The document is a comprehensive overview of appendicitis, covering topics such as surgical anatomy, etiology, clinical features, diagnosis, treatment, and complications. It highlights the importance of surgical intervention, the variations in presentation among different age groups, and the potential complications associated with the condition. Special considerations are also discussed for managing appendicitis in infants, children, pregnant women, and the elderly.

1. 1
JUBA TEACHING HOSPITAL DEPARTMENT
OF SURGERY
TOPIC: APPENDICITIS
PRAPERED BY HO. DOMINIC MATONG WOL
SUPPERVISED BY SURGEON
DR.JOHN CHOL
SPECIALIST DR. ALIER MARKO

2. 2
TOPIC OUTLINE
• Introduction
• Surgical Anatomy
• Duplications and positions of the appendix.
• Etiology and pathogenesis, clinical features differential
diagnosis, investigations and complications
• Treatment
• Appendicitis in infancy/children, elderly and pregnancy

3. 3
INTRODUCTION
• Previously considered a vestigial organ, the appendix now
is linked to the development and preservation of gut-
associated lymphoid tissue ant to the maintenance of the
intestinal flora
• is one of the most common causes of the acute abdomen
• one of the most frequent indications for an emergent
abdominal surgical procedure worldwide

4. 4
INTRODUCTION
• Appendicitis occurs most frequently in the second and
third decades of life
• It is also higher among men (male to female ratio of
1.4:1)

5. 5
SURGICAL ANATOMY
• It is located at the terminal end of the caecum where
three taeniae join
• The appendix is a true diverticulum of the cecum about
2 cm below the ileocaecal orifice
• Usually, around 5-10 cm in length but can be variable
• diameter of lumen is 1-3 mm (matchstick)

6. 6
SURGICAL ANATOMY
• Mesoappendix is extension of the mesentery contains
appendicular artery, a branch of ileocolic artery
• Often an accessory appendicular artery (of Seshachalam)
may be present

7. 7
Duplications and positions of the appendix
• Wallbridge classification:
-Type A—Partial duplication in a single caecum.
-Type B—Two separate appendices in a single caecum.
-Type C—Double caecum with each one having one
appendix.

8. 8

9. 9
Most common position is retrocaecal (75%).Next
common is pelvic (21%).

10. 10
ETIOLOGY AND PATHOGENESIS
• The natural history of appendicitis is similar to that of
other inflammatory processes involving hollow visceral
organs
• Initial inflammation of the appendiceal wall is followed
by localized ischemia, perforation, and the development of
a contained abscess or generalized peritonitis

11. 11
ETIOLOGY AND PATHOGENESIS
• Appendiceal obstruction may be caused by fecaliths (hard
fecal masses), foreign body, lymphoid hyperplasia,
infectious processes, and benign or malignant tumors
• When obstruction of the appendix is the cause of
appendicitis, the obstruction leads to an increase in
luminal and intramural pressure, resulting in thrombosis
and occlusion of the small vessels in the appendiceal
wall, and stasis of lymphatic flow

12. 12
ETIOLOGY AND PATHOGENESIS
• As the appendix becomes engorged, the visceral afferent
nerve fibers entering the spinal cord at T8-T10 are
stimulated, leading to vague central or periumbilical
abdominal pain
• Well-localized pain occurs later in the course when
inflammation involves the adjacent parietal peritoneum.

13. 13
ETIOLOGY AND PATHOGENESIS
• Once significant inflammation and necrosis occur, the
appendix is at risk of perforation, which leads to
localized abscess formation or diffuse peritonitis.

14. 14
TYPES OF APPENDICITIS
• Acute non obstructive appendicitis (catarrhal)
• Acute obstructive appendicitis
• Recurrent appendicitis
• Subacute appendicitis is milder form of acute
appendicitis

15. 15
CLINICAL FEATURES
Clinical manifestations:
History
o Right lower quadrant (right anterior iliac fossa) abdominal pain
o Anorexia
o Nausea and vomiting
o Fever
 Murphy’s triad: pain, vomiting and temperature

16. 16
CLINICAL FEATURES
• In many patients, initial features are atypical or nonspecific, and
can include:
Indigestion
Flatulence
Bowel irregularity
Diarrhea
Generalized malaise

17. 17
CLINICAL FEATURES
Physical examination:
• Tenderness and rebound tenderness at McBurney’s point in right
iliac fossa ( release sign – Blumberg’s sign) are typical
• Rovsing’s sign
• Cope’s psoas’ test
• Obturator test
• P/R examination shows tenderness in right side of the rectum.

18. 18
CLINICAL FEATURES
• Hyperaesthesia in ‘Sherren’s triangle’.
• Bastedo sign( air through rectum)

19. 19

20. 20
CLINICAL FEATURES
McBurney’s point Sherren’s triangle

21. 21
DIFERENTIAL DIAGNOSIS
Gynecologic and
obstetrical conditions:
• Tubo-ovarian abscess
• Pelvic inflammatory disease
• Ruptured ovarian cys
• Mittelschmerz syndrome
• Ovarian and fallopian tube
torsion
• Endometriosis
• Ovarian hyperstimulation
syndrome
• Ectopic pregnancy
• Acute endometritis

22. 22
DIFERENTIAL DIAGNOSIS
Urologic conditions:
o Renal colic
o Testicular torsion
o Epididymitis
o Torsion of the appendix testis or appendix epididymis

23. 23
DIFERENTIAL DIAGNOSIS
Others:
Perforated peptic ulcer
Acute cholecystitis
Enterocolitis
Mesenteric lymphadenitis
Lobar pneumonia
Crohn’s disease
Acute pancreatitis
Meckel’s diverticulitis
Diabetic abdomen
Intussusception
Roundworm colic
Carcinoma caecum – acute features
Mesenteric ischaemia
Intestinal obstruction
Aortic aneurysm leak

24. 24
INVESTIGATIONS
Laboratory findings:
 CBC - Total leucocyte count is increased.
 Urine HCG in females
Imaging studies:
 Abdominal U/S
o Noncompressible appendix of size > 6 mm AP diameter.
o Appendicolith.
o Periappendicular fluid.

25. 25
INVESTIGATIONS
 Computed tomography( abdominalCT with contrast)
findings:
o Enlarged appendiceal diameter >6 mm with an occluded lumen
o Appendiceal wall thickening (>2 mm)
o Appendiceal wall enhancement
o Appendicolith (seen in approximately 25 percent of patients)
o periappendicular fluid collection
o presence of mass/abscess
o Associated pathology like carcinoma can be identified

26. 26
INVESTIGATIONS
 Plain radiograph( abdominal X-ray) findings:
Plain radiographs are usually not helpful for establishing the
diagnosis of appendicitis;
o Right lower quadrant appendicolith
o Localized right lower quadrant ileus
o Loss of the psoas shadow
o Free air (occasionally)
o Deformity of cecal outline
o Right lower quadrant soft tissue density

27. 27
A ppendicolith on abdominal films

28. 28
INVESTIGATIONS
 Magnetic resonance imaging(MRI):
o An enlarged fluid-filled appendix (>7 mm in diameter) is
considered an abnormal finding
o An appendix with a diameter of 6 to 7 mm is considered
an inconclusive finding

29. 29
TREATMENT
• Surgery-Appendicectomy
• Postoperatively, IV fluids, antibiotics
are continued
• Once bowel sounds are heard, oral
diet is started.

30. 30
COMPLICATIONS
preoperative complications:
o Gangrenous appendix perforates causing localized or generalized
peritonitis
o Abscess formation ( appendicular abscess)
o Mass formation (appendicular mass)

31. 31
COMPLICATIONS
Postoperative complications:
o Paralytic ileus
o Reactionary haemorrhage due to slipping of ligature of the
appendicular artery
o Residual abscess (pelvic, paracolic, local, subdiaphragmatic)

32. 32
COMPLICATIONS
Postoperative complications:
o Adhesions and intestinal obstruction
o Right inguinal hernia
o Wound infection 10%
o Faecal fistula
o Respiratory problems and DVT

33. 33
APPENDICULAR MASS
• It is the localisation of infection occurring 3 to 5 days after an
attack of acute appendicitis.
• Inflamed appendix, greater omentum, oedematous caecum, parietal
peritoneum and dilated ileum (Ileus) forms a mass in the right
iliac fossa.
• This mass is tender, smooth, firm, well localised, not moving with
respiration, not mobile, all borders well made out (well localized)
and resonant on percussion. Patient may have fever and features
of toxicity.

34. 34
APPENDICULAR MASS
Diagnosis:
• Hx, P/E and
• Investigations (WBC is increased, U/S confirms the mass).
Treatment:
Conservative (Ochsner-Sherren Regimen).
• Temp, BP, Pulse chart.
• Marking the mass to identify the progression/regression.
• Antibiotics

35. 35
APPENDICULAR MASS
• IV fluids.
• Analgesics.
• Initial nasogastric aspiration.
Patient usually shows response by 48 to 72 hours.
Patient is discharged and advised to come for interval
appendicectomy after 6 weeks.

36. 36
APPENDICULAR MASS
• Criteria to discontinue Ochsner-Sherren regimen:
1. Patient becomes more toxic
2. Persistent vomiting
3. Increase or spread of pain abdomen
4. Increased size of the mass
5. Suppuration (abscess formation) in the mass
 Treatment is immediate surgery

37. 37
APPENDICULAR MASS
• Contraindications for Ochsner-Sherren Regimen
1.When diagnosis is in doubt.
2. In acute appendicitis in children and elderly.
3. In burst, gangrenous appendicitis.
4. In patients in whom diffuse peritonitis sets in.
 Treatment is immediate surgery

38. 38
APPENDICITIS IN SPECIAL GROUPS
• Acute appendicitis in infancy:
Even though it is rare, when it occurs, it has got 80% chances of
perforation with high mortality (50%).
• Acute appendicitis in children:
Here localization is not present, and so peritonitis occurs early. It
requires early surgery. Dehydration, septicemia are common.

39. 39
APPENDICITIS IN SPECIAL GROUPS
• In pregnancy:
Appendix shifts to upper abdomen. So pain is higher and more
lateral. After 6 months, maternal mortality increases by 10 times
than usual and also leads to premature labour. Appendicitis is the
most common non-gynaecologic surgical emergency during
pregnancy. Incidence of perforation is highest in 3rd trimester.
Surgery is the treatment. Fetal death rate is 5%.

40. 40
APPENDICITIS IN SPECIAL GROUPS
• In elderly:
Gangrene and perforation are common. Because of lax abdominal
wall, localization is poor and so peritonitis sets in early.

41. 41
SRB’ S MANUAL OF SURGERY
VAILEY AND LOVE OF SURGERY
SCHWARTE ‘S PRINCIPLES OF
SURGERY