APPENDICITIS

Dr.sigid djuniawan, spB

Anatomy and physiology of

appendix

The appendix is a slender, worm-shaped

pouch, averaging 510cm in length, that
protrudes from the top of the colon in the
lower right abdomen

Location
McBurneys point:one-third of the way
from the anterior,superior iliac spine to the
umbilicus.
Pelvis and right ilac fossa appendix
Anterior or posterior ileum appendix
Retrocaceal appendix
Right lateral caceal appendix

Retrocaceal appendix

Supply & nerve

Appendix artery: a final artery ,from
ileocolic artery
Appendix vein :
portal vein
sympathetic nerve :celiac plexus and
lesser splanchnic nerve
T10,T11

Acute appendicitis
Appendicitis is a
common cause
of abdominal
pain

life-threatening condition because of systemic

sepsis (systemic inflammatory response
syndrome/SIRS leading to multiple organ failure)
following rupture and abscess formation

Etiology
Obstruction:
anatomy :wormed-shaped
narrow
plenty of lymph glands
mechanical reason:
food residue, ascarid,
tumor,etc.

Etiology
Gastrointestial disease
Bacteria invasion:
all kinds of G- bacilus

Pathology
Four type:
Acute simple appendicitis
Acute purulent appendicitis
Perforation and gangrenous
Appendiceal abscess

Acute simple appendicitis

Acute purulent appendicitis

Perforation and gangrenous

Gangrenous
Perforation

Appendiceal abscess

Results
Inflammation disappear
Inflammation localization
Inflammation diffusion

Clinical manifestation
symptoms :
abdominal pain :
Periumbilical or epigastric pain that
migrates to right lower quadrant
Pain becomes persistent and well
localized. It worsens with moving,
breathing deeply, coughing, sneezing,
walking, or being touched

Symptoms :

Gastrointestinal symptoms:

Anorexia, nausea, and vomiting

occur after the onset of pain
Constipation
Diarrhea
bladder and rectum stimulus
symptoms

Symptoms
General symptoms :
tired ,headach
fever
Rapid pulse
SIRS (systemic inflammatory response
syndrome)

Signs

Tenderness in the right lower abdomen,

usually about a third of the distance from
the navel to the top of the hip bone
peritoneal irritation sign : muscular
rigidity
Blumberg sign
bowel sounds disappear

Others

Rovsings sign:pain in the right lower

quadrant upon palpation of the left
lower quadrant.
Psoas sign :pain on active elevation of
the legs
The obturator sign: pain on internal
and external rotation of the hip
Rectal exam & vaginal exam

Lab test

Mild to moderately elevated WBC with

left shift is typical but rarely may be
normal, range of 11000-17000/mm 3
over 20000/ mm3
perforation
UA may show ketonuria or a few RBCs
or WBCs
pregnancy test (women only)

Lab test
B-us
X-ray
Diagnostic abdominal puncture

Diagnosis
Periumbilical or epigastric pain
that migrates to right lower
quadrant
Tenderness in the right lower
abdomen, usually about a third of
the distance from the navel to the
top of the hip bone

Differential diagnosis
Two type :
A:
B:

required surgery
not required surgery

Differential diagnosis
Required surgery:
Perforation of gastointestinal tract
ulcer,tumor, diverticulitis
obstetrics and gynecologic disease:
ectopic pregancy,ovarion torsion
Meckel diverticulitis
Tumor

Differential diagnosis
Not required surgery
Pelvic inflammation
Mesenteric adenitis:at exploration a
normal appendix and enlarged lymph
nodes in the mesentery
Viral & bacterial gastroenteritis
Pneumonia, pleurisy

Treatment
Early operation:
surgical removal(appendectomy)
Acute simple appendicitis: appendectomy
Acute purulent and gangrenous
appendicitis:
appendectomy and/or drainage

Treatment
Appendiceal abscess:

if local in right low quadrant

antibiotic therapy and general treatment
if infection diffusion
incision and drainage

Treatment
Operation
Incision :
incision over the point of maximal
tenderness,generally at McBurny point
true McBurneys incision
tansvers skin incision
36cm long

Incision
McBurneys
incision

Incision
tansvers
skin
incision

Treatment
Operation
Process:
The taenia of
the colon are
followed to the
base of the
appendix

Treatment
Operation
Process:
Mesoappendix is
divided
between
clamps and
ligated

Treatment
Operation
Process:
The base of
appendix is divided
and ligated 0.5cm
from caceum and
inverted using a
purse-string

Treatment
Suspected case: not definite.
Admit the patient to hospital for further
observation 12-24hrs
Operation
exploration incision

Treatment
Antibiotic thearpy:
Acute simple appendicitis
Contraindication of operation
Appendiceal abscess

Treatment
Antibiotic thearpy
antibiotics: broadspectrum antibiotics
ampicillin-sulbactam
gentamycin
triad drugs
metronidazol
3rd generation cefotides

Treatment
New method :
laparoscopy appendectomy

Complication
Acute appendicitis:
Abdomen abscess
Inter or extra fistula
Phylephlebitis

Complication
Operation :
Incision infection
Peritonitis and abdomen abscess
Bleeding
Stool fistula
Stump infection
Adhesive intestinal obstruction

Appendicitis in neonate
Seldom
Non-specific clinical manifestation
Anorexia, nausea, and vomiting diarrhea
dehydration

Difficult in early diagnosis

High rate of perforation
High mortality

Appendicitis in neonate
Diagnosis &Treatment
Carefully physical exam
Early operation

Appendicitis in child
Quick onset and severe
high fever and vomiting present early
Non-typical tenderness at right low
quadrant
High rate of perforation
High mortality
More complication

Appendicitis in child
Treatment:
Early operation
Transfusion and correct dehydration
Broadspectrum antibiotics

Appendicitis in pregnancy
Uterus enlargement

appendix displaced
superiorly

Tenderness
site upper shift

elevation of
abdominal
wall

Inconspicuous of
tenderness
rebound tenderness
muscular rigidity

Without
adherent
blanket of
omentum

Peritonitis
diffusion

Appendicitis in pregnancy
Treatment :
Operation :appendectomy
To late pregancy :early operation
Superior Incision
No drainage
Broadspectrum antibiotics
Parturient with perforation :
cesarean section and appendectomy

Appendictis in the elderly

Less well-defined symptoms and signs

Severe pathologic type
Error diagnosis easily
High rate of perforation
Pay attention to tumor

Chronic appendicitis
Etiology and pathology
Clinic feature and diagnosis
right low quadrant pain
local tenderness
x-ray
Treat
appendectomy