Kharkov National Medical University

Department of Surgery No.

Course: 4th, general medicine

Group: 11
Date: 20/11/2015
Topic: Acute Appendicitis

ACUTE APPENDICITIS
1

Definition: Acute appendicitis is inflammation of the appendix.

Anatomy
Layers of the wall of the appendix
Serous coat
Muscular coat; outer longitudinal, inner circular
Submucosa: has lymphoid tissue and lymphoid follicles
Mucous coat; similar to hat of the large intestines
Appendix has mesentery called mesoappendix.
McBurneys point corresponds to the base of the appendix. McBurneys point
is located on the line drawn from the anterior superior iliac spine to the
umbilicus. The one-third of this line that is closest to the anterior iliac spine is
McBurneys point.
Blood supply:
Appendix is supplied by the appendicular artery, which is a branch of the
ileocolic artery. The appendicular artery reaches the tip of the appendix. The
accessory appendicular artery, a branch of the posterior cecal artery supplies
of the base of appendix.
The appendix is drained by the appendicular vein which travels with the
appendicular artery.
Anatomical positions of the appendix
Retorcecal
Pelvic
Subcecal
Periileal
Right pericolic
Role of the appendix
The appendix is also known as the abdominal tonsil. It is invovled in
maturation of B lymphocytes (its lymphoid follicles) and is part of the GALT
9gut associated lymphoid system)
Etiology of acute appendicitis:
1. Obstruction of the lumen of the appendix by a fecolith or hyperplasia
of submucosa lymphoid follicles. It is the most common cause of acute
appendicitis. Other causes of obstruction: worms, fruit seeds, etc

Pathophysiology of acute appendicitis involves:

Obstruction
Continuous mucosal secretion
Worsened edema, high luminal pressure and bacterial proliferation
Transmural necrosis and bacterial penetration
Classification
Four types of acute appendicitis
Acute catarrhal (simple) appendicitis
Acute phlegmonous (purulent) appendicitis
Acute gangrenous appendicitis
Acute perforated appendicitis
Note: there is simple appendicitis (catarhhal appendicitis) and destructive
forms of appendix (purulent, gangrene and perforated appendicitis).
There is also appendicular colic.
Clinical Features
Right lower quadrant (RLQ) pain but it depends on position of the appendix
Dry tongue
Local tenderness in RLQ
Low grade fever 38C
Guarding
Peritoneal signs
anorexia
Signs in acute appendicitis:
Psoas sign- patient lies on left side, extend the right thigh to stretch
the iliopsoas muscle. If there is pain, this is positive Psoas sign
Obturator sign while the patient is lying down, raise the right leg,
bend the right knee and rotate the knee inwards towards the midline of
the patients body. If pain is felt, this is positive obturator sign.
Rovsings sign- palpation in the left lower quadrant produces pain in
the right lower quadrant. This is also known as referred rebound
tenderness. This is due to the displacement of air or intestinal loops
from the left side to the right side thus irritating the inflamed appendix.
Dunphys sign- coughing increases pain in right lower quadrant
Razdolskys sign- pain upon light percussion at McBurneys point.
Sitovskys sign turning to the left side increases the right lower
quadrant pain.
Blumbergs sign = rebound tenderness upon pressing and releasing if the
examiners hand. It is a sign of peritonitis
3

Investigations
CBC= moderate leukocytosis
Normal urine analysis
Imaging investigations: US, CT are the preferred methods of imaging. X-ray
does not show any signs of appendicitis.
Treatment of acute appendicitis:
The trestment of choice in acute appendicitis is surgical. Antegrade or
retrograde appendectomy and laparoscopic appendectomy can be used.
Complications of acute appendicitis
Appendicular mass can be treated conservatively
Appendicular abscess
Peritonitis
Sepsis
Pyelophlebitis
Complications of appendectomy:
Infection of the incision (subcutaneous tissues)
Infection of the formed stump
Peritonitis
Abdominal abscess: pelvic, subphrenic, intra-abdominal
Intestinal obstruction
Bleeding
Stool fistula
Differential Diagnosis of acute appendicitis:
1. Acute cholecystitis
2. Perforated peptic ulcer
3. Meckels diverticulitis
4. Acute pancreatitis
5. Mesenteric vascular occlusion
6. Right ureteric colic
7. Twisted right ovarian cyst
8. Gynecological disorders: salpingitis, ectopic gestation, ruptured
ovarian follicle