acute appendicitis- April 2025

1. ACUTE APPENDICITIS
DR.WILSON MTWANA
FACILITATOR – DR. DATTA RANADIVE – GENERAL AND LAPARASCOPIC SURGEON.
18th
April 2025

2. CLINICALVIGNETTE
A 34-year-old male with a history of an appendectomy 6 years ago presents with a 48-hour history of
intermittent right lower quadrant pain, nausea, and low-grade fever. On physical examination, he has
localized tenderness over the right lower abdomen with mild rebound tenderness. Blood tests show
mild leukocytosis.
What is your impression?
What investigation will you order?
Plan of management

3. CONTENTS
• Introduction
• Embryology
• Surgical Anatomy
• Pathophysiology
• Clinical diagnosis
• Laboratory and imaging studies
• Management
• References

4. INTRODUCTION
• Most common diseases faced by the surgeon in practice.
• It is the most common urgent or emergent general surgical operation
performed in the United States and is responsible for as many as 3,000,000
hospitalizations annually
• lifetime incidence is 8.6% in men and 6.7% in women
• Acute appendicitis is relatively rare in infants
• Incidence peaking in the second decade of life

5. EMBRYOLOGY
• The appendix is a midgut organ and is first identified at 8 weeks of
gestation as a small outpouching of the cecum
• The appendix is a true diverticulum of the cecum as it contains all the
histological layers of the colon
• During childhood, continued growth of the caecum commonly rotates the
appendix into a retrocaecal.
• In approximately one-quarter of cases, rotation of the appendix does not
occur, resulting in a pelvic, subcaecal or paracaecal position.
• The position of the base of the appendix is constant

7. SURGICAL ANATOMY
• It is located at the terminal end of the caecum where
three taeniae join, about 2 cm below the ileocecal orifice.
• Diameter of appendix is 3- 8 mm; diameter of lumen is 1-
3 mm (matchstick).
• The average length is between 7.5 and 10 cm
• The blood supply of the appendix is appendiceal artery,
branch of ileocolic artery, branch of the superior
mesenteric artery which courses through the
mesoappendix
• Lymphatic drainage into ileocaecal lymph nodes

8. PATHOPHYSIOLOGY
• Appendicitis is caused by luminal obstruction
• In pediatric populations, occurs as a result of lymphoid hyperplasia;
• In adults, it may be due to fecaliths, fibrosis, foreign bodies (food, parasites, calculi), or neoplasia
• Intestinal parasites, particularly Oxyuris vermicularis (pinworm)
• Infections associated with appendicitis is polymicrobial
• Common isolates include Escherichia coli, Bacteroides fragilis, enterococci, Pseudomonas
aeruginosa, Klebsiella pneumoniae, and others

9. PATHOPHYSIOLOGY
• Obstructed proximal appendiceal lumen (closed-loop obstruction), resulting in: Stasis of mucosal
secretions bacterial multiplication and local inflammation transmural spread of infection
→ → →
clinical features of appendicitis
• Increased intraluminal pressure obstruction of veins edema of the appendiceal walls
→ → →
obstruction of capillaries ischemia gangrenous appendicitis with/without perforation
→ →
• Inflammation can spread to serosa, leading to peritonitis

10. PATHOPHYSIOLOGY
Risk factors for perforation of the appendix
• Extremes of age
• Immunosuppression
• Diabetes mellitus
• Faecolith obstruction
• Pelvic appendix
• Previous abdominal surgery

11. TYPES OF APPENDICITIS
1. Acute nonobstructive appendicitis (catarrhal) (mucosa/ appendicitis:-
Inflammation of mucous membrane occurs with redness, oedema and hemorrhages which may
go for following courses:
• Resolution
• Ulceration
• Fibrosis
• Suppuration
• Recurrent appendicitis
• Gangrene-rare initially in nonobstructive type but later can occur
• Peritonitis.

12. TYPES OF APPENDICITIS CONT…
2. Acute obstructive appendicitis: -Here pus collects in the blocked lumen of appendix
which is blackish, gangrenous,oedematous and rapidly progresses leading to perforation
either at the tip or at the base of appendix.
This leads to peritonitis,formation of appendicular abscess or pelvic abscess.
Most often, there will be thrombosis of the appendicular artery

13. TYPES OF APPENDICITIS CONT…
3. Recurrent appendicitis: Repeated attacks of nonobstructive appendicitis leads to fibrosis,
adhesions causing recurrent appendicitis.
4. Subacute appendicitis is milder form of acute appendicitis.
5. Stump appendicitis is retained long stump of appendix after commonly laparoscopic
appendicitomy.

14. CLINICAL PRESENTATION
Symptoms
• Abdominal pain: initial periumbilical pain with migration to the right lower quadrant (RLQ)
• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Constipation
• Indigestion

15. SYMPTOMS
• The classic visceral–somatic sequence of pain is present in only about half of those
patients subsequently proven to have acute appendicitis.
• Atypical pain is more common in the elderly
• Pelvis appendix causes suprapubic discomfort and tenesmus, may be elicited only on
rectal examination
• During the first 6 hours, there is rarely any alteration in temperature or pulse rate.
• After that time, slight pyrexia (37.2–37.7ºC) with a corresponding increase in the pulse
rate to 80 or 90 is usual.
• However, in 20% of patients there is no pyrexia or tachycardia in the early stages

16. SIGNS OF ACUTE APPENDICITIS
• Pyrexia
• Localized tenderness in the right iliac fossa
• Muscle guarding
• Rebound tenderness

17. SIGNS TO ELICIT IN ACUTE APPENDICITIS
• Rovsing sign: the presence of right lower quadrant pain on
palpation of the left lower quadrant (normal position)
• Obturator sign: right lower quadrant pain on internal rotation of
the hip (pelvic appendix)
• Psoas sign: pain with extension of the ipsilateral hip
• Dunphy’s sign: pain with coughing (retrocecal appendix)

18. SPECIAL FEATURES ACCORDING TO POSITION OF
THE APPENDIX
• Retrocaecal: Rigidity is often absent, and even application of deep
pressure may fail to elicit tenderness (silent appendix)
• Pelvic: diarrhea, absence rigidity, most common in children, rectal
tenderness present.
• Postileal: most difficult to diagnose

19. SPECIAL FEATURES ACCORDING TO AGE

20. LABORATORY STUDIES
• Routine Full blood count:
leukocytosis with left shift is present in 90% of the cases
higher leukocytosis associated with gangrenous and perforated appendicitis
( 17,000 cells/mm3)
∼
• Urinalysis- to rule out nephrolithiasis
• Pregnancy test- mandatory in child bearing age
• Urea and electrolytes
• C-reactive protein

21. IMAGING STUDIES
• Imaging studies in patients suspected to
have acute appendicitis can reduce the
negative appendectomy rate, which can
be as high as 15%
• Plain radiographs
• Ultrasound (US)
• Computed tomography (CT) scanning
• Magnetic resonance imaging (MRI)

22. ULTRASOUND
• Ultrasonography has a sensitivity of 85% and a specificity of 90%1
• An easily compressible appendix <5 mm in diameter generally rules out
appendicitis.
• Features on an ultrasound that suggest appendicitis include
Diameter of greater than 6 mm
Pain with compression,
Presence of an appendicolith
Increased echogenicity of the fat,
Periappendiceal fluid

23. CT SCAN
A contrast-enhanced CT scan has a sensitivity of 0.96 (95% confidence
interval [CI] 0.95–0.97) and specificity of 0.96 (95% CI 0.93–0.97)
Features on a CT scan that suggest appendicitis include
Enlarged lumen and double wall thickness (greater than 6 mm)
Wall thickening (greater than 2 mm)
Periappendiceal fat stranding
Appendiceal wall thickening and/or
An appendicolith

25. MRI
MRI is typically reserved for use in the pregnant patient; the study is performed without
contrast agents.
Criteria for MRI diagnosis include
Appendiceal enlargement (>7 mm),
Thickening (>2 mm), and
The presence of inflammation.
Sensitivity of MRI to be 97% with a specificity of 95%

26. MODIFIED ALVARADO SCORE
score of 7 or more: strongly predictive of acute appendicitis.
(5–6): equivocal score

27. MODIFIED ALVARADO SCORE
The sensitivity and specificity of the modified Alvarado Score have been
reported to be 53–88% and 75–80% respectively

28. APPENDICITIS INFLAMMATORY RESPONSE SCORE-
(AIR) SCORE.

29. MANAGEMENT OF ACUTE APPENDICITIS
• Non-operative management
• Operative management

30. NON OPERATIVE MANAGEMENT
• Patients with uncomplicated (absence of appendicolith, perforation or abscess) appendicitis.
• Bowel rest and intravenous antibiotics, often metronidazole and 3rd generation cephalosporin.
• Intravenous fluids: Ringer Lactate and Normal saline Electrolyte repletion as needed
• IV analgesics: Ketorolac 30mg (Toradol) OR Tramadol 100mg (Tramol)
• IV antiemetics as needed: Metoclopramide Or Dimenhydrinate
• Antipyretic therapy: IV Paracetamol 1g/100ml x TDS/BD
• The available data indicate initial successful outcomes in more than 90% of patients with CT
confirmed appendicitis
• However, approximately one-quarter of patients initially treated conservatively will require surgery
within 1 year for recurrent appendicitis

31. OPERATIVE MANAGEMENT
Non-perforated appendicitis
Appendectomy (laparoscopic or open)
 should be performed within 12 hours of diagnosis
 laparoscopic approach is more common and popular
Perforated appendicitis with hemodynamic instability, sepsis, perforation, or peritonitis
emergency appendectomy: irrigation and drainage of peritoneal cavity, colon resection if needed
Stable perforated appendicitis
initial nonoperative management: IV antibiotics, percutaneous drainage of abscess if present
Rescue appendectomy for patients who do not respond to antibiotics

32. MANAGEMENT OF AN APPENDIX MASS
Standard treatment is the conservative Ochsner–Sherren regimen
Criteria for stopping conservative treatment of an appendix mass
• A rising pulse rate
• Increasing or spreading abdominal pain
• Increasing size of the mass
Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn’s disease.
Using this regime, approximately 90% of cases resolve without incident

33. POST OPERATIVE COMPLICATIONS
• Wound infection is the most common postoperative complication, occurring in 5–10% of all patients.
• Intra-abdominal abscess:Approximately 8% of patients
• Ileus:
A period of adynamic ileus is to be expected after appendicectomy, and this may last a number of days
following removal of a gangrenous appendix.
Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is indicative of
continuing intra-abdominal sepsis and should prompt further investigation
• Faecal fistula: from appendicular stump

34. REFERENCES
1. Bailey and love textbook of surgery, 27th edition
2. Sabiston’s textbook of surgery-21st
Edition
3. Schwartz textbook of surgery, 11th edition.
4. Scheins common sense Emergency abdominal surgery- 4th
Edition
5. Uptodate

36. THANKYOU 