2. The Appendix
Introduction
1889 Mac Burney described location, the clinical
features of appendicitis and the importance of
operative intervention and muscle-splitting
incision.
Molecular Immunogenetics
3. The Appendix
Surgical Anatomy
Surface anatomy
Development: diverticulum of ceacum appearing in
the 8th
week of life
Positions: constant base, tip varies (retroceacal, pelvic,
subcaecal, preileal, pericolic)
Blood supply
Location during surgery
Surrounding anatomical structures
Part of the gut lymphoid tissue.
Molecular Immunogenetics
6. Molecular Immunogenetics
The appendix sits at the junction of the small intestine and
large intestine. It’s a thin tube about four inches long. Normally,
the appendix sits in the lower right abdomen.
The function of the appendix is unknown. One theory is that
the appendix acts as a storehouse for good bacteria,
“rebooting” the digestive system after diarrheal illnesses. Other
experts believe the appendix is just a useless remnant from
our evolutionary past. Surgical removal of the appendix causes
no observable health problems.
7. Molecular Immunogenetics
For years, the appendix was credited with very little physiological
function. We now know, however, that the appendix serves an
important role in the fetus and in young adults. Endocrine cells appear
in the appendix of the human fetus at around the 11th week of
development. These endocrine cells of the fetal appendix have been
shown to produce various biogenic amines and peptide hormones,
compounds that assist with various biological control (homeostatic)
mechanisms. There had been little prior evidence of this or any other
role of the appendix in animal research, because the appendix does not
exist in domestic mammals.
8. Molecular Immunogenetics
Among adult humans, the appendix is now thought to be involved
primarily in immune functions. Lymphoid tissue begins to accumulate
in the appendix shortly after birth and reaches a peak between the
second and third decades of life, decreasing rapidly thereafter and
practically disappearing after the age of 60. During the early years of
development, however, the appendix has been shown to function as a
lymphoid organ, assisting with the maturation of B lymphocytes (one
variety of white blood cell) and in the production of the class of
antibodies known as immunoglobulin A (IgA) antibodies. Researchers
have also shown that the appendix is involved in the production of
molecules that help to direct the movement of lymphocytes to various
other locations in the body
9. Molecular Immunogenetics
In this context, the function of the appendix appears to be to expose
white blood cells to the wide variety of antigens, or foreign
substances, present in the gastrointestinal tract. Thus, the appendix
probably helps to suppress potentially destructive humoral (blood-
and lymph-borne) antibody responses while promoting local
immunity. The appendix--like the tiny structures called Peyer's
patches in other areas of the gastrointestinal tract--takes up antigens
from the contents of the intestines and reacts to these contents. This
local immune system plays a vital role in the physiological immune
response and in the control of food, drug, microbial or viral antigens.
The connection between these local immune reactions and
inflammatory bowel diseases, as well as autoimmune reactions in
which the individual's own tissues are attacked by the immune
system, is currently under investigation.
10. The Appendix
Acute Appendicitis
Epidemiology
Most common surgical emergency.
Slightly more common in men.
Incidence are falling from 100 to 50 in 100 000 (1975-1991).
1 in 6 of the population will have an appendectomy.
In Saudi Arabia incidence are comparable to western figures
? More common in European societies (Diet).
? Relation to class status.
Age > 2 yrs, (associated with lymphoid development).
Up to 16% of appendicectomies are normal 75% are in women
Molecular Immunogenetics
11. The Appendix
Acute Appendicitis
Pathology I
Luminal obstruction.
Lymphoid hyperplasia 60%
Faecolith 35%.
Inspissated barium.
Fruit seeds. }<4%
Worms. < 1%
Extra-luminal obstruction eg Ca Cecum
Raised intra-luminal pressure
Mucus accumulation
Multiplication of bacteria.
( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)
Venous and lymphoid congestion and.
Molecular Immunogenetics
12. The Appendix
Acute Appendicitis
Pathology II
Impaired arterial flow, thrombosis and gangrene.
Perforation may occur through devitalized tissue.
Histological terms used:
Catarrhal appendicitis
Suppurative ;;;
Necrotic ;;;
Gangrenous ;;;
Perforated ;;;
Appendicular mass
The risk of perforation is not inevitable.
Molecular Immunogenetics
13. The Appendix - Acute Appendicitis
Clinical Features I
Only 55% have classical features.
Atypical 45%
History 24-36 hours
Abdominal pain:
(diffuse and periumbilical, localizing to the RIF)
Anorexia (almost always).
Vomiting (75%).
Low grade fever.
If >38 suspect perforation
Tenderness, guarding and rebound: Be gentle
Rovsing’s, psoas, obturator signs: unreliable and late
Molecular Immunogenetics
Full History Duration, severity, onset, System review.
and examination: General, throat, chest…..etc
14. The Appendix - Acute Appendicitis
Clinical Features II
Tender Appendicular mass
Atypical:
(loin, high RUQ, deep pelvic)
Diarrhea ( not always gastroenteritis)
Urinary frequency
The Extremes of Age:
Children < 5 rapid progression
Pain in the elderly is less intense
Molecular Immunogenetics
15. The Appendix - Acute Appendicitis
Investigations
White cell count: high sensitivity 96%, low specificity
Urine analysis
Plain Xray, nonspecific
Ultrasound highly sensitive (80-90%), excludes
other pathologies.
Computer Tomography: More superior to USS in diagnostic accuracy.
Barium enema: Good accuracy, but technically
difficult and false positives are common.
Laparoscopy
Active observation
Computer aided diagnosis.
Peritoneal lavage
Molecular Immunogenetics
18. The Appendix - Acute Appendicitis
The Very Young
Diagnosis may be more difficult to establish, WBC is
likely to be normal
(12% are normal).
Children are more likely to progress to perforated
appendix
(? Under-developed Greater Omentum).
Molecular Immunogenetics
19. The Appendix - Acute Appendicitis
The Very Old
Greater morbidity and mortality
Less typical presentation
Cancer may be a possibility as an underlying
cause.
Perforation of 50% and mortality of 20% has been
reported
Molecular Immunogenetics
20. The Appendix - Acute Appendicitis
The Pregnant
Implications: Clinical Findings, Lab Ix, SurgeryImplications: Clinical Findings, Lab Ix, Surgery
1: 2000 pregnancies.
More common in the first two trimesters
The appendix is pushed superiorly and laterally
WBC > 15
Premature Labor 10-15% with surgery
Perforated appendix leads to fetal death in 20%
Rapid diagnosis and treatment is advised.
Molecular Immunogenetics
21. The Appendix - Acute Appendicitis
In AIDS Patients
Be aware of CMV or Kaposi sarcoma as the
underlying cause
WBC may not rise
Molecular Immunogenetics
22. The Appendix - Acute Appendicitis
The Management
Preop:
IVI,
analgesia,
IV antibiotics
Conventional appendicectomy
Types of incisions
Laparoscopic appendicectomy:
(questions regarding pain, hospital stay, operation time,
to daily activity, wound infection)
Molecular Immunogenetics
24. The Appendix - Acute Appendicitis
Post-Operative
1. Check the vitals
2. Check the abdominal signs and bowel
movement
3. Check the wound
4. Advise on mobilization
5. In OPD:
1. Check wound
2. Check the Histology
Molecular Immunogenetics
25. The Appendix - Acute Appendicitis
Prognosis
Mortality: from 0.2% to 1%
Complications increase with perforation
Morbidity:
Wound abscess,
Wound infection (less with MacBurney’s incision),
Wound dehiscence
Intra-abdominal abscess,
Faecal fistula,
Intestinal obstruction,
Adhesive band,
inguinal hernia.
Fertility
Molecular Immunogenetics
27. The Appendix - Acute Appendicitis
Problems
Mass palpable pre-operatively
Appendix is normal at operation
Tumor is found in appendix
Prophylactic appendicectomy
Molecular Immunogenetics
28. The Appendix – Chronic Appendicular Conditions
Chronic Appendicitis
A loose term referring to a multitude of
conditions associated with RIF pain and in which
pathology of the appendix has been found.
Molecular Immunogenetics
29. The Appendix – Chronic Appendicular Conditions
Appendicular Mass
Results from either:
1. Localized by edematous, adherent omentum and
loops of small bowel
2. Appendicular abscess
Incidence is 10%
Higher in children
Management controversy:
Interval vs Immediate appendicectomy
Molecular Immunogenetics
30. The Appendix – Chronic Appendicular Conditions
Tumors of The Appendix
Carcinoid:
Arise from Kluchitsky cells
Mean age 20-40
Yellow bulbar mass
In F>M
In third decade of life
Usually lies near the tip
In the absence of LN spread with <2 cm in diameter
appendicectomy is sufficient. Otherwise a R
hemicolectomy is necessary.
Adenocarcinoma and Lymphoma.
Molecular Immunogenetics
31. Molecular Immunogenetics
Referance
•Ajmani ML, Ajmani K (1983). the position length and arterial supply of
vermiform appendix. Anatomisecher Anzeiger 153(4): 369-374
•Al-fallouji MM, Mchbrien MP (1993). Appendectomy in Al-fallouji MA
Mebrien MP (edn) Evolution of some important surgical procedures
Headway press, Great Britain pp.273.
•Badoe EA (1994). The appendix: in Badoe EA Achampong E, Jaja MO
(editors) Principle and Practice of surgery including pathology in the
tropics, second edn. Tema Ghana publishing corporation 1199-501.
•Bakheit MA, Warille AA (1999) Anomalies of the vermiform appendix and
Prevalence of acute appendicitis in Khartoum East Afr med. j.,
1616:336-340.
•Balteazar EJ, Gade M (1976). The normal and abnormal development of
appendix Radiology 121:599 -604
•Birnbaum BA Wilson SR (2000). Appendicitis at the millennium, radiology
215:337-348
