1. Acute appendicitis is caused by obstruction of the appendix lumen, leading to increased intraluminal pressure, edema, and bacterial invasion. 2. The classic presentation includes initially vague periumbilical pain that later localizes to the right lower quadrant, accompanied by anorexia, nausea, and low-grade fever. 3. On examination, tenderness is elicited over McBurney's point with guarding and rebound tenderness. Diagnosis is suggested by clinical scoring systems and confirmed by ultrasound or CT scan showing a thick-walled, inflamed appendix.

1. ACUTE APPENDICITIS
DR.SYED UBAID
ASSOCIATE PROFESSOR OF SURGERY

2. Introduction
• Vestigeal organ
• Surgical importance: Propensity for
inflammation
• Most important cause of “Acute Abdomen” in
young adults
• Appendicectomy is most common surgery
performed worldwide

3. 3
History
• Recognition as clinical entity
Reginald Fitz ‘perforating
inflammation of the vermiform
appendix’
• Charles McBurney described
the clinical manifestation the
point of max. tenderness in the
right iliac fossa

4. Anatomy
• Present only in humans,
• At birth: Short & broad at its junction with the
Caecum
• Typical tubular structure produced by 02 years
of age
• Results from differential growth of caecum

5. Anatomy
• Position: constant  at the confluence of
the 03 taenia coli of caecum
• Mesoappendix : Arises from the lower surface
of the mesentery of terminal ileum
• Appendicular Artery: Branch of Ileo-colic
artery – End Artery
• 04-06 Lymphatic channels traverse
Mesoappendix ----------> Ileo-caecal LNs

6. Anatomy
• The three taeniae coli converge at the junction
of the cecum with 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.

7. ANATOMY

8. Microscopic anatomy
• Layers:
- Mucosa
- Submucosa
- Muscularis
- Serosa

9. Anatomy

10. Microscopic anatomy
• Lumen has longitudinal folds of mucous
membrane
• Lining: Columnar cells of colonic type
• Crypts: Argentaffin ( Kulchitsky cells )
• Submucosa: Lymphatic aggregations/Follicles

11. Anatomical Positions
RETROCAECAL 74%
PELVIC 21%
PARACAECAL 2%
SUBCAECAL 1.5%
PREILEAL 1%
POSTILEAL 0.5%

12. Anatomical positions

13. Etiology
• No unifying hypothesis
• Bacterial proliferation
• Initiating event is controversial
• Obstruction of appendix lumen
• Faecolith or fibrotic stricture
• Worm infestations: Oxyuris vermicularis
• Neoplasms: Ca caecum, carcinoids
• Viral
• No luminal obstruction
• Low dietary fibre

14. • A faecolith (sometimes referred to as an
‘appendicolith’) is composed of inspissated
faecal material, calcium phosphates,
bacteria and epithelial debris

15. Pathological sequence

16. Pathological sequence

17. Pathological sequence

18. Pathology
• Continued mucous secretion and inflammatory
exudation intraluminal pressure
obstructing lymphatic drainage.
• Edema and mucosal ulceration develop with
bacterial translocation to submucosa .
• Further distention may cause venous obstruction
and ischcemia of the appendix wall.
• Bacterial invasion through muscularis externea
producing acute appendicitis.
• Ischaemic necrosis of appendicular wall
gangrenous appendix bacterial contamination of
peritoneal cavity.

19. Pathology cont.
• Greater omentum becomes
adherent to inflamed
appendix paracaecal abscess
• Extremes of age
• Immunosuppression
• Faecolith obstruction
• Pelvic appendix
• Previous abdominal surgery

20. Pathology cont.

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

23. Pathology
Lymphatic hyperplasia
Luminal obstruction
Increased intra-luminal pressure
Edema, mucosal ulceration
Bacterial translocation to submucosa

24. Pathology
Resolution Venous obstruction
Ischaemia of appendix wall
Invasion of muscularis propria, submucosa

25. Pathology
Acute Appendicitis Lump/mucocele
Gangrenous appendicitis
Peritonitis

26. Bacteriology of perforated appendicitis
TYPE OF BACTERIA PATIENTS (%)
ANAEROBIC
B. fragilis 80
B. thetiaotaomicron 61
Bilophila wadsworthia 55
Peptostrptococcus spp 46
AEROBIC
E.coli 77
S.viridans 43
Group D streptococcus 27
P.aeruginosa 18

27. Clinical features
Symptoms:
1. Periumbilical pain 50% cases
2. Pain shifts to RIF
3. Anorexia
4. Nausea/vomiting

28. Two clinical syndromes of acute appendicitis can
be discerned, acute catarrhal (non-
obstructive) appendicitis and acute
obstructive appendicitis, the latter
characterised by a more acute course.

29. The classical history
Periumbilical
pain
One or two
episodes of
vomiting
Right iliac fossa
pain
Anorexia
Nausea

30. Abdominal pain
• Visceral abdominal pain
• Somatic abdominal pain
• referred abdominal

31. Visceral abdominal pain
• Visceral abdominal pain, organs, visceral
peritoneum, mesentery
1-distention of a hollow viscus
2-ischemia to a viscus
3-inflammation
Referred to midline embryological development

32. Relevant Anatomy
umbilicus
ASIS
Pubic
symphisis
T6
T10
T12
unpaired
Paired organs
4. Innervation of appendix & other organs
Foregut
(inc. duodenum)
Midgut
(inc. appendix)
Hindgut
Lower urinary tract
Sexual organs

33. 3/23/2017 33
Colicky pain
• Colicky pain form of visceral pain rhythmic
pain resulting from smooth muscle spasm as
a reaction to luminal obstruction
• intestinal obstruction, passage of gallstone in
biliary ducts, ureteric colic
• Often thought to be indigestion, constipation
and is frequently ignored.
• Lasts for a variable period, usually few hours
/ 2 or 3 days, rarely longer

34. 3/23/2017 34
Referred pain
• The vague referred pain in the periumblical
• stretching of the lumen or spasm.
• The visceral innervation comes from the 10th
thoracic spinal segment.
• Accompany the sympathetic nerves through the
superior mesenteric plexus and the lesser
splanchnic nerve
• If the visceral innervation is higher, then the
mid-line pain will be higher.
• Testicular pain due to visceral referral of
afferent nerve impulses to the same spinal
segment

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Somatic pain
• Skin, fascia, muscle and parietal peritoneum
• Sever and precisely localized
• Inflamed parietal peritoneum cutaneous
hyperesthesia and tenderness
• The right iliac fossa pain is due to the irritation
of parietal peritoneum
• somatic pain as opposed to earlier visceral.

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Guarding and rigidity
• Guarding is the protective phenomenon
• abdominal muscles increase in tone
• attempts to localize the inflammation
• There is tenderness causing the patient to
constantly tense the abdominal wall
muscles in palpation
• Voluntary guarding /apparent guarding
• Involuntary guarding /true guarding
• Muscular spasm rigidity
• localized initially progressing to generalized
with perforation or increasing peritonitis

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Tenderness
• Tenderness:
–localised over McBurney's point
–not evident before later inflammation of
serosa and parietal peritoneum
–often masked in obese due to inability to
displace viscus
• Blumberg’s sign The pain is elicited with
pressing the abdominal wall deeply with
fingers and abruptly releasing it.

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Reflexes
• Visceral afferent fibers participate in reflex
activities. Reflex sweating, salivation, nausea,
vomiting and tachycardia may accompany
visceral pain.
• Carried by autonomic nerve fibers

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Signs
• lying still, with shallow breaths and reluctant to cough
• fever 37.5-38.5C, worsening with perforation
• Foetor oris - halitosis
• Furred tongue
• Flushed
• infrequently, diarrhoea:
– early and transient as a result of visceral pain
– later if retroileal or pelvic involvement appendix; this is
typically prolonged and mucoid
• constipation - sometimes for a few days before the
attack

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Signs to elicit in appendicitis
• Pointing sign
• Rovsing’s sign
• Psoas sign
• Obturator sign

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Pointing sign

42. 3/23/2017 42
Psoas sign

43. 3/23/2017 43
Obturator sign

44. Clinical features
• Signs:
1. Pyrexia
2. Localized tenderness in RIF
3. Muscle guarding
4. Rebound tenderness
5. Rovsing’s sign
6. Pointing sign
7. Psoas sign
8. Obturator sign

45. Clinical features
• Risk factors for perforation:
1. Extremes of age
2. Immunosuppression
3. Diabetes mellitus
4. Pelvic appendix
5. Previous abdominal surgery

46. “Typical” Presentation
• Dull, crampy central abdo pain
• Malaise/vomiting/anorexia/low grade fevers
• Pain worsens & localises to RIF with
cough/movement tenderness
• Systemic symptoms

47. Early Appendicitis
• Pain:
– Location: Periumbilical (T10)
– Character: Dull
– Over time: Colicky
– Associated symptoms:
• Vomiting
• Anorexia
obstruction
mucus
distention

48. Later Appendicitis
• Pain:
– Location: R Iliac Fossa
– Character: Localised
– Over time: Constant
– Aggravating: going over bumps, coughing,
walking
– Relieving: hip flexion, staying still
• Exam findings:
– “peritonism”
• Guarding
• rebound tenderness
• percussion tenderness
– Rovsing, psoas, other signs
Distention causing
ischaemia
Localised peritoneal
inflammation

49. Late Appendicitis
• Pain:
– Location: lower abdominal/generalised
– Character: diffuse, severe
– Over time: constant
– Aggravating: movement, coughing, palpation,
rebound
– Associated: Fever
• Exam findings:
– Systemic features- fever, tachycardia, hypotension
– Abdominal – severe, generalised “peritonism”
– RIF mass (sometimes)
Gangrene

50. Time Course
Appendiceal
obstruction/early
appendicitis – visceral
peritoneal irritation
• Periumbilical
colicky pain
Appendiceal distension
• Anorexia,
vomiting, malaise
Irritation of parietal
peritoneum (localised)
•Constant RIF pain,
pain on coughing,
going over bumps
etc
Perforation,
localised/generalised
peritonitis, mass
•Fever/Sepsis

51. Special clinical scenarios
• According to position:
1. Retro-caecal
- Silent appendix
- Quadratus lumborum rigidity
- Psoas sign
- Loin tenderness

52. Special clinical scenarios
2. Pelvic
- Early diarhoea
- Increased urinary frequency
- Deep tenderness over symphysis pubis
- DRE: Rectovesical pouch/POD tenderness
- Obturator/Psoas sign +ve

53. Special clinical scenarios
3. Post-ileal
- Diarrhoea
- Marked retching
- Ill defined tenderness to rt of umbilicus

54. Special clinical scenarios
• As per age:
1. Infants
- Uncommon <36 mths
- Difficult to diagnose
- Diffuse peritonitis common
- High incidence of perforation

55. Special clinical scenarios
2. Children
- Vomiting
- Marked anorexia
3. Elderly
- High incidence of gangrene & perforation
- Features of SAIO
4. Obese
- Diminished signs/ delayed dignosis
- Midline/ Laparoscopic approach

56. Special clinical scenarios
5. Pregnancy
- Most common extra-uterine cause of acute
abdomen
- Delayed presentation
- Fetal loss
• 3-5%
• Upto 20% : Perforation

57. Going through the sea of DDX
• Mesenteric lymphadenitis
• Acute appendicitis
• Henoch Schonlein purpura
• lobar pneumonia
• Meckel's diverticulitis
• Intussusception
• Ureteric stone
• Enterocolitis
• Familial Mediterranean fever

58. Differential Diagnosis
1. Children
- Gastroenteritis
- Mesenteric adenitis
- Meckel’s diverticulitis
- Intussusception
- HS purpura
- Lobar pneumonia

59. Differential Diagnosis
2. Adults
- Regional enteritis
- Ureteric colic
- Perforated peptic ulcer
- Torsion of testis
- Pancreatitis
- Rectus sheath haematoma

60. Differential Diagnosis
3. Adult female
- Mittelschmerz
- PID
- Pyelonephritis
- Ectopic pregnancy
- Torsion/ rupture of ovarian cyst
- Endometriosis

61. Differential Diagnosis
4. Elderly
- Diverticulitis
- Intestinal obstruction
- Ca colon
- Mesenteric infarction
- Torsion of appendix epiploicae
- Leaking aortic aneurysm

62. Differential Diagnosis
5. Rare
- Tabetic crisis
- Spinal conditions
- Porphyria
- Diabetes
- Typhilitis

63. Investigations
• Diagnosis is essentially clinical
• Clinical diagnosis alone
- 15-30% negative appendicectomy
• Use of
- Clinical scoring systems
- Imaging modalities
- Diagnostic Laparoscopy
- Routine laboratory examinations

64. Alvardo Score

65. ALVORADO Score
Migratory RIF pain 1
Symptoms Anorexia 1
Nausea & vomiting 1
RIF tenderness 2
Signs Rebound tenderness 1
Elevated temperature 1
Laboratory Leucocytosis 2
Shift to left 1
_______________________________________
Total 10

66. ALVORADO Score
• < 4: Excludes diagnosis
• 5-6: Equivocal
• >7 : Strongly s/o appendicitis
• Modified Alvorado Score:
- 9 points
- Differential count not done
• PAS:
- Total : 10
- Rebound tenderness excluded
- Cough/percussion/hopping tendeness = 2
- Leucocytosis > 10,000  1

67. Tzanakis Score
1. Rt lower abdominal tenderness = 4
2. Rebound tenderness = 3
3. WBC’s> 12,000 in the blood = 2
4. Positive USS findings of appendicitis = 6
• Total score = 15
• > 8 = 96% chances

68. X-ray signs
• Reported signs include:
• increased soft tissue density in the right lower
quadrant
• a faecolith in the right iliac fossa
– the majority are radio-opaque
– occur in about 10% of those with appendicitis
– often mistaken for ureteric calculus or gallstones
• a gas-filled appendix
• free intraperitoneal gas

69. Plain Abdominal X-Rays
• Low sensitivity
• Appendicoliths picked up in only 10-15% cases
• Can be combined with Barium enema
• Failure of appendix to “Fill up”
• Low specificity  20% of normal Appendices
do not fill up

70. X-rays

71. X ray abdomen

72. US Scans
• Sensitivity = 85% Operator based
• Specificity > 90%
• AP dia appendix > 7mm
• CROSS SECTIONAL VIEW:
- Thick walled
- Non compressible luminal structure : Target Lesion
• Periappendiceal fluid/ Mass

73. USG
•

74. Inflamed appendix on U/S

75. Inflamed appendix

76. 3/23/2017 76
Ultrasound

77. 3/23/2017 77
Color-flow Ultrasound

78. Computed Tomography
• Commonly used in the West
• 5mm slices :
- Sensitivity: 90%
- Specificity: 80 – 90%
• RCT for 64-MDCT: 95% accuracy
• Sensitivity PROPORTIONATE TO Severity
• Faecoliths/Appendicoliths detected in 50% pts
of appendicits ???

79. Computed Tomography
• Classical findings:
- Distended appendix > 7mm diameter
- Halo/ Target sign
- Periappendiceal fat stranding
- Edema
- Peritoneal fluid
- Phlegmon
- Periappendiceal abscess

80. Computed Tomography
• Rational use:
- Elderly
- Atypical presentations
- Neoplasms
- Acute diverticulits
- Intestinal obstruction
• MRI: ??

81. CT Scan images of Appendicitis:
1. enlarged appendix 2. appendiceal wall thickening
Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings
for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-

82. CT Scan images of Appendicitis
3. appendicolith 4.periappendiceal fat stranding
Source:Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, Chung EC. The most useful findings
for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiologica 44 (2003) 574-

83. 3/23/2017 83
CT-scan

84. Diagnostic Laparoscopy
• Small fraction of pts
• Women of child bearing age
• Prompt intervention ------- Implications on
future fertility

85. Laboratory Examinations
• WBC’s elevated
• Normal in 10% cases
• TLC > 20,000 s/o PERFORATION
• Polymorphs > 75%
• Minimal pyuria Common
• Microscopic haematuria

86. Appendiceal Rupture
Immediate appendectomy has long been the recommended treatment for acute appendicitis
because of the presumed risk of progression to rupture.
The overall rate of perforated appendicitis is 25.8%. Children <5 years of age and patients >65
years of age have the highest rates of perforation (45 and 51%, respectively)
delays in presentation are responsible for the majority of perforated appendices.
Appendiceal rupture occurs most frequently distal to the point of luminal obstruction along
the antimesenteric border of the
appendix. Rupture should be suspected in the presence of fever with a temperature of
>39°C (102°F) and a white blood cell
count of >18,000 cells/mm3

87. Options
• Open / traditional surgery
• Laparoscopic
• Natural orifice surgery (no incision
appendectomy )

88. Appendicectomy - Open
• Incision over McBurney’s point or point of
maximal tenderness
• Straightforward, good exposure, technically
easier
• Longer recovery, risk of hernia & adhesions,
can’t see pelvic structures as well

89. Open appendetomy
• For open appendectomy most surgeons use either a McBurney
(oblique) or Rocky-Davis (transverse) right lower quadrant muscle-
splitting incision in patients with suspected appendicitis. The
incision should be centered over either the point of maximal
tenderness or a palpable mass

90. Open / traditional
• if incision is perpendicular to the line :
• Grid iron incision
• Why called grid iron ?
• if better access is needed , one
can change gridiron to
Rutherford Morrison's incision
• Lanz incision (transverse skin crease incision ,
2cm below umbilicus at mid-clavicular line)

91. Gridiron vs. Lanz

92. layers

93. Steps of operation in appendicitis

94. Steps of operation in appendicitis

95. Steps of operation in appendicitis

96. Steps of operation in appendicitis

97. Steps of operation in retrocaecal appendicitis

98. Steps of operation in retrocaecal retroperitoneal
appendicitis

99. Almost done

100. Then
• put drain if you find dirty iliac fossa ,
otherwise :
• suture .

101. Laparoscopic appendetomy
• Laparoscopic appendectomy usually requires the use of three
ports. Four ports may occasionally be necessary to mobilize a
retrocecal appendix. 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), and a second trocar is placed in
the suprapubic position. Some surgeons place this second port in
the left lower quadrant. The suprapubic trocar is either 10 or 12
mm, depending on whether or not a linear stapler will be used.
• The placement of the third trocar (5 mm) is variable and usually is
either in the left lower quadrant, epigastrium, or right upper
quadrant.

102. Laparoscopic access

103. Appendicectomy - Laparoscopic
• “Keyhole” surgery
• Lower complication rate, quicker
recovery
• Sometimes difficulty in mobilisation
requiring open procedure

105. Natural orifice surgery
• No incision appendectomy
• Using the natural orifices like
anal canal endoscopically or
trans-vaginally .
• Less pain
• No scar
• Less hospital stay
• Fewer complications
• It takes about 50 minutes

106. 3/23/2017 106
Meckel’s diverticulum

107. Management of Appendicular
abscess/Lump
• Late presentation
• Clinically mass & fever
• Subject to imaging studies to ascertain:
- Presence
- Size
• > 4-6cms  Antibiotics+Drainage
• < 4 cms  Conservative mgt(Oschner
Sherren’s Regime)

108. Management of Appendicular
abscess/Lump
• Criteriae for stopping conservative mgt:
- Rising pulse rate
- Increase in the size of the mass
- Increasing/ spreading abdominal pain

109. THANK YOU FOR YOUR KIND PATIENCE