Acute appendicitis is caused by obstruction of the appendix lumen, usually by a fecalith, leading to infection. It presents with migratory abdominal pain that localizes to the right lower quadrant, along with anorexia, nausea, and sometimes vomiting. On examination, tenderness is maximal near McBurney's point. Imaging such as ultrasound or CT can identify a swollen appendix. Treatment is appendectomy, either open or laparoscopically. Prognosis is generally good due to advances in care, but complications from perforation or infection can still arise.

1. ACUTE APPENDICITIS
Presenter:
Dr. Saad Andalib.
M.B.B.S

2. Definition:
• Appendicitis is defined as an inflammation of the inner
lining of the vermiform appendix which spreads to its other
parts.
• It results from luminal obstruction followed by infection.
• Calcified fecal matter known as fecolith often plays a role.

3. Anatomy
• The three taeniae coli converge at the junction of the cecum
and the appendix and can be a useful landmark to identify
the appendix.
• The appendix can vary in length from <1 cm to >30 cm; most
appendices are 6 to 9 cm long.

4. Variations in topographic position of the
appendix
From its base at the cecum, the appendix may extend (A) upward, retrocecal and
retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to
the left, ileocecal (may pass anterior or posterior to the ileum)

5. Surgical Anatomy – Position:

6. Etiology:
Obstruction of the lumen is the dominant etiologic factor in
acute appendicitis.
• – Faecolith / faecal stasis
• – Submucosal lymphoid hyperplasia
• – Inspissated barium
• – Vegetable/fruit seeds
• – Worms (Entrobius vermicularis)
• – Tumors of caecum/appendix

7. Pictorial Explanation
Appendiceal
obstruction/early
appendicitis – visceral
peritoneal irritation
Appendiceal
distension
Irritation of parietal
peritoneum
(localised)
Perforation,
localised/generalised
peritonitis, mass
obstruction
Distention
Distention
causing
Ischemia
Gangrene

8. Bacteriology:
Common organisms seen in patients with acute
appendicitis

9. 1-Abdominal pain: Classically, pain is initially diffusely centered in the
umbilical area, is moderately to severe in intensity, cramping in nature. After a
period varying from 1 to 12 hours, the pain localizes to the right lower quadrant.
Symptoms:
2-Anorexia: Nearly always accompanies appendicitis. It is so constant that the
diagnosis should be questioned if the patient is not anorectic.
3-Nausia and vomiting: Nausea more common than vomiting. Occurs
in nearly 75% of patients.
4-Obstipation: Begins before the onset of abdominal pain.

10. -Temperature elevation is rarely > 38.6 °C
-Pulse rate is normal or slightly elevated
-Tenderness often is maximal at or near the McBurney point
-Direct rebound tenderness
-Rovsing sign: pain in the right lower quadrant when palpatory pressure
is exerted in the left lower quadrant
-Psoas sign: indicates an irritative focus in proximity to psoas muscle.
-Obturator: stretching the obturator internus causes irritation of the inflamed
appendix. The test is performed by passive internal rotation of the flexed right thigh
with the patient supine.
Signs:

11. • Leukocytosis, ranging from 10,000 to 18,000 cells/mm3, usually is
present in patients with acute, uncomplicated appendicitis and often is
accompanied by a moderate polymorphonuclear predominance.
• White blood cell counts are variable. It is unusual for the white blood cell
count to be >18,000 cells/mm3 in uncomplicated appendicitis.
• White blood cell counts above this level raise the possibility of a
perforated appendix with or without an abscess.
• Urinalysis can be useful to rule out urinary tract infection.
Laboratory findings:

12. USG W/A : Sonographically, the appendix is identified as a blind-ending,
nonperistaltic bowel loop originating from the cecum.
Common signs of acute appendicitis:
A fluid filled non compressible appendix.
Diameter greater than 6mm.
Appendicolith.
Pericecal fluid.
Increased echogenicity.
CT scan: Sensitivity and specificity > 95 %.
Imaging:

13. Manifestations Value
Symptoms Migration of pain 1
Anorexia 1
Nausea and/or
vomiting
1
Signs Right lower quadrant
tenderness
2
Rebound 1
Elevated temperature 1
Laboratory values Leukocytosis 2
Left shift in leukocyte
count
1

15. 1-ACUTE MESENTERIC ADENITIS
2-Pelvic Inflammatory Disease
3-Ruptured Graafian Follicle
4-Twisted Ovarian Cyst
5-Ruptured Ectopic Pregnancy
6-ACUTE GASTROENTERITIS
7-Meckel's Diverticulitis
8-Crohn's Enteritis
9-Colonic Lesions

16. Treatment:
Appendectomy :
1- Open appendectomy
2- Laparoscopic appendectomy
Once the decision to operate has been made, the patient should be
prepared for the operating room. Adequate hydration should be
ensured, electrolyte abnormalities should be corrected.
Pre-existing cardiac, pulmonary, and renal conditions should be
addressed.
Administration of antibiotics to all patients with suspected appendicitis.

17. Open appendectomy:
For open appendectomy most surgeons use either a McBurney (oblique) or
Langer’s incision.

18. Laparoscopic appendectomy:
• Laparoscopic appendectomy requires the use of three ports.
• The surgeon usually stands to the patient's left. One assistant is
required to operate the camera.
• One trocar is placed in the umbilicus (10 mm).
• Second trocar (5mm) is placed in the suprapubic position. Some
surgeons place this second port in the left lower quadrant.
• Third trocar (5 mm) is variable and usually is either in the left lower
quadrant, epigastrium, or right upper quadrant.

20. Prognosis:
• The mortality from appendicitis in has steadily decreased
from a rate of 9.9 per 100,000 in 1939 to 0.2 per 100,000 in
recent years.
• Factors responsible are advances in anesthesia, antibiotics, IV
fluids, and blood products.
• Death is usually attributable to uncontrolled sepsis,
peritonitis, intra-abdominal abscesses, or gram-negative
septicemia.

21. Have a nice day.