LITERATURE REVIEW

ACUTE APPENDICITIS
FUNCTION AND ANATOMY
Lymphoid tissue appeas i! the appe!di" # $ee%s a&te 'ith( The !um'e o& &o))i*)es
pea%s at #++ 'et$ee! a,es -# a!d #+ yeas( Se*etoy immu!o,)o'u)i!s ae podu*ed as pat
o& ,ut.asso*iated )ymphoid tissues to pote*t the mi)ieu i!teio( Appe!de*tomy does !ot
pedispose to 'o$e) *a!*e o a)te the immu!e system( The appe!di" is use&u) 'ut !ot
i!dispe!sa')e( The 'ase aises &om the posteomedia) aspe*t o& the *e*um/ $hee thee
tae!iae *o)i meet( The )e!,th a!d )o*atio! o& the &ee e!d ae 0aia')e1 pe)0i*/ eto*e*a)/ o
eithe )o$e 2uada!t( Co!,e!ita) de&e*ts ae ae a!d *)i!i*a))y i!si,!i&i*a!t(
INFLAMMATION1 ACUTE APPENDICITIS
I!*ide!*e Most *ommo! a*ute su,i*a) *o!ditio! o& the a'dome!( Most &e2ue!t i!
the se*o!d a!d thid de*ades3 paa))e)s amou!t o& )ymphoid tissues i! appe!di"( Moe
*ommo! i! ma)es/ espe*ia))y dui!, pu'eta) yeas( O0ea)) i!*ide!*e -(41- ma)e
pedomi!a!*e( I!*ide!*e has 'ee! de*)i!i!, i! the )ast se0ea) de*ades(
Etio)o,y a!d Patho,e!esis O'stu*tio! o& )ume! *aused 'y &e*a)ith/ )ymphoid
hypetophy/ i!spissated 'aium/ seeds/ o i!testi!a) $oms( Symptomati* *)osed.)oop
o'stu*tio! de0e)ops 'e*ause o& the *o!ti!ued mu*osa) se*etio! i!to +(-.mL *apa*ity )ume!
a!d 'e*ause o& apid mu)tip)i*atio! o& eside!t 'a*teia o& the appe!di"( Diste!tio! stimu)ates
0is*ea) a&&ee!t pai! &i'es/ podu*i!, 0a,ue/ du))/ di&&use midd)e a!d )o$e a'domi!a) pai!(
Sudde! diste!tio! may *ause peista)sis $ith *ampi!,( Ve!ous pessue is e"*eeded/ a!d
ateio)a i!&)o$ *auses 0as*u)a *o!,estio! o& the appe!di"/ $ith e&)e" !ausea( Seosa)
e!,o,eme!t i!&)ames the paieta) peito!eum $ith shi&t o moe se0ee pai! to the i,ht
)o$e 2uada!t( Mu*osa) *ompomise a))o$s 'a*teia) i!0asio!/ $ith *o!se2ue!t &e0e/
ta*hy*adia/ a!d )eu%o*ytosis( With po,essi0e diste!tio!/ a!timese!tei* i!&a*tio! a!d
pe&oatio! o**u( O**asio!a))y/ episodes o& a*ute appe!di*itis eso)0e i& o'stu*tio! is
e)ie0ed3 su'se2ue!t patho)o,i* e"ami!atio! e0ea)s thi*%e!ed/ s*aed appe!di*ea) $a))(
C)i!i*a) Ma!i&estatio!s Symptoms C)assi* po,essio! o& symptoms i!*)udes
a!oe"ia 5a)most a)) ha0e it6/ &o))o$ed 'y *o!sta!t modeate peium'i)i*a) pai! $ith shi&t i!
789 h to shap i,ht )o$e 2uada!t pai!( Vaia')e positio! o& the tip o& the appe!di" o
ma)otatio! a))o$s 0aia'i)ity i! pai! )o*atio!( Su'se2ue!t episodes o& emesis may o**u
$ith o'stipatio! o diahea/ pati*u)a)y i! *hi)de!(
Si,!s Detemi!ed 'y the positio! o& the appe!di" a!d $hethe uptued( Vita) si,!s
sho$ mi)d ta*hy*adia o tempeatue e)e0atio! o& -:C( Positio! o& *om&ot is &eta) o supi!e
$ith )e,s da$! up/ espe*ia))y i,ht( Positio!a) mo0eme!t *auses pai!( A!teio appe!di"
,i0es ma"ima) te!de!ess/ ,uadi!,/ a!d e'ou!d at M*;u!ey<s poi!t 5o!e.thid the dista!*e
&om the a!teosupeio i)ia* spi!e to the um'i)i*us6( Cuta!eous hypeesthesia may 'e pese!t
ea)y i! the aea supp)ied 'y i,ht spi!a) !e0es T-+/ T--/ a!d T-#( Ro0si!,<s si,! 5pai! i!
the i,ht )o$e 2uada!t $ith pa)patio! i! the )e&t )o$e 2uada!t6 i!di*ates peito!ea)
iitatio!( Psoas si,! 5s)o$)y e"te!di!, the patie!t<s i,ht thi,h $he! )yi!, o! the )e&t side6
demo!states !ea'y i!&)ammatio! $he! stet*hi!, the i)iopsoas mus*)e( O'tuato si,!
5passi0e i!te!a) otatio! o& the &)e"ed i,ht thi,h $ith patie!t supi!e6 i!di*ates iitatio! !ea
the o'tuato i!te!us( A eto*e*a) appe!di*itis may pese!t $ith &)a!% pai!( A pe)0i*
appe!di*itis may ,i0e pai! o! e*ta) e"ami!atio! $ith pessue o! the *u).de.sa* o& Dou,)as(
La'oatoy Fi!di!,s Mi)d )eu%o*ytosis o& -+/+++8-=/+++>mm4 $ith modeate
po)ymopho!u*)ea pedomi!a!*e( Pyuia is pese!t $he! the i!&)amed appe!di" )ies !ea the
uete o ')adde( ;a*teiuia i!di*ates ui!ay ta*t i!&e*tio!(
Radio,aphy Radio,aphs ae)y ae he)p&u)( P)ai! a'domi!a) &i)ms may sho$ a
!o!spe*i&i* 'o$e) ,as patte!( A &e*a)ith i! the i,ht )o$e 2uada!t is su,,esti0e o&
appe!di*itis( ?e!t)e 'aium e!ema sho$s !o!&i))i!, o& the appe!di" a!d mass e&&e*t o! the
media) a!d i!&eio 'odes o& the *e*um3 *omp)ete &i))i!, o& the appe!di" u)es out
appe!di*itis( ?aded *ompessio! so!o,aphy may e0ea) a !o!*ompessi')e appe!di"/ 9 mm
o ,eate i! the a!teoposteio die*tio!( Computed tomo,aphi* 5CT6 s*a! is use&u)/
espe*ia))y $ith suspe*ted a's*ess( Chest adio,aphy u)es out i,ht )o$e )u!, &ie)d disease/
$hi*h may simu)ate i,ht )o$e 2uada!t pai! 'y iitati!, T-+/ T--/ a!d T-# !e0es(
Lapaos*opy *a! 'e dia,!osti* a!d theapeuti*/ espe*ia))y i! &ema)es to u)e out
,y!e*o)o,i* patho)o,y( Lapaos*opi* appe!de*tomy is possi')e(
Comp)i*atio!s@Ruptue Ruptue o**us a&te u!e)e!ti!, o'stu*tio! o& the )ume!
)eads to ,a!,e!e dista) to the o**)usio!( Usua))y o**us dista) to a &e*a)ith( Spi))a,e is
*o!tai!ed )o*a))y i! AB pe*e!t o& patie!ts( A ph)e,mo! o& i!&)amed/ matted )oops o& i!testi!e
a!d ome!tum may eso)0e o may e"pa!d i! *o!tai!ed &ashio! to &om a peiappe!di*ea)
a's*ess o to *ause i!testi!a) o'stu*tio!(
I!*ide!*e Ruptue is pese!t i! -B8#B pe*e!t o& patie!ts at pese!tatio!/ $ith a
hi,he i!*ide!*e i! pediati* a!d ,eiati* a,e ,oups(
Dia,!osis A'domi!a) pai! o**asio!a))y 5o!)y 7 pe*e!t6 )esse!s tempoai)y a&te
uptue 'e*ause o& sudde! e)ie& o& diste!tio!3 i! most patie!ts/ pai! *o!ti!ues u!a'ated( A
te!de/ 'o,,y mass may 'e pa)pa')e o! e*ta) e"ami!atio! i! the i,ht )o$e 2uada!t(
De,ee o& diste!tio!/ i)eus/ &e0e/ ta*hy*adia/ )eu%o*ytosis/ a!d to"i* appeaa!*e paa))e) the
se0eity o& peito!itis( Tempeatue ise a!d de,ee o& )eu%o*ytosis ae ma%ed)y hi,he tha!
$ith simp)e appe!di*itis(
Di&&ee!tia) Dia,!osis That o& the a*ute a'dome!( Peopeati0e dia,!osis o& a*ute
appe!di*itis shou)d 'e =B pe*e!t a**uate depe!di!, o! the )o*atio! o& the appe!di"/ the
)e!,th o& the symptoms/ a!d the a,e a!d se" o& the patie!t(
A*ute Mese!tei* Ade!itis Most o&te! i! *hi)dhood/ e*e!t uppe espiatoy
i!&e*tio!/ ,e!ea)iCed )ymphade!opathy(
A*ute ?astoe!teitis ?e!ea))y 0ia) etio)o,y3 asso*iated 0omiti!,/ diahea/
*ampi!,/ a!d e)a"atio! 'et$ee! hypepeista)ti* $a0es( Sa)mo!e))a ,astoe!teitis esu)ts
&om i!,estio! o& *o!tami!ated &ood3 histoi*a))y disa')es ,oups o& patie!ts( S( typhosa
i!&e*tio! is ae/ *haa*teiCed 'y ash/ i!appopiate 'ady*adia/ )eu%ope!ia/ a!d positi0e
stoo) *u)tues(
Diseases o& the Ma)e The diseases that mimi* a'domi!a) pai! ae testi*u)a tosio!/
epididymitis/ a!d semi!a) 0esi*u)itis(
Me*%e)<s Di0eti*u)itis Same peopeati0e pi*tue as appe!di*itis( Re2uies
di0eti*u)e*tomy/ o**asio!a))y 'o$e) ese*tio!(
I!tussus*eptio! Most u!de # yeas o& a,e/ *ua!t De))y stoo)/ i!temitte!t *ampy
atta*%s o& pai!/ i,ht )o$e 2uada!t sausa,e.shaped mass( I!itia) attempt at edu*tio! 'y
'aium e!ema(
A*ute I)eitis o Re,io!a) E!teitis Asso*iated $ith diahea a!d o&te! a *ho!i*
histoy/ 'ut i!&e2ue!*y o& a!oe"ia/ !ausea/ a!d emesis( I& &ou!d at )apaotomy/ i!*ide!ta)
appe!de*tomy is i!di*ated to de*ease su'se2ue!t *o!&usi!, symptoms 5!ot do!e i& the
*e*um is i!0o)0ed 'e*ause o& the ,eate is% o& postopeati0e &istu)a6(
Pe&oated Pepti* U)*e Ri,ht ,utte spi))a,e o& uppe ,astoi!testi!a) *o!te!ts $ith
apid sea)i!, o& pe&oatio! *auses pomi!e!*e o& i,ht )o$e 2uada!t symptoms(
Di0eti*u)itis o Pe&oati!, Ca*i!oma o& the Co)o! Re2uies e"p)oatio!( Epip)oi*
Appe!da,itis I!&a*tio! se*o!day to tosio!( Pai! pese!t 'ut !o peito!itis o o'stu*tio!(
Ui!ay Ta*t I!&e*tio! Ri,ht *osto0ete'a) a!,)e te!de!ess a!d 'a*teiuia pese!t(
Uetea) Sto!e Eematuia a!d e&eed pai! to s*otum o )a'ia pese!t( Pye)o,aphy
*o!&ims dia,!osis( Pimay Peito!itis Teated $ith a!ti'ioti*s a&te paa*e!tesis sho$s
simp)e ,am.positi0e &)oa( Ee!o*h.S*hF!)ei! Pupua O**us se0ea) $ee%s a&te
stepto*o**a) i!&e*tio!3 asso*iated $ith pupua/ Doi!t pai!s/ a!d !ephitis( Yesi!iosis
Ta!smitted 0ia *o!tami!ated &ood3 mimi*s appe!di*itis( Campy)o'a*te DeDu!i *auses
diahea a!d pai! $ith positi0e stoo) *u)tues( ?y!e*o)o,i* Disodes Pe)0i* i!&)ammatoy
disease/ usua))y 'i)atea)/ asso*iated $ith )o$e pe)0i* pai! a!d *e0i*a) motio! te!de!ess/
o**us peime!stua))y3 ?am stai! o& 0a,i!a) dis*ha,e o&te! sho$s ,am.!e,ati0e
dip)o*o**i( Ruptued ,aa&ia! &o))i*)e mimi*s appe!di*itis $ith spi))a,e o& su&&i*ie!t ')ood
a!d &)uid i!to pe)0is3 o**us at o0u)atio! 5Mitte)s*hmeC6( O0aia! tosio!/ e!dometiosis/
uptued e*topi* pe,!a!*y( Lapaos*opy is use&u) i! dia,!osis( Othes Foei,!.'ody 'o$e)
pe&oatio!s/ mese!tei* 0as*u)a o**)usio!/ i,ht )o$e *hest p)euitis/ a*ute pa!*eatitis/
hematoma o& a'domi!a) $a))(
Se)e*t ?oups
TEE YOUN?
Faste po,essio! o& disease $ith hi,h &e0e a!d emesis a!d moe &e2ue!t uptue at
dia,!osis 5-B8B+ pe*e!t6(
TEE ELDERLY
De*epti0e)y mi)d *)i!i*a) *ouse $ith i!*eased mo'idity 'e*ause o& hi,he i!*ide!*e
o& *o!*omita!t disease a!d hi,he pe&oatio! ate(
TEE PRE?NANT
E"pe*ted &e2ue!*y &o a,e ,oup( Dia,!osis moe di&&i*u)t 'e*ause the appe!di" is
disp)a*ed *epha)ad a!d )atea) 'y ,a0id uteus3 pai!/ !ausea/ a!d )eu%o*ytosis ae *ommo!
i! !oma) pe,!a!*y/ 'ut a )e&t shi&t i!di*ates a! a*ute po*ess( Mate!a) mota)ity is
!e,)i,i')e( Feta) mota)ity o0ea)) is #8=(B pe*e!t/ #+ pe*e!t $ith appe!di*ea) pe&oatio!
a!d peito!itis( Opeatio! *aies -+8-B pe*e!t is% o& pematue )a'o(
AIDS OR EIV INFECTION
C)i!i*a) pese!tatio! !o di&&ee!t/ a)thou,h )eu%o*ytosis may 'e a'se!t(
Cytome,a)o0ius e!teitis/ tu'e*u)osis/ o )ymphoma o& dista) i)eum *a! mimi* appe!di*itis(
Teatme!t
Teatme!t is a)$ays opeati0e 'e*ause the o'stu*ted )ume! $i)) !ot eso)0e $ith
a!ti'ioti*s a)o!e( A*ute appe!di*itis $ithout uptue is teated $ith immediate appe!de*tomy
a&te the medi*a) e0a)uatio! is *omp)ete( Ruptued appe!di*itis $ith )o*a) peito!itis o
ph)e,mo! is opeated o! ea)y a&te esus*itatio! &o &)uid a!d e)e*to)yte )osses( Ruptued
appe!di*itis $ith speadi!, peito!itis e2uies moe e"te!si0e &)uid esus*itatio!/ 'ut the
patie!t shou)d u!de,o opeatio! !oma))y $ithi! 7 h to pe0e!t *o!ti!ued peito!ea)
*o!tami!atio!(
Ruptued appe!di*itis $ith peiappe!di*ea) a's*ess &omatio! may 'e teated a*ute)y
$ith opeatio!/ 'ut this is asso*iated $ith i!*eased mo'idity( I& symptoms ae o& se0ea)
days< duatio!/ su'sidi!,/ a!d asso*iated $ith i,ht )o$e 2uada!t mass/ i!itia) !o!opeati0e
theapy $ith &)uid esus*itatio!/ 'o$e) est/ a!d )a,e doses o& a!ti'ioti*s is appopiate/
possi')y i! *o!Du!*tio! $ith u)tasou!d.,uided a's*ess dai!a,e( I& 0ita) si,!s/ )eu%o*ytosis/
a!d a'domi!a) si,!s po,ess/ dai!a,e o& a's*ess may 'e i!di*ated/ &o))o$ed 'y
*o!se0ati0e theapy( I!te0a) appe!de*tomy i! 9 $ee%s to 4 mo!ths is ad0ised/ a)thou,h the
o0ea)) ate o& e*ue!*e $ithout i!te0a) appe!de*tomy a!,es &om +84G pe*e!t(
Peopeati0e a!ti'ioti*s )o$e i!&e*tious *omp)i*atio!s/ 'ut the e,ime! is
*o!to0esia)( I& simp)e a*ute appe!di*itis/ thee is !o 'e!e&it to moe tha! #7 h o& a!ti'ioti*s(
I& pe&oated o ,a!,e!ous/ a!ti'ioti*s ae ,i0e! u!ti) the patie!t is a&e'i)e a!d the $hite
')ood *e)) *ou!t is !oma)( Patho,e!s i! a*ute appe!di*itis ae mi"ed *o)o!i* &)oa/ 'oth
aeo'i* a!d a!aeo'i*3 ;a*teoides &a,i)is !eeds *o0ea,e( C)i!damy*i! p)us a!
ami!o,)y*oside o a se*o!d.,e!eatio! *epha)ospoi! e,ime! is popu)a(
Po*edue I!*isio! shou)d 'e i! the i,ht )o$e 2uada!t &o patie!ts $ith suspe*ted
appe!di*itis( A M*;u!ey 5o')i2ue6 o a Ro*%y.Da0is 5ta!s0ese6 mus*)e.sp)itti!, i!*isio!
is most *ommo!( I& a! a's*ess is suspe*ted/ a )atea) i!*isio! is used to pe0e!t peito!ea)
*o!tami!atio!( A )o$e mid)i!e i!*isio! is used i& the dia,!osis is i! 2uestio!( A )o$e
mid)i!e i!*isio! a)so is used &o ,e!ea) e"p)oatio! 'ut is *o!tai!di*ated $ith a's*ess
'e*ause i!&e*ted mateia) must 'e 'ou,ht thou,h the u!*o!tami!ated peito!ea) *a0ity(
The appe!di*ea) stump *a! 'e simp)y )i,ated o )i,ated $ith puse.sti!, o H.stit*h
i!0esio!( I& appe!di*itis is !ot &ou!d/ the pe)0i* o,a!s a!d emai!i!, a'domi!a) 0is*ea ae
e"p)oed( The mese!tey is e"ami!ed &o )ymphade!itis( The i)eum is Iu!J &o temi!a)
i)eitis o Me*%e)<s di0eti*u)itis(
Dai!a,e o& )o*a)iCed pus is a**omp)ished $ith )atea) dai!s( The peito!ea) *a0ity
*a!!ot 'e dai!ed( I& the appe!di" is uptued/ su'*uta!eous &at a!d s%i! ae )e&t ope! to hea)
'y ,a!u)atio! o se*o!day *)osue( Pimay $ou!d *)osue is a)most a)$ays used i!
*hi)de!(
Appe!de*tomy *a! 'e pe&omed 'y the )apaos*opi* appoa*h( This is espe*ia))y
suited to $ome! i! $hom a di&&ee!tia) dia,!osis o& ,y!e*o)o,i* disease is e!tetai!ed(
O'ese patie!ts may 'e!e&it &om the )apaos*opi* appoa*h( I!ta*opoea) stap)i!, de0i*es
ae used to di0ide the mesoappe!di" a!d the appe!di*ea) 'ase(
Prognosis
Mota)ity is +(- pe*e!t i& u!uptued a*ute appe!di*itis/ 4 pe*e!t i& uptued/ a!d -B
pe*e!t i& uptued i! the e)de)y( Death usua))y is &om sepsis/ pu)mo!ay em'o)ism/ o
aspiatio!3 impo0i!, ates ae see! $ith ea)ie dia,!osis 'e&oe uptue a!d 'ette
a!ti'ioti*s(
Mo'idity is i!*eased $ith uptue a!d o)de a,e( Ea)y *omp)i*atio!s ae septi*(
Wou!d i!&e*tio! e2uies eope!i!, o& the s%i! i!*isio!/ $hi*h pedisposes to dehis*e!*e
5)ess *ommo! $ith mus*)e.sp)itti!, i!*isio!6( I!taa'domi!a) a's*esses may o**u &om
peito!ea) *o!tami!atio! a&te ,a!,e!e a!d pe&oatio!( Fe*a) &istu)a esu)ts &om !e*osis o&
a potio! o& the *e*um 'y a! a's*ess o *o!sti*ti!, puse.sti!, sutue o &om a s)ipped
)i,atue( I!testi!a) o'stu*tio! may o**u $ith )o*u)ated a's*esses a!d adhesio! &omatio!(
Late *omp)i*atio!s i!*)ude adhesio! &omatio! $ith me*ha!i*a) o'stu*tio! a!d he!ia(