Surgery

1. APPENDICITIS
BY: Dr BIENFAIT MUMBERE VAHWERE
LECTURER/ KIU SURGERY DPT
FEB, 2024

2. OUTLINE
• DEFINITION
• INTRODUCTION
• EPIDEMIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL MANIFESTATION
• CLASSIFICATIONS
• DIAGNOSIS
• MANAGEMENT
• COMPLICATIONS

3. DEFINITION
• APPENDIX VERMIFORM: The appendix is a
finger-shaped pouch that sticks out from the
colon on the lower right side of the abdomen.
• APPENDICITIS: is the inflammation of the
appendix

4. HISTORIQUE PERSPECTIVE
• 1736: The first appendectomy was
performed by AMYAND
• 1886: The word “appendicitis” was
introduced by REGINALD FITZ
• 1899: MC BURNEY, described the clinical
manifestation of early appendicitis,
including the point of maximum tenderness
in the R.I.F.

5. INTRODUCTION
• Appendicitis is one of the most common cause of
acute abdomen world wide with a life risk 8.6 %
in males and 6.9% in females
• For over a century, open appendectomy was the
only standard treatment for appendicitis.
• Contemporary management of appendicitis is
laparoscopic appendectomy
• treat uncomplicated appendicitis nonoperatively
with antibiotics alone.

6. EMBRYOLOGY
• First becomes visible in the eighth week of
embryologic development as a protuberance
off the terminal portion of the cecum.
• During both antenatal and postnatal
development, the growth rate of the cecum
exceeds that of the appendix, displacing the
appendix medially toward the ileocecal valve

7. ANATOMY
• Small blind-ending, muscular tube at the meeting
point of the 3 taenia coli, just distal to the I. C.
junction.
• located in the right lower section of the abdomen.
• The average length is 7.5-10cm(2-20cm)
• The normal lumen (< 6mm): , irregular, being
encroached by multiple longitudinal folds of M.M.
• Blood supply: app. A. I. C. A
• Venous drainage: app. V. I.C.V.
• Lymphatic vessels: 4,6,more I.Caecal. L.Ns.

8. ABA-The Appendix- 4th
year Lectures

9. Normal position of appendix

10. Exceptions exist in the classic presentation due to
anatomic variability of the appendix

11. EPIDEMIOLOGY
• Most common acute surgical condition of the
abdomen
• Peak incidence in early adulthood
• 7-10% of population develop acute appendicitis
• More in males 1.3-2 : 1
• Mortality is 0.3to 0.85% but in elderly it is >20%
• Despite newer imaging techniques, acute
appendicitis can be very difficult to diagnose.

12. ETIOLOGY
• Luminal obstruction.
• Lymphoid hyperplasia 60%
• Faecolith 35%.
• Inspissated barium.
• Fruit seeds. }<4%
• Worms. < 1%
• Extra-luminal obstruction eg Ca Cecum
• Raised intra-luminal pressure
• Mucus accumulation
• Multiplication of bacteria.
• ( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)
• Venous and lymphoid congestion and.

13. etio
• STRICTURE (fibrosis, Crohn’s disease )
• FOREIGN BODY
• NEOPLASM: ca. of caecum, carcinoid synd.
• PARASITES:oxyuris vermicularis (pin warm
• INFECTION:
- bacterial proliferation within the appendix
- mixed growth of aerobic & anaerobic
(E.coli 85%, Enterococi 30%, Bacteroids, Cl. Welchi)
• RACE &DIET: The incidence is lowest in societies with high dietary
fiber intake.
• SOCIAL STATUS: more common among the upper & middle class

14. CLINICAL CLASSIFICATION
• ACUTE APPENDICITIS
• SUBACUTE APPENDICITIS
• RECURENT APPENDICITIS
• CHRONIC APPENDICITIS

15. PATHOLOGICAL CLASSIFICATION
• OBSTRCUCTIVE
• NON OBSTRUCTIVE

16. PATHOPHYSIOLOGY
• Acute appendicitis is thought to begin with
obstruction of the lumen
• Obstruction can result from food matter,
adhesions, or lymphoid hyperplasia
• Mucosal secretions continue to increase
intraluminal pressure
• Eventually the pressure exceeds capillary
perfusion pressure and venous and lymphatic
drainage are obstructed.

17. PATHOPHYSIOLOGY…cont.
• With vascular compromise, epithelial mucosa
breakdown and bacterial invasion by bowel
flora occurs.
• Increased pressure also leads to arterial stasis
and tissue infarction
• End result is perforation and spillage of
infected appendiceal contents into the
peritoneum

18. CLOSED LOOP OBSTRUCTION (fecalith, foreign body, etc.)
DISTENTION (Mucosal secretion, bacteria....)
INFECTION, EDEMA
INFARCTION (gangrene, perforation.)
PATHOPHYSIOLOGY

19. PATHOPHYSIOLOGY
• NONE OBSTRUCTIVE APPENDICITIS
• Inflammation start from the mucosa membrane
but no obstruction, less distention but if serosa is
involved patient develop local peritonitis and
hence pain in the RIF
• This inflammation can lead to: suppuration, or
gangrene, perforation or resolution
• Subacute, recurrent and chronic peritonitis
results from this none obstructive type

20. 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

21. EPIDEMIOLOGY
• Incidence of appendicitis is higher in developed
countries due to consumption of low fiber diet
• Incidence of appendicitis is lower in cultures
with higher fiber diet is intake
• Peak incidence in early adulthood
• 7-10% of population develop acute appendicitis
• More in males 1.3-2 : 1

22. Clinical Manifestations
• PAIN- dull, vague, Epigastric or peri-umblical, for 6-12 hrs. then
• shifts to the right lower quadrant.
• ANOREXIA ( constant c.feature > 90%, children)
• NAUSEA and
• INFREQUENT VOMİTING (1or 2 episodes,75%).
• Constipation, occasionally diarrhea
• Often, H.O. similar discomfort that settled spontaneousl
• Family H. ( up to 1/3rd
of children)

23. Atypical presentation:
• Pain , predominantly somatic/ visceral,&
poorly localized (elderly).
• R.L.Q.
• L.L.Q long app., infl. tip in the L.L.Q.
• Flank/ back: retroperitoneal app.
• Supra-pubic: pelvic

24. Clinical SIGNS
• Appears uncomfortable,
• Activity: quiet
• Position: frequently shifting position(flexed hip)
• Vital signs:
In the 1st
6 hrs., rare alteration in temp. & P.R. (normal)
• Slight pyrexia (37.2- 37.7°C ) + P.R. to 80 or 90/min.
• 39-40°C: perforation/ gangrene, then if shock ensue.
• > 40°C- abscess, septicemia, infection in C.N.S, Lungs,
U.T.I.

25. Clinical SIGNS
• Muscle guarding
• Localized tenderness in the R.L.Q. (Maximal at the Mc
Burney’s p.)
• Rebound tenderness
• Cutaneous hyperasthesia
• Rovsing Sign
• Iliopsoas Sign
• Obturator Sign
• Rectal exam. : extreme anterior pelvic tenderness

26. Psoas Sign Pain on extension of the rt. thigh

27. Obturator Sign;
“Pain on flexion and rotation

28. MANTRELS Score(Alvarado)
Established in 1986 for Murphy.
• Migration of pain:1
• Anorexia: 1
• Nausea / vomiting: 1
• Tenderness RLQ: 1
• Rebound: 2
• Elevated temp:1
• Leukocytosis:2
• Shift to left(Neutrophilia):1

29. ALVARADO SCORE
Total score:10
Score 8-10: acute appendicitis=> Appendectomy
Score 6-8: possibility of appendicitis(need for
Abd USS or CT Scan for confirmation
Score <6: less likely appendicitis

30. Atypical Presentations
Most common in:
• – elderly
• – children
• – pregnancy

31. HIGH RISK PATIENTS, CONT'D
• Pregnancy
– Most common surgical emergency in pregnancy
– Mortality rate if missed = 2 % for mother, up to 35
% for fetus
– WBC elevated in pregnancy
– Appendix changes location

32. HIGH RISK PATIENTS, CONT'D.
• Pediatrics
– Most common surgical disorder in kids
– Accounts for 5 % of abd. pain visits
– Up to 50 % initially misdiagnosed
• < 2 yrs. : perforation rate approaches 100 %
• 3 to 5 yrs. = 71 %
• 6 to 10 yrs. = 40 %
– Most common misdiagnosis is AGE
– Sequence of pain and vomiting may be helpful
– Localized tenderness not a feature of AGE

33. HIGH RISK PATIENTS, CONT'D.
• Elderly
– Vital signs and exam may not reflect severity
– > age 60 : only 5 to 10 % diagnosed without delay
– Perforation rate = 46 to 83 %
– RLQ tenderness absent in 23 %
– N/V, anorexia less common
– Leukocytosis less pronounced
– Only 20 % classic presentation

34. HIGH RISK PATIENTS
• Ovulating women
– PID, TOA, ovarian cyst rupture can mimic
appendicitis
– Look for cervical motion tenderness, adnexal
tenderness, history of STD’s
– Can have CMT with pelvic appendix

35. HIGH RISK PATIENTS, CONT'D.
Immunocompromised
– HIV, chronic steroids, sickle cell anemia,
chemotherapy, DM, dialysis
– Increased risk of complications and misdiagnosis
• Inflammatory response decreased

36. INVESTIGATIONS
• CLINICAL DIAGNOSIS OF ACUTE APPENDICITIS
IS IRREFUTABLE, NO INVESTIGATION CAN
REPLACE IT

37. LABORATORY STUDIES
• FBC
– 75 to 85 % have elevated WBC, but it is
nonspecific
– WBC normal in 80 % in the first 24 hrs.
– WBC usually 12 to 18,000 in appendicitis
• Chemistry panel
– May help with diagnosis of dehydration
•

38. IMAGING STUDIES
• Plain films
– Low sensitivity and specificity
– Appendicolith specific, but seen in only 2 %
– May see local air-fluid levels, psoas obliteration, soft tissue
mass, gas in appendix : all nonspecific
• Ultrasound
– 75 to 90 % sensitive, 86 to 100 % specific
– Noninvasive, low cost, but operator-dependent
– Good for diagnosing GYN disorders

39. USS

40. CT SCAN
– Early studies showed low yield, but helical CT much more
accurate
– Sensitivity 97 to 100 %, specificity 95 % (similar no matter
what type or whether contrast is used)
– Often shows alternative diagnosis
– More expensive, radiation exposure
Criteria for appendicitis :
• Diameter > 6 mm
• Failure to completely fill with contrast or air
• Appendicolith
• Wall thickening or enhancement
– Other contributory signs include fat stranding, fluid,
inflammatory mass, adenopathy

41. DIFFERENTIAL DIAGNOSES
Systemic
• Diabetic ketoacidosis
• Henoch-Schonlein
purpura
Pulmonary
• Pleuritis
• Pneumonia (basilar)
• Pulmonary infarction
Genitourinary
• Kidney stone
• Pyelonephritis
• Wilms' tumor
Other
• Parasitic infection
• Psoas abscess
• Rectus sheath hematoma

42. DIFFERENTIAL DIAGNOSES
Gastrointestinal
•Cholecystitis
•Crohn's disease
•Duodenal ulcer perforate
•Gastroenteritis
•Pancreatitis
•Meckel's diverticulitis
•Mesenteric lymphadenitis
•Necrotizing enterocolitis
•Neoplasm (carcinoid,
carcinoma, lymphoma)
Gynecologic
•Ectopic pregnancy
•Endometriosis
•Ovarian torsion
•Pelvic inflammatory
disease
•Ruptured ovarian cyst
•Tubo-ovarian abscess

43. TREATMENT
The goal of the surgical approach
An early diagnosis with resection of an acutely
inflamed appendix prior to perforation,
A minimum of negative appendectomies.
• Appendectomy is the standard of care
• Patients should be NPO, given IVF, and preoperative
antibiotics
• Antibiotics are most effective when given preoperatively
and they decrease post-op infections and abscess
formation

44. MANAGEMENT
• Pre-operative treatment
• Operation
• post operative treatment
• Treatment of complications

45. Problems encountered during appendectomy
• A normal appendix is found. This demands careful exclusion of other
possible diagnoses, particularly terminal ileitis, Meckel’s diverticulitis and
tubal or ovarian causes in women. It is usual to remove the appendix to
avoid future diagnostic difficulties, even though the appendix is
macroscopically normal
• The appendix cannot be found. The caecum should be mobilised, and the
taeniae coli should be traced to their confluence on the caecum before the
diagnosis of ‘absent appendix’ is made.
• An appendicular tumour is found. Small tumours (under 2.0 cm in diameter)
can be removed by appendicectomy; larger tumours should be treated by a
right hemicolectomy
• An appendicular tumour is found. Small tumours (under 2.0 cm in
diameter) can be removed by appendicectomy;mlarger tumours
should be treated by a right hemicolectomy

46. Management of an appendix mass
• If an appendix mass is present and the condition of
the patient is satisfactory, the standard treatment is
the conservative
• This strategy is based on the premise that the
inflammatory process is already localised and that
inadvertent surgery is difficult and may be
dangerous.
• Give antibiotics and anti inflammatory and then do
interval appendicectomy after 4 to 6 weeks

47. PRE-OPERATIVE TREATMENT
• Pain…Analgenic?.Important:Only after
diagnosis
• Antibiotics
• Fluids
• Preparation: Skin, NGT, Urine Catheter
• Consent

48. OPERATIVE TREATMENT
• Transverse Rocky-Davis or the classical McBurney
or midline skin incision is made in the abdomen
over the area of maximal tenderness.
• If purulent or cloudy peritoneal fluid is
encountered, it should be sent for culture and
sensitivity.
• The appendix is identified at the confluence of the
taeniae coli, and the mesoappendix is clamped and
divided.

49. APPENDECTOMY PROCEDURE
These involve:
-Open appendectomy – an incision is made through the
skin, the underlying tissue and the abdominal wall in
order to access the appendix.
-Laparoscopic (‘keyhole’) appendectomy – this involves
making three small incisions in the abdomen, through
which particular instruments are inserted. A gas is gently
pumped into the abdominal cavity to separate the
abdominal wall from the organs. This makes it easier to
examine the appendix and internal organs.

50. COMPLICATIONS
• Perforation
• Abscess and mass formation
• Liver abscess
• Gen.peritonitis
• Septicemia

51. Appendicular abscess
• Incision and dreinage
• antibiotics
• Appendicectomy if possible otherwise
• Skin of surgical site should be left opened
• Interval appendicectomy

52. operative complications
• – infection
• – hemorrhage
• – damage to other organs
• – ileus
• – adhesions

53. SUMMURY
• If diagnosis of appendicitis is clear from history and
physical examination no further testing is needed
• When diagnosis of appendicitis is uncertain CT &
ultrasonography may reduce the rate of
perforation and are cost effective
• CT is a better imaging modality for appendicitis
than ultrasonography
• Be aware of other imaging modalities especially
MRI in inconclusive
● ultrasonography or MRI in pregnant females