A 15-year-old boy presented with abdominal pain localized to the right lower quadrant. A provisional diagnosis of acute appendicitis was made based on his fever, leukocytosis, and tenderness on examination. Acute appendicitis is defined as inflammation of the appendix caused by obstruction. It presents with abdominal pain shifting to the right lower quadrant, nausea, anorexia, and vomiting. Imaging and lab work can help in diagnosis. Treatment involves antibiotics, IV fluids, and an appendectomy to remove the inflamed appendix. Complications can include wound infections, abscesses, and bowel obstructions.

1. Acute Appendicitis
Presented By : Dr. Khadija
Farid

2. Case Presentation :
• A 15 year-old boy with no past medical history presents to the SER
with 24 hours of abdominal pain. The day prior to presentation, he
developed diffuse, vague abdominal discomfort , he lost his appetite
and went to bed early secondary to malaise. The following morning,
the pain worsened in intensity, became sharp, and localized to the
right lower quadrant.
• The patient is febrile, with increased pulse rate. On examination, he is
focally tender to palpation in the right lower quadrant with voluntary
guarding. Palpation of the left lower quadrant reproduces pain on the
right. Scrotum is normal , His lab work is unremarkable with the
exception of a mild leukocytosis to 13.
• Provisional Diagnosis : Acute Appendicitis

3. Definition :
• Appendicitis is defined as an inflammation of the inner
lining of the vermiform appendix that spreads to its other
parts , despite diagnostic and therapeutic advancement in
medicine, appendicitis remains a clinical emergency and
one of the most common cause of acute abdominal pain –
Acute Abdomen.

4. • Blood supply : appendicular artery (ileocolic artery )
• Venous drainage : appendicular vein ( post ceceal vein )
• Lymphatic drainage : lymphatics drain into ileocaecal
lymph nodes
• Types:
• 1) Acute catarrhal (non obstructive) appendicitis
• 2) Acute obstructive appendicitis

5. Pathophysiology :

6. Presentation
• The classic history of anorexia and periumblical pain followed
by nausea , RLQ pain , and vomiting occurs in 50% of cases.
Features include the following :-
• Abdominal pain (colicky or dull periumblical pain that shift to
right iliac fossa of the abdomen , pain exacerbated on
coughing or laughing
• associated with:
• Nausea
• Anorexia
• Vomiting ( nearly always follows the onset of pain ; vomiting
that precedes pain suggests intestinal obstruction)
• Diarrhea or constipation

7. Clinical Signs :
• Pointing Sign Rovsing’s Sign
• Obturator and Psoas Sign Markle Sign or Jar tend.

10. Investigation :
• CBC :
WBC > 14,000 / microliter
Neutrophilia
• C-reactive Protein :
CRP > 1mg/dl
Very high levels of CRP in appendicitis indicate gangrenous
evolution of the diseases , esp if it is associated with
leukocytosis and neutrophilia.
• Urinary 5-HIAA :
Its level increases significantly in acute appendicitis and
decreases when inflamation shift to necrosis of appendix ,
therefore , such decrease could be an early warning sign of
perforation of appendix.
• Pregnancy test
• Urea and electrolytes

11. Imaging :
• Ultrasonography : (of abdomen and pelvis)
• Pain abdominal Xray
• CT scan (contrast enhanced )
• MRI

12. Alvardo Scoring System :

13. Management :
In SER :
• Establish IV access and administer aggressive crystalloid
therapy to patients with clinical signs of dehydration or
septecemia.
• Keep patients NPO
• Administer analgesic and antiemetic
• If there is appendiceal mass :-
• Phlegmon or small abscess : after IV antibiotic therapy
interval appendectomy performed 4- 6 weeks later.
• Larger well-defined abscess : after percutaneous drainage
and IV antibiotics administration , patient can be discharged
with catheter in place , interval appendicectomy can be
performed after fistula is closed.

14. • Multicompartmental abscess : These patients require
early surgical drainage.
• Antibiotics : Antiobiotic prophylaxis should be
administered before every appendecectomy.
• Broad spectrum gram negative and anaerobic coverage is
indicated.
• Cefotetan and cefoxitin seem to be the best choices of
antibiotic
• In penicillin allergic patients , carbapenems are good
option.
• Pregnant patients should receive Category A or B
antibiotics.

15. Surgical Treatment :
Appendectomy :
1- Conventional Open Appendectomy :
Incision :-
• Gridiron incision /
Mc Burney’s incision
• Transverse Skin crease
(Lanz) incision
• Rutherford Morison’s incision
• Lower midline incision

16. • Procedure :-
• There are three muscle layers in the lateral abdominal wall.
As these are encountered when entering the abdomen,
these are the external oblique, the internal oblique, and the
transversus abdominis muscles.
• Each muscle aponeurosis is cut in the direction of the
muscle fibers.
• A muscle-splitting technique
is used to spread apart each
muscle layer along the
orientation of the muscle fibers
until the peritoneum is reached

17. • The peritoneum is then
grasped with forceps in
order to assure no bowel
is adherent and is incised
with sciccors to enter
abdomimal cavity
• An appropriate retractor
is placed to enhance
operative exposure.
• After opening the periton
-eal cavity , any serous
exudates or pus around
appendix is sucked and
pack is inserted in wound
on medial side to push the
loops of small intestine medially.

18. Exposure of the Appendix
• After the peritoneum is entered, the cecum is identified.
Sponge sticks can be helpful to sweep the small bowel in a
lateral to medial direction in order to expose the cecum.
• Once the cecum is identified, the anterior taenia is identified
, the cecum is then
mobilized, following the anterior
taenia to its confluence with the
appendiceal base.
• The convergence of all three
teniae coli allows for the correct
identification of the base of the
appendix.

19. • Inflamatory adhesions of appendix, if present are divided
and appendix is delivered into the wound with the help of
Babcock forceps.
• The mesoappendix is ligated and divided,
• This is critical to ensure that the entire appendix is
removed.Failure to remove the base of the appendix may
cause a closed loop obstruction between a persistent fecalith
at the base of
• the appendix and the stump staple line. This may lead to an
appendiceal stump blowout postoperatively.
• In cases of retrocecal appendicitis the cecum will need to be
fully mobilized in a lateral to medial fashion so that it is
completely reflected from the retroperitoneum in order to find
the appendix.

21. • The completely free appendix is crushed near its junction
with cecum with artery forceps , artery forceps is removed
and reapplied just distal to the crushed portion.
• An absorbable ( vicryl 3/0 ) ligature is tied around the
crushed porion and the appendix is amputated between the
artery forceps and the ligature.

22. • Inversion of the appendiceal stump may be performed if the
surgeon desires. Commonly, a “Z-stitch” is used for this
purpose.
• In cases of severe appendiceal stump edema and
inflammation, a gastrointestinal stapler may be used to
transect the base of the appendix, even including a segment
of healthy cecal base in the resection; be careful to avoid
impingement of the ileocecal valve when firing the stapler.
• All three muscle layers are
closed separately with running
absorbable suture.
No drain is indicated in simple appendicitis.

23. •

24. Closure :-
• Hemostasis is checked , peritoneum is closed with vicryl 3/0
( depends on surgeon’s decesion)
• Internal oblique and transverse abdominis muscle are
approximated with vicryl no1 in an interrupted manner andn
external oblique aponeurosis is closed in continuous
manner.
• Skin can be closed by few interuppted stitches.

25. 2- Laproscopic Appendectomy
• Pneumoperitoneum is crceated either by closed or open
technique through a small incision at umblicus.
• Laproscope is then passed through 10mm umblical port .
• Thorough peritoneal examination is done , diagnosis
confirmedd , appendix is identified.

26. • Then two 5mm working ports are inserted , one at
suprapubic and other at right lumbar area in ant. Axillary
line.
• Mesoappendix is clipped or
cauterized.
• Appendicular base is clipped
or ligated by intra-corporeal
suture. Appendix removed through lumbar port.

27. Complications:
Per operative :-
• Injury to cecum and ileum
• Bleeding from appendicular artery
• Urinary bladder injury with suprapubic port
Post – Operatively :-
• Appendicular stump leakage / Wound dehiscence
• Adhesive intestinal ostruction
• Abdominal / pelvic abscess formation
• Wound infection
• Portal pyema ( pylephlebitis )
• Stump appendicitis
• Ileus
• Venous thrombosis and embolism
• Fecal fistula

28. • Check List for Unwell patient following
appendicectomy :-
• Examine the wound and abdomen for abscess.
• Consider a pelvic abscesss , and perform a DRE.
• Examine the lungs – pneumonitis or collapse.
• Examine the legs – consider venous thrombosis.
• Examine the conjuctivae for an icteric tinge and the liver
for enlargement , and enquire wether the patient has had
rigours ( pylephlebitis )
• Examine the urine for organisms ( pylephlebitis ).
• Suspect subphrenic abscess.

29. THANK YOU !!!