ACUTE
APPENDICITIS
By - Muskan Bhardwaj
Group 01
INTRODUCTION
•Appendicitis is an inflammation of the
appendix.
ANATOMY
ANATOMICAL VARIANTS
• Pre-ileal – anterior to the terminal ileum – 1 or 2 o’clock.
• Post-ileal – posterior to the terminal ileum – 1 or 2 o’clock.
• Sub-ileal – parallel with the terminal ileum – 3 o’clock.
• Pelvic – descending over the pelvic brim – 5 o’clock.
• Subcecal – below the cecum – 6 o’clock.
• Retrocecal – behind the cecum – 11 o’clo ck.
• The most common position is retrocecal.
• 2nd MC - pelvic
• Least common -post ileal.
ARTERIAL SUPPLY
• The appendix is derived from the embryologic midgut.
• The vascular supply is via branches of the superior mesenteric vessels.
• Arterial supply is from the appendicular artery (derived from the ileocolic
artery, a branch of the superior mesenteric artery)
• Accessory - Artery of seshachalam
• ( branch of Post. Caecal Artery)
VENOUS DRAINAGE
• v. appendicularis -----> v. ileocolica----> v. mesenterica
superior----> v. portae
•
Clinical relevance
• Portal way of the infection spread –
• pilephlebitis (fatal comlication of
• appendicitis)
LYMPHATIC DRAINAGE
• Lymphatic fluid from the appendix drains into lymph nodes within
the mesoappendix and into the ileocolic lymph nodes (which
surround the ileocolic artery) .
NERVOUS SYSTEM
• the appendix is innervated by the superior mesenteric plexus,
whereas the parasympathetic fibers come from the vagus nerve
(cranial nerve X).
CLASSIFICATION
• I. Acute appendicitis
• 1.1. Acute simple (catharral ) appendicitis.
• 1.2. Acute destructive appendicitis:
• - Flegmonous ;
• - Gangrenous ;
• - Gangreno -per forative.
• 1.3. Complications of the acute appendicitis:
• - Peritonitis - localized, generalized;
• - Appendicular infiltrat;
• - Appendicular abscess;
• - Pilephlebitis;
• II. Chronic appendicitis – result of the not operated resolved
• acute appendicitis.
CAUSES
• 1- OBSTRUCTIVE CAUSES
• FECALITH- a fecal calculus or stone that occlude lumen of the appendix
• Twisting or curling or the appendix
• Swelling of the bowel wall
• Lymphoid hyperplasia
• 2- NON-OBSTRUCTIVE CAUSES
• Haematogenous spread of infection
• Vascular occlusion
• Trauma
• Diet lacking fibres.
PATHOPHYSIOLOGY
SYMPTOMS
• Abdominal pain (100%) constant, moderately intensive. ( Right
lower quadrant)
• Epigastric phase(40-50%): first pain in epigastric or umbilical
region or all over the abdomen (in children) ---------->after a couple
of hours the pain migrates to the right iliac region – symptom of
pain
• Migration Kocher’s-Wolkowitch’s (only almost pathognomonic
symptom of appendicitis).
• Pain right away in the right iliac region (50-60%) .
• ANOREXIA
• Nausea, vomitting (40-50%) 1-
2 times, comes after pain,
reflectory. can be absent;
• NOTE! if nausea or
vomitting before pain - not
a appendicitis
characteristic;
• Tongue firstly wet, then dry.
• TACHYCARDIA
• NOTE! if dry tongue - sign
of dehydration.
SIGNS
• 1- Tenderness at MCBURNEY'S POINT
• 2- POINTING SIGN - patient point towards the site of
maximum Tenderness (RT. Iliac fossa)
• 3- ROVSING SIGN- pain in RIF when LIF is pressed
• 4- PSOAS SIGN/COPE PSOAS/ OBRAZTSOV SIGN -
hyperextension of right leg( c/h of retrocaecal appendix)
• 5- OBTURATOR SIGN- flexion and internal rotation of right
hip.
NON-SPECIFIC SIGN
• DUNPHRY SIGN - pain on coughing
• TEN HORN SIGN - pain in RIF when right testes is pulled
• ARON SIGN -pain in RIF when epigastrium is pressed
• BLUMBERG SIGN (rebound tenderness )
• Frequent urination ( tip irritates bladder) interpreted as UTI
• Diarrhoea and tenesmus
• Pain on DRE.
DIAGNOSTIC CRITERIA
•
Alvarado score (a.k.a MANTRELS
score)
• Score total
• 5-6 compatible with acute appendicitis
• 7-8 probable acute appendicitis
• 9-10 very probable acute appendicitis
• ruling out appendicitis with a score <5
than "ruling in" appendicitis with a >7 .
• APPEND score -male gender
•
anorexia
• .
migratory pain
•
localised peritonism
• .
elevated CRP >15 mg/L
• .
neutrophilia >7.5x109/L
• in children, clinicians sometimes use other scores for the same purpose:
• paediatric appendicitis score (PAS)
• paediatric appendicitis risk calculator (pARC) scor e
LABORATORY FINDINGS
• 1- Increased TLC( total leucocytes count) 4000 -11000
• 2- Increased neutrophils (2000-7000 / ml)
• 3- Increased CRP(0.3-1.0 mg/dl)
• IMAGING TEST
• IOC- 1-Adults- CECT
•
2- Children - USG
CECT
USG
DIFFERENTIAL DIAGNOSIS
• inflammatory bowel disease,
especially Crohn disease, which may
affect the appendix
• other causes of terminal ileitis
• appendiceal mucocele
• lymphoid hyperplasia
• pelvic inflammatory disease (PID)
• right-sided diverticulitis
• appendiceal diverticulitis
• Meckel diverticulitis
• acute epiploic appendagitis
• omental infarction
• appendiceal endometriosis
• appendiceal malignancy
• colorectal cancer
• peritoneal metastases
• carcinoid
• isolated appendiceal submucosal
lipomatosis 26
• Valentino syndrome (from perforated
peptic ulcer)
MANAGEMENT
OPEN
APPENDICECTOMY
LAPAROSCOPIC
APPENDICECTOMY
MC Burney's incision
1- grid iron incision( int.
Oblique and transverse
muscle splitting incision)
2- Rutherford Morrison
incision
Lan'z incision ( in gap of
4-6 weeks
appendectomy)
Lower middle line
abdominal incision ( for
perforated appendix)
3 ports
1- infraumblical
2- left iliac fossa 3supra pubic region
STEPS
• 1- locate appendix after peritoneum is open - base is at junction of
three taenia coli
• 2- ligate the appendicular Artery and remove mesoappendix
• 3- clamp the base
• 4- remove the appendix
• NOTE! stump of appendix should be left not more than 4 -5 mm.
COMPLICATION AFTER SURGERY
• 1- haemorrhage
• 2-wound/ surgical site infection (MC)
• 3- ilio-hypogastric nerve injury
• 4- portal pyemia
• 5- pelvic abscess
• 6- stump appendcitis
Source
• https://en.medicina.ru/clinical -c as e/differential -di agnosis -of-acute -appendicitis /
• https://emedicine.medsc ape.com/ar ticle/773895 -differentia
• https://radiopaedia.org/
• https://www.sciencedi rec t.c om/
• https://medlineplus .gov /lab -tes ts /appendici tis -tes ts /
• Pre-pg.c om
THANKYOU