It is a vestigial organ

↳ an organ that had a function but no longer has one.

Appendix had enzymes that could digest cellulose but with the change
in diet, it has become vestigial
- Has a worm-like (verimiform) structure
- has an internal diameter of 1-3mm
- has an external diameter of 3-8mm
change in this thickness can be diagnostic of inflammation
- the average length is 7- 9cm , or 7.5cm averagely
Can be as long as 15cm to 30cm
- The appendix mainly arises from the posterio medial aspect of the
ileocecal junction,3cm below the Ileocecal value
- Can be found where the 3 tinea coli meet
↳ 3 separate longitudinal ribbons of smooth muscle on the outside
of the colon
The opening of the appendix has a mucosal value (arises from itself)
called the value of gerlach

blood supply
- there are 3 main branches from the abdominal aorta
- Coeliac trunk O

t
- SMA
- IMA Superior

aims
Supplied by the appendiceal artery
↳ branch of the ileocolic artery
↳ most inferior branch of superior mesenteric artery
↳ branch of abdominal aorta
 drained by appendiceal vein
↳ drains into ileocolic vein
↳ drains into superior mesenteric vein
↳ drains into the portal vein
↳ Splenic vein + SMV = hepatic portal vein

NERVE SUPPLY OF THE APPENDIX

- Sympathetic Innervation of the appendix is derived from T9-T10
- parasympathetic is derived from the vagus nerve
Retooecal
Positions of the Appendix
- pre / post ileal (1 or 2 o'clock) prelpostileal
-subileal: parallel with the terminal ileum(3 o’clock)
- Retro-cecal (11 o'clock)
- Pelvic (5 o'clock)
y Paracecal

- Sub cecal (6 o’clock) fsub l Pelvic

- Paracecal (10 o’clock)

Abnormal Positions Of The Appendix

Mal descent of the cecum-the cecum denelops in the sub hepatic region
and descents into the right iliac fossa but if it fails to descend you have
this. And symptoms are in the right hypochondriac region
Mal rotation of the gut-during the 10th week of gestation the gut
develops outside the fetus and after passes through the umbilicus to
return into the body. Whiles returning, it twists twice before settling into
its normal position. When this twisting(rotation) does not occur it causes
situs inversus , causing the gut to be in the reverse order, ie the appendix
will be in the left iliac fossa
Definition
- Acute or sudden onset inflammation of the appendix
Etiology / Risk factors
- dietary factors : due to the low fiber or cellulose-depleted meals,
they have a longer transit time in our intestines
hence water is continuously taken from it and it becomes compact forming a
faecolith

This faecolith blocks the lumen of the appendix → increased intra luminal
pressure → cut off blood supply to the lumen → hypoxia → ischemia →
release of inflammatory mediators + dead tissue acts as a focus for infection

- Socio-economic status
↳ eating foods less in fiber
- Obstructive factors
↳ prior fibrosis and adhesions in the intestines
- calcium oxalate stones in the intestines
- Infections : bacteria, viral or protozoan
commonest bacteria : E-Coli, Streptococcus faecalis, bacteriodes,
peptostreptococcus
-familial factors : some families have long appendices, however there is a short
appendiceal artery hence the appendix is
prone to ischemia → gangrene → infection and perforation

Variants of Appendicitis
- Simple or Catarrhal appendicitis
↳ appendicitis here resolves without treatment (ie appendectomy)
↳ forms bands and adhesions which can later cause a more severe episode.
- obstructive appendicitis
↳ caused by an obstruction
Recurrent appendicitis
↳ similar to simple appendicitis but recurs frequently

Stump appendicitis
↳ appendicitis after a partial appendectomy

Clinical features of Appendicitis

-Fever you can remember the easy ones by the MANTRELS
-Pain
↳ migratory pain
initially it is a visceral pain referred from the 10th thoracic
nerve which reflects as peri umbilical pain
as the disease progresses though it distends and comes in contact with the
parietal peritoneum and pain is felt at the right iliac region
Periumbilical Pain: Dull achy pain
- Nausea and vomiting-reflex pylorospasm
anorexia
- Change in bowel habit
↳ mainly constipation
diarrhea in pelvic appendicitis
- Dysuria - Pelvic appendix

Physical findings/signs in appendicitisr

- Fever mcburney's
- fur tongue: Seen in most infections po
- fetor oris or appendiceal fetor: bad breath
Dumphy’s Sign: patient feels pain on coughing
- Blumberg's sign: Rebound tenderness at the mcburney's point
- Mcburney's Sign: tenderness at the McBurney’s point
- Rovsing’s Sign : displacement of colonic gases and intestines

- Copes Psoas Sign-Hyperextension of the right hip causes pain

in the right iliac region. For only retrocecal appendix
- Copes obturator Sign : flexion of the hip and internal rotation of the hip will
cause pain at the right iliac fossa
- Markle's Sign (heel drop sign) -modified now so you jerk patients
feet while they lie supine and you
pull patient’s leg. Originally the patient had to stand on their toes and drop
themselves down suddenly. Pain is felt in the RIF-
- Hyperaesthesia in Sherrer's triangle: bounded by pubic symphysis, anterior superior
iliac spine and Umbilicus
- On light palpation in the sherrens triangle, patient feeds pain
- Hamburger's Sign- refuse their favorite foods, due to anorexia
- Aaron's Sign-continuous palpation of the RIF will cause referred pain to the
epigastric region
- Murphy's Triad- RIF pain / Lower abdominal pain
- nausea and vomiting
- fever
Investigation
- Plain abdominal radiography / X-ray
↳ faecolith or gasing in the appendix
↳ air fluid levels in the terminal ileum
- Abdominal ultrasound-Confirmatory test but does not rule out (gold standard)
- Incompressible appendix
- thickened wall
- wide diameter (>6mm internal diameter)
- Peri appendiceal fold
CT-Computered tomography. Confirmatory test and rules out
- 94% sensitivity and 97 % specifaly
-Laparoscopy : diagnostic and therapeutic
INCIDENCE
- more common in adolescents and young adults (11 yrs-25 yrs)
- if it falls outside the age group suspect something else first.
- due to development of lymphoid tissue which was previously not
developed. ie in children the lumen is wide and patent and so lymphoid tissue is
sparse hence rarely can be blocked.
- and in older people the lumen is obliterated completely and lymphoid tissue is
sparse
More in male than females
- have undeveloped peyer's patches
TREATMENT
- Appendectomy

Scores to Help Diagnose Appendicitis

- Alvarado's Score
- Tzanaki's Score
-Appendicitis Inflammatory Response Score (AIRS)

Alvarado's Score
Migrating pain -1 O-3: less likely
Anorexia - 1 4- 7: likely
Nausea and vomiting-1 >8: Definite
Tenderness in right iliac fossa-2
Rebound tenderness -1
Elevated temperature -1
Leucocytosis with count more than 1000-2 (lab)
shift to left with neutrophilia in peripheral smear-1 (lab)

Modified alvarado score is the same but does not contain the shift to left

SURGICAL TREATMENT
Appendectomy -Resect appendix
Push Normal saline and lavage
Antibiotic cover

Immediate appendicectomy: done right away

Urgent appendicectomy : done after 12 hours but less than 24 hours of
presentation
Emmergent appendicectomy: done within the first 12 hours
Interval appendicectomy : 6-8 weeks after the presentation
due to abscess or appendiacal mass
Oschner Sherrens Regimen (Conservative management)
ABCDEF
A- Aspiration (pass NG tube)
B-bowel care (Nil per Os / don't give purgative )
C -Charting Vitals: Temp, pulse, HR, BP, volume of stool, volume of vomitus
D- Drugs : antibiotic cover (metronidazole, cefuroxime or Ceftriaxone)
analgesics after localisation
E- Exploratory laparotomy: give 100mg pethidine then go do this
F- fluids
Never give analgesics until you localize the pain

Other pathologies of the Appendix

APPENDICEAL MASS
-has indefinite edges
- usually resolves on its own
- resolve in 7- 14 days
- monitor patient and size of the mass by marking its size on the
skin and monitoring if it shrinks
- antibiotic cover
- if it does not Appendectomy
APPENDICEAL ABSCESS
- walled off area of pus
- Should resolve on its own
otherwise drain (depends on size)
Other pathologies of the Appendix
- Mucocele of the appendix
Dilation of the appendiceal lumen as a result of mucous
accumulation
↳ 2 types :Primary and secondary
Primary -Obstruction in the appendix
NB-the appendix epithelial wall lining secretes mucosa to help indigestion
if the lumen is blocked, the mucus accumulates and causes
a mucocele which can lead to appendicitis
Secondary- due to hypersecretion of mucus in the appendix by the epithelial lining.
the mucus becomes "cancerous"
mucus becomes a pseudomyxoma peritonei
↳ treatment is appendectomy + chemotherapy
results from the lumen being obstructed in the appendix, which is
secondary to the inflammatory or neoplastic proliferation of the appendix
mucosa or of lesions in the cecum

Carcinoid tumor of the Appendix

Differentials
- Typhoid ileal perforation
- Acute cholecystitis
- perforated viscus
- Peptic ulcer
- Acute intestinal obstruction

In children-mesenteric adenitis
- Diverticulitis (mainly inflammation of a Merkel's diverticulum
Elderly -malignancy of the cecum or appendix
women-Ruptured ectopic pregnancy
- PID
- Tubo-ovarian abscess
- Torsion of the Ovarian cyst
- Ruptured graafian follicle (ovulation pain-mittelschmerz)

Men- testicular torsion

Complications
- Appendiceal mass
- Appendiceal abscess
- Sub hepatic abscess
- Pelvic abscess
- generalized peritonitis
- sepsis
Cecal fecal loading - accumulation of fecal matter in the caceum due to paralysis
of the musculature preventing the empty of content into the ascending colon and
hence on x ray fecal matter can be seen at the caceum causing dilation of the
caceum