Acute abdomen is an emergency condition whose urgent diagnosis is mandatory for a better result.

1. ACUTE APPENDICITIS
Presenter:
Dr. Saad Andalib.
M.B.B.S

2. Definition:
• Appendicitis is defined as an inflammation of the inner
lining of the vermiform appendix which spreads to its other
parts.
• It results from luminal obstruction followed by infection.
• Calcified fecal matter known as fecolith often plays a role.

3. Anatomy
• The three taeniae coli converge at the junction of the cecum
and the appendix and can be a useful landmark to identify
the appendix.
• The appendix can vary in length from <1 cm to >30 cm; most
appendices are 6 to 9 cm long.

4. Variations in topographic position of the
appendix
From its base at the cecum, the appendix may extend (A) upward, retrocecal and
retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to
the left, ileocecal (may pass anterior or posterior to the ileum)

5. Surgical Anatomy – Position:

6. Etiology:
Obstruction of the lumen is the dominant etiologic factor in
acute appendicitis.
• – Faecolith / faecal stasis
• – Submucosal lymphoid hyperplasia
• – Inspissated barium
• – Vegetable/fruit seeds
• – Worms (Entrobius vermicularis)
• – Tumors of caecum/appendix

7. Pictorial Explanation
Appendiceal
obstruction/early
appendicitis – visceral
peritoneal irritation
Appendiceal
distension
Irritation of parietal
peritoneum
(localised)
Perforation,
localised/generalised
peritonitis, mass
obstruction
Distention
Distention
causing
Ischemia
Gangrene

8. Bacteriology:
Common organisms seen in patients with acute
appendicitis

9. 1-Abdominal pain: Classically, pain is initially diffusely centered in the
umbilical area, is moderately to severe in intensity, cramping in nature. After a
period varying from 1 to 12 hours, the pain localizes to the right lower quadrant.
Symptoms:
2-Anorexia: Nearly always accompanies appendicitis. It is so constant that the
diagnosis should be questioned if the patient is not anorectic.
3-Nausia and vomiting: Nausea more common than vomiting. Occurs
in nearly 75% of patients.
4-Obstipation: Begins before the onset of abdominal pain.

10. -Temperature elevation is rarely > 38.6 °C
-Pulse rate is normal or slightly elevated
-Tenderness often is maximal at or near the McBurney point
-Direct rebound tenderness
-Rovsing sign: pain in the right lower quadrant when palpatory pressure
is exerted in the left lower quadrant
-Psoas sign: indicates an irritative focus in proximity to psoas muscle.
-Obturator: stretching the obturator internus causes irritation of the inflamed
appendix. The test is performed by passive internal rotation of the flexed right thigh
with the patient supine.
Signs:

11. • Leukocytosis, ranging from 10,000 to 18,000 cells/mm3, usually is
present in patients with acute, uncomplicated appendicitis and often is
accompanied by a moderate polymorphonuclear predominance.
• White blood cell counts are variable. It is unusual for the white blood cell
count to be >18,000 cells/mm3 in uncomplicated appendicitis.
• White blood cell counts above this level raise the possibility of a
perforated appendix with or without an abscess.
• Urinalysis can be useful to rule out urinary tract infection.
Laboratory findings:

12. USG W/A : Sonographically, the appendix is identified as a blind-ending,
nonperistaltic bowel loop originating from the cecum.
Common signs of acute appendicitis:
A fluid filled non compressible appendix.
Diameter greater than 6mm.
Appendicolith.
Pericecal fluid.
Increased echogenicity.
CT scan: Sensitivity and specificity > 95 %.
Imaging:

13. Manifestations Value
Symptoms Migration of pain 1
Anorexia 1
Nausea and/or
vomiting
1
Signs Right lower quadrant
tenderness
2
Rebound 1
Elevated temperature 1
Laboratory values Leukocytosis 2
Left shift in leukocyte
count
1

15. 1-ACUTE MESENTERIC ADENITIS
2-Pelvic Inflammatory Disease
3-Ruptured Graafian Follicle
4-Twisted Ovarian Cyst
5-Ruptured Ectopic Pregnancy
6-ACUTE GASTROENTERITIS
7-Meckel's Diverticulitis
8-Crohn's Enteritis
9-Colonic Lesions

16. Treatment:
Appendectomy :
1- Open appendectomy
2- Laparoscopic appendectomy
Once the decision to operate has been made, the patient should be
prepared for the operating room. Adequate hydration should be
ensured, electrolyte abnormalities should be corrected.
Pre-existing cardiac, pulmonary, and renal conditions should be
addressed.
Administration of antibiotics to all patients with suspected appendicitis.

17. Open appendectomy:
For open appendectomy most surgeons use either a McBurney (oblique) or
Langer’s incision.

18. Laparoscopic appendectomy:
• Laparoscopic appendectomy requires the use of three ports.
• The surgeon usually stands to the patient's left. One assistant is
required to operate the camera.
• One trocar is placed in the umbilicus (10 mm).
• Second trocar (5mm) is placed in the suprapubic position. Some
surgeons place this second port in the left lower quadrant.
• Third trocar (5 mm) is variable and usually is either in the left lower
quadrant, epigastrium, or right upper quadrant.

20. Prognosis:
• The mortality from appendicitis in has steadily decreased
from a rate of 9.9 per 100,000 in 1939 to 0.2 per 100,000 in
recent years.
• Factors responsible are advances in anesthesia, antibiotics, IV
fluids, and blood products.
• Death is usually attributable to uncontrolled sepsis,
peritonitis, intra-abdominal abscesses, or gram-negative
septicemia.

21. Have a nice day.