This document discusses the anatomy, clinical presentation, diagnosis, and treatment of acute appendicitis. It notes that the appendix is commonly located retrocecally and is supplied by the appendicular artery. The classic symptoms of acute appendicitis are known as Murphy's triad of periumbilical pain shifting to the right lower quadrant, anorexia, and fever. Diagnosis is made through physical exam finding tenderness at McBurney's point and confirmed through blood tests, urine analysis, and imaging like ultrasound or CT scan. Treatment is through open or laparoscopic appendectomy, while appendicular masses may be initially treated conservatively with antibiotics using the Ochsner-Sherren regimen before interval appendectomy

1. Dr. Dinesh. M.G
Professor of Surgery
J.J.M.M.C.
Davangere

2. Introduction
 Considered by most to be a vestigial organ
 Its importance in surgery
 Acute appendicitis
 Carcinoid tumour

3. Anatomy
 Blind muscular tube
 Mucosa, submucosa, muscularis propria and serosa
 Positions
 Retrocaecal 74%
 Pelvic 21%
 Paracaecal 2%
 Pre ileal 1%
 Post ileal 0.5%
 Subcaecal 1.5%

4. Anatomy
 Appendicular artery runs in mesoappendix
 It is an ‘end-artery’ & a branch of ileocolic artery
 Microscopic anatomy
 Lined by columnar cell of colonic type
 Crypts are present in the mucosa in which lie the
argentaffin (Kultschitzsky) cells

5. Acute appendicitis
 Reginald Fitz first published paper on appendicular
perforation in 1886
 Charles McBurney described clinical features including
the point of maximum tenderness in Rt. iliac fossa
 McBurney’s point

6. Aetiology
 No definite single aetiology
 Obstruction of lumen by
 Faecolith
 Pin worms
 Carcinoma caecum etc.

7. Clinical features
Murphy’s triad
 Periumbilical pain shifting to Rt.iliac fossa
 Anorexia, nausea and vomiting
 Fever
Signs
 Tachycardia, pyrexia
 Tenderness or rebound tenderness in Rt. iliac fossa
 Guarding or rigidity
 Rovsing’s sign
 Positive ‘Psoas sign’
 Positive ‘Obturator test’

8. Psoas test

9. Obturator test

10. Differential diagnosis
 Children
 Acute gastroenteritis
 Mesenteric lymphadenitis
 Meckel’s diverticulitis
 Intussusception
 Lobar pneumonia and pleurisy
 Adults
 Right ureteric colic
 Rt. Acute pyelonephritis
 Perforated peptic ulcer
 Testicular torsion
 Acute pancreatitis

11. Differential diagnosis
Adult females
 Salpingitis
 Mittelschmerz
 Torsion /heamorrhage of an ovarian cyst
 Ectopic pregnancy
Elderly
 Carcinoma of caecum

12. Investigations
 CBC
 leucocytosis
 Urine analysis
 Serum creatinine and electrolytes
 X ray erect abdomen in diffuse peritonitis
 Usg abdomen
 CT abdomen
 Urine pregnancy test

13. Investigations
 Usg abdomen

14. CT scan

15. Treatment
 Appendicectomy
 Open
 Laparoscopic

16. Appendicular mass
 May form by 3rd day of acute appendicitis
 Consists of inflamed appendix, greater omentum,
oedematous caecal wall & oedematous coils of small
intestine
 It may form an abscess or resolve with treatment
 Differential diagnosis of appendicular mass
 Carcinoma caecum
 Ileocaecal tuberculosis

17. Management of appendicular mass
Ochsner-Sherren regimen
 Conservative treatment with
 Nil by mouth
 Ryle’s tube aspiration
 Antibiotic therapy
 Cephalosporins
 Aminoglycoside
 Metronidazole
 Recording of size of mass daily
 Recording of TPR chart 4hourly
 Input & output chart

18. Management of appendicular mass
 Interval appendicectomy if mass resolves after 6-8 weeks
 Early laparotomy if appendicular abscess develops
Management of appendicular abscess
 Controversial
 Early laparotomy and drainage of abscess with
appendicectomy in one sitting
 Percutaneous US or CT guided catheter drainage followed
by elective appendicectomy 8-12 weeks later

19. Complications of appendicitis
 Perforation
 Postoperative wound infection
 Intra abdominal and pelvic abscess
 Pyelephlebitis
 Enterocutaneous fistula
 Small bowel obstruction

20. Points to remember
 Diff. diagnosis of acute appendicitis in adult males include
 Right ureteric colic
 Rt. acute pyelonephritis
 Perforated peptic ulcer
 Testicular torsion
 Acute pancreatitis
 Diff diagnosis of acute appendicitis in adult females include
 Salpingitis
 ovarian torsion
 ectopic pregnancy

21. Points to remember
 Complications of acute appendicitis include
 Perforation
 Postoperative wound infection
 Intra abdominal and pelvic abscesses
 Pyelephlebitis
 Enterocutaneous fistula
 Small bowel obstruction
 Treatment of choice in acute appendicitis is
 Open or laparoscopic appendicectomy
 Regimen for conservative treatment of appendicular mass is
 Ochsner- Sherren regimen

22. Thank you