4. Blood Supply
• The blood supply of the appendix is derived
from the superior mesenteric artery.
The ileocolic artery------gives rise to the
appendiceal artery, which courses through the
mesoappendix.
The mesoappendix also contains lymphatics of the
appendix, which drain to the ileocecal nodes,
along the blood supply from the superior
mesenteric artery.
5. Structure of Histology
• The appendix has four layers to include:
• 1.Mucosa / The colonic type,with columnar
epithelium, neuroendocrine cells,and mucin-producing
goblet cells/
• 2. Submucosa /lymphoid tissue/
• 3. Muscularis /inner circular,outer longitudinal/
• 4. Serosa
• The important structure is Normal colonic
flora
6. Reason of obstruction
• The causes of the luminal obstruction are many
and varied
These most commonly include :
• fecal stasis
• fecaliths
• lymphoid hyperplasia
• neoplasms
• fruit and vegetable material
• ingested barium
• parasites such as ascarids etc…
7. Pathophysiology
Appendicitis is caused by luminal obstruction
Obstruction of the proximal lumen
Progressive distention of the appendix
Mucosal ischemia
/continued obstruction/ Full-thickness ischemia ensues
Bacterial overgrowth within the
appendix /bacterial stasis/
Perforation
Di useff
8.
9. History
• Abdominal pain / most commonly periumbilical /
• Anorexia is often present /nausea/
• Either diarrhea or constipation may be present
as well.
• The clinician must be aware that the disease
may be manifested in an atypical fashion.
For example, patients with
• a retroperitoneal appendix
• an appendiceal tip in the pelvis.
11. Physical Examination
1. Patients with appendicitis typically appear ill.
2. They frequently lie still because of the presence of
localized peritonitis, which makes any movement painful.
3. Tachycardia and mild dehydration are
often present to varying degrees.
4. Fever (<38.5° C) is depending on the status of the
disease process and the severity of the patient’s
inflammatory response.
Absence of fever does not exclude a diagnosis of
appendicitis
12. Abdominal examination
• The location of the tenderness is classically McBurney point,
which is located one-third the distance between the anterior superior iliac
spine and the umbilicus.
• Spasm of the overlying abdominal wall musculature is strongly suggestive of
perforation and di use peritonitisff
Diagnosis sign
These include:
1. The Rovsing sign (the presence of right lower quadrant pain on palpation of
the left lower quadrant),
2. The Obturator sign (right lower quadrant pain on internal rotation of the hip)
3. The Psoas sign (pain with extension of the ipsilateral hip) others…
Rectal examination or pelvic examination /in female patients/
13. Laboratory diagnosis
• A leukocytosis, often with a “left shift” (a predominance
of neutrophils and sometimes an increase in bands) /
90%/
• A normal white blood cell count is found in 10% of cases
• Urinalysis is typically normal as well.
• Pregnancy testing is mandatory in women of
childbearing age.
• C-reactive protein has been demonstrated to be neither
sensitive nor specific in diagnosing appendicitis.
14. Diagnostic od radiographic
• These consist of plain radiographs:
1.computed tomography(CT) scanning
2.ultrasound (US)
3.magnetic resonance imaging (MRI)
• Plain radiographs /AP/ are lack both sensitivity and
specificity .
• The diagnosis include the presence of a calcifed fecalith
in the right lower quadrant, typically present in only 5%
of cases.
• Pneumoperitoneum /nonspecificity/
15. Computed Tomography //CT//
• CT scanning is the most common imaging study to diagnose
appendicitis .
CT has been shown to have
1. a sensitivity of 90% to 100%,
2. a specifcity of 91% to 99%,
3. a positive predictive value of 92% to 98%,
4. a negative predictive value of 95% to 100%.
16. • A thickened, inflamed appendix with surrounding
“stranding” indicative of inflammation.
• The appendix is typically more than 7 mm in
diameter with a thickened, inflamed wall and
mural enhancement or “target sign”
• Periappendiceal fluid or air is also highly
suggestive of appendicitis and suggests
perforation.
17.
18. Magnetic resonance imaging /MRI/
• MRI is typically reserved for use in the pregnant patient
/without contrast agents/
• Criteria for MRI diagnosis include:
1. appendiceal enlargement (>7 mm)
2. thickening (>2 mm),
3. presence of inflammation
The sensitivity of MRI is reported to be 100%
• the specificity 98%,
• the positive predictive value 98%
• the negative predictive value 100%.
22. TREATMENT OF APPENDICITIS
• Acute Uncomplicated Appendicitis
• Perforated Appendicitis
• Delayed Presentation of Appendicitis
• The Normal-Appearing Appendix at Operation
• Nonoperative Treatment of Uncomplicated
Appendicitis
23. Acute Uncomplicated Appendicitis
• Treatment of acute uncomplicated appendicitis is prompt
appendectomy.
• The patient should undergo fluid resuscitation as indicated, and the
intravenous antibiotics directed against gram-negative and
anaerobic organisms should be initiated immediately..
• For open appendectomy, the choice of incision is a matter of the
surgeon’s preference, whether it is an oblique muscle-splitting
incision (McArthur-McBurney; ), a transverse incision
(RockeyDavis), or a conservative midline incision.
24.
25.
26. • For laparoscopic appendectomy, the patient is placed in
the supine position.
• The bladder is emptied by a straight catheter
• The abdomen is entered at the umbilicus, and the
diagnosis is confrmed by inserting the laparoscope.
Two additional working ports are then placed,
1. left lower quadrant
2. suprapubic area
3. supraumbilical midline
Discharge is usually possible the day after operation
27.
28. Perforated Appendicitis
• The operative strategy for perforated appendicitis is
similar to that for uncomplicated appendicitis with a few
notable exceptions.
• As with uncomplicated appendicitis, antibiotic therapy
should be initiated immediately on diagnosis.
• Both the open and laparoscopic approaches are
acceptable for the treatment of perforated appendicitis.
• Although the technique of appendectomy for perforation
is the same as for simple appendicitis, the level of
difficulty encountered in removing a friable,gangrenous,
perforated appendix.
29. Delayed Presentation of Appendicitis
• Patients may occasionally present several days to even
weeks after the onset of appendicitis.
• Fluid resuscitation is initiated, and broad-spectrum
antibiotic therapy is initiated.
• CT scan is obtained, and perforated appendicitis with
a localized abscess or phlegmon is confrmed
• Interval appendectomy in adults has been the
observation by some investigators of a higher incidence
of appendiceal neoplasms found in interval
appendectomy specimens .
30.
31.
32.
33. Differantial diagnosis
• Appendicitis must be considered in every patient (who has not
had an appendectomy) who presents with acute abdominal pain.
• mesenteric adenitis (often seen after a recent viral illness)
• acute gastroenteritis
• Intussusception
• Meckel’s diverticulitis
• inflammatory bowel disease
• (in males) testicular torsion.
• Nephrolithiasis and urinary tract infection may be manifested with
right lower quadrant pain in either gender.
34. • In women of childbearing age, the di erential diagnosis.ff
• These include:
• Ruptured ovarian cysts
• Mittelschmerz (midcycle pain occurring with ovulation)
• Endometriosis
• Ovarian torsion
• Ectopic pregnancy
• Pelvic inflammatory disease.
35. In the elderly:
•acute diverticulitis
•Malignant disease as possible causes of
lower abdominal pain.
•In the neutropenic patient, typhlitis (also
known as neutropenic enterocolitis)
