presented to PAKISTAN MEDICAL ASSOCIATION MANDI BAHAUDDIN during CME session 2016 by Dr. NABEEL NAQVI

1. ACUTE
APPENDICITIS
Dilemma of Diagnosis and Management

2. • Although typical, uncomplicated cases of acute appendicitis are easy to
diagnose and treat, diagnosis of atypical appendicitis is a difficult task and
remain a clinical challenge and that may test the diagnostic skills of an even
experienced surgeons.
• Reginald H. Filz, anatomopathologist at Harvard, first described the disease
and first introduced the term appendicitis in 1886.
• In industrialized countries, individuals have a 7% lifetime risk of developing
appendicitis.
• Highest frequency occurring at ages from 10 to 30 years. The risk gradually
decreases until age 50, when it stabilizes.

3. Anatomy
• Appendix develops as a diverticulum of caecum (caecal bud) in the
embryonic week 8, as a part of caudal midgut.
• The human appendix averages 9 cm in length but can range from 2 to 20 cm.
The diameter of the appendix is usually between 7 and 8 mm. The longest
appendix ever removed measured 26 cm from a patient in Zagreb, Croatia.

5. Anatomy
The appendix is usually located in the lower right quadrant of the abdomen,
near the right hip bone. The base of the appendix is located 2 cm beneath the
ileocecal valve that separates the large intestine from the small intestine. It start
from the joining point of three taeniae coli of the caecum.
Its position within the abdomen corresponds to a point on the surface known
as McBurney's point.

6. POSITIONS OF APPENDIX
• During childhood , continued growth of caecum commonly rotates the
appendix into retrocaecal but intraperitoneal position. In quarter of cases,
rotation of the appendix does not occur resulting in pelvic, subcaecal or
paracaecal positions. Occasionaly , the tip of appendix becomes
extraperitoneal behind the caecum or ascending colon.
• Rarely caecum does not migrate during development to its normal position
in RLQ. In these circumstances appendix can be found in RHC or LIF.

11. Function of Appendix
Specific functions of the human appendix remain unclear.
Suspected functions include
• Housing and cultivating beneficial gut flora that can repopulate the digestive
system following an illness that wipes out normal populations of these flora.
• Providing a site for the production of endocrine cells in the fetus that
produce molecules important in regulating homeostasis.

12. • Serving a possible role in immune function during the first three decades of
life by exposing leukocytes (white blood cells) to antigens in the
gastrointestinal tract, thereby stimulating antibody production that may help
modulate immune reactions in the gut.

13. Pathophysiology.
Appendicitis is caused by a blockage of the hollow portion of the appendix,
most commonly by a calcified "stone" made of feces. However inflamed
lymphoid tissue from a viral infection, parasites, gallstone or tumors may also
cause the blockage. This blockage leads to increased pressures within the
appendix, decreased blood flow to the tissues of the appendix, and bacterial
growth inside the appendix causing inflammation. The combination of
inflammation, reduced blood flow to the appendix and distention of the
appendix causes tissue injury and tissue death.

14. If this process is left untreated, the appendix may burst, releasing bacteria into
the abdominal cavity, leading to severe abdominal pain and increased
complications.

15. HISTORY OF APPENDECTOMY
• The first recorded successful removal of an appendix was in 1735 by
Claudius Aymand, but it was done during a hernia operation.
• Early cases of appendicitis were described as “iliac passion”. The disease was
poorly understood, and the appendix was not implicated until the 1800’s
• Boston surgeon Reginald Fitz published a paper in 1886 establishing a link
between appendicular inflammation and iliac passion (he was the first to call
this pathology “appendicitis.”) A German physician named Matterstock
published similar findings in Europe around that time.

16. • American Dr. Thomas Morton performed the first appendectomy for
appendicitis successfully in 1887
• First performed laparoscopically by German Kurt Semm in 1981
• Laparoscopic procedure was rejected originally as “unethical,” but quickly
became mainstream.

17. DIAGNOSIS
Accuracy of diagnosis entitles recognition and removal of the
inflamed appendix prior to perforation with a minimal number of
negative appendectomies

18. CLINICAL SYMPTOMS
PAIN
Classically Pain starts in para umbilical area then shift to right lower
quadrant of abdomen.
Pain in start is the somatic pain, mid gut pain.
Shifting is due the local irritation of anterior abdominal wall at RIF

19. • It is dull and continous pain.
• It increase with the changes of position or coughing or straining.
• Pain may be masked with the pain killers.

20. • Atypical cases
Pain may start in the RIF, LIF , hypogastrium, right lumber region, right
hypochondrium. It depends upon the position of caecum and tip of appendix.

23. VOMITING
• It is one of the classical symptom.
• There may be only nausea or anorexia.

24. Pain
paraumb
lical
vomiting Pain RIF

25. FEVER
• Fever is in 50 to 70% of cases.
• It is mild (up to 100’C ) in the early stages but may be high grade after
rupture of appendix or pus formation.

26. Other Symptoms
• Loose motions.
• Burning micturition.
• Tenesmus.
• Painfull movements of right hip joint.

27. CLINICAL SIGNS
• TACHYCARDIA
• HYPERTHERMIA
• FURRED WHITISH TOUNGE
• TENDERNESS AT RIF
• GAURDING AT RIF
• REBOUND TENDERNESS AT RIF

29. TENDERNESS/GAURDING
• It is due to the inflammation extending from the appendix to the
surrounding structures. With pain killers, pain can be masked but not the
tenderness.
• Tenderness is more when appendix touches the peritoneum of anterior
abdominal wall. Guarding of the muscle is also more in this position.
• Tenderness may be only on deep palpation when appendix is retrocaecal or
subserosal variety.
• Rebound tenderness is more on retrocaecal appendix. Blumberg sign

31. OBTURATOR’S SIGN
Internal rotation causes pain due to stretch on the inflamed internal
obturator muscle. Inflammed appendix when touches the muscle causes muscle
inflammation and irritability.
Sensitivity 8%
Specificity 94%

33. PSOA’S SIGN
• Sensitivity 13-42%
• Specificity 79-95%

34. • Dunphy’s sign
Pain at RIF on coughing. It can differentiate between the
intraperitoneal and extra peritoneal organs pathology.
• Rovesign sign
Pain in RIF on deep palpation at LIF. It is due to the
movement of intestines towards RIF and touch the inflamed appendix. It
also differentiate between intraperitoneal and extra peritoneal pathology.

35. • Pt unable to stand straight up due to spasm in the ileopsoas muscles.
• Rectal and vaginal examination are crucial in the pelvic appendix.
• Caecal gurgle is important sign in the retrocaecal appendix.

36. ALVARADO SCORING SYSTEM

37. ALVARADO SCORING SYSTEM
Patients with a score
1—4 unlikely to have acute appendicitis
5—6 possible diagnosis of acute appendicitis but not
convincing enough to have urgent appendectomy.
7—9 probably having acute appendicitis.

38. ALVARADO SCORING SYSTEM
• The positive predictive value of Alvarado score is reported as high as 85.3%,
87.5% and 87.4% in many studies.
• It is ease to apply and have high accuracy.

39. ACTIVE OBSERVATION
The accuracy of clinical diagnosis of suspected cases of acute appendicitis can
further be improved by repeated clinical examinations. As in 30-40% of cases ,
a firm diagnosis is not possible initially.
Patients under active observation are kept fasting and re-evaluated for
progression or regression of their symptoms and signs by repeated clinical
examinations every 2-3 hours, preferably by the same physician.
Blood test can be repeated, if required, and compared.

40. • Active observation result in substantial fall in the negative appendectomy rate
and it is widely considered as safe and effective approach to the management
of patients.
• In the bigger surgical units, it is practiced that different surgeons evaluate
these atypical cases repeatedly and combine decision can be taken.

41. LABORATORY INVESTIGATIONS
• White blood cell (WBC) count is elevated ( more than 10000) in 80% of
cases of appendicitis.
• 95% of patients have Neutrophillia.
• Elevated pre-operative CRP level is likely to be associated with acute
appendicitis.
• There sensitivity is high but specificity is low.
• If all three above indicators are absent, the chances of appendicitis is low.

42. ULTRASOUND
• Graded compression Sonography is relatively inexpensive, rapid, non-
invasive, and requires no patient preparation or contrast material
administration.
• USG is helpful or necessary to rule out the important differential diagnosis
like renal, gynecological and hepatic conditions.
• Inflamed appendix is non-compressible tubular structure, more than 6 mm
in diameter, with a thickened wall.

45. ULTRASOUND
• Sensitivity 78%
• Specificity 92%
• Accuracy 87%
Limitations:
Operator dependent.
Patient cannot be send home after negative result.

46. Contrast-Enhanced CT
• It is highly sensitive and specific to diagnose acute appendicitis.
• Typical CT findings of an inflamed appendix is a thickened wall and a non-
filling appendix associated with peri-appendicular inflammatory fluid.

49. C T SCAN
• It is highly sensitive for the complications developed due to appendicitis.
• It helps us in the decision of time of intervention.
• Helical CT has
Sensitivity 90-100%
Specificity 91-99%
Accuracy 94-98%

50. Positive predictive value 92-98%
Negative predictive value 95-100%
CT scanning of patients with suspected appendicitis may reduce the number of
patients admitted for observation and decrease the rate of negative
appendectomy.

52. MRI
• It’s usage has become increasingly common in children and pregnant women
as it has negligible radiation toxicity. In pregnancy it roll is quite helpful as
enlarging uterus displaces the appendix. In the first trimester its use is still
not recommended as fetus is still in the phase of organogenesis.

53. Diagnostic Laparoscopy
• Several surgeons have advocated the use of laparoscopy as a diagnostic
modality in the evaluation of a patient suspected of having acute
appendicitis. It is more preferable in female patients or in the doubtful cases.
Secondly if there is inflamed appendix then it can be removed during the
same procedure.

54. Appendicitis in PREGNANCY
Incidence of appendicitis during pregnancy is 1/1500 pregnancies. It is the
most common non-gynecologic surgical emergency during pregnancy.
The evaluation of a pregnant woman for appendicitis can be bit confusing
because
• Nausea and vomiting can be incorrectly attributed to the morning sickness.
• Tachycardia is normal in pregnancy.
• Fever a common finding in appendicitis is often not present in pregnancy.

55. • Leukocytosis (12000cell/ml) is common in pregnancy. However left shift is
always abnormal.
• Appendectomy during pregnancy is indicated in a pregnant patient as soon as
the diagnosis of appendicitis is suspected. A negative appendectomy carries a
risk of fetal loss of up to 3%, but fetal demise rates reach 35% in the setting
of perforation and diffuse peritonitis (Southern Med J.1976;69:1161-1163)

56. Appendicitis in Children
• Delayed diagnosis is common in children especially in very young ones. Perforation
rate is 50% in infancy.
• Major difficulties in diagnosis are the lack of history and altered physical
examination. 50% of children lack of migration of pain to RLQ, 40% will not have
associated anorexia and 52% will not have rebound tenderness (Acad Emerg
Med.2007;14(2):124-129).
• In infants and young children the position of caecum is not fixed as it is mobile
most of time.
• Incidence of perforation and post operative morbidity are high in children due to
underdeveloped omentum, malnourishment or less developed immune system.

57. Appendicitis in Elderly patients
• Lack of abdominal muscles laxity may hide the clinical signs. Clinical picture
may simulate with subacute intestinal obstruction which delay the final
diagnosis. Obesity can obscure and diminish all signs of acute appendicitis.
• Chances of perforation is 30% in the patients more than 60 years old
because of low immune system.

58. Appendicitis in obese people
• All the local signs are masked in the obese patients so the diagnosis is more
dependent on the detail investigations like ultrasound or CT scan.
• There may be technical difficulties in operation.

59. Differential Diagnosis

60. Gynecological.
PID
can present with the symptoms indistinguishable from those of
appendicitis. Cervical motion tenderness and milky discharge strengthened the
diagnosis of PID. Pain is usually bilateral with intense guarding. Trans vaginal
ultrasound is very helpful to locates the tubo-ovarian abscess.
ECTOPIC PREGNANCY
needs to be rule out in all female patients of child bearing age. A positive
pregnancy test should prompt the ultrasound investigation.

61. OVRIAN CYST.
can have mild to severe pain. It can be ruled out on ultrasound.
OVARIAN TORSION
patient with twisted organ can have fever, leukocytosis and pain in RIF.
Ovarian torsion can be confirmed on Doppler ultrasound.
Mittelschmerz
midcycle rupture of a follicular cyst with bleeding.

62. Urological diseases
PYELONEPHRITIS
patients can have fever, vomiting, rigors, costovertebral pain and
tenderness. Diagnosis can be confirmed by urine analysis and ultrasound.
URETERIC COLIC
pain and vomiting are the common feature but tenderness is minimal.
Hematuria suggest the diagnosis which can be confirmed on US and urine
analysis.

63. OTHER CAUSES
GASTROENTERITIS
nausea and vomiting start before pain along with fever, diarrhea and poorly
localized abdominal pain and tenderness. WBC count is often normal in
gastroenteritis.
MECKEL DIVERTICULUM
present with symptoms and signs indistinguishable from those of appendicitis, but
it characteristically occurs in infants.
Testicular torsion
pain start in RLQ and the local tenderness.

64. MESENTERIC LYMPHADENITIS
usually occurs in patients younger than 20 years old and present with
middle, followed by RLQ abdominal pain but without tenderness or guarding.
TYPHLITIS
characterized by inflammation of wall of caecum.
Peptic ulcer disease, Diverticulitis and Cholecystitis.

65. MANAGEMENT
OF
APPENDICITIS

66. SURGICAL MANAGEMENT
Appendectomy is the only curative treatment for acute appendicitis. Typical
cases should be operated without unnecessary delay for the time-consuming or
expensive investigations.
Open appendectomy is time tested for more than a century since its
introduction by McBurney.
Laparoscopic appendectomy , introduce by Semm in 1983, has struggled to
prove its superiority over the open technique.

67. In different studies, laparoscopic appendectomy has claimed to reduce
postoperative pain, length of hospital stay, analgesic doses and surgical
associated complications.

68. MEDICAL MANAGEMENT
The standard treatment for acute appendicitis is appendectomy, but in the
isolated environment where there are no surgical capabilities, medical
management is required until surgical resources become available.
Adams retrospectively reviewed the 9 cases of US Navy men on a submarine
who had appendicitis treated at sea with various antibiotic protocol; he found
good response to treatment in all cases.
A Swedish multicenter study randomized 252 men, aged 15-50 years, to surgery
or antibiotic treatment alone, excluding patients with a high suspicion of major

69. Perforation or complications. The study concluded that acute non-perforated
appendicitis can be treated successfully with antibiotics. However, there is a risk
of recurrence, and this risk should be compared with the risk of complications
after appendectomy .
Hansson et al. randomized 369 consecutive adults with presumed appendicitis
to either antibiotics or surgery as primary treatment. Their conclusion is that
antibiotics are an appropriate first line treatment for adults without obvious
sign of intraabdominal perforation.

70. COMPLICATIONS OF ACUTE
APPENDICITIS
• Appendix mass.
• Generalized peritonitis.
• Pelvic peritonitis.
• Frozen pelvis.
• Intestinal obstruction.
• Paralytic ileus.
• Sub phrenic abscess.

71. APPENDIX MASS
• An appendix mass is a common surgical entity, encountered in 2-6% of
patients presenting with acute appendicitis. It may be composed of the
inflamed appendix, omentum and the bowel loops.

76. Ochsner-Sherren regimen
• At the beginning of the 20th century, Ochsner (1901) proposed non-
operative management for the appendix mass, followed by interval
appendectomy 6-8 weeks after successful conservative management as also
proposed by Murphy.

77. Ochsner-Sherren regimen
Protocols:
• Make the limits of mass on the abdominal wall using a skin pencil.
• NPO. A nasogastric tube should be passed .
• Intravenous fluid for the daily requirements . Maintain input output chart.
• Intravenous antibiotic therapy started.
• Temperature and pulse rate should be recorded 4-hourly .

78. If the condition of the patient is satisfactory, the standard treatment is the
conservative Ochsner-Sherren regimen. The inflammatory process is already
localized & surgery is difficult & may be dangerous. It may be impossible to
find the appendix & a fecal fistula may form. So, non-operative program is
advised.

79. • Clinical improvement is usually evident within 24—48 hours at which time
the nasogastric tube can be removed and oral fluids introduced.
• Failure of the mass to resolve should raise suspicion of a carcinoma or
Crohn’s disease.
• Using this regime approximately 90 per cent of cases resolve without
incident.
• It is advisable to remove the appendix usually after an interval of 6—8
weeks.
• Clinical deterioration or evidence of peritonitis is indication for early
laparotomy

80. If the condition of patient deteriorate:
• A rising pulse rate.
• Increasing or spreading abdominal pain.
• Increasing size of the mass.
• Vomiting or increase gastric aspirate.
Prepare the patient for surgery.

81. Main goal of surgery is to remove or drain the pus, so that the toxicity of
patient can be decreased. An attempt can be made to remove the inflamed
appendix with minimal manipulation of surrounding structures especially
caecum and ileum.
Special emphasis should be given to the steps which prevent the spread of pus
on opening of the mass, like placing the mobs, effective and active suction,
positioning of patients and peritoneal lavage after surgery.

82. In the recent years, the treatment of appendix mass took a turn from the
traditional approach. Many studies showed that early intervention is known to
be an effective alteration to conservative therapy as it considerably reduces the
total hospital stay and obviates the need for a second admission.
It is also learnt that mostly early mass is composed of appendix and omentum
only, which can be easily separated.

83. Interval Appendectomy
The value of interval appendectomy has been increasingly questionable. The
principle reasons for the justifying interval appendectomy are firstly to prevent
recurrence of acute appendicitis and secondly to avoid misdiagnosing an
alternative pathology such as a malignancy.
Kaminski et al. (2005) identified 1012 patients over a 13 years period with an
appendix mass that had successful initial non-operative treatment. 864 did not
had interval appendectomy later on. 39 of the 864 (5%) had a recurrence at a
mean follow-up of 48 months.( the mean time of recurrence was 10-15
months). They concluded that interval appendectomy was not justified as vast

84. majority (95%) of patients will not develop recurrence.
• Willemsen et al. studied 233 patients who had interval appendectomy after
successful initial conservative management of an appendix mass. He found
that histological examination of the specimen showed a normal appendix
and without the signs of previous inflammation in 30 % of cases. In addition
complications due to interval appendectomy were seen in 18% of patients,
including sepsis, bowel perforation, small bowel ileus and various wound
abscesses. He concluded that interval appendectomy seems to be
unnecessary in most of the patients.

85. Ahmed et al. review recent literature on interval appendectomy. They
concluded that interval appendectomy is unnecessary in majority (86-95%) of
the patients as they don’t develop recurrence. If the recurrence does occur it is
likely to occur within one year and is usually associated with a milder clinical
course.

86. SUMMARY
• Acute appendicitis remains the most common general surgical emergency
and most common cause of acute abdomen requiring surgical intervention.
• Typical uncomplicated acute appendicitis cases are easy to diagnose and treat.
• Diagnosis of atypical cases is a difficult task and remains a clinical challenge
that may test the diagnostic skills of even most experienced surgeons.
• Difficulties of diagnosis of atypical cases results from variation of the
anatomical positions of appendix, appendicitis occurring at extremes of age
and in pregnant females.

87. • Diagnostic accuracy can be improved by using different clinical scoring
system. Alvarado scoring system is the most famous system one.
• Accuracy of diagnosis can also be improved by adoption o an active
observation policy.
• Laboratory investigation include WBC count and C reactive protein help in
supporting the diagnosis.
• Ultrasound, CT scan and MRI improve the diagnostic accuracy and reduce
the chances of complications.

88. • Appendectomy is the only curative treatment for acute appendicitis.
• Conservative management is the standard treatments for Appendix mass,
but in recent years early intervention is also recommended which save
resources and time of surgical facilities.
• The value of interval appendectomy has been increasingly questionable in
the recent studies.

89. THANK YOU