Appendix - General Surgery Dr. Bishoy Alfred William - MBBS . MRCS , Sudan - Khartoum

1. Appendix
01
Bishoy Alfred william
MBBS – NRU

2. Anatomy :-
The commonest position of the appendix :-
- Retrocaecal ( most common )
- pelvic position .(2nd common )
- paraceacal .
- post-ileal . ( least common )

3. Blood supply :-
has One or two appendicular arteries
arising from ileocolic artery .

4. - For many years, the appendix was
believed to be a vestigial organ with no
known function. It is now well recognized
that the appendix is an immunologic organ
that actively participates in the secretion
of immunoglobulins, particularly
immunoglobulin A.

5. Acute Appendicitis
* is the most common acute abdominal
surgical emergency .
* is most prevalent in 2nd & 3rd decades of life
, and is rare in the extremes of life .

6. Pathology :-
* Gross types :-
1- obstructive acute appendicitis :-
* obstruction is usually caused by faecolith
or swelling of lymph nodes or adhesions ,
appendix tumors Distention promotes
overgrowth of bacteria inflammation
spreads to the mucosa suppuration or
gangrene .

7. 2- Non-obstructive Acute appendicitis :-
- accounts one third of AA .
- inflammation usually starts in mucosa
and remain there , less likely to perforate .

8. The course in untreated pts :-
1- it may resolves .
2- persistent obstruction , with a faecolith .
Tends to produce gangrene and perforation .
* perforation is followed by peritonitis .
* the risk of perforation is 25% after 24 hrs
from onset of pain & rises to 50% after 36
hrs .

9. 3- when the inflammation process is
slower , the body has the time to wall off
the inflamed appendix by adhesions and
within 3-5 days an appendicular mass
( Phlegmon ) forms in the RIF .
4- Appendicular abscess , perforation of
the appendix within appendicular mass .

10. Clinical Features :-
symptoms :-
1- Acute abdominal pain , starts periumbilically ,
then it shifts to be localized in the RIF , it
aggravates be movements & cough .
2- Nausea and anorexia are always present .
3- vomiting preceded by pain .
4- constipation .

11. Examination :-
1- fever & increase pulse rate .
2- Dunphy sign ( the pain becomes more sharp
& localized when the pt asked to cough )
3- localized tenderness ( & rebound
tenderness ) In RIF .
4- Rigidity indicates perforation .
5- Rovsing sign ( RLQ pain with palpation of
the LLQ ) suggests peritoneal irritation .

12. 6- LLQ tenderness In pts with situs
inversus , a lengthy appenix and in
pregnant ladies .

13. Investigations :-
1- CBC shows lecuocytosis .
2- CRP .
3- hCG , to exclude ectopic pregnancy .
4- UG , to exclude UTI .
5- urinary 5-HIAA , increases in acute
appendicitis and decreses when inflammation
shifts to necrosis .
6- U/S to exclude other diseases that
simulate AA .

14. Alvarado Score

15. Differential Diagnosis :-
1- Chest diseases :-
- Rt.side pneumonia .
2- Upper abdominal diseases :-
- perforated peptic ulcer .
- Acute cholecystitis .

16. 3- Lower abdominal diseases :-
- ca caecum .
- Regional ileitis .
- Meckel diverticulitis
- Gastroenteritis .
4- Pelvis diseases :-
- Ruptured ectopic pregnancy .
- Twisted ovarian cyst .
- PID .

17. 5- Urological diseases :-
- Rt. Ureteric colic .
- Rt, pyelonephritis

18. Treatment

19. 1- uncomplicated AA :-
Treatment is urgent appendicectomy .
2- Appendicular mass :-
urgent appendicectomy is not recommended
because :-
- it presents success of the body to isolate
the inflammation .
- appendicectomy is difficult & carries hazard
.

20. * Treated by conservative management
( Ochsener – sherren regimen ) :-
- bed rest .
- I/V fluids .
- Antibiotics .
- Analgesic .
- Meticulous observation for the Temp ,
pulse , pain , vomiting , degree of
tenderness , rigidity & size of the mass

21. * In 80 -90 % of the pts the mass is
resolved and the pt is scheduled for
interval appendicectomy after 3 months .

22. 3- Perforated appendicitis with
generalized peritonitis :-
- urgent surgery is required ,
appendicectomy with peritoneal toilet .

23. Appendicectomy

24. Indications :-
- Acute appendicitis .( the commonest )
- Appendicular mass & abscess .
- Carcinoid tumors .
- Chronic appendicitis .

25. The incision is called gridiron ( McBurney )
incision .

26. Complications :-
1- Wound infection ( the commonest )
2- chest infection .
3- DVT .
4- paralytic ileus .
5- adhesions leads to intestinal obstruction
or female infertility .
6- incisional hernia . ( unlikely )
7- pertonitis .

27. If at the operation the appendix looks
normal , the surgeon should check the
terminal ileum for Meckels diverticulum &
the Rt. Ovary & fallopian )

28. Neoplasms of Appedix

29. 1- Carcinoid Tumors ( Argentaffinoma ) :-
- is the commonest tumor of appendix .
- The appendix is also the most commonest
site affected by it followed by ileum .

30. - The tumor arises from Kulchisky cells
from the mucosa .
- The majority are benign .
- 5% are malignant and mets to liver
- appendicectomy is sufficient for small
tumors , large lesions required
Rt.hemicolectomy .

31. MCQs
Bishoy alfred william
MBBS - NRU

32. 1- A 24 year old man presents with a 10 day
history of right sided abdominal pain. Prior to
this he was well. On examination he has a low
grade fever and a mass palpable in the right
iliac fossa. The rest of his abdomen is soft. An
abdominal USS demonstrates matted bowel
loops surrounding a thickened appendix.

33. A. Colonoscopy
B. MRI Abdomen
C. Appendicectomy
D. Abdominal CT scan
E. Conservative management with
intravenous antibiotics

34. 2- A 22 year old man presents with a 48 hour
history of right iliac fossa pain. On
examination he has a low grade pyrexia and is
tender with voluntary guarding in the right
iliac fossa. His blood tests reveal a WCC of 13
and a CRP of 6. A urine dipstick is positive for
leucocytes

35. A. Colonoscopy
B. MRI Abdomen
C. Appendicectomy
D. Abdominal CT scan
E. Conservative management with
intravenous antibiotics

36. 3- A 7 year old boy presents with a three day
history of right iliac fossa pain and fever. He
has a history of URTI in the last week. On
examination he has a temperature of 39.9o C.
His abdomen is soft and mildly tender in the
right iliac fossa.

37. A. Appendicitis
B. Mesenteric adenitis
C. Inflammatory bowel disease
D. Irritable bowel syndrome
E. Mesenteric cyst

38. 4- The most important step to do in
management of a pt with appendicular
mass is
a) keep him fasting .
b) cover him with antibiotics .
c) give analgesia .
d) follow up chart for pain , fever, size of
the mass .
e) correct electrolytes imbalance .

39. 5- A 63 year old man presents with a
48 hour history of right iliac fossa he has
a low grade pyrexia and is tender with
some voluntary guarding in the right iliac
fossa. Some of his blood tests are :-
Hb : 8.1 , WBC : 13.8 , Albumin : 22 ,
CRP : 24 .
- What is your management ?

40. A. Colonoscopy
B. MRI Abdomen
C. Appendicectomy
D. Abdominal CT scan
E. Conservative management with
intravenous antibiotics

41. 6- Which of the following types of
patients do not have an increased risk
of perforation?
A. Extremes of age
B. Immunosuppressed
C. Diabetes mellitus
D. Pelvic position of appendix
E. Obese patient

42. 7- In the elderly, which of the
following is not part of the differential
diagnosis of acute appendicitis ?
A. Diverticulitis
B. Intestinal obstruction
C. Mesenteric infarction
D. Leaking abdominal aortic aneurysm
E. Carcinoma of the caecum
F. Bladder calculus.

43. Thanks