2. ACUTE APPENDICITIS
INCIDENCE
Incidence (overall) 4-6 per 1000
Europe 5 per 1000
Russia 1 per 304
Moscow 1 per 404
steadily dropping over the past 25 years (developed countries)
up to 6-7% of population might have an appendicitis
relatively rare in Asian countries and in Africa
5. ACUTE APPENDICITIS
About 200.000 appendectomies are performed annually in
the USA
More than 120.000 operations for acute appendicitis
performed yearly in Russia
Second cause of hospitalization in surgical department
after acute cholecystitis
6. Although most patients with acute appendicitis can be
easily diagnosed, there are many in whom the signs and
symptoms are quite variable, and a firm clinical
diagnosis may be difficult to establish.
7. What we wish to accomplish in the treatment of
appendicitis is, not to save half of our cases, not four
cases out of five, but all of them.
Charles McBurney, 1889
9. ANATOMY
- right lover quadrant (RLQ)
- arises from the cecum
- convergation of the taeniae at the
base of appendix
- 2,5 cm below the ileocecal valve
- mean length 9 cm
- mean diameter 8 mm
10. ANATOMY
CONGENITAL ANOMALIES
Absence of the appendix (Morgagni, 1719; Hunter, 1762)
Absence of both appendix and cecum (Collins, 1963)
Ectopic appendix (mostly left-sided appendix):
- situs inversus viscerum;
- nonrotation of the intestines;
- “wandering” cecum with a long mesentery;
- excessively long appendix crossing the midline
11. ANATOMY
CONGENITAL ANOMALIES
Duplication of the appendix (by Cave-Wallbridge, 1936, 1963):
Type A – single cecum and a partial duplication
Type B1 – two separate appendices arise from a single cecum
Type B2 – the second appendix arises from the taenia of the cecum
Type C – double cecum, each with its own appendix
12. Smith et al., 1974: 40 cases of LLQ appendicitis and 97 cases of
appendicitis and situs inversus.
Collins, 1963: 71.000 specimens, 40 cases LLQ appendix, 17 cases of
situs inversus, 11 with dextrocardia; 4 cases of absence of the
appendix, 2 cases of double appendix.
Arda et al., 1992: found 100 cases of duplication in literature.
Tinckler et al., 1968: triplicated appendix (1 case).
Mesko et al., 1989: a case of horseshoe appendix – continuous lumen
with two separate openings into the cecum.
ANATOMY
CONGENITAL ANOMALIES – ARE THEY RARE?
Appendiceal anomalies should be routinely checked at
surgery, especially when clinical signs of appendicitis occurs
and normal appendix have been found !
13. ANATOMY
POSITION OF THE APPENDIX
pelvic, retrocecal retroperitoneal, infrahepatic
COMMON ATYPICAL LOCALIZATION OF THE APPENDIX
16. L – lower ileocolic lymph nodes
Lymphatic drainage from ileocecal
region is trough a chain of nodes on the
appendicular, ileocolic and superior
mesenteric arteries to the celiac lymph
nodes and cisterna chyli.
Lymph nodules in the wall of the
appendix are not connected with the
lymphatic drainage of the organ.
Knowledge of lymphatic drainage and regional nodes is important in
the management of malignancies of the appendix (rare).
ANATOMY
LYMPHATIC DRAINAGE
24. LABORATORY DATA
90% of patients have leukocyte counts over 10.000/μL
average leukocyte count is 15.000/μL (10.000 – 20.000)
differential white count shows more than 75% neutrophils in 75% of
cases
normal leukocyte level and differential cell count in 10% of cases,
especially in elderly patients
insignificant urine leukocyte and erythrocyte levels in 25% of cases
hematuria may occur particularly in retrocecal or pelvic appendicitis;
gross hematuria or leukocyte count indicates a primary urinary tract
disorder
serum C-reactive protein sample is also used in some institutions
25. PLANE X-RAY IMAGING
both sensitivity and specificity are poor in classic cases; in general,
findings on plain films are nonspecific and rarely of help in diagnosis
most useful in differential diagnosis of appendicitis (perforated GI ulcer,
ureterolithiasis, renal calculi etc); routinely used in urgent surgery
barium enema may show an absence of filling of the appendix; no more
used in acute cases (chronic appendicitis?)
plain films may show a dilated cecum, air-fluid levels in RLQ and
localized ileus in 50% of patients; less common findings are an altered
right psoas shadow, abnormal right flank stripe or a calcified fecalith,
occasionally – a foreign body
free intraperitoneal air appears to be a rare manifestation of perforated
appendicitis (most common cause is a perforated peptic ulcer)
26. ULTRASONOGRAPHY
an enlarged appendix could be visible
quite special view in cross section imaging – “target” sign
may be helpful in detecting of an abscess
local fluid accumulation is one of the most important signs
practical importance is still contradictory (same for CT)
28. DIFFERENTIAL DIAGNOSIS
MORE COMMON LESS COMMON
acute gastroenteritis ureteral stones
cholecystitis cystitis
pyelitis perforated peptic ulcer
salpingitis ectopic pregnancy
tubo-ovarian abscess acute regional enteritis
ruptured ovarian cyst testicular torsion
29. THE ESSENTIALS OF DIAGNOSIS
SUMMARIZED LITERATURE DATA
Abdominal pain
Anorexia, nausea and vomiting
Localized right lower quadrant abdominal tenderness
Low-grade fever
Leukocytosis
Finding localized tenderness over McBurney’s point is the
cornerstone of diagnosis
30. SOME USEFUL NOTES
BASED UPON LITERATURE REPORTS
People with early nonperforated appendicitis often do not
appear ill and may even apologize for taking your time.
(A rule that will help considerably with atypical cases is)
never to place appendicitis lower than second in the
differential diagnosis of acute abdominal pain in a
previously healthy person.
31. SOME USEFUL NOTES
BASED UPON LITERATURE REPORTS
If a patient persists in having pain in the right lower
quadrant that cannot be explained by some other definitive
diagnosis, the patient should be considered to have acute
appendicitis and should be operated on or at least carefully
observed.
The best strategy in equivocal cases is to observe the
patient for a period of 6 hours or more. During this time,
patients with appendicitis experience increasing pain and
signs of inflammation and those without appendicitis
generally improve.
32. LAPAROSCOPY
major signs minor signs
visible appendix invisible appendix
rigid walls exudate in RLQ
local or spread wall hemorrhage infiltration of cecum
fibrin marks, mesentery infiltration local peritoneum hyperemia
diagnostic accuracy - 95-98%
in atypical cases is mostly
indicated
33. APPENDICITIS DURING PREGNANCY
delay in operation runs a higher risk of perforation and diffuse peritonitis;
omentum is not in close contact with appendix therefore it could not be
isolated in case of inflammation
cases are equally distributed through the three trimesters of pregnancy
pregnant women develop appendicitis with the same frequency as do
nonpregnant of the same age
most common nonobstetric surgical disease of the abdomen during
pregnancy
the mother is in greater danger of serious abdominal infection and the
fetus is more vulnerable to premature labor with complications
typical abdominal signs may be absent; nausea and vomiting are not of
great value
34. APPENDICITIS DURING PREGNANCY
most of diagnostic and tactical problems
appear in 2 half of pregnancy
diagnosis is always difficult due to
displacement of cecum; the enlarged
uterus occasionally will have pushed the
appendix into the right upper quadrant
fever is less common; >38° in 20% cases
leukocytosis is typical (physiologic
leukocytosis!) but it too may be absent
early appendectomy has decreased the maternal death rate to under
0,5%, fetal death rate to under 10%
35. APPENDICITIS IN INFANTS
AND CHILDREN
diagnosis is always difficult since these patients cannot provide a history
while Immune system is insolvent and greater omentum is too short to
wall off the inflammation area, destructive appendicitis often develop
earlier; the incidence of peritonitis is much higher!
symptoms of general illness and intoxication are predominant over the
local symptoms and abdominal pain
differential diagnosis with enteric infection must be performed
36. APPENDICITIS IN ELDERLY
clinical symptoms are not clear, common areactivity of the organism
could obscure or hide real situation; symptoms of acute inflammation are
poor
abdominal wall relaxation leads to unclear peritoneal signs
high incidence of destructive types of appendicitis due to atherosclerotic
injury of blood vessels (a gangrene may be primary in absence of other
causes of inflammation)
body temperature is not high even when destruction of appendix occurs;
leukocyte level tends to be lower (8.000-12.000/μL), nausea and vomiting
are rare, although constipation is frequent
38. OPEN APPENDECTOMY
The incision for appendectomy (blue
line) in relation to McBurney’s point
Actual location of appendix in 30
patients
Claudius Amyand, 1736
Lawson Tait, 1880
Kroenlein, 1884
Who performed first appendectomy?
41. MECKEL’S DIVERTICULUM
Incidence -2-3:100 appendectomies
Abdominal cavity should be routinely
examined for M’sD in all cases of
exploration during appendectomy
MODERN APPROACH
Meckel’s diverticulum showing pathological changes should always be
removed. In gangrenous or perforated appendicitis, an incidentally
detected Meckel’s diverticulum should be left intact. In low-grade
inflammatory appendicitis, the low associated complication rate would
militate in favor of removal of the diverticulum. (World J. Surg., 2005, vol. 29, # 4)
