Acute Appendicitis

1. Acute Appendicitis
Dr. Raju Khatiwada
Resident
General surgery
KISTMCTH

2. CONTENTS
• Introduction
• Embryology and anatomy
• History
• Pathophysiology
• Clinical diagnosis
• Laboratory and imaging studies
• Management
• References

3. INTRODUCTION
• Most common diseases faced by the surgeon in practice.
• It is the most common urgent or emergent general surgical operation performed in
the United States and is responsible for as many as 3,00,000 hospitalizations
annually
• lifetime incidence is 8.6% in men and 6.7% in women
• Acute appendicitis is relatively rare in infants
• Incidence peaking in the second decade of life
• Appendicitis is much less common in underdeveloped countries

4. Embryology and Anatomy
• The appendix is a midgut organ and is first identified at 8 weeks of gestation as a
small outpouching of the cecum
• The appendix is a true diverticulum of the cecum as it contains all the histological
layers of the colon
• Previously considered a vestigial organ
• The appendix is now linked to the development and preservation of gut-associated
lymphoid tissue (GALT) and to the maintenance of intestinal flora

5. Embryology and
Anatomy
• During childhood, continued growth of the
caecum commonly rotates the appendix into
a retrocaecal
• In approximately one-quarter of cases,
rotation of the appendix does not occur,
resulting in a pelvic, subcaecal or paracaecal
position
• The position of the base of the appendix is
constant
Bailey and love textbook of surgery, 27th edition

6. Embryology and
Anatomy
• The average length is between 7.5 and 10 cm
• The blood supply of the appendix is
appendiceal artery, branch of ileocolic artery,
branch of the superior mesenteric artery
which courses through the mesoappendix
• Lymphatic drainage into ileocaecal lymph
nodes
Bailey and love textbook of surgery, 27th edition

7. History
• In 1735, The first appendectomy was reported by a French surgeon, Claudius
Amyand
• May 1880, The first surgeon to perform deliberate appendectomy for acute
appendicitis was Lawson Tait
• In 1886, First formal description of the disease process, was by Reginald Heber
Fitz of Harvard University.
• In 1887, Thomas Morton was the first to diagnose appendicitis,
• Charles McBurney described the clinical manifestations of acute appendicitis
including the point of maximum tenderness in the right iliac fossa

8. History
• In 1889 publication, Charles McBurney advocated for early appendectomy
• In 1894, classic muscle-splitting incision and technique for removal of the
appendix
• In 1982, First laparoscopic appendectomy by Kurt Semm

9. Pathophysiology
• Appendicitis is caused by luminal obstruction
• In pediatric populations, occurs as a result of lymphoid hyperplasia;
• In adults, it may be due to fecaliths, fibrosis, foreign bodies (food, parasites,
calculi), or neoplasia
• Intestinal parasites, particularly Oxyuris vermicularis (pinworm)
• Infections associated with appendicitis is polymicrobial
• Common isolates include Escherichia coli, Bacteroides fragilis, enterococci,
Pseudomonas aeruginosa, Klebsiella pneumoniae, and others

10. Pathophysiology
Risk factors for perforation of the appendix
• Extremes of age
• Immunosuppression
• Diabetes mellitus
• Faecolith obstruction
• Pelvic appendix
• Previous abdominal surgery

11. Clinical diagnosis (symptoms)
• Periumbilical colic
• Pain shifting to the right iliac fossa
• Anorexia
• Nausea

12. Symptoms
• The classic visceral–somatic sequence of pain is present in only about half of
those patients subsequently proven to have acute appendicitis.
• Atypical pain is more common in the elderly
• Pelvis appendix causes suprapubic discomfort and tenesmus, may be elicited only
on rectal examination
• During the first 6 hours, there is rarely any alteration in temperature or pulse rate.
• After that time, slight pyrexia (37.2–37.7ºC) with a corresponding increase in the
pulse rate to 80 or 90 is usual.
• However, in 20% of patients there is no pyrexia or tachycardia in the early stages.

13. Signs of acute appendicitis
• Pyrexia
• Localised tenderness in the right iliac fossa
• Muscle guarding
• Rebound tenderness

14. Signs to elicit in appendicitis
• Rovsing sign: the presence of right lower quadrant pain on palpation of the left
lower quadrant (normal position)
• Obturator sign: right lower quadrant pain on internal rotation of the hip (pelvic
appendix)
• Psoas sign: pain with extension of the ipsilateral hip
• Dunphy’s sign: pain with coughing (retrocecal appendix)

15. Special features, according to position of the
appendix
• Retrocaecal: Rigidity is often absent, and even application of deep pressure may
fail to elicit tenderness (silent appendix)
• Pelvic: diarrhea, absence rigidity, most common in children, rectal tenderness
present.
• Postileal: most difficult to diagnose

16. Special features, according to age
• Infant: rare, perforation
• Children: rare to find without vomiting, complete aversion to food
• Elderly: gangrene and perforation common
• Obese: diminishes all local signs
• Pregnancy:
m/c extrauterine acute abdomen
Frequency 1: 1500-2000
Diagnosis complicated by delayed presentation
Fetal loss 3-5%, 20% if perforation at operation

17. Laboratory studies
• Routine Full blood count:
leukocytosis with left shift is present in 90% of the cases
higher leukocytosis associated with gangrenous and perforated appendicitis
(∼17,000 cells/mm3)
• Urinalysis- to rule out nephrolithiasis
• Pregnancy test- mandatory in child bearing age
• Urea and electrolytes
• C-reactive protein

18. Imaging studies
• Imaging studies in patients suspected to have
acute appendicitis can reduce the negative
appendectomy rate, which can be as high as
15%
• Plain radiographs
• Ultrasound (US)
• Computed tomography (CT) scanning
• Magnetic resonance imaging (MRI)

19. USG
• Ultrasonography has a sensitivity of 0.85 (95% CI 0.79–0.90) and a specificity of
0.90 (95% CI 0.83–0.95)1
• An easily compressible appendix <5 mm in diameter generally rules out
appendicitis.
• Features on an ultrasound that suggest appendicitis include
Diameter of greater than 6 mm
Pain with compression,
Presence of an appendicolith
Increased echogenicity of the fat,
Periappendiceal fluid

20. CT-scan
• A contrast-enhanced CT scan has a sensitivity of 0.96 (95% confidence interval
[CI] 0.95–0.97) and specificity of 0.96 (95% CI 0.93–0.97)
• Features on a CT scan that suggest appendicitis include
Enlarged lumen and double wall thickness (greater than 6 mm)
Wall thickening (greater than 2 mm)
Periappendiceal fat stranding
Appendiceal wall thickening and/or
An appendicolith

21. Sabiston’s textbook of surgery-21st Edition

22. MRI
• MRI is typically reserved for use in the pregnant patient; the study is performed
without contrast agents.
• Criteria for MRI diagnosis include
Appendiceal enlargement (>7 mm),
Thickening (>2 mm), and
The presence of inflammation.
• Sensitivity of MRI to be 97% with a specificity of 95%

23. Migratory RIF pain 1
Anorexia 1
Nausea and vomiting 1
Tenderness (RIF) 2
Rebound tenderness 1
Elevated temperature 1
Leukocytosis 2
MODIFIED ALVARADO SCORE
score of 7 or more: strongly predictive of acute appendicitis.
(5–6): equivocal score

24. Modified Alvarado score
The sensitivity and specificity of the Alvarado Score and the modified Alvarado
Score have been reported to be 53–88% and 75–80% respectively
Baidya N, Rodrigues G, Rao A, et al. Evaluation of Alvarado score in acute appendicitis: a prospective study. Int
J Surg. 2007

25. Management of appendicitis
• Non-operative management
• Operative management

26. Non-operative management
• Patients with uncomplicated (absence of appendicolith, perforation or abscess)
appendicitis.
• Bowel rest and intravenous antibiotics, often metronidazole and 3rd generation
cephalosporin.
• The available data indicate initial successful outcomes in more than 90% of
patients with CT confirmed appendicitis
• However, approximately one-quarter of patients initially treated conservatively
will require surgery within 1 year for recurrent appendicitis

27. In the APPAC III trial (66 patients), 87 percent (95% CI 75-99) of those treated
with placebo and 97 percent (95% CI 92-100) of those treated with antibiotics were
successfully treated without surgery within 10 days; the difference was not
statistically significant (p = 0.142)

28. Operative management
• For open appendectomy, the patient is placed in the supine position.
• The choice of incision is a matter of the surgeon’s preference, whether it is an
Oblique muscle-splitting incision (McArthur-McBurney)
Transverse incision (Rockey-Davis) or
Conservative midline incision

29. Bailey and love textbook of surgery, 27th edition

30. Open vs Laparoscopic appendectomy
• The debate about the choice of open versus laparoscopic appendectomy for the
treatment of appendicitis was historically a major point of controversy among
surgeons.
• Although no level I data exist to support one approach over another

31. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
database (2005-2008)

32. CONCLUSION
• The investigators observed that laparoscopic appendectomy was associated with
lower risk of wound complications and deep surgical site infection in
uncomplicated appendicitis.
• In complicated appendicitis, laparoscopic appendectomy was associated with
fewer wound complications but a slightly higher incidence of Intraabdominal
abscess.

33. Management of appendix mass
• Standard treatment is the conservative Ochsner–Sherren regimen
• Criteria for stopping conservative treatment of an appendix mass
A rising pulse rate
Increasing or spreading abdominal pain
Increasing size of the mass
• Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn’s
disease.
• Using this regime, approximately 90% of cases resolve without incident.

34. Post operative complications
• Wound infection is the most common postoperative complication, occurring in 5–
10% of all patients.
• Intra-abdominal abscess: Approximately 8% of patients
• Ileus:
A period of adynamic ileus is to be expected after appendicectomy, and this may
last a number of days following removal of a gangrenous appendix.
Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is
indicative of continuing intra-abdominal sepsis and should prompt further
investigation
• Faecal fistula: from appendicular stump, rare

35. REFERENCES
1. Keyzer C, Zalcman M et al, Comparison of US and unenhanced multi-detector
row CT in patients suspected of having acute appendicitis. Radiology. 2005
Aug;236(2):527-34. doi: 10.1148/radiol.2362040984. PMID: 16040910.
2. Bailey and love textbook of surgery, 27th edition
3. Sabiston’s textbook of surgery-21st Edition
4. Schwartz textbook of surgery, 11th edition.
5. Uptodate

36. THANK YOU!
ANY QUESTIONS?