This document discusses appendicitis, providing information on its anatomy, etiology, clinical presentation, diagnosis, treatment, and complications. Key points include: - Appendicitis most commonly affects adolescents and is caused by obstruction of the appendix. - Diagnosis is based on physical exam findings like localized tenderness and scoring systems. Imaging like ultrasound can also help. - Treatment is typically an appendectomy, which can be open or performed laparoscopically. - Complications include wound infections, abscesses, and obstruction, but mortality is now near zero with antibiotic use.

1. Justly Ann Thomas
Group 4

2. INTRODUCTION
 Inflammation of appendix.
 Accounts for about one-third of childhood admissions for
abdominal pain
 Peak incidence during adolescence(11- 18)
 The lifetime risk
 9% for male
 7% for female
 Diagnosis is difficult especially in younger children
 Definite diagnosis only in 50% to 70% of cases
 Appendectomy is still the treatment of choice;however, in
select patients nonoperative management can be attempted

3. • The appendix 1st becomes visible
during the 8th week of gestation as a
continuation of the inferior tip of the
cecum.
• The appendix rotates to its final position
on the posteromedial aspect of the
cecum, about 2 cm below the ileocecal
valve, during late childhood.
• The variability in this rotation leads to
multiple possible final positions of the
appendix.
• The exact location varies widely
ANATOMY

4.  The appendix averages 8 cm in
length but can vary from 0.3 to 33
cm.
 The diameter of the appendix
ranges from 5 to 10 mm.
 The base of the appendix
arises at the junction of the three
taeniae coli, a useful landmark
 The mesoappendix arises from
the lower surface of the mesentery
or the terminal ileum.

5. Location:
Intraperitoneal (95%)
Pelvis (30%) and Retrocecal (65%)
Retroperitoneal (5%)
McBurney point: most common
location of the appendix; onethird
of the distance from the anterior
superior iliac spine to the umbilicus

6. Blood supply: appendiceal branch of ileocolic artery (lies behind
ileum)

7. ETIOLOGY
EXACT CAUSE – not completely understood
ASSOCIATED FACTORS:
Fecoliths
Decreased dietary fibre
Increased consumption of refined carbohydrates
Incompletely digested food particles
Lymphoid hyperplasia

8.  INTRALUMINAL SCARRING
 blunt trauma
 •TUMORS OR MALIGNANCIES
 carcinoid tumors
 •MICROORGANISMS (bacteria,
virus )
 OTHERS - Ascaris lumbricoides

9. Pathophysiology:
• Obstruction of appendiceal lumen → distention due to
accumulating mucus
• Distention activates T-10 visceral nerve fibers referring to
periumbilical region
• As pressure increases, lymphatic, venous, and, later, arterial
flow are compromised; thus, ischemia ensues
• Localized inflammation activates somatic parietal peritoneum
pain fibers causing pain in right lower quadrant (RLQ)
• Localized abscess or peritonitis occurs late in the process (>24-
36 h)
• Diffuse peritonitis is more common in young children and
infants owing to proportionally smaller omentum that is less
able to contain advancing inflammatory process
• Rare in children <2 years of age
• Children <5 years of age more likely to present with perforation

12. CLINICAL PRESENTATION
 Appendicitis can affect any age group; however, it
is extremely rare in neonates and infants
 Classic presentation: a child with periumbilical pain
that over past 12 hours has migrated to RLQ with
associated nausea, anorexia, lowgrade fever, and
leukocytosis.

13. • Children often lie in bed with minimal
movement
• Infants may flex their right leg over the
abdomen.
• Older children will often limp or flex
trunk.
• Referred testicular pain or urinary
frequency in of pelvic appendicitis
• Anorexia
• Nausea
• Indigestion or subtle changes in bowel habits
• Diarrhea
• Low-grade fever with temperature <38.6°C is the norm in
nonperforated appendicitis.
• Higher temperature suggests severe inflammation or
perforation

14. DIAGNOSIS
 Best made with careful history and physical
examination
 Laboratory investigations
 Scoring systems

15. PHYSICAL EXAMINATION
 Presence of LOCALIZED ABDOMINAL
TENDERNESS the SINGLE MOST reliable finding
in the diagnosis of acute appendicitis

16. Signs during physical examination depend
on the time course of the disease as well as
anatomic location of the appendix.
• Initially tenderness is mild and vague over
RLQ.
• As the parietal peritoneum becomes
irritated, tenderness becomes localized
over McBurney point.
• Once appendicitis has progressed beyond 24 hours,
there may be a period of pain relief, which may be
due to rupture of the appendix where the
intraluminal pressure is relieved.
• Peritonitis manifests as muscle rigidity, guarding,
and rebound tenderness.

17. Pyrexia
Localized tenderness in the right iliac fossa
Muscle guarding
Rebound tenderness
Signs to elicit in appendicitis :
Pointing sign
Rovsing’s sign
Psoas sign
Obturator sign
Physical Signs

18. Rovsing sign: palpation of LLQ produces
RLQ pain.
Psoas sign: right hip extension or raising
straight leg against resistance.
• Above signs are all nonspecific findings.
• Rectal examination may reveal a
palpable, tender extrinsic mass or
abscess; however, it is not routinely
performed.
Obturator sign: passive internal rotation of
the right thigh.

19. LABS
 CBC
 WBC – elevated leukocyte and neutrophil count
 Urine analysis ( Indicated to help exclude genitourinary
conditions)
 May have some WBC or RBC
Others include
 Serum electrolytes
 Liver function tests
 C-reactive protein
 Tumor markers
 Tuberculin Test
 Viral markers
 Beta HCG

20. SCORING SYSTEM
The ALVARADO (MANTRELS)Score
Symptoms Score
Migratory RIF pain 1
Anorexia 1
Nausea and vomiting 1
Signs
Tenderness(RIF) 2
Rebound tenderness 1
Elevated temperature 1
Laboratory
Leukocytosis 2
Shift to left(segmented neutrophils) 1
Total 10
<3 – low likelihood
4-6 – needs further evaluation
>7 – high likelihood

21. Paediatric appendicitis scores
Features Scor
e
Fever >38oC 1
Anorexia 1
Nausea/Vomiting 1
Cough/percussion/hopping
tenderness
2
Right lower quadrant tenderness 2
Migration of pain 1
Leukocytosis > 10,000/L 1
Polymorphonuclear
neutrophilia>7500/L
1
Total 10
≤2 low likelihood
3-7 needs further
evaluation
≥8 high likelihood

24. OTHER IMAGINGS
 USG
Findings –
Wall thickness >6mm
Appendicolith
Luminal distension
Lack of compressibility
Complex mass in the RLQ
 MRI (is expensive and time consuming and may
require sedation in young children.)
 Barium enema contrast Radiograph

25. DIFFERENTIAL DIAGNOSIS
Gastrointestinal
 Mesenteric adenitis
 Crohn disease
 Meckel diverticulitis
 Cecal diverticulitis
 Viral gastroenteritis
 Regional bacterial enteritis (Yersinia and
Campylobacter in
 particular)
 Cholecystitis
 Pancreatitis
 Typhlitis (leukemia)
Genitourinary Tract
 Urinary tract infection
 Hydronephrosis
 Other
 Pneumonia
 Henoch–Schönlein purpura
 Kawasaki disease
 Omental torsion
 Porphyria
 Sickle cell anemia
 Lymphoma
 Vasculitis
 Parasitic infection
 Ureteral calculi
 Wilms tumor
 Ovarian torsion
 Ruptured ovarian cyst
 Salpingitis
 Testicular torsion

26. TREATMENT

27. SURGICAL MANAGEMENT

30. OPEN APPENDECTOMY

32. TRANSUMBILICAL LAPROSCOPIC
ASSISTED APPENDECTOMY
Figure 1 Surgical steps for video-assisted transumbilical appendectomy. A:
Umbilical access for 10 mm port and operative camera; B: The appendix
(phlegmonous) is externalized through the umbilicus; C: Open “classic”
appendectomy; D: Skin closure: the umbilicus is closed with rapid 4/0 absorbable
stitches.

33. COMPLICATIONS
 Wound infection
 Intraabdominal abscess
 Ileus
 Adhesive intestinal obstruction
 Faecal fistula

34. OUTCOME
 The mortality rate for complicated appendicitis has
dropped to nearly 0
 Antibiotics have markedly decreased the incidence
of infectious complications.
 The overall morbidity in children with complicated
appendicitis is <10%