Appendicitis

Handbook of pathophysiology,
2008
Histology

Handbook of pathophysiology,
2008
Anatomy

Gastrointestinal Surgery, Debas,

2004
 Physiology
Lymphoid tissue appears in the appendix
2 weeks after birth. The number of
follicles peaks at 200 between ages 12
and 20 years.
Secretory immunoglobulins are produced
as part of gut-associated lymphoid tissues
to protect the milieu interior.
Appendectomy does not predispose to
bowel cancer or alter the immune system.

Schwartz : Principles of Surgery,

1997
 is innervated by T-10,the same somatic
innervation as the skin surrounding the umbilicus.
Thus, in early appendicitis, when only the visceral
wall of the appendix is involved, the pain is
initially referred to the region of the umbilicus.
 Pathophysiology
Inflammation of the appendix, known as
appendicitis, may occur (1) for no obvious
reason, (2) after obstruction of the appendix
with stool, or (3) from either the organ or its
blood supply being twisted.
The inflammation results in a swollen, tender
appendix, which can lead to gangrene of the
organ as blood supply is compromised.
The appendix may also burst; this typically
happens between 36 and 48 hours after the
onset of symptoms.
Handbook of pathophysiology,
2008
 A primary event in the initiation of acute appendicitis is luminal
obstruction, which in over 70% of cases is caused by fecalith, foreign
body, tumor of the appendix or cecum, parasites, or fibrous bands.
When such definitive obstruction is present, appendicitis is likely to
progress rapidly and result in gangrene and perforation, known as
acute obstructive appendicitis.
In approximately 25% to 30% of patients with acute appendicitis, no
luminal cause for obstruction is found. Instead, hyperplasia of the
submucosal lymphoid follicles appears to compromise the appendiceal
lumen. Such lymphoid hyperplasia has been related to recent or
concurrent incidences of upper respiratory tract or other viral
infections, particularly in children.
Acute obstructive appendicitis can progress within 12 to 24 h to
gangrene of the wall of the appendix and perforation.
Perforation may become rapidly confined by the omentum and/or
small bowel and develop into an appendiceal abscess.

Gastrointestinal Surgery, Debas,

2004
 When the perforation is not localized, general
peritonitis develops. Unless quickly treated,
pelvic, intramesenteric and/or subphrenic
abscesses ensue.
Acute appendicitis may lead to hematogenous
spread of bacteria and infection of the portal
vein (pylephlebitis) or liver abscesses.
The diagnosis of acute appendicitis can be
difficult in the very young, the very old, and in
individuals on steroid therapy, in whom the
classic signs and symptoms may not be evident.
Gastrointestinal Surgery, Debas,
2004
 sequence of events to explain appendicitis:
(1) closed loop obstruction is caused by a fecalith and
swelling of the mucosal and submucosal lymphoid
tissue at the base of the appendix;
(2) intraluminal pressure rises as the appendiceal
mucosa secretes fluid against the fixed obstruction;
(3) increased pressure in the appendiceal wall exceeds
capillary pressure and causes mucosal ischemia; and
(4) luminal bacterial overgrowth and translocation of
bacteria across the appendiceal wall result in
inflammation, edema, and ultimately necrosis.

Maingot's, 2010
 Symptomatic closed-loop obstruction develops because of the
continued mucosal secretion into 0.1-mL capacity lumen and
because of rapid multiplication of resident bacteria of the
appendix.
Distention stimulates visceral afferent pain fibers, producing
vague, dull, diffuse middle and lower abdominal pain. Sudden
distention may cause peristalsis with cramping.
Venous pressure is exceeded, and arteriolar inflow causes
vascular congestion of the appendix, with reflex nausea.
Serosal engorgement inflames the parietal peritoneum with shift
or more severe pain to the right lower quadrant.
Mucosal compromise allows bacterial invasion, with consequent
fever, tachycardia, and leukocytosis. With progresive distention,
antimesenteric infarction and perforation occur.

Schwartz : Principles of Surgery,

Companion Handbook, 1997