Lecture 7.

3 | APPENDIX
SURGERY
BATCH AUMONT TRANS DR. M. SINGCO 18 AUGUST 2021

OUTLINE PAGE NUMBER INCIDENCE

Anatomy and Function 1 • Lifetime rate of appendectomy:
Incidence 1 o 12% for men
Etiology and Pathogenesis 1 o 25% for women
o 7% acute appendicitis
Bacteriology 2
• Appendicitis
Clinical Manifestations 2
o Seen in 2nd through 4th decades of life
Laboratory Signs 2
o Mean age: 31.3 years
Imaging 2
o Median age: 22 years
Appendiceal Rupture 2
o M:F – 1.2 to 1.3:1
Differential Diagnosis 3 o Misdiagnosis: higher among women
Acute Appendicitis 3
Chronic Appendicitis 3 ETIOLOGY AND PATHOGENESIS
Appendiceal Parasites 3 • Obstruction of the lumen with fecaliths
Incidental Appendectomy 3 o Dominant causal factor
Tumors 3 o 40% simple acute appendicitis
ANATOMY AND FUNCTION o 65% gangrenous appendicitis w/o rupture
• Visible in the 8th week of embryologic development o 90% gangrenous appendicitis with rupture
**Appendix has no exit
• As protuberance off the terminal portion of the cecum
**Usual problem of appendix: obstruction of fecaliths
• Both antenatal and postnatal development, the growth rate
• Proximal obstruction of the lumen produces a closed-loop
of the cecum exceeds the appendix
obstruction
• The base to the cecum remains constant
**Closed-loop obstruction – there’s no distal opening. So if
**Important in surgery: the base of the cecum
the feces enters the proximal it can’t exit -> closed loop
obstruction
The tip of the appendix varies
**Appendicitis is a closed-loop type of obstruction
• Retrocecal
• Rapidly produces distention
• Pelvic o Normal luminal capacity is 0.1ml
• Subcecal o As little as 0.5ml of fluid distal to an obstruction raises
• Preileal the intraluminal pressure to 60cmH2O
• R pericolic position • Stimulates nerve endings of visceral afferent stretch fibers
- Useful landmarks to identify the appendix o Vague, dull, diffused pain in the mid-abdomen of lower
• The 3 tinea coli converge at the junction of the cecum epigastrium
• Distention continues, continued mucosal secretion, rapid
Normal length multiplication of the resident bacteria
• <1cm to >30cm o Causes reflex nausea and vomiting
• Most common at 6-9 cm o Diffuse visceral pain becomes more severe
• As pressure in organ increases, venous pressure is
Function exceeded
• Immunologic organ o Capillaries and venules are occluded
• Secretes immunoglobulin A (IgA) (in children) • Arteriolar inflow continues
• Integral component of gut-associated lymphoid tissue o Engorgement and vascular congestion
(GALT) system • Inflammatory process soon involves the serosa and in turn
o Lymphoid tissue 1st appears 2wks after birth parietal peritoneum in the region
o Decrease with age o Produces the characteristic shift in pain to the RLQ
o After 60yrs old virtually no lymphoid tissue remains

Page 1 of 3 | Transcribed by EIYMirasol, NATNocete, JACNuique, & MLMOlpos | Edited by TMDPerater | Checked by GGValledor
• Progression of the distention, subsequently the arteriolar ROVSING’S SIGN
inflow is affected • Pain in the RLQ when palpatory pressure is exerted in the
o Poorest blood supply suffer most LLQ
- Ellipsoidal infarcts develop in the antimesenteric
border PSOAS SIGN
• As distention, bacterial invasion, compromise of vascular • Indicates an irritative focus in proximity to the muscle
supply, and infarction progress, perforation occurs • Positive if extension produces pain
o Beyond the point of obstruction rather than the tip
OBTURATOR SIGN
- Perforation usually happens in the antimesenteric
area • Pain on stretching the obturator internus indicates irritation
- This is the chronological event of Appendicitis in the pelvis

BACTERIOLOGY LABORATORY SIGNS

Principal Organisms • Mild leukocytosis, ranging from 10,000 to 18,000/mm3
• Acute appendicitis and perforated appendicitis • Moderate polymorphonuclear
o Escherichia coli • WBC count >18,000/mm3
o Bacteroides fragilis • Just confirmatory to your Diagnosis from the History and PE
o Facultative and anaerobic bacteria • If laboratory result is not very prominent, decide with your
• Antibiotic coverage History and PE results
o Non-perforated appendicitis – 24-48 hrs
o Perforated appendicitis – 7-10 days IMAGING STUDIES
o IV antibiotics usually given until the WBC is normal and • Plain films of the abdomen
afebrile for 24 hrs o Not beneficial to the acute AP
o Beneficial to rule out other pathology
CLINICAL MANIFESTATIONS • Chest x-ray
Symptoms o R lower lobe pneumonic process
Abdominal pain prime symptoms (classic) • Barium enema
• Period of 1-12 hrs, usually within 4-6 hrs • Radioactive-labeled leukocyte
• The pain localizes to the RLQ • Graded compression sonography
• Variations: o Accurate way to diagnose AP
o Long appendix with the inflamed tip at the LLQ
o Retrocecal cause flank or back pain Table 29-2 Alvarado Scale for the Diagnosis of Appendicitis
o Pelvic cause suprapubic pain Manifestations Value
o Retroileal cause testicular pain Symptoms Migration of pain 1
Anorexia 1
Anorexia (no appetite) Nausea/vomiting 1
• Nearly always accompanies AP Signs RLQ Tenderness 2
• Vomiting occurs in nearly 75% Rebound 1
o Vomit only once or twice due to neural stimulation and Elevated temperature 1
presence of ileus Laboratory Leukocytosis 2
• More than 95% of patients with acute AP Left shift 1
o Anorexia is the 1st symptom Total Points 10
o Followed by abdominal pain
o Then vomiting APPENDICEAL RUPTURE
Overall rate is 25.8%
Signs
• In children younger than age 5 yrs – 45%
• Vital signs
• Older than age 65 yrs – 51%
o Temperature elevation is rarely >1oC
Mostly occurs in the distal to the point of luminal obstruction
o Pulse rate is normal or slightly elevated
along the antimesenteric border
• Classical physical sign
Clinical findings
o Direct and rebound tenderness RLQ area
• Fever >39oC
o Referred or indirect tenderness
▪ Palpation on the LLQ and felt the maximum • WBC count >18,000/mm3 or cumm
tenderness on the RLQ
• Localized peritoneal irritation

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 DIFFERENTIAL DIAGNOSIS Prognosis
• Acute Mesenteric Adenitis • Primary Peritonitis • Principal factors in mortality
• Acute Gastroenteritis • Henoch-Schonlein o Rupture occurs before surgical treatment
• Male Urogenital disease Purpura o The age of the patient
• Meckel’s Diverticulitis • Yersiniosis • Overall mortality in ruptured AP is 3%
• Intussusception • Gynecologic Disorders • In elderly, it is 15%
• Crohn’s Disease o Pelvic Inflammatory
• Perforated Peptic Ulcer Disease CHRONIC APPENDICITIS
• Colonic lesions o Ruptured Graafian • The pain lasts longer
• Epiploic Appendagitis Follicle • Less intense but same location
• Urinary Tract Infection o Ruptured Ectopic • Leukocyte count is normal
• Ureteral Stones pregnancy • Treatment
o Twisted Ovarian Cyst o Appendectomy
ACUTE APPENDICITIS APPENDICEAL PARASITES
Acute Appendicitis in the Young • Ascaris lumbricoides is the most common
• More difficult to diagnose than in the adult • Treatment
o Inability to give accurate history o Antibiotic therapy
o Frequency of GIT upset o Appendectomy
• Treatment regimen – Ruptured AP
o Immediate appendectomy INCIDENTAL APPENDECTOMY
o Irrigation of the peritoneal cavity • Highest annual incidence of appendicitis is 9-19 years of
o Antibiotic coverage for 7-10 days age
o IV antibiotic are usually given until the WBC count is • Males more likely to develop than females
normal and afebrile for 24hrs
• Perforation more common in males
Acute Appendicitis in the Elderly
• Lower in younger patient TUMORS
• Delays in diagnosis Carcinoid
o More rapid progression to perforation • Most common site- tip of the appendix
o Comorbid disease • Treatment
• >80 years old perforation rates at 49% o Tumor <1cm- Simple Appendectomy
• Mortality rates at 21% o Tumor >1.5cm- R Hemicolectomy

Acute Appendicitis during Pregnancy Adenocarcinoma

• Frequently occurs during the first two trimesters • Rare
• Appendiceal perforation • Subtypes: Mucinous, Colonic, Adenocarcinoid
o Fetal mortality rate- 3-5% to 20% • Treatment: R Hemicolectomy

Treatment: Mucocele
• Open Appendectomy • Types:
o McBurney (Oblique) o Retention Cysts
o Rocky-Davis (Transverse) o Mucosal Hyperplasia
o Diagnosis is in doubt o Cystadenomas
▪ Lower midline incision o Cystadenocarcinomas
o Delayed primary closure within 4-5 days • Treatment: Simple Appendectomy
• Laparoscopic Appendectomy
o 1983 Pseudomyxoma Peritonei
o Remains controversial • Rare
• Interval Appendectomy • Common in females
o 6-10 weeks later • CT scan done before surgery
Lymphoma
• Treatment: Appendectomy, R Hemicolectomy

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