APPENDICITIS
DR KULWANT
LOGO SINGH
Contents
1
Definition
2
Pathophysiology
3
Clinical Features
4
Diagnosis
5
Differential Diagnosis
6
Treatment
Dr Kulwant Singh
Incidence
 Commonest abdominal surgical
emergency.
 One person in six develops
appendicitis at some time.
 It is relatively uncommon in
developing rural communities.
Dr Kulwant Singh
Appendicitis
INFLAMMATION OF
APPENDIX IS
APPENDICITIS
Generally Caused by
an obstruction:
Faecalith. Lymphoid
obstruction, Infection.
Dr Kulwant Singh
Surgical Anatomy
The appendix is attached at the
point of convergence of the
three taeniae coli of the caecum
on its posteromedial wall
- The meso-appendix is a
peritoneal fold containing fat &
appendicular artery
- Commonly behind the caecum
(Retrocaecal)
- On psoas muscle at or below
pelvic brim (Pelvic)
- Rarely : Pre-ileal – Post-ileal –
Paracaecal
- Length less than 1 to greater than
30cm (most are 6-9 cm in length)
- After age of 60 no lymphoid tissue
remains
Dr Kulwant Singh
Surgical Anatomy
Predisposing factors :
1- Obstructive agents
2- Infective agents
Obstructive agents
Foreign bodies :
• animal (e.g. thread worms ,round
worms) ,
• vegetables (e.g. seeds , date stones)
• mineral (faecalith = common cause)
• submucous lymphoid tissue
hyperplasia leads to obstruction
Dr Kulwant Singh
POSITIONS OF APPENDIX
Dr Kulwant Singh
CAUSES
Infective agents :
• Primary infection leading to
lymphoid hyperplasia
• Secondary infection caused
by pressure of an obstructed
agent leads to epithelial
erosion and bacteria gain
access to the wall
• Both aerobic & anaerobic
organisms are involved
including ( coliforms ,
enterococci , bacteroids &
other intestinal commensals )
Dr Kulwant Singh
APPENDICITIS
PATHOPHYSIOLOGY
 Acute appendicitis is thought
to begin with obstruction of
the lumen
 Obstruction can result from
food matter, adhesions, or
lymphoid hyperplasia
 Mucosal secretions continue
to increase intra luminal
pressure
Dr Kulwant Singh
APPENDICITIS
PATHOPHYSIOLOGY
 Eventually the pressure
exceeds capillary perfusion
pressure and venous and
lymphatic drainage are
obstructed.
 With vascular compromise,
epithelial mucosa breaks down
and bacterial invasion by
bowel flora occurs.
Dr Kulwant Singh
APPENDICITIS
PATHOPHYSIOLOGY
Increased pressure also
leads to arterial stasis and
tissue infarction
End result is perforation
and spillage of infected
appendiceal contents into
the peritoneum
Dr Kulwant Singh
APPENDICITIS
PATHOPHYSIOLOGY
As inflammation
continues, serosa and
adjacent structures
become inflamed
This triggers somatic pain
fibers, innervating the
peritoneal structures.
causing pain in the
RLQ
Dr Kulwant Singh
APPENDICITIS
PATHOPHYSIOLOGY
The change in stimulation
form visceral to somatic
pain fibers explains the
classic migration of pain
in the peri-umbilical area
to the RLQ seen with
acute appendicitis.
Dr Kulwant Singh
APPENDICITIS
PATHOPHYSIOLOGY
 Exceptions exist in the classic
presentation due to anatomic
variability of the appendix
 Appendix can be retrocecal
causing the pain to localize to
the right flank
 In pregnancy, the appendix ca
be shifted and patients can
present with RUQ pain
Dr Kulwant Singh
APPENDICITIS
TYPE
ACUTE
APPENDCITIS
ACUTE
APPENDCITIS
WITH MASS
ACUTE
APPENDCITIS
WITH
PERITONITIS
Dr Kulwant Singh
Acute appendicitis
- Organisms enter the
wall & lodge in sub
mucosa , proliferate ,
wall becomes red &
turgid
- Rate of acceleration of
inflammation increase
in presence of
obstruction to lumen
of appendix
Dr Kulwant Singh
Acute appendicitis with mass
Obstruction + infection lead
to distension with pus
hence increase intraluminal
pressure lead to venous
occlusion , oedema ,
arterial occlusion ,
gangrene and perforation
follows , rapidly localised by
defence mechanism
(greater omentum & coils of
bowel ) . Appendix mass is
formed , can undergo
suppuration to produce an
appendix abscess
Dr Kulwant Singh
Acute appendicitis with peritonitis
- Free perforation following
obstruction + infection
allows infected material to
disperse widely in
peritoneal cavity lead to
intense peritoneal reaction
with outpouring of fluid
- Serosal surfaces of bowel
become injected flaked
with clotted lymph
Dr Kulwant Singh
Clinical Features
1
Abdominal pain
periumblical at
first , then to
right iliac fossa
within a few
hours it
becomes
persistent .
Onset is usually
sudden , may
arise in right
iliac fossa and
remains there
2
Retrocaecal
appendix may
cause flank or
back pain
Pelvic appendix
may cause
suprapubic
pain
3
Anorexia
nearly always
accompanies
appendicitis
Vomiting
occurs in about
75% of patients
(most vomit
once or twice )
Dr Kulwant Singh
Clinical Features
4
Most patients
give history of
constipation
before onset
of pain ,
diarrhea in
some
particularly
children
5
6
Fever
Murphy’s Triad
Low grade
Pain
Around 100
degee F
Vomiting
Fever
Oc.
Haematuria
Dr Kulwant Singh
Clinical Features
1
2
3
Stage of shock
pale , sweating
& anxious
- Elevated pulse
rate
- Low blood
pressure
- Temperature
is subnormal
- Respiration is
rapid & shallow
- Tenderness in
the RIF
Stage of
perritoneal
reaction
Severe local
tenderness in
the RIF
- Rebound
tenderness
- Board –like
rigidity
- Marked rectal
tenderness
RIF
Stage of flank
peritonitis
Abdominal
distension
Absent bowel
sounds
Faecal vomitus
Dehydration
Appendicitis with peritonitis : three stages
Dr Kulwant Singh
CLINICAL FEATURES
LOCAL SIGNS
Tenderness of a localised & persistent nature is the most
important abdominal finding , situated at RIF , classically at
McBurney’s point
( junction of middle & outer third of a line from umbilicus to
anterior superior iliac spine
Rigidity over RIF
Rebound tenderness (best elicited by percussion)
Tenderness on right side during rectal examination (may be only
sign with pelvic appendicitis )
Dr Kulwant Singh
CLINICAL FEATURES
ROVSING’S SIGN
Continuous deep palpation
starting from the left iliac
fossa upwards (anti
clockwise along the colon)
may cause pain in the right
iliac fossa, by pushing
bowel contents towards the
ileocaecal valve and thus
increasing pressure around
the appendix. This is the
Rovsing’s sign.
Dr Kulwant Singh
CLINICAL FEATURES
PSOA’S SIGN
caecum
CAECUM
Iliacus
muscle
Iliacus
muscle
inflamed
appenix
Inflamed appendx
Psoas muscle
Psoas muscle
Psoas sign is right lowerquadrant pain that is produced
with the patient extending the
hip due to inflammation of the
peritoneum overlying the
psoas muscles and
inflammation of the psoas
muscles themselves.
Straightening out the leg
causes the pain because it
stretches the muscles, and
flexing the hip into the "fetal
position" relieves the pain.
Dr Kulwant Singh
CLINICAL FEATURES
OBTURATOR’S SIGN
Iliac
tuberosity
Caecum
Inflamed appendix
Pain on passive internal
rotation of the flexed
thigh. Examiner moves
lower leg laterally while
applying resistance to
the lateral side of the
knee (asterisk) resulting
in internal rotation of
the femur..
Obturator internus
Ischial tubersosity
Dr Kulwant Singh
CLINICAL FEATURES
BLOOMBERG’S SIGN
Also referred as rebound
tenderness. Deep
palpation of the viscera
over the suspected
inflamed appendix
followed by sudden
release of the pressure
causes severe pain on the
site indicating positive
Blumberg's sign and
peritonitis.
Dr Kulwant Singh
CLINICAL FEATURES
MCBURNEY’S SIGN
To elicit Mcburney’s sign
patient should be in supine
position with his knees
slightly flexed and his
abdominal
muscles
relaxed. Palpate deeply
and slowly in the right
lower
quadrant
over
McBurney’s point located
about 2” from the Rt. Ant.
Sup. Iliac Spine. On a line
between the spine and
umbilicus
(1/3rd
outer
side). Point pain and
tenderness is a positive
sign
and
indicates
appendicitis.
Dr Kulwant Singh
Clinical Features
COATED TONGUE
B
UNWELL LOOK
A
C
FOUL BREATH
SIGNS
POINTING SIGN
F
COUGH TENDERNESS
E
D
TACHYCARDIA
Dr Kulwant Singh
Alvarado Score
Above 8-9: Sure
Below 5: negative
5-8: investigate
Anorexia
Rt Iliac Fossa Pain
Nausea and Vomiting
Rt Iliac Fossa Tender
(2)
Fever
Rebound Tenderness
Leucocytosis (2)
Shift to left
Dr Kulwant Singh
Differential Diagnosis
Pancreatitis
Ileo caecal TB
Eterocolitis
Ileo caecal TB
Liver and GB inflamm.
Ca Caecum
Renal Mass
Perforated P.U.
Differential
Diagnosis
Ovarian cyst
Empyema GB
Fibroid uterus
Crohn’s disease
Ureteric calculus
Rt Lobar Pneumonia
Ectopic gestation
Worm Ball
Oophoritis
Dr Kulwant Singh
Differential Diagnosis
CHILD
Gastroenteritis, Mesenteric adenitis, Meckel’s
diverticulum, Intussception
ADULT
Regional enteritis, Ureteric Colic, Perforated
P.U., Torsion of Testis, Pancreatitis
FEMALE
Pelvic Inflammatory Diseases,
Pyelonephritis, Ectopic Pregnancy, Ovarian
Cyst, Endometriosis, uterine fibroids.
OLD
Diverticulitis, intestinal obstruction,
carcinoma colon etc.
Dr Kulwant Singh
Homoeopathic Medicines
Iris
Tenax
Specific. Severe Pain Rt Groin. > warmth,
Dryness of mouth and eyes
Bryonia
Pain RIF, >rest <motion, Constipation,
Dryness of m.m., Thirst ++. Vomiting.
Lycopod
Pain RIF, Dyspepsia, Constipation, <4-8 PM,
sedentary habit, intellectual person, lack of
exercise,
Bell
Acute stage, severe pain, violent, unbearable,
sudden onset. Vomiting. High Fever
Dr Kulwant Singh
Homoeopathic Medicines
Echin.
Chronic, suppurative and inflammation
persists, pain with fever
Violent and Active. Caecal region painful.
Merc Cor Tenesmus. Hot urine passed drop wise.
Merc Sol
Pain RIF, dysenteric stool, bruised sensation,
tender lump in RIF, perspiration ++
Ars. Alb
Sepsis, Chills, Restlessness, Prostration,
Diarrhoea, Fever, Fear of Death
Dr Kulwant Singh
QUICK REPERTORISATION
BOERICKE
APPENDICITIS
TOTAL MEDICINES: 30
Dr Kulwant Singh
QUICK REPERTORISATION
KENT
APPENDICITIS
TOTAL MEDICINES: 22
Dr Kulwant Singh
QUICK REPERTORISATION
PHATAK
APPENDICITIS
TOTAL MEDICINES: 20
Dr Kulwant Singh
QUICK REPERTORISATION
CLARKE
APPENDICITIS
TOTAL MEDICINES: 19
Dr Kulwant Singh
LOGO