APPENDICITIS

OTHIENO IVAN
[email protected]
Learning objectives
By the end of this session, the learner should
be able to;
1. Briefly review the surgical anatomy of the
vermiform appendix
2. Define, classify Appendicitis
3. Outline the etiological factors for acute
appendicitis
4. Describe the pathophysiology of
appendicitis
5. List the clinical features of appendicitis
6. Describe the management of acute
appendicitis
7. List the complications of appendicitis
Introduction
The vermiform appendix is considered
by most to be a vestigial organ; its
importance in surgery results only from
its propensity for inflammation, which
results in the clinical syndrome known
as ‘acute appendicitis’.
Acute appendicitis is the most common
cause of an ‘acute abdomen.
It is relatively rare in infants and
becomes increasingly common in
childhood and early adult life; being
one of the most common surgical
Surgical Anatomy
The vermiform appendix is a blind muscular
tube with mucosal, submucosal, muscular
and serosal layers.
It is attached at the part of convergence of
the three taenia coli of the caecum on its
posteromedial wall.
It varies considerably in length and
circumference, average length is between
7.5-10cm.
It is stabilised by an extension of the
mesentery called mesoappendix, which is a
peritioneal fold containing fat and
appendicular artery, a branch of the ileocolic
artery.
Mesoappendix
Surgical anatomy contd
At birth, the appendix is short
and broad, at its junction junction
with the caecum but differential
growth of the caecum produces
the typical tubular structure by
about the age of two years.
During childhood, continued
growth of the caecum commonly
rotates the appendix into the
various positions,
Topographic variations in the
position of the appendix
 Location of the appendix
Located at;
 McBurney's
point (1),
located two thirds
the distance from
the umbilicus (2)
to the anterior
superior iliac
spine (3).
In the right lower
abdominal
quadrant.
Acute appendicitis
Definition of appendicitis
Appendicitis is defined as an
inflammation of the inner lining of the
vermiform appendix that spreads to
its other parts.
This condition is a common and
urgent surgical illness with protean
manifestations, generous overlap with
other clinical syndromes, and
significant morbidity, which increases
with diagnostic delay
Epidemiology
In 2021, the global age standardized
incidence rate was 214 per 100,000
people, which is equivalent to 17 million
new cases.
Distribution of appendicitis is most
common in people ages 5-45 years, with a
peak incidence in the second and third
decade of life.
There is a slight preponderance of
appendicitis in males with a life time
incidence of 8.6% compared to 6.7% in
females.
Types of appendicitis
Acute non obstructive appendicitis
(catarrhal); inflammation of the
mucous membrane occurs with
oedema and haemorrhage.
Acute obstructive appendicitis; Here
the pus collects in the blocked lumen
of the appendix which is blackish,
gangrenous, oedematous and rapidly
progresses leading to perforation
either at the tip or at the base of the
appendix.
Types of appendix
Recurrent appendicitis; Repeated
attacks of non obstructive
appendicitis leads of fibrosis,
adhesions causing recurrent
appendix
Sub-acute appendicitis; is a milder
form of acute appendicitis
Stump appendicitis; It is retained
long stump of appendix after
commonly laparascopic
appendicectomy.
Aetiological factors of acute
appendicitis
The causes of acute appendicitis
can be classified into;
 Luminal obstruction
 Raised intraluminal pressure
 Infection
Luminal obstruction
Sub-mucosal lymphoid hyperplasia;
rapid increase in number of normal
lymphocytes: can be caused by primary
infection.
Foreign obstructive agents; fruit seeds,
thread worms, round worms,
Faecolith(most common cause),
inssipated barium.
Extra-luminal obstruction; adhesions and
kinking caused by conditions such as Ca
caecum and ileoceacal Crohn’s disease
Raised intraluminal
pressure
Mucus accumulation
Multiplication of bacteria
These may cause venous and
lymphoid congestion accompanied
by impaired arterial flow. This may
result in thrombosis and gangrene
as well as increased risk of
perforation through the devitalized
tissue.
 Pictorial Explanation

Distention
causing
Ischemia

obstruction mucus
Distention

Gangrene

Appendiceal Appendiceal Irritation of Perforation,

obstruction/early distension parietal localised/generalis
appendicitis – peritoneum ed peritonitis, mass
visceral peritoneal (localised)
irritation
Infection
Common organisms seen in patients
with acute appendicitis
 Pathophysiology of
appendicitis
Lymphoid hyperplasia narrows the lumen of the
appendix,
leading to luminal obstruction. Once obstruction
occurs, continued mucus secretion and
inflammatory exudation increase intraluminal
pressure, obstructing lymphatic drainage.
Oedema and mucosal ulceration develop with
bacterial translocation to the submucosa.
Resolution may occur at this point either
spontaneously or in response to antibiotic
therapy. If the condition progresses, further
distension of the appendix may cause venous
obstruction and ischaemia of the appendix wall.
With ischaemia,bacterial invasion
occurs through the muscularis
propria and submucosa, producing
acute appendicitis.
Finally, ischaemic necrosis of the
appendix wall produces gangrenous
appendicitis, with free bacterial
contamination of the peritoneal
cavity.
Alternatively, the greater omentum
and loops of small bowel become
adherent to the inflamed appendix,
walling off the spread of peritoneal
contamination, and resulting in a
phlegmonous mass or paracaecal
abscess. Rarely, appendiceal
inflammation resolves, leaving a
distended mucus-filled organ
termed a ‘mucocoele’ of the appendix.
Mucoccele of the
appendix
It is the potential for diffuse
peritonitis that is the great threat
of acute appendicitis. Peritonitis
occurs as a result of free
migration of bacteria through an
ischaemic appendicular wall,
frank perforation of a gangrenous
appendix or delayed perforation
of an appendix abscess.
N.B
Acute inflammation of the mucus
membrane with secondary
infection without obstruction
causes acute non obstructive
appendicitis. It may lead into
resolution, fibrosis, recurrent
appendicitis or eventual
obstructive appendicitis.
 CLINICAL FEATURES OF
APPENDICITES
HISTORY.
The classical features of acute
appendicitis begin with poorly localised
colicky abdominal pain. This is due to
midgut visceral discomfort in response to
appendiceal inflammation and
obstruction.
The pain is frequently first noticed in the
periumbilical region and is similar to, but
less intense than, the colic of small bowel
obstruction.
Central abdominal pain is associated with
anorexia, nausea and usually one or two
episodes of vomiting that follow the onset
of pain (Murphy). Anorexia is a useful and
constant clinical feature, particularly in
children. The patient often gives a history
of similar discomfort that settled
spontaneously.
Murphy's triad

• Pain
• Vomiting
Presentation of
appendicitis
Symptoms of Clinical signs in
appendicitis appendicitis
 Periumbilical colic  Pyrexia
 Pain shifting to the
 Localised
right iliac fossa
 Anorexia
tenderness in
the right iliac
 Nausea
fossa
 Obstipation;
 Muscle guarding
beginning before
the onset of  Rebound
abdominal pain. tenderness.
Signs to elicit in appendicitis
 Pointing sign
 Rovsing’s sign
 Psoas sign
 Obturator sign.
Blumberg's sign (Release sign)
Cope's psoas test
Baldwing's test ETC
Signs to elicit contd
Contd
Mcburney’s sign
Alvarado’s score
Clinical algorithm for suspected
cases of acute appendicitis
 OTHER INVESTIGATIONS
Total leucocyte count is increased CBC
• U /S is done to rule out other conditions like
uretericstone, p ancreatitis, ovarian cyst,ectopic
pregnancy and also to confirm appendicular mass or
abscess.
 Urine analysis
 Plain Xray, nonspecific
 Ultrasound highly sensitive (80-90%), excludes
other pathologies.
 Computer Tomography: More superior to USS in
diagnostic accuracy.
 Barium enema: Good accuracy, but technically
difficult and false positives are common.
 Laparoscopy
 Active observation
 Computer aided diagnosis.
 Peritoneal lavage
Management
It In definitive
involves
supportive/symptom management,
atic management; treatment is given in
drugs like antibiotics line with the
and fluid therapy underlying cause.
If presents as an
Appendicectomy is
normally performed
emergency, adhere following confirmation
to the recommended of the diagnosis by
resuscitation imaging and the blood
protocols; primary picture.
and secondary It can either be
survey. laparoscopic or open
appendicetomy.
Complications of appendicitis
Complications after
Immediate perforation
complications  Intra-abdominal
 Appendicular mass abscess
 Faecal fistula
 Appendicular
 Intestinal obstruction
abscess
Complications of
 Peritonits caused
appendicectomy
by appendiceal  Paralytic ileus
rupture  Residual abscess
 Pelvic abscess  Wound sepsis
 Respiratory
complication
 Case Scenario
A 19/M presents with a 2-day hx of abdominal pain.
The pain started in the central abdomen and has
now become constant and shifted to the RIF. He
has vomited twice today and is off his food. His
motions were loose today with no associated rectal
bleeding. On examination, he has T=37.8C,
HR=110/min. Adbomen, localised tenderness and
guarding in RIF. Urinalysis is clear.
 What is the likely diagnosis?
What are the differential diagnoses for this
condition?
How would you manage this patient?
What are the complications of any surgical
interventions that may be required?