Presenter: Dr. Elias M Chrisant
Facilitator: Prof Obadia Nyongole
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Outline
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Definition
A historical perspective
Epidemiology
Etiology
Classification
Pathophysiology
Clinical presentation
Differential Diagnosis
Work up
Treatment
Complications.
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DEFINITION
• Appendicitis refers to inflammation of the vermix
appendix
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A HISTORICAL PERSPECTIVE
• First described by Reginald Fitz in 1886 who also was
the first to advocate appendicectomy as the cure
• In 1889 Charles McBurney described the clinical
findings of acute appendicitis including the point of
maximum tenderness in RIF which bears his name
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EPIDEMIOLOGY
• Incidence:
– The incidence is higher in developed countries and in
developing countries which are adopting a more refined
western type diet
– Incidence of appendicitis is lower in cultures with a higher
intake of dietary fiber
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EPIDEMIOLOGY [cont’d]
• Mortality/Morbidity:
– 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 an increase in
morbidity and mortality rates
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EPIDEMIOLOGY [cont’d]
• Sex:
– The incidence of appendicitis is approximately 1.4 times
greater in men than in women
– The incidence of primary appendicectomy is approximately
equal in both sexes
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EPIDEMIOLOGY [cont’d]
• Age:
– Appendicitis may occur at all ages, but is most commonly
seen in the 2nd and 3rd decades of life
– The incidence of appendicitis gradually rises from birth,
peaks in the late teen years, and gradually declines in the
geriatric years
– Although rare, neonatal and even prenatal appendicitis have
been reported in literature
– The emergency physician must maintain a high index of
suspicion in all age groups
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AETIOLOGY
• Etiological factors for appendicitis include:– Appendiceal luminal obstruction
– Diet
– Social status
– Familial susceptibility
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Appendiceal luminal obstruction
• Luminal causes
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Feacolith
Lymphoid follicle hyperplasia
Worms e.g. ascaris
Foreign body
• In the wall
– Stricture
– Neoplasms
• Outside the wall
– Adhesions
– kinks
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Diet
• Low intake of dietary fiber is associated with
increased incidence of appendicitis
• Dietary fiber is thought to decrease the viscosity of
feces, decrease bowel transit time, and discourage
formation of faecaliths that predispose individuals to
obstructions of the Appendiceal lumen.
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Familial tendency
• Appendicitis tends to run in certain families
may be due to peculiar position of the organ
which predisposes to infection
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CLASSIFICATION
• Clinical classification
• Pathological classification
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Clinical classification
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Acute appendicitis
Sub-acute appendicitis
Recurrent appendicitis
Chronic appendicitis
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Pathological classification
• Obstructive appendicitis
• Non-obstructive appendicitis
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PATHOPHYSIOLOGY
• Two types:– Obstructive appendicitis
– Non-obstructive appendicitis
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Obstructive appendicitis
• Luminal obstruction and mucus production result in
increased intraluminal pressure
• Bacteria trapped within the Appendiceal lumen begin to
multiply, and the appendix becomes distended
• Luminal distention stimulates visceral nerve endings
concerned with pain [visceral pain]
• This produce dull aching pain felt periumbilically
according to nerve supply of the appendix (T10) 
referred pain
• Venous congestion and edema follow next, and by 12 hours
after onset, the inflammatory process may become transmural
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Obstructive appendicitis [ cont.]
• Peritoneal irritation then develops
• If the obstruction is left untreated, arterial blood flow
to the appendix is compromised, and this leads to
tissue ischemia and necrosis
• This stimulates parietal nerve endings shift of pain
to the RIF
• Full thickness necrosis of the Appendiceal wall leads
to perforation with the release of fecal and
suppurative contents into the peritoneal cavity
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Obstructive appendicitis [cont.]
Depending on the duration of the disease process,
either a localized walled-off abscess or mass occurs, or
if the pathologic process has advanced rapidly, the
perforation is free in the peritoneal cavity and
generalized peritonitis occurs
The commonest bacterial growth from inflamed
appendices include Escherichia coli, Kleblesiella spp., Proteus
spp and Bacteroids
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Non-obstructive appendicitis
• This is less dangerous type
• Inflammation commences in the mucous membrane or in the
lymphoid follicles and gradually spread to the sub mucosa
• As there is no obstruction there is not much distension, but
when the serosa is involved localizing peritonitis develops and
the patient c/o RIF pain
• Such inflammation terminates either by:–
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Suppuration
Gangrene
Fibrosis
Resolution
• Many of the sub-acute appendicitis, recurrent appendicitis and
chronic appendicitis develop from this variety
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CLINICAL PRESENTATION
• History: classic symptoms include:– Periumbilical pain [visceral pain] which shifts and localize
to the RIF [parietal or somatic pain]
– Periumbilical pain is colicky in nature in obstructive type
and is dull aching and constant in non-obstructive type
– RIF pain is sharp intense and well localized to the RIF
– Anorexia
– Nausea & Vomiting
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CLINICAL PRESENTATION [cont’d]
• Physical examination
– Pyrexia
– RIF tenderness
– Muscle guarding
– Rebound tenderness
– Special test to elicit in appendicitis
• Pointing sign[The pt will point where the pain begun and where it
moved]
• Rovsing’s sign [RIF pain with palpation or purcasion of the LIFdue to referred pain ]
• Obturator sign [RIF pain with passive internal rotation of the
flexed right hip]
• Psoas sign [RLQ pain with hyperextension of the right hip If the
appendix is lying near the psoas muscle ]
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DIFFERENTIAL DIAGNOSIS
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Abdominal disorders
Gynecological disorders
Retroperitoneal disorders
Thoracic disorders
Others
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Abdominal disorders
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Acute cholecytitis
Perforated peptic ulcers
Enterocolitis
Intestinal obstruction
Carcinoma caecum
Crohn’s diseases
Amoebic colitis
Meckel’s diverticulitis
Acute pancreatitis
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Gynecological disorders
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Pelvic Inflammatory Disease (PID)
Ectopic pregnancy
Twisted ovarian cyst
Ruptured ovarian follicles
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Retroperitoneal disorders
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Right ureteric colic
Right sided acute pyelonephritis
Right sided testicular torsion
Retroperitoneal hematoma.
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Thoracic disorders
• Basal pneumonia
• Pleurisy
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Miscellaneous
• Henoch-Schoenlein purpura
• Porphyria
• Diabetic abdomen
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WORK UP
• Lab investigations
– Complete blood cell count
• Leukocytosis
• Neutrophilia greater than 75%
– C-reactive protein test
– Urinalysis
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WORK UP [cont’d]
• Imaging investigations
– Abdominal radiography
• The kidneys-ureters-bladder (KUB) view is typically used
• Visualization of an appendicolith in a patient with symptoms
consistent with appendicitis is highly suggestive of appendicitis,
but this occurs in fewer than 10% of cases
• The consensus in the literature is that plain radiographs are
insensitive, nonspecific, and is not cost-effective
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WORK UP [cont’d]
• Abdominal Ultrasonography
– An outer diameter of greater than 6 mm,
noncompressibility, lack of peristalsis, or
periappendiceal fluid collection characterizes an
inflamed appendix
– The normal appendix is not visualized
– It’s noninvasive, short acquisition time, lack of
radiation exposure, and potential for diagnosis of
other causes of abdominal pain, particularly in
the subset of women of childbearing age
– However it is operator dependent
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WORK UP [cont’d]
• Computed tomography
– Abdominal CT has become the most important imaging study in the
evaluation of patients with atypical presentations of appendicitis
– Advantages of CT scanning include
• Sensitivity and accuracy compared with those of other imaging
techniques
• Readily available
• Noninvasive
• potential to reveal alternative diagnoses
– Disadvantages
• lengthy acquisition time if oral contrast is used
• patient discomfort if rectal contrast is used
• Exposure to radiation
– It is really required to make diagnosis of acute appendicitis
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DIAGNOSTIC SCORING SYSTEM
• Various scoring systems have been devised to aid diagnosis
of appendicitis
• Although many diagnostic scores have been advocated, most
are complex and difficult to implement in the clinical
situation
• The Alvarado score, is a simple scoring system that can be
instituted easily
• The Classic Alvarado score [1986] is based on three
symptoms, three signs and two laboratory findings ad has a
total score of 10
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Classic Alvarado Score [1986]
Features
Score
Symptoms
• Migratory RIF pain
• Anorexia
• Nausea & vomiting
Signs
• Pyrexia
• Tenderness RIF
• Rebound tenderness RIF
Lab investigations
• Leucocytosis
• left shift of neutrophil maturation
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1
Total
10
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1
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2
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Diagnostic Scoring System [cont.]
• Kalan et al [1994] omitted one lab parameter [left
shift of neutrophil maturation] which is not
routinely available in many laboratories, and
produced a modified score which have only one lab
findings
• A modified Alvarado score [1994] is based on three
symptoms, three signs and one laboratory findings
[total score of 9]
• MAS is commonly used.
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Modified Alvarado Score [1994]
Features
Symptoms
Migratory RIF pain
Anorexia
Nausea & vomiting
Score
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1
Signs
Pyrexia
Tenderness RIF
Rebound tenderness RIF
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Lab investigation
leucocytosis
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Total
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MASS- interpretation
• A score of 1-4:[ discharging group] The
diagnosis of acute appendicitis is unlikely
• A score of 5-6: [observing group] Probable to
have appendicitis but not convincing to have
urgent appendicectomy
• A score of 7-9:[emergency group] Regarded as
probable to have acute appendicitis and needs
emergency appendicectomy
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TREATMENT
• The treatment of appendicitis is
appendicectomy
• appendicectomy can be elective, emergency or
interval
• Two types of appendicectomy:– Conventional open appendicectomy
– Laparoscopic appendicectomy
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Preoperative care
• Iv fluid
• Analgesics
• Preoperative antibiotics with broad spectrum
antibiotics
• Check Hb, blood grouping and cross
matching
• Shaving
• Written informed consent
• Pre-anaesthetic visit
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Intraoperative care
• Open appendicectomy
– Incisions
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Grid-iron incision
Rutherford Morrison’s
Lanz’s [transverse skin crease]
SUMI when the diagnosis is not clear
Right lower Para median
Midline incision
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Intraoperative care cont’d
• Appendiceal locations of the tip
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Retrocaecal appendix [70%]
Pelvic appendix [25%]- the tip hangs in the pelvic brim
Subcaecal appendix [2%]
Splenic appendix [1%]- either pre- or post-ileal i.e anterior
or posterior to the terminal ileum
– Paracaecal appendix [1%]
– Paracolic appendix [1%]-either to the right or left of
ascending colon, the tip in the extraperitoneal tissue
• Location of the base-is constant, being found at
confluence of 3 taeniae coli of the caecum which
fuse to formthe outer longtudinal muscle coat of the
appendix.
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Post operative care
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Iv fluids
Analgesics
Antibiotics
MonitorVital signs
Discharge home in 2-3 days postoperatively
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COMPLICATIONS
• Complications of acute appendicitis
• Postoperative complications
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i. Complications of acute appendicitis
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Appendicular mass
Appendicular abscess
Recurrent appendicitis
Perforation peritonitis
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Treatment of complications
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Appendicular abscess
Appendicular mass
Peritonitis
Recurrent appendicitis
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A. Appendicular mass
• Use conservative Ochsner-Sherren regime
– Iv fluid
– NGT
– Analgesics
– Antibiotics –parenteral
– Mark the limits of the mass on the abdominal wall
using a skin pencil
– Monitor- vital sign, size of the mass, input/output
chart
– Clinical improvement is expected in 24-48 hours.
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Appendicular mass [cont.]
• Criteria for stopping OSR
– Increased pulse rate
– Increasing or spreading abdominal pain
– Increasing the size of the mass
– Vomiting or increasing gastric contents
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B. Appendicular Abscess
• I&D
• Antibiotics
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C. Recurrent appendicitis
• Elective appendicectomy
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ii. Postoperative complications
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Wound infections
Intrabdominal abscess
Paralytic ileus
Fecal fistula
Adhesive intestinal obstruction
Portal pyrexia due to septicemia in the portal venous
system
Respiratory complications
DVT embolism
RIH due to damage to iliopogastric / ilioinguinal
nerves
Incisional hernia
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THE END
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