ACUTEAPPENDICITIS

1. APPENDICITIS
SHUBHAM(A.R)

2. DEFINITION
INFLAMMATION of the APPENDIX
First described in 1886 by DR. REGINALD FITZ1
Most common surgical condition requiring
emergency surgery in adults.
Remains the most common acute surgical
condition in children & major cause of childhood
morbidity.

3. DEFINITION
SIMPLEAPPENDICITIS inflamed appendix, in
the absenceof gangrene, perforation, or
abscessaround the appendix2
COMPLICATEDAPPENDICITIS perforated or
gangrenousappendicitis or the presenceof
peri-appendicular abscess2

4. EPIDEMIOLOGY
GENDER male-to-female ratio is 1.4:1
AGE most common age group ––– 10–19 y/o1
1-2/10,000 children ––– BIRTH TO 4 y/o5
19-28/10,000 children ––– <14 y/o
RACE WHITES>BLACKS; more frequently in WESTernized societies, but
increasing inAfricanAmericans,Asians, and NativeAmericans
SEASON peak incidence in AUTUMN and SPRING
INCIDENCE RATE 1/1,000 (West)1, 2.5/1,000 (Philippines)
~100,000 children treated in children’s hospitals forAP each year5
MORTALITYRATE <1% (low)
LIFETIMERISKS:
MALE3
8.6%
FEMALE3
6.7%
CHILDREN5
~7%

5. ETIOLOGY
EXACT CAUSE not completely
understood1
ASSOCIATED FACTORS:
• FECALITHS or APPENDICOLITHS
common in developed countries with refined,
low- fiber diets
• INCOMPLETELY DIGESTED FOODRESIDUE
to include foreign body ingestion
• LYMPHOID HYPERPLASIA
SUBMUCOSAL LYMPHOID FOLLICLES
few at birth but multiply steadily during
childhood

6. ETIOLOGY
ASSOCIATED FACTORS (con’t)1,5:
• INTRALUMINAL SCARRING blunt trauma
• TUMORS OR MALIGNANCIES carcinoid tumors
• MICROORGANISMS:
a. BACTERIA Yersinia, Salmonella,&Shigellaspp.,
b. VIRUSES Mumps,Coxsackievirus B&Adenovirus,
Infectious mononucleosis
c. OTHERS Ascaris lumbricoides
• OTHER DISEASES:
a. IBD1 foradults)
b. CYSTICFIBROSIS5 forchildren

7. PATHOPHYSIOLOGY
 Luminal Distention Bacterial Overgrowth
INFLAMMATION Loss of Function, Pain,Swelling, Heat,Redness  Intraluminal Pressure
Cont’d
OBSTRUCTION OF THE APPENDICEAL LUMEN
FECALITHS /
APPENDICO LITHS
LYMPHOID
HYPERPLASIA
INCOMPLETELY
DIGESTED FOOD
RESIDUE
INTRALUMINAL
SCARRING TUMORS
PATHOGENS
(VIRUSES,
BACTERIA)
OTHER
DISEASES
FECALITHS /
APPENDICO LITHS
LYMPHOID
HYPERPLASIA

8. PATHOPHYSIOLOGY
PERFORATION
GANGRENOUS APPENDICITIS
*50% ofpatientswithfecaliths
*Patients withS/Sfor>48 hrsmorelikelytoperforate
Leak of Contents into the Omentum
and Surrounding Tissues
INHIBITION OF LYMPHATIC
A N D BLOOD FLOW
(82%
Vascular
Thrombosi
s
Abscess
Formation Peritonitis
Supportive
Thrombosis
COMPLICATIONS
*Childrenwith perforationrate
for<5yo & 100% forinfants)
Ischemic
Necrosi
s
*Impaired arterialperfusion,ischemia
ofthewallofthe appendix
*Escalating diffuseabdominal pain
withrapiddevelopmentoftoxicity
evidencedbydehydrationandsigns
ofsepsisincludinghypotension,
oliguria,acidosis,& high-gradefever
SmallBowel
O bstruction

9. CLINICAL MANIFESTATIONS
LOCATION1:
• Right Lower Quadrant
• Right Upper Quadrant
• Left Side of theAbdomen
• Pelvis and Right flank
PRESENTATION2:
• Retrocecal/retrocolic (64%)
• Subcaecal (32%)
• Pre-ileal (1%)
• Post-ileal (2%)
• Pelvic appendix
POSITIONof theappendix isa critical factor affecting presentations of signs& symptoms

10. CLINICAL MANIFESTATIONS
PAIN (depends on the location) 1:
• IF UNUSUALLY POSITIONED – challenge
in diagnosis regarding the pain
• IF BEHIND THE CECUM OR BELOW
THE PELVIC BRIM – may prompt very little
tenderness
• IF RETROCECAL/RETROCOLIC – psoas
stretch sign
FORELDERLY canbesubtle,nausea,anorexia,and
emesismaybethepredominantcomplaints1
FORVERYYOUNG atypicalpresentation,pain
patterns––common1

11. CLINICAL MANIFESTATIONS
EMESIS only mild and scant1
NAUSEA& VOMITING occur in more than half the patients, usually follow the
onset of abdominal pain by several hours
ANOREXIA so common that the diagnosis of appendicitis SHOULD
BE QUESTIONED IN ITSABSENCE1
PELVICAPPENDICITIS more likely to present with dysuria, urinary frequency,
diarrhea, or tenesmus1
DIARRHEA & URINARY SYMPTOMS also common, particularly in cases of
perforated appendicitis when there is likely inflammation near the rectum and
possible abscess in the pelvis
FEVER common, typically low-grade unless perforation has occurred

12. CLINICAL MANIFESTATIONS
ADULTS
NONSPECIFIC COMPLAINTS occur first1
Changes in bowel habits, malaise & vague,
perhaps intermittent, crampy, abdominal
pain in the EPIGASTRIC or
PERIUMBILICAL REGION1
Pain migrates to RLQ in
12–24 hours,
(sharper &localized atMCBURNEY’S POINT)1
1  Anterior superior iliac spine
2  Umbilicus
x  McBurney’s point

13. CLINICAL MANIFESTATIONS
PEDIA
SAMECLASSICPRESENTATION <50% of cases,
therefore, majority of Cases of appendicitis have an
“atypical” presentation5
BEGINS INSIDIOUSLYwith brief period of
generalized malaise & anorexia family is not likely to
seek consultation – assumption of “STOMACH FLU”
ESCALATES RAPIDLYwith progressive abdominal
pain followed by vomiting perforation likely to occur
within 48° of the onset

14. CLINICAL MANIFESTATIONS
SYMPTOMS
MANIFESTATION PERCENTAGE
Abdominal pain >95%
Anorexia >70%
Constipation 4–16%
Diarrhea 4–16%
Fever 10–20%
Migration of painto RLQ 50–60%
Nausea >65%
Vomiting 50–75%
MANIFESTATION PERCENTAGE
Abdominal tenderness >95%
RLQ tenderness >90%
Rebound tenderness 30–70%
Rectal tenderness 30–40%
Cervical motion tenderness 30%
Rigidity ~10%
Psoas sign 3–5%
Obturator sign 5–10%
Rovsing’s sign 5%
Palpable mass <5%
SIGNS

15. MORPHOLOGY
OUTER ASPECT OF APPENDIX INVOLVED BY ACUTE
INFLAMMATION. A THICK PURULENT COATING IS SEEN TOGETHER
WITH MARKED HYPEREMIA OF THE SEROSA.
Gross Findings4 Histologic Findings4
ACUTE APPENDICITIS WITH MASSIVE INFLAMMATORY INFILTRATE,
EXTENSIVE ULCERATION, AND HEMORRHAGE. AN ISLAND OF
HEAVILY INFLAMED RESIDUAL MUCOSA IS SEEN IN THE CENTER.

16. MORPHOLOGY
Gross Findings4
RUPTURE OF APPENDIX SECONDARY TO TRANSMURAL ACUTE APPENDICITIS

17. PHYSICAL EXAMINATION
HALLMARK of diagnosing acute
appendicitis remains a careful and
thorough Hx & PE
Presence of LOCALIZED
ABDOMINAL TENDERNESS the
SINGLE MOST
reliable finding in the diagnosis of
acute appendicitis

18. PHYSICAL EXAMINATION
CLASSIC SIGNS OFAPPENDICITIS IN PATIENTS WITHABDOMINAL
PAIN
REBOUND TENDERNESS
Elicited by deep palpation of the
abdomen followed by the sudden
release of the examining hand5

19. PHYSICAL EXAMINATION
CLASSIC SIGNS OFAPPENDICITIS IN PATIENTS WITHABDOMINAL
PAIN
ROVSING’S SIGN
Palpating in the left lower
quadrant causes pain in the
right lower quadrant1

20. PHYSICAL EXAMINATION
CLASSICSIGNSOFAPPENDICITISIN PATIENTSWITHABDOMINAL PAIN
OBTURATORSIGN
INTERNAL ROTATION OF HIP
SUGGESTING THE POSSIBILITY OF
PAIN AND INFLSMED APPENDIX
LOCATED IN PELVIS.

21. PHYSICAL EXAMINATION
CLASSICSIGNSOFAPPENDICITISIN PATIENTSWITHABDOMINAL PAIN
ILIOPSOAS SIGN
Extending the right hipcauses
pain
back
along posterolateral
and hip, suggesting
retrocecal appendicitis1

22. PHYSICAL EXAMINATION
CLASSICSIGNSOFAPPENDICITISIN PATIENTSWITHABDOMINAL PAIN
DUNPHYSIGN Coughingmayelicit pain
d/t abdominal wall movement5

23. PHYSICAL EXAMINATION
OTHERSIGNSOFAPPENDICITIS:
BASSLER SIGN Sharp
compressing the inflamed
abdominal wall and Iliacus
pain created by
appendix between
TENHORN SIGN Pain in the RLQor McBurney’s
Point caused by gentle traction of right testicle or
thespermaticcord for males

24. DIAGNOSTIC FACTORS
LABORATORYTESTS
CBC(withDIFFERENTIALCOUNT)
• WBC 10,000–18,000/mm3 in 70%cases1
11,000–16,000/mm3 for pediatric patients5
>20,000/mm3 –––– indicates PERFORATEDCASES
• “LEFTSHIFT”toward immaturePMNleukocytes in>95% of cases
URINALYSIS
• Indicated to help EXCLUDEgenitourinary conditions1
• Often with WBC and RBC d/t result of the proximity of the
inflamed appendix to the ureter or bladder, but it should be free
of bacteria5

25. DIAGNOSTIC FACTORS
OTHERTESTS
• ELECTROLYTES & LIVER PANEL most helpful only in
assessing the level of illness and direct fluid
resuscitation,but RARELYaid accurate diagnosis5
• C-REACTIVE PROTEIN increases in proportion to the
degree of inflammation, but non-specific as well5
• AMYLOID A PROTEIN consistently elevated in
patients with acute appendicitis (SENSITIVITY –– 86%;
SPECIFICITY–– 83%)

26. DIAGNOSTIC FACTORS
IMAGING TESTS
PLAINRADIOGRAPHS
• Mosthelpful in evaluating complicated casesinwhich
smallbowel obstruction or free air is suspected5
• FINDINGS:
1. Sentinelloops of bowel & localized ileus
2. Scoliosisfrom psoasmusclespasm
3. Colon“CUT-OFF”Sign colonicair–fluid level above
the right iliac fossa
4. RLQsoft-tissue mass
5. Calcified appendicolith (5-10% of cases)

27. DIAGNOSTIC FACTORS
ULTRASOUND
• Highly operator dependent
• SENSITIVITY – 0.86
• SPECIFICITY– 0.81
• FINDINGS5:
1. Wall thickness≥6 mm
2. Appendicolith
3. Luminal distention
4. Lackof compressibility
5. Complexmassin the RLQ
WALL-C
MAIN LIMITATION an inability to visualizethe appendix in up to 20% cases

28. DIAGNOSTIC FACTORS
COMPUTEDTOMOGRAPHY
• GOLDSTANDARDfor pediatricevaluation
• BUT carries negative effects of radiation &
increased costs
• SENSITIVITY – 0.94
• SPECIFICITY– 0.95
• FINDINGS5:
1. Distended(>7 mm)thick-walled appendix
2. Inflammatory streaking of surroundingmesenteric fat
3. Pericecalphlegmonor abscess
4. Appendicoliths more readily seen (40-50%) than
plain radiographs (5-15%
Alsohelpful in demonstratingNON-APPENDICEAL
CAUSESof abdominal pain

29. DIAGNOSTIC FACTORS
COMPUTEDTOMOGRAPHY

30. DIAGNOSTIC FACTORS
MAGNETICRESONANCEIMAGING
• EQUIVALENT to CT in diagnostic
accuracy for appendicitis
• LIMITED because it is less available,
morecostly,often requires sedation
• DOESNOTinvolve ionizing radiation
• Most useful in adolescent girls
when advanced imaging is
needed

31. DIAGNOSTIC FACTORS
WHITEBLOODCELLSCAN
• RADIONUCLIDE-LABELEDWBCSCANS
• Also been used in some centers in
evaluating atypical cases of possible
appendicitis in children
• SENSITIVITY – 0.97
• SPECIFICITY– 0.80

32. MANAGEMENT
MEDICALMANAGEMENT
ANTIBIOTIC THERAPY
• Lowers the incidence of POSTOPERATIVE WOUND INFECTIONS
& INTRAPERITONEALABSCESSESin perforated appendicitis, but
their role islesswell defined in simple appendicitis5
• Antibiotic coverage iscontinuedpostoperatively for 3-5 days
• For SIMPLE NON-PERFORATED AP one pre-op dose of a single broad-
spectrum agent (CEFOXITIN)or equivalent is sufficient
• ForPERFORATEDORGANGRENOUSAPPENDICITIS combination regimens suchas
Zosyn(piperacillin/tazobactam), ticarcillin/clavulanate, or ceftriaxone/metronidazole

33. MANAGEMENT
SURGICALMANAGEMENT
ForUNCOMPLICATEDAPPENDICITIS:
NON-OPERATIVEvs OPERATIVE
• NON-OPERATIVE:
a. Usedin anenvironmentwhereSxnotavailable & antibiotics alone not effective
b. Pt’swhodid notpursuemedical treatment occasionally havespontaneousresolution
• OPERATIVE remainsthe standard of care
URGENTvsEMERGENT
• Dependent oneach institution & surgeon
• URGENT best done within hours
• EMERGENT done assoonaspossible becauseminutescanmakea difference

34. MANAGEMENT
ForCOMPLICATEDAPPENDICITIS:
• Refersto PERFORATEDAPPENDICITIScommonlyassociatedwith anABSCESS
or PHLEGMON
NON-OPERATIVEvsOPERATIVE
• NON-OPERATIVE patients with complicated appendicits & a contained
abscessor phlegmon but limited peritonitis ––– conservative management only
(antibiotics, bowel rest, fluids, and possible percutaneous drainage) d/t
 risk for POSTOPERATIVEINTRA-ABDOMINALABSCESSFORMATION
• OPERATIVE sepsis & generalized peritonitis would prompt immediate
managementat the ORwith concurrent resuscitation

35. MANAGEMENT
OPERATIVEINTERVENTIONS:
1. INTERVALAPPENDECTOMY3,5
• Performing appendectomy following initial successfulnon-operative management
in patients with nofurther symptoms
• GOAL––Toprevent future attacks or to identify other disease(e.g. malignancies)
• Role following successful management of conservative treatment of complicated
appendicitis –– UNCLEAR
• Majority of pediatric surgeonsperform thisroutinely (4-6 wk interval) after initial
non-operative management of perforated appendicitis5

36. MANAGEMENT
IF WITHOUT CONTRAINDICATIONS –
if suggestive of medical Hx & PEwith
supportive Labs should
APPENDECTOMYurgently1
2. OPENAPPENDECTOMY3
undergo
• Under GA, placed insupine position
• RLQ MCBURNEY’S INCISION (oblique) or
ROCKY-DAVISINCISION (transverse)3

37. MANAGEMENT
2. OPENAPPENDECTOMY(con’t)
• If appendix not easily identified, the CECUM
and MESENTERYshouldbe located3
• Appendiceal stump managed by
SIMPLELIGATIONor by LIGATIONAND
INVERSION3
• If appendicitis not found, a methodical search
mustbe made for an alternative diagnosis3
• NEGATIVE APPENDECTOMY term used for
an operation performed for suspected
appendicitis, in which the appendix isfound to
be normal onhistological evaluation2

38. MANAGEMENT
3. LAPAROSCOPICAPPENDECTOMY3
• First reported laparoscopic appendectomy
wasperformed in 1983 by Semm
• Under GA, an OGTand NGTare used
• Surgeonand assistantstandsonthe pt’s left
FACINGTHEAPPENDIX
• Screens should be positioned on the pt’s
right or at the foot of the bed
• Stump should be carefully examined to
ensurehemostasis,complete transection, and
ensurethat nostumpisleft behind

39. MANAGEMENT
3.LAPAROSCOPICAPPENDECTOMY(con’t)
ADVANTAGES:
• Fewerincisional surgical site infections
• Lesspain, shorter length of stay
• Quicker return to normal activity
DISADVANTAGES:
• Increasedrisk of intra-abdominal abscess LAPAROSCOPIC APPENDICECTOMY.ARROW
SHOWS THE INFLAMED APPENDIX.

40. MANAGEMENT
4. LAPAROSCOPICSINGLE-INCISIONAPPENDECTOMY
• “GROWING INTEREST”3 –– Instead of two or three incisions, a SINGLE INCISION
made,typically periumbilical
• Almostsimilar with the typical laparoscopic appendectomy
• NO DIFFERENCEin the ff:
a. Return to bowelfunction
b. Post-operative pain
c. Returnto normalactivity
d. Overall cost
e. Incidenceof hernia formation
• Late outcomes& patient quality-of-life outcomesREMAINTO BEINVESTIGATED

41. MANAGEMENT
5. NATURALORIFICETRANSLUMINALENDOSCOPICSURGERY
• New surgical procedure usingFLEXIBLEENDOSCOPESin the abdominal cavity
• Access gained by way of organs that are reached through a NATURAL, ALREADY-
EXISTINGexternal orifice (e.g. transvaginal approach)

42. THANK YOU