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1. Acute Appendicitis
Wuletaw C.(MD)
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2. Anatomy of the appendix
 Convergence of 3 taenia coli
 Near caecum in right iliac fossa
 Useful landmark to identify the appendix
 Base is 2 cm from ileo-caecal valve
 Vary in length from less than 1 cm to
greater than 30 cm
 Most are 6 to 9 cm in length
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3. The anatomy of the appendix
 Base of the appendix to
the cecum remains
constant
 Tip of appendix varies!
 Can be found in a
retrocecal, pelvic, subcecal,
preileal, or right pericolic
position
 Majority are retrocaecal
 Influences presentation Numbers indicate % of
occurance
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4. The anatomy of the appendix
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5. The Appendix
 A non-essential lymphoid organ
 Secretion of antibodies
 Vermiform (Latin: worm-like)
 Blind intestinal diverticulum
 Obstruction of lumen causes appendicitis
 Faecaliths most common cause.
 Lymphoid hyperplasia
 Filarial worms
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6. Appendicitis
 Most common causes of the acute
abdomen worldwide
 Occur most commonly in the second and
third decades
 Highest in the 10- to 19-year-old age
group
 Male to female ratio = 1.4:1
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7. Pathogenesis
• Luminal obstruction at neck believed to be the major
cause of acute appendicitis
• Continued secretion of mucus leads to intraluminal
distention and increased wall pressure
– Stretch of visceral peritoneum produces pain experienced by
the patient as periumbilical pain
• Lymphatic and venous return impaired in area
– Inflammation affects serosa
– Stretch of parietal peritoneum in area
– Leads to mucosal ischemia
– Progress to gangrene and perforation
– Inflammation of the adjacent peritoneum gives rise to localized pain in
the right lower quadrant
• Epithelial breakdown
– Bacteria can get across epithelium
• Inflammation Perforation Peritonitis
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8. Bacteriology
 Flora in the normal appendix is very
similar to the colon
 Selection or duration of antibiotic use
 Appendiceal flora remains constant
throughout life
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9. Bacteria Commonly Isolated in
Perforated Appendicitis
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10. Clinical features
History
• Abdominal Pain
– Periumbilical pain that shifts to RLQ
(McBurney’s point) after 4-6 hours
– Vague pain Precise
– Visceral pain Parietal Pain
– Precise pain depends on location of tip of
appendix
• Retrocaecal can cause flank pain
• Pevlic appendix can cause suprapubic pain…
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11. McBurney’s Point
 2/3 along from umbilicus to right anterior superior iliac
spine
 Maximal point of tenderness
1) McBurney’s Point
2) Umbilicus
3) Right ASIS
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12. McBurney’s Point
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13. Clinical Features cont…
 Anorexia
 Nearly always accompanies appendicitis in
most patients
 Nausea and Vomiting (early)
 Occurs in nearly 75% of patients
 Only once or twice
 Neural stimulation and the presence of ileus
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14. Clinical Features cont…
 Sequence of symptom appearance has
great differential diagnostic significance
 In more than 95% of patients anorexia is
the first symptom, followed by abdominal
pain, which is followed, in turn, by vomiting
(if vomiting occurs)
 If vomiting precedes the onset of pain, the
diagnosis of appendicitis should be
questioned
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15. Signs
 Tachycardia
 Low-grade fever (37.5-38.5oC)
 Lying still
 Movement hurts patient
 Guarding
 Physical findings are determined principally by
the anatomic position of the inflamed appendix
 Tenderness at McBurney’s point
 Rebound and percussion tenderness
 Diminished bowel sounds
 Focal tenderness with voluntary guarding
 Coughing may cause increased pain (Dunphy's sign)
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16. Signs
 Pain in the right lower quadrant during
palpation of LLQ (Rovsing's sign)
 Pain on internal rotation of the hip
(obturator sign, suggesting a pelvic
appendix)
 Pain on extension of the right hip
(iliopsoas sign, typical of a retrocecal
appendix)
 Tenderness on rectal examination (if the
appendix is located within the pelvis) 16

17. 17

18. Psoas
sign
Obturator
sign
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19. Clinical Features
 Diagnosis is
difficult!
 Alvarado score
 0-4 – Unlikely
 5-6 – Maybe
 7-8 – Probably
 9+ -- Yes!
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20. Differential diagnosis
surgical: gyneco:
 Renal stone
 Gastroenteritis
 Pancreatitis
 Cholecystitis
 Mesenteric adenitis
 Hernia
 Bowel obstruction
 Preterm labor
 Placenta abruptio
 Chorioamnionitis
 Adnexal cyst torsion
 Ectopic pregnancy
 Pelvic inflammatory
disease
 Round lig. pain
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21. Investigations
 White cell count
 Usually slightly elevated with left shift
 Mild leukocytosis (10,000 to 18,000/mm3)
 Urine dipstick
• To rule out urinary tract infection?
• Microscopic hematuria and pyuria are found in up to
one-third of patients with acute appendicitis
 Pregnancy test
 To rule out ectopic pregnancy?
 Erythrocyte sedimentation rate 21

22. Radiography
 Ultrasound of appendix
 Accurate way to establish the diagnosis of
appendicitis
 Thickening of the appendiceal wall and
periappendiceal fluid is highly suggestive
 Easily compressible blind-ending tubular
structure measuring 5 mm or less in diameter,
excludes the diagnosis of acute appendicitis
 Sensitivity 55 to 96% and specificity 85 to
98%
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23. Radiography cont…
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24. Ultrasonographic signs of acute
appendicitis
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25. 
 1.thickened
appendix
 2.Caecum
 3.Small amount of
pericaecal fluid
 4.perippendicular
hyperemia

26. Radiography cont…
 Computed tomography scan (CT scan)
 A thick wall (>2 mm)
 Appendicolith (seen in approximately 25
percent of patients)
 Target structure (concentric thickening of the
inflamed appendiceal wall)
 Phlegmon
 Abscess
 Free fluid
 Fat stranding/right lower quadrant
inflammation 26

27. Radiography cont…
 CT typically shows a
distended appendix
(arrow) with diffuse
wall-thickening and
periappendiceal fluid
(arrowhead)
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28. Radiography cont…
 Laparoscopy
 Diagnostic and therapeutic maneuver for
patients
 Females with lower abdominal complaints
 Differentiating acute gynecologic pathology
from acute appendicitis can be effectively
accomplished by using the laparoscope
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29. Radiography cont…
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30. Management
 Conservative
 Observation – only if low suspicion
 Medical
 Antibiotics
 Prophylaxis nonperforated, a single dose &
therapy in perforated or gangrenous appendicitis
should be continued for 3 to 5 days
 Surgical
 Appendicectomy
 Main treatment, as 25% appendicitis rupture
 Need to intervene early 30

31. Appendicectomy
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32. Appendicectomy
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33. Appendicectomy
Normal appendix (top) and inflammed appendix (bottom
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34. Complications
 Perforation
 Appendceal mass
 Inflamed, palpable
appendix covered with
momentum
 Drainage
 Appendceal abscess
 Local collection of pus
surrounded by a cavity
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35. THANK U
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