Acute appendicitis is caused by obstruction of the narrow appendix, which becomes thrombosed due to its end artery blood supply. The appendix's submucosal lymphoid tissue hypertrophies with inflammation behind the obstruction, causing severe pain. Clinical presentation varies from localized right lower quadrant pain to atypical in different positions or extremes of age. Investigations include blood tests, ultrasound, and sometimes CT or laparoscopy. Treatment involves resuscitation, nil by mouth, antibiotics, and appendectomy surgery using various incisions or laparoscopically. Complications include wound infections, abscesses, ileus, and fistulas.

1. Acute Appendicitis
Dr.Bawantha Gamage.
Consultant Surgeon & Senior Lecturer in Surgery

2. OBJECTIVES :
• Understand the Surgical Anatomy of the
appendix.
• Outline Pathophysiology
• Understand the variability of clinical presentation
• Outline the Principles of Investigations
• Understand the Principles of Management

3. Vermiform Appendix
 Surgical Anatomy
• Varying position in RIF – Cause varying
clinical pictures
• Lumen – Infants – wide – Less chance of
obstn.
Elderly – Obliterated – Less obstn
• Artery – End artery
• Mucosa , sub-mucosa – rich lymphatics and
Lymphoid aggregates

4. Appendicitis
• Commonest surgical abdominal pathology
• End artery – Thrombosed in inflammation
• Submucosal lymphoids – Hypertrophy with
inflammation - obstruct lumen
• Acute obstructive – Mechanical obstruction
more severe problem
• Acute non-obstructive – Obstruction due to
lymphatics – may get better with antibiotics

5. Out come ?

6. Out come
• Suppuration
• Perforation
• Resolution
• Mass formation

7. Clinical Presentation ?

8. Clinical Presentation.
• Abdominal pain – initially peri-umbilical
• Later shift to persistent RIF pain
• Constitutional symptoms – Anorexia ,
Nausea , Vomiting , diarrhoea
• Fever
• Extremes of age / Different position –
Atypical presentation

9. Examination ?

10. Examination
• Relatively well Very ill patient
• General Examination :
Coated tongue , Evidence of SIRS
• Abdominal examination
• Don’t forget DER

11. What is it ?
M …………………………………………. 1
A …………………………………………. 1
N …………………………………………. 1
T …………………………………………. 2
R …………………………………………. 1
E …………………………………………. 1
L ………………………………………….. 2
S ………………………………………….. 1
Is it use full ?
ALVARADO SCORE

12. • Differential diagnosis –
Think anatomically
Common things are common
Consider medical conditions
• Investigations
WBC / DC
UFR – may show few pus cells
Abdominal x – ray }
USS abd. & pelvis } in selected patients
Pregnancy test }
Laparoscopy }

13. Management
• Admit
• Nil orally
• Resuscitate – I.V Fluids
• Reassess
• Definitive treatment

14. Surgery
• Mac-Burney's point
• Be ready for a laparotomy
• Various incisions
• Laparoscopic appendicectomy
Always send for histology

15.  Complications :
Wound infections
 Intra abd. Abscess
 Post op Ileus
 Faecal fistula
 Portal pyaemia
 RIH
 Adhesive intestinal obstruction.
 Others related to GA

16. Appendicular mass
• Admit
• “conservative management at door step of theater”
• Ochsner-sherren regimen
• Initially – IVF , IV antibiotics : PR , TEMP – 4 hrly
• Size of mass , tenderness, tempt, General condition -
monitor
• Operate if parameters unsatisfactory
• If resolve – Interval appendicectomy in 6 – 8 wks

17. THANK YOU