Acute Appendicitis causes pathophysiology and management

1. Dr Anil Kumar
Assistant Professor
Department of Surgical Disciplines.
All India Institute of Medical Sciences, Patna
Email: dranil4@gmail.com

2. Objective
 History
 Anatomy & Anomaly
 Acute Appendicitis(Causes, Pathology, C/F, Inv & M/n)
 D/D of Acute Appendicitis
 Appendicular Lump & malignancy ( Carcinoid tumor)
 Appendectomy & Complications

3. History
 In 1492,Leonardo da Vinci first depicted the appendix in anatomic
drawings
 In 1521, Jacopo Beregari da Capri, a professor of anatomy in
Bologna, identified the appendix as an anatomic structure.
 In 1710, Phillipe Verheyen coined the term appendix vermiformis.
 The first recorded successful appendectomy was in 1735 by
Claudius Amyand
 Kurt Semm, ( German gynecologist) did first laparoscopic
appendectomy on May 30, 1980.

4. Anatomy

5. Position of the Appendix

6. Position of Appendix
Position Incidence
Retrocecal 74% Commonest postion
Pelvic 21% 2nd Commonest position
Pre-ileal 1%
Post- ileal 0.5%
Paracaecal 2%
Promontoric( Subileal /subcaecal)
1.5%

7. In Situs Inversus Viscerum:
Appendix in LIF

8. Size of the Appendix
 Range : 2- 20 cm
 Average: 11 cm
 Diameter: 7-8 mm

10. The longest appendix measured
26cm, Safranco August (Croatia)
Zagreb, Croatia, on 26 August 2006.

11. Anatomy:
 Origin – Postero-medial wall of the caecum ( 2 cm
below the ileocaecal orifice)
 Appendicular orifice: Guarded by an indistinct
semilunar fold of mucous membrane k/as Valve of
Gerlach.
 Mesoappendix: peritoneum – lower surface of the
mesentery of the terminal ileum.

12. Appendicular Artery- Lower
Division of Ileo-colic artery

13. Appendicular artery in
mesoappendix

14. Thrombosis of Appendicular
artery(as it is an end artery) -
Gangrenous appendicitis

15. Venous Drainage & Nerve Supply
 Appendicular Vein
 Ileocolic vein Portal Vein
 Superior Mesenteric vein
 Sympathetic Nerves- Derived 4m T9-T10
( Celiac Plexus)
 Para Sympathetic Nerves- Vagus

16. Lymphatic & KULTSCHITZSKY Cells
 8-15 lymphatic vessels - mesoappendix
 Ileocolic Node ( Sup & Inf group)
 Ileocolic Nodes SMN Celiac nodes
 In the base of the crypts lie argentaffin cells
(Kultschitzsky cells) which may give rise to carcinoid
tumours .
 The submucosa contains numerous lymphatic
aggregations or follicles.

17. Wallbridge Anomaly: A,B1,B2,C

18. Wallbridge Anomaly
 1. Type A anomaly. Single cecum and a partial
duplication of the appendix with a single base.
 2. Type B1 anomaly. Two completely separate
appendices arise from a single cecum.
 3. Type B2 anomaly. The second appendix is usually
found arising from the taenia coli of the wall of the
cecum.
 4. Type C anomaly. Double cecum, each with its own
appendix,

19. Predisposing Factors:Appendicitis
 Age: 20-30 years( peack incidence in early 20s)
 Socio-economic condition: High profile( Low fibre)
 Lymphoid hyperplasia of the appendix
 Fibrosis of the appendix cos of previous damage

20. Causes of appendicitis:
 Obstructive causes- faecolith or stricture
 Bacterial proliferation : mixed growth commonest is
streptococci & E.Coli.
 Intestinal parasites – Oxyuris Vermicularis(pin worm)
 Tumour( Ca of the Caecum) in elderly & middle age.
 Fibrotic stricture of the appendix

21. Composition of Faecolith:
 Bacteria
 Calcium phosphate
 Epithelial Debris
 Inspissated fecal material
 Foreign bodies ( Rarely)

22. Pathology: Obstructive & Non
obstructive
 Obstructive- Primarily
- Acute appendicitis
- Gangrenous appendicitis
- Phlegmonous mass/paracaecal abscess
- Mucocele of the appendix
- Rupture of appendix

23. Obstruction:
 Mucus + Inflammatory exudation Increases
intraluminal P Obstructing lymphatic drainage
Edema+ M.Ulceration+ Bacterial Translocation to the
submuosa.
Venous obstruction( cos of further distension)
Ischemia Bacterial Invasion Acute Append.

24. Inflamed Appendix

25. Perforation- If Fever > 102*F &
WBC> 18,000
If Ischemia continue
Necrosis of the appendicular wall
Gangrenous appendicitis
Perforation with free bacterial contamination of the
peritoneal cavity

26. Gangrenous appendix.

27. Phlegmonous Mass/Paracaecal
abscess
Greater omentum & loops of small bowel become
adherent to the inflamed appendix
Walling off the spread of peritoneal contamination
Phlegmonous Mass / Paracaecal abscess

28. Phlegmonous appendicitis

29. Appendicular inflammation-
resolves- distended mucus filled
organ- Mucocele of appendix

30. Peritonitis ??? If perforation??
 Extreme of Age
 Immunosuppression
 Diabetes Mellitus
 Faecolith obstruction
 Pelvic appendix
 Previous Abdominal surgery

31. C/F- Symptoms
 PAIN: Initially Periumbilical region ( midgut visceral
discomfort) in response to A.I & obstruction.
:Pain shift to right iliac fossa : Parietal
peritoneum irritated and inflamed.
 ANOREXIA
 NAUSEA/VOMITTING

32. Clinical Sign
 Pyrexia: Low grade after 6 hours
 Tenderness (localized) in the RIF
 Muscle guarding
 Rebound Tenderness/ BLUMBERG’S Sign
 Foul breath.
 Tachycardia: Perforation, Gangrene & Peritonitis

33. Sign to elicit in Appendicitis

34. Rovsing’s Sign

35. Psoas Sign

36. Obturator Sign:

37. Obturator Sign

38. Dunphy’s Sign: Any movement
( Coughing) causes Pain.

39. Hyperesthesia in Sherren’s

40. Localized tenderness at Mc
Burney’s Point

41. Mc Burney’s Point -Tenderness

42. Investigation:
 TLC- Raised: 10000 to 18000 ( Neutrophils >75%). If TLC
>18000 perforation.
 Abdominal X-Ray: TRO I.O, U.Colic etc.
 USG: Especially if clinical Dx is equivocal.
 CT: Especially in Adult patient with equivocal history ,
physical examination & lab findings.
 Pregnancy test: In reproductive age group

43. ALVARADO SCORING SYSTEM
SYMPTOMS SCORE
Migratory RIF Pain 1
Anorexia 1
Nausea/Vomiting 1
SIGN
Tenderness in RIF 2
Rebound tenderness in RIF 1
Elevated Temperature 1
Laboratory Findings
Leucocytosis 2
Shift to the left of neutrophils 1
Total 10

44. Interpretation of ALVARADO Score.
Aggregates
score
7-10 Strongly
predictive of
Appendicitis
Aggregates
score
5-6 Equivocal CT & USG
helpful in
making Dx.
Aggregates
score
1-4 Appendicitis
can be ruled
out

45. Treatment of Acute Appendicitis
 Absolute bed rest & NPO
 IV Fluids Supplements.
 Analgesics( Pethidine)
 Antibiotics( Ofloxacine + Orinidazole)
 Appendectomy ( within 24 hours ASAP)

46. Indications of Appendectomy
 Acute Appendicitis
 Recurrent Appendicitis
 Mucocele of Appendix
 Carcinoma confined to the mucosa.

47. Incision in Appendectomy.
 Gridiron and lanz incisions : Muscle-splitting
incisions .They differ in the orientation of the skin
incision alone.
 BIKNI INCISION: Modified Lanze incision slightly
lower
 Rutherford Morison : The gridiron incision can be
more readily extended laterally into an oblique,
curvilinear muscle-cutting incision:

48. Grid-iron/ Lanze & Modified Lanze:
GridIron
LanzeIncision
ModifiedLanze

50. Muscles splitting & Cut the Peritoneum

51. Follow the taneia coli to reach upto the
appendix

52. Appendicular artery in the
Mesoappendix

53. Identified the base of the appendix
to Ligate

54. Ligate the base of the appendix.

55. After crushing the base, cut the
appendix

56. Z-Suture to invaginate the stump

57. Invaginating the stump

58. Buried Appendicular stump

59. Remember the steps in
Appendectomy
 Pre-Op( NPO, Shaving, consent, PAC, Draping)
 Incision- Grid-iron , Rutherford Incision, Bikney
Incision)
 Follow the taenia coli to find the appendix
 Ligate the Appendicular artery in mesoappendix
 Crush the base of the appendix

60. Appendectomy
 Ligate the base of the appendix( absorbable suture)
 Appendix is divided distal to the ligature.
 Clean the stump with betadine
 Take purse string around the caecal wall to buried the
stump.
 Close the wound in layers.

61. Methods in special situation
When the cecal wall is edematous & Inflamed: Purse
string is not recommended
When the base of the appendix is inflamed:
Base is not crushed . Appendix is ligated close to the
caecum, after which it is amputed and the stump is being
invaginated
If the base of the appendix is gangrenous:
It is neither ligated nor crushed. 2 stiches are placed through
the caecal wall. Take the appendix out. Close the wound .

62. Complication of Appendectomy
Wound Infection
Intra-abdominal abscess
Ileus
Respiratory complication like pneumonia
DVT & Embolism
Portal Pyemia
Adhesive Intestinal Obstruction
Fecal Fistula
Ritcher’s Hernia

63. Appendicular Lump

64. Appendicular Lump- on 3rd day.
Appendix
Edematous Caecum
Terminal Ileum
Omentum ( Greater Omentum)
Loop of Intestine
Ascending Colon
Adjacent Peritoneum

65. Presentation of Appendicular Lump
 Usually on 3rd day of attack of appendicitis.
 Lump in RIF
 Rigidity over the lump
 Tenderness
 Fever/ Increase pulse.

66. Appendicular Lump- Don’t Operate
 Severe adhesion/ Difficult to separate the part.
 Bloody and dangerous to operate
 Chance of Fecal fistula
 Max chance of iatrogenic injury

67. OCHSNER- SHERREN REGIMEN.
 Ist mark the size of the swelling for further assessment
 NPO & IV Fluid supplements
 Antibiotics, Analgesics
 Temp, Pulse( 4 hourly) & Fluid record charting .
 Allow oral liquid on subsequent days.

68. OCHSNER- SHERREN REGIMEN
 If more vomiting- antiemetic &/+ PPI
 If size of the lump decreases – continue the same.
 After 6-8 weeks = Interval Appendectomy
 Prognosis: 90% success rate for this regimen.
 Failure to this regimen: suspect Crohn’s & Ca????

69. When to stop conservative t/t in
Lump
CRITERIA FOR STOPPAGE OF CONSERVATIVE TREATMENT IN
APPEDICULAR LUMP
RISING PULSE RATE
RISING TEMPERATURE
INCREASING or SPREADING ABDOMINAL PAIN
INCREASING SIZE OF MASS
VOMITING or COPIOUS GASTRIC ASPIRATE

70. D/D of Appendicular Lump
Hypertrophic Ileo- caecal Tuberculosis
Carcinoma of the Caecum
Crohn’s Disease
Actinomycosis
Twisted ovarian cyst in female
Right sided iliac lymphadenitis
Parametritis

71. Appendicular Malignancy
Mucinous Adenocarcinoma - MC neoplasm of appendix 38%
Adenocarcinoma 26%
Carcinoid Tumour 17%
Goblet Cell Carcinoma 15%
Signet – ring cell carcinoma 4%

72. Carcinoid tumor of Appendix
 Neuroendocrine tumor
 Origin- Argentaffin cells ( KULCHITSKY Cells of
crypts of Lieberkuhn)
 Contains sustentacular cells that express S-100
 MC Site: distal third i.e tip of the appendix

73. T/T 4 Carcinoid tumor of Appendix
 TOC- Appendectomy
 Right hemicolectomy is indicated when-
- Tumor is > 2 cm in size.
- Involves the base of the appendix.
- Involves the caecal wall or mesoappendix.
- Lymph nodes are involved.

74. D/D of Acute Appendicitis:
In Adult In Female
Terminal Ileitis Ruptured Ectopic Pregnancy
Ureteric colic Torsion/Rupture of an Ovarian cyst
Right sided pyelonephritis Salpingitis( Right sided)
Perforated peptic ulcer Endometriosis
Torsion of Testes Mittelschmerz ( Painful Ovulation)
Acute Pancreatitis
Rectus Sheath Hematoma

75. D/D of Acute Appendicitis:
In Children In Elderly
Gastroenteritis Sigmoid diverticulitis
Meckele’s Diverticultitis Intestinal obstruction
Intussusception Carcinoma of the caecum
Lobar Pneumonia
Henoch- shchonlein Purpura
Mesenteric adenitits

76. Home Message
 Appendicitis is common surgical emergency in 20-30
years age group
 Commonest cause is Faecolith
 Pain in RIF, N/V, Anorexia with findings of Tenderness
in RIF, increase temp & Leucocytosis usually confirm
the Dx
 Appendectomy should be performed ASAP

77. Home Message
 Ochsner- sherren regimen is the gold standard t/t for
Appendicular lump
 Interval Appendectomy after 4-6 weeks is the
preferred Surgical steps in Appendicular Lump
 Commonest site 4 Carcinoid tumor is the tip of the
Appendix
 Appendectomy is the TOC for Carcinoid tumor of
appendix