AC.

APPENDICI
TIS
By;
Col.Abrar Hussain Zaidi
 OUTLINE
Introduction
Surgical anatomy
Epidemiology
Pathophysiology
Diagnosis
Management
Complications
Prognosis
INTRODUCTION
A wormlike intestinal diverticulum
starting from the blind end of the cecum in
the right lower part of the abdomen and
ending in a blind extremity.
Located At OR NEAR McBurney's point
Appendicitis (or epityphlitis) is condition
characterized by inflammation of the
appendix
 INTRODUCTION

Fitz described the natural history

of appendicitis as early as 1889.
That same year, Mc.Burney gave
his classic treatise on the anatomy
of appendicitis
Mc.Burney's point, 1/3 of the way along
a line drawn from the Anterior Superior
Iliac Spine to the Umbilicus.
INTRODUCTION[cont]
Appendicitis is a common and urgent surgical illness
with protean manifestations, generous overlap with other
clinical syndromes, and significant morbidity, which increases
with diagnostic delay. No single sign, symptom, or diagnostic
test accurately confirms the diagnosis of appendiceal
inflammation in all cases.

The surgeon's goals are to evaluate a relatively small

population of patients referred for suspected appendicitis and
to minimize the negative appendectomy rate without
increasing the incidence of perforation. The emergency
department clinician must evaluate the larger group of patients
who present to the ED with abdominal pain of all etiologies with
the goal of approaching 100% sensitivity for the diagnosis in a
time-, cost-, and consultation-efficient manner.
Anatomy
Anatomy
Anatomy

The appendix averages from 5 to 20

cm, with an average length of 9 cm.
Mc.Burneys point is defined as the
area under a single finger that lies
1.5 to 2 inches from the ASIC along
a straight line from that anatomical
landmark to the umbilicus.
Epidemiology
The lifetime risk of developing acute appendicitis
is 7% and hasnt changed since
it was first characterized.
Mortality is low, less the 1%, except in the elderly
andpediatric populations.
Mean age at time of surgery is 25.5 years.
Sex a slight predominance of men affected vs.
women, up to 67% in some studies.
Negative appendectomy rates traditionally 20-30%
are improving slightly,
Perforation rate still remains at near 20% despite
advances in technology.
Pathophysiology

Inciting factor
Obstruction of the appendiceal lumen
Bacterial overgrowth of the distal lumen takes
place.
Intraluminal pressure rises . This results in
venous hypertension, which perpetuates the
cycle by contributing to wall thickening.
This sequence of events occurs over 24-36
hours.

unchecked -leads to perforation and peritonitis.

Pathophysiology[cont.]

Inflammation of appendiceal lymphoid

tissue
results in the majority of cases of appendicitis,
about 60%.

This can be caused by something as simple as

gastroenteritis or may be a manifestation
of more advanced colonic disease such as
Crohns.
 Pathophysiology[cont.]

luminal obstruction fecaliths+others

[Fecaliths calcium salts and fecal debris become layered around a
nidus of inspissated fecal material located within the appendix ]
[ Obstruction of the appendiceal lumen has less commonly been
associated with parasites (eg, Schistosomes species, Strongyloides
species), foreign material (eg, shotgun pellet, intrauterine device,
tongue stud, activated charcoal), tuberculosis, and tumors

and
lymphoid follicle hyperplasia-many causes
[Crohn disease, gastroenteritis, amebiasis, respiratory infections,
measles, and
mononucleosis.]
 Diagnosis

ACUTE APPENDICITIS IS
ESSENTIALLY
A CLINICAL DIAGNOSIS
 Some considerations
Acute abdominal pain is defined as
previously undiagnosed pain of <72
hours duration
Accounts for about 2% of hospital
admissions
In only 50% of patients is the
preoperative diagnosis correct
Right iliac fossa pain accounts for
about half of all cases of acute
abdominal pain
Clinical presentation

1. CLASSICAL
2. VARIANT
Clinical
presentation[cont]
Patients profile
Complaints/H.O Present illness
Past history
Clinical presentation
[cont]
While taking history and doing
physical examination;
Careful attention should be paid to the
sequence of events.

Pain almost always precedes nausea and

vomiting
patients that state they are hungry
(hamburger sign) almost invariably are
not suffering from acute appendicitis.
Clinical presentation
[cont]
Essential Diagnostic features
Shifting of pain to right iliac fossa
Localized tenderness
Rebound tenderness
Alternative modes
of presentations.
TYPICAL /CLASSICAL < 50%
VARIABLITY COMMON
Children
Pregnancy
Adolescent girls
Elderly
Variable positions of appendix
Sub-acute and recurrent appendicitis
Special features

The signs/, according to position of

the appendix-
Retrocaecal. Pelvic. Post ileal
Special features

Pointing sign
Rovsings sign
The psoas sign
The obturator test
Variable /atypical
presentation
Children
Pregnancy
Adolescent girls
Elderly
Variablepositions of appendix
Sub-acute and recurrent
appendicitis
Alvarados Scoring
System
Symptoms Score
Migratory right iliac fossa pain 1
Nausea / Vomiting 1
Anorexia 1
Signs
Tenderness in right iliac fossa 2
Rebound tenderness in right iliac fossa 1
Elevated temperature 1
Laboratory findings
Leucocytosis 2
Shift to the left of neutrophils 1
Total 10
 Scoring
Aggregate score 7-10 (emergency surgery group):
These patients were prepared for emergency
appendicectomy.
Aggregate score 5-6 (observation group): admitted
and kept under observation for 24 hours with frequent
re-evaluation of the
clinical data and reapplication of the score. Patients
who improve shown by a decrease in score are
discharged with the instructions that they should come
back if symptoms persist or increase in intensity.
Aggregate score 1-4 (discharge home group):
These patients, after giving initial symptomatic
treatment,are discharged and sent home with the
instructions,to come back if symptoms persist or
condition become worse.
Causes of right iliac
fossa pain-D/D
Appendicitis, Diverticulitis
Urinary tract infection
Non-specific abdominal pain
Pelvic inflammatory disease
Renal colic
Ectopic pregnancy
Constipation
Causes of right iliac
fossa mass-D/D
Appendix mass
Crohn's disease
Caecal carcinoma
Mucocele of the gallbladder
Psoas abscess
Pelvic kidney
Ovarian cyst
Radiology/imaging
In most cases of appendicitis,
radiographs are not necessary.

Radiologic examinations are reserved in

cases where ambiguity exists, or where
the morbidity of the operation (including
anesthesia) would be poorly tolerated
by the patient.
Radiology/imaging
Plain films
A fecalith is present in < 15% of cases. Free air
from perforation is seen 1% of
the time.1 Overall a very poor study.
Ultrasound
Most effective in young females of child-bearing
age in the evaluation of adnexal disease which is
high on the differential.
U/S is no better than history and physical alone
INDEED MORE IMPORTANT TO RULE OUT A
CONDITION OR FIND AN ASSOCIATED PROBLEM
Radiology/imaging

Computed Tomography
Superior in both pediatric and adult
populations in elucidating equivocal
cases
It has a sensitivity ranging from 96-
100%, a specificity of 89-97%,a PPV of
92-97%, and a NPV of 95-100%. CT scan
of the appendix has been
Radiology/imaging

Radio-nuclide SCAN

Sensitivity and specificity of >90% achieved.

Added expense of about $500 and the

Delay in acquisition of 5 hours rarely justify

this novel radiographic approach.
Management

The goal of the surgical

approach

An early diagnosis with resection of

an acutely inflamed appendix prior to
perforation,
A minimum of negative
appendectomies.
Management

Pre-operative treatment
Operation
post operative treatment
Treatment of complications
Pre-operative treatment

Pain
Antibiotics
Fluids
Preparation
Consent
OperativeTreatment

Open Appendectomy
A transverse Rocky-Davis or the classical McBurney
skin incision is made in theRLQ over the area of
maximal tenderness.
If purulent or cloudy peritoneal fluid is encountered, it
should be sent for culture and sensitivity.
The appendix is identified at the confluence of the
taeniea coli, and the mesoappendix is clamped and
divided.
A silk purse string suture is placed at the base of the
appendix,then clamped,ligated with catgut, and
divided sharply.
OperativeTreatment[co
nt]
The appendiceal stump can be cauterizedeither
chemically or electrically (dealers choice), and
dunked into the cecum.
The fascia is closed, and the skin also except in
cases of perforated appendicitis.
OperativeTreatment[co
nt]
If the appendix is perforated, historical management
has been either delayed primary closure or primary
closure with drainage.

When a normal appendix is encountered, a limited

exploration is warranted to rule out nearby pathology. In
all cases except for IBD, the appendix should be
removed to eliminate the possibility of confusion in
future cases of RLQ pain. If an appendix is removed in
the presence of active IBD, a fecal fistula may ensue.
LOOK FOR MECKLES DIVERTICULUM/OTHRERS
OperativeTreatment[co
nt]
Laparoscopic Appendectomy
One randomized study suggests that even though hospital stay was
about the same, patients undergoing laparoscopic appendectomy
returned to work in 7 versus10 days. They also had fewer wound
infections. However, laparoscopy was associated with a greater number
of intra abdominal abscesses (5% versus 1%) and a longer operating
time (60 versus 40 minutes). Finally, almost a fourth of 285 patients
randomized to laparoscopy required conversion to open
apendicectomy. Nonetheless,the patients who underwent
laparoscopy were more pleased with their cosmetic surgery.Another
study suggests that laparoscopic appendectomy at least had no obvious
disadvantages. In defense of laparoscopy, it has proved its worth in
certain circumstances,for example in women of child-bearing age, due to
its increased diagnostic value. Additionally,in obese or heavily
muscles individuals where larger incisions and excessive retraction
may be required, laparoscopy has turned out to be the preferred
modality for many.4
If normal appendix
removed -need to look for:
Meckel's diverticulum
Acute salpingitis
Crohn's disease
Antibiotics

Generally not disputed, but the length of treatment is.

For perforated appendicitis, some surgeons will use
extended spectrum synthetic penicillins.

Others will use ampicillin, gentamycin, and metronidazole.

Nevertheless, monotherapy with a second generation
cephalosporin is more economical

A total of 3 days of antibiotic therapy above and beyond

the point where the patient is no longer febrile or has a
leukocytosis is sufficient.
COMPLICATIONS

Perforation
Abscess and mass formation
Liver abscess
Gen.peritonitis
Septicaemia
Appendiceal Mass and
Abscess
A palpable conglomeration of inflamed tissues,
including the appendixand adjacent viscera.
CT scan of the abdomen and appendix can
delineate a phlegmon versus an abscess, the
treatment of which are distinct.
A difference of opinion revolves around the
necessity of an operative approach
conservative regimen. A conservative approach
with antibiotics, the so-called Ochsner method,

Ochsner method,
Based on the following three principles:

1. It is more difficult to remove the appendix

2. One can always revert to an operative approach
if the patient deteriorates
3. Conservative treatment works in > 80%

however, the conservative approach requires an extended

hospital stay initially, not to mention the interval
appendectomy that will be performed at a later date.
Appendicular abscess may be treated
with ;
Percutaneous Drainage and concomitant IV antibiotics. As
it resolves, an interval appendectomy can be entertained,
usually at least 3 months after the attack. It has been shown
that of the patients treated nonoperatively for abscess as
well as phlegmon

5% will fail this approach,and up to 40% will return within a

year with recurrent acute appendicitis requiring
appendectomy.4

Open drainage
Prognosis and Outcomes

CURE RATES HAVE SIGNIFICANTLY

IMPROVED OVER LAST 70 YEARS

THANKS TO;
Better diagnosis,antibiotics,early and
better surgical treatment
Prognosis and Outcomes
The overall mortality rate of 0.2-0.8% is attributable to
complications of the disease rather than to surgical
intervention.

Mortality rate rises above 20% in patients older than 70

years, primarily because of diagnostic and therapeutic delay.

Perforation rate is higher among patients younger than 18

years and patients older than 50 years, possibly because of
delays in diagnosis.
Appendiceal perforation is associated with a
sharp increase in morbidity and mortality rates.
Prognosis and Outcomes
Although perforation rates have not
decreased over the past 70 years, mortality
has decreased from 26% to less than 1% over
the same period. Most of the morbidity
and mortality associated from appendicitis is
suffered by the very young and the very old.
A retrospective review found a perforated
appendix rate of 20%.
Overall mortalitywas only 0.24%, but of the deaths
reported, 93% occurred in the age group >50