Lecture notes for medical students

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3. First show the blank slides (eg. Aetiology ) > Ask
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5. This will be an ACTIVE LEARNING SESSION x
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6. Good for self study also.
7. See notes for bibliography.

2. Learning Objectives
1.

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Appendicitis is defined as an inflammation
of the inner lining of the vermiform
appendix that spreads to its other parts.

6. Relevant Anatomy
•

7. Relevant Anatomy
• The appendix is a wormlike extension of the
cecum and, for this reason, has been called
the vermiform appendix.
• The average length of the appendix is 8-10
cm (ranging from 2-20 cm).
• Taenia coli converge on the posteromedial
area of the cecum, which is the site of the
appendiceal base

8. •

9. Relevant Anatomy:Positions
• Subcecal
• Pelvic
• Pre ileal
• Post ileal
• Retrocecal
• Retro colic

10. Aetiology

11. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

12. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

13. Aetiology of Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoing/ Toxins/ Dtug induced

14. Aetiology of Aetiology
Appendicitis is caused by obstruction of the
appendiceal lumen.
Luminal obstruction is caused by –
•

15. Aetiology of Aetiology
Appendicitis is caused by obstruction of the
appendiceal lumen.
Luminal obstruction is caused by –
• Lymphoid hyperplasia
• Fecal stasis
• Fecaliths- elderly, poor fiber intake
• Parasites
• More rarely, foreign body
• Neoplasms.

16. Aetiology of Aetiology
Lymphoid hyperplasia is caused by -
•

17. Aetiology of Aetiology
Lymphoid hyperplasia is caused by -
• Inflammatory bowel disease (IBD)
• Infections (more common during childhood and in
young adults-
– Gastroenteritis
– Amebiasis
– Respiratory infections
– Measles
– Mononucleosis.

18. Pathophysiology

19. Pathophysiology
• Obstruction of the appendiceal lumen
• Increase in pressure within the lumen.
• Intestinal bacteria within the appendix multiply
• Ischemia begins, resulting in a loss of epithelial
integrity and allowing bacterial invasion of the
appendiceal wall
• Thrombosis of the appendicular artery and veins,
leading to perforation and gangrene of the
appendix.
• Periappendicular abscess or peritonitis may occur.

20. Pathophysiology:Stages
•

21. Pathophysiology:Stages
• Early- catarrhal
• Suppurative
• Gangrenous
• Perforated
• Phlegmonous
• Spontaneous resolving
• Recurrent
• Chronic.

22. Clinical Features
•

23. Clinical Features
• Demography
• Symptoms
• History
• Signs
• Prognosis
• Complications

24. Demography

25. Demography
• Incidence & Prevalence
• Geographical distribution.
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

26. Demography
Incidence & Prevalence
•

27. Demography
Incidence & Prevalence
• 7% of the US population is affected in
lifetime.
• incidence 1.1 cases per 1000
• Some familial predisposition exists.

28. Demography
Geographical distribution.
•

29. Demography
Geographical distribution.
• lower in Asian and African countries.

30. Demography
• Age

31. Demography
Age
• The incidence of appendicitis gradually
rises from birth
• peaks in the late teen years
• gradually declines in the geriatric years.
• The mean age when appendicitis occurs in
the pediatric population is 6-10 years.
• Can occur at any age even prenatal.

32. Demography
• Sex
• There is a slight male preponderance of 3:2.

33. Demography
• Socioeconomic status
•

34. Demography
• Socioeconomic status
• No data.

35. Demography
• Temporal behaviour

36. Demography
• Temporal behaviour
• Incidence is falling since 1940s

37. Symptoms

38. Symptoms
• Murphy's triad

39. Symptoms
• Murphy's triad
• PVT
1. Pain.
2. Vomiting
3. Temp.

40. Symptoms
• Murphy's triad
1. Lower right abdominal pain
2. Nausea, vomiting,
3. Fever.

41. Symptoms
Classic history
• Anorexia and periumbilical pain
• Followed by nausea, right lower quadrant
(RLQ) pain, and vomiting.

42. Symptoms
Classic history
• Which comes first Pain or Vomiting?

43. Symptoms
Classic history
• Vomiting: Nearly always follows the
onset of pain; vomiting that precedes pain
suggests intestinal obstruction

44. Symptoms
Classic history
• Pain

45. Symptoms
Classic history - Abdominal Pain
• Typically begins as periumbilical or
epigastric pain, then Shifts to the RLQ.
• Patients usually lie down, flex their hips,
and draw their knees up to reduce
movements and to avoid worsening their
pain

46. Signs

47. Signs
• General Examination
• Systemic Examination
• Local Examination

48. Signs
• General Examination

49. Signs:General Examination
1. Tachycardia
2. Mild Fever
3. Shock in peritonitis

50. Signs
• Systemic Examination

51. Signs:Systemic Examination
Per abdomen-
• Initially No distension
• Soft
• Tenderness in RLQ
• Generalised rigidity and tenderness in
peritonitis.

52. Signs
• Local Examination

53. Signs:Local Examination
• RLQ tenderness rebound tenderness, pain
on percussion, rigidity,
• Latter half of pregnancy, right upper
quadrant (RUQ) Pain

54. Signs:Local Examination
• Rovsing sign ?

55. Signs:Local Examination
• Rovsing sign (RLQ pain with palpation of
the LLQ)

56. Signs:Local Examination
• Obturator sign

57. Signs:Local Examination
• Obturator sign (RLQ pain with internal and
external rotation of the flexed right hip)

58. Signs:Local Examination
• Psoas sign

59. Signs:Local Examination
• Psoas sign (RLQ pain with extension of the
right hip or with flexion of the right hip
against resistance).

60. Signs:Local Examination
• Dunphy sign

61. Signs:Local Examination
• Dunphy sign (sharp pain in the RLQ elicited
by a voluntary cough).

62. Signs:Local Examination
• Markle sign

63. Signs:Local Examination
• Markle sign (pain elicited in a certain area
of the abdomen when the standing patient
drops from standing on toes to the heels
with a jarring landing).

64. Prognosis

65. Prognosis
• Morbidity
• Mortality rate
• 5 year survival in Malignancy

66. Prognosis
• Overall mortality rate of 0.2-0.8%
• The mortality rate in children ranges from
0.1% to 1%
• Older than 70 years, the rate rises above
20%,

67. Complications

68. Complications
• Occur in 1-5% of patients
• Peritonitis.
• Phlegmon- Appendicular Lump
• Abscess
• Surgical site infection

69. Investigations

70. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germline Testing and Molecular Analysis
• Diagnostic Laparotomy.

71. Investigations
• Laboratory Studies

72. Investigations
• Laboratory Studies-
1. WBC count
2. CRP

73. Investigations
Laboratory Studies
• WBC >10,500 cells/µL:
• Neutrophilia
– In infants and elderly patients, a WBC count is
especially unreliable

74. Investigations
• CRP levels >1 mg/dL are common in
patients with appendicitis
• Very high levels of CRP in patients with
appendicitis indicate gangrenous evolution
of the disease, especially if it is associated
with leukocytosis and neutrophilia
• In adults who have had symptoms for
longer than 24 hours, a normal CRP level
has a negative predictive value of 97-100%
for appendicitis

75. Diagnostic Studies

76. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

77. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy : Laparascopy
• Nuclear scan

78. Diagnostic Studies
Imaging Studies:USG
•

79. Diagnostic Studies
Imaging Studies:USG
• Ultrasonography for confirmation, but not
exclusion, of acute appendicitis.
• A healthy appendix usually cannot be
viewed with ultrasonography
• When appendicitis occurs, the
ultrasonogram typically demonstrates a
noncompressible tubular structure of 7-9
mm in diameter

80. Diagnostic Studies
Imaging Studies:CT
•

81. Diagnostic Studies
Imaging Studies:CT
• CECT:most important imaging study in the
evaluation of patients with atypical
presentations of appendicitis.
• CT scanning used in those cases in which
ultrasonograms are negative or
inconclusive.
• To definitively exclude acute appendicitis.

82. Diagnostic scoring system

83. Differential Diagnosis

84. Differential Diagnosis
• Pelvic inflammatory disease
• Endometriosis
• Ovarian cyst or torsion
• Ureterolithiasis and renal colic
• Degenerating uterine
leiomyomata
• Diverticulitis
• Crohn disease
• Colonic carcinoma
• Rectus sheath hematoma
• Cholecystitis
• Bacterial enteritis
• Perforated duodenal ulcer
• Mesenteric adenitis
and ischemia
• Omental torsion
• Biliary colic
• Renal colic
• Urinary tract
infection (UTI)
• Gastroenteritis
• Enterocolitis
• Pancreatitis
•

85. Non Operative Therapy

86. Non Operative Therapy
• Traditionally Appendectomy is the correct
treatment though lately some studies have
shown equal results with antibiotics.

87. Minimally invasive Therapy

88. Minimally invasive Therapy
• Laparoscopic appendectomy is now
preferred .

89. Operative Therapy

90. Operative Therapy
• Early appendectomy.
• Antibiotics for apeendicular lump +/-
followed by interval appendectomy
(Ochsner–Sherren regime).
• Drainage of appendicular abscess.

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