in diagnosis coupled with operative
technical difficulties makes it wiser to consider
.midline abdominal incision

:PREGNANCY
AA is the most common extrauterine abdominal
condition in pregnancy with a frequency of 1 in
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1500 to 1 in 2000 pregnancies. Early non specific
signs are often attributed to the pregnancy. As
pregnancy develops during the 2nd& 3rd trimester,
the caecum& appendix are pushed to the Rt upper
quadrant of the abdomen, However pain in the Rt
lower quadrant remains the cardinal feature of AA
in pregnancy. Fetal loss occurs in 3-5% of cases
.increasing to 20% in perforated AA

:DIFFERENTIAL DIAGNOSIS CHILDREN

ACUTE GASTROENTERITIS: There is -1
intestinal colic, diarrhea& vomiting but
localised tenderness doesnt usually occur.
There is often a history of other family member
being affected. Postileal AA may mimic this
condition, thus hospital admission
&observation, if serious doubt persist,
Laparoscopy or surgical exploration may be
.indicated
MESENTRIC LYMPHADENITIS; colicky -2
pain, the Pt may be completely free from pain
between attacks which last few minutes.
Cervical LN may be enlarged. Shifting
tenderness when the child turns on to his Lt side

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may be present. If doubt exist, exploration is
.advisable

MECKELS DIVERTICULITIS; the pain is -3

similar to AA, however signs may be central or
Lt sided. History of intermittent lower GI
.bleeding

INTUSSUSCEPTION; AA is uncommon -4
before age of 2 where as median age of the
intussusception is 18 mths. A mass may be
palpable in the Rt lower quadrant, reduced by
.barium enema
HENOCH-SCHONLEIN PURPURA; -5
Often preceded by a sore throat or respiratory
infection, sever abdominal pain, always there is
ecchymotic rash mainly at extensor surfaces of
the limbs& buttocks. Microscopic hematuria is
common. Platelets count & bleeding time are
.normal

LOBAR PNEUMONIA& PLEURISY; -6

Especially the Rt base may give rise to Rt sided
abdominal pain, abdominal tenderness is
minimal, marked pyrexia, may be pleural rub,
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altered breath sound, a chest radiography is
.diagnostic

:ADULTS
TERMINAL ILEITIS; May be -1
indistinguishable from AA unless doughy mass
can be felt. History of abdominal cramping, wt
loss& diarrhea suggest regional ileitis which
.may be due to crohns or yersinia infection
URETERIC COLIC; Character&radiation -2
of pain differs from that of AA. Urinalysis
should always be performed. KUB or IVU is
.diagnostic
RIGHT SIDED ACUTE -3
PYELONEPHRITIS; is accompanied or
preceded by increased frequency of micturition.
Tenderness confined to the loin, fever (39C) &
.may be rigor& pyrexia

PERFORATED PEPTIC ULCER; The -4

duodenal contents pass along the paracolic
.gutter to the right iliac fossa
There is a history of dyspepsia, very sudden
onset of pain that starts in the epigastrium&
passes to the RIF. Rigidity& tenderness are
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present in both conditions, but in PPU the
rigidity usually greater in the Rt
hypochondrum. An erect CXR will show gas
under diaphragm in 70% of pts
TESTICULAR TORSION; in a teenage or -5
young adult male, pain may be referred to the
RIF. The scrotum is odematus & red with
.tender testis
ACUTE PANCREATITIS; Excluded by -6
serum or urinary amylase level
RECTUS SHEATH HEMATOMA; It's -7
rare, but easily missed. Acute pain& localised
tenderness in the RIF without GI upset often
after episode of strenuous exercise. In an
elderly it may occur when anticoagulant
.therapy taken

:ADULT FEMALE
In women of childbearing age, the pelvic
disease most often mimic AA, so careful
gynecological history should be taken in all
.cases of suspected AA
PELVIC INFLAMMATORY DISEASES -1
(PID): It includes salpingitis endometritis&
tubo-ovarian sepsis. Typically the pain is lower
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than in AA& is bilateral. History of vaginal
discharge, dysmenorrhea, burning micturition is
helpful diagnostic points. On PV cervical
tenderness. High vaginal swab should be taken.
Transvaginal U/s is helpful

MITTELSCHMERZ: Mid-cycle rupture of -2

ovarian follicular cyst with bleeding can
produce lower abdominal& pelvic pain.
Systemic upset is rare. Pregnancy test is
negative. Symptoms usually subside within
.hours

TORSION/HEMORRHAGE OF AN -3
OVARIAN CYST; Pelvic U/S& gynecol.
.Opinion should be sought
ECTOPIC PREGNANCY; Its unlikely that -4
a ruptured ectopic pregnancy with sign of
haemoperitonium will be mistaken for AA, but
Rt sided tubal abortion or unruptured tubal
pregnancy may be difficult except that the pain
commences on the Rt side& stays there, the
pain is sever& continue till operation. Usually
there is a history of a missed period. Pregnancy
test may be positive. Severe pain is felt when
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the cervix is moved in vaginal examination.
Pelvic U/S is helpful

;ELDERLY
SIGMOID DIVERTICULITIS; in some -1
patients with long sigmoid loop, the colon lies
to the Rt of midline & it may be impossible to
differentiate between diverticulitis &
appendicitis. Abdominal CT is useful. A trial of
conservative treatment with IVF& antibiotics is
often benefit. If no response or deterioration,
.exploratory laparotomy is performed
INTESTINAL OBSTRUCTION; -2
Diagnosis of I.O is usually clear
CARCINOMA OF THE CAECUM; May -3
mimic or cause obstructive AA. Altered bowel
habit. Unexplained anaemia should raise
suspicion. Mass may be palpable. Barium
enema is diagnostic

;RARE DIFFERENTIAL DIAGNOSIS

PREHERPETIC PAIN OF THE Rt 10th or 11th-1
DORSAL NERVE: Pain doesnt shift, marked
hyperesthesia, no intestinal upset, Herpetic
eruption after few hrs
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;TABETIC CRISIS-2
SPINAL CONDITIONS: TB of the spine, -3
Metastatic cancer, Osteoporosis, Multiple
myeloma
PORPHYRIA& DM-4
TYPHLITIS OR LEUKEMIC -5
ILEOCAECAL SYNDROME

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