APPENDICITIS

Dr Phillipo Leo Chalya

M.D. (Dar); M.Med Surg (Mak)
Specialist surgeon - Bugando Medical Centre
 FORMAT
 Definition
 A historical perspective
 Epidemiology
 Aetiology
 Classification
 Pathophysiology
 Clinical presentation
 Differential Diagnosis
 Work up
 Treatment
 Complications
 DEFINITION
 Appendicitis refers to inflammation of the vermix
appendix
 A HISTORICAL PERSPECTIVE

 First described by Reginald Fitz in 1886 who

also was the first to advocate appendicectomy
as the cure

 In 1889 Charles McBurney described the

clinical findings of acute appendicitis including
the point of maximum tenderness in RIF which
bears his name
 EPIDEMIOLOGY
 Incidence:
 The incidence is higher in developed countries and in
developing countries which are adopting a more refined
western type diet
 Incidence of appendicitis is lower in cultures with a higher
intake of dietary fiber
 EPIDEMIOLOGY [cont’d]
 Mortality/Morbidity:
 The overall mortality rate of 0.2-0.8% is attributable to
complications of the disease rather than to surgical intervention
 Mortality rate rises above 20% in patients older than 70 years,
primarily because of diagnostic and therapeutic delay
 Perforation rate is higher among patients younger than 18 years
and patients older than 50 years, possibly because of delays in
diagnosis
 Appendiceal perforation is associated with an increase in
morbidity and mortality rates
 EPIDEMIOLOGY [cont’d]
 Sex:
 The incidence of appendicitis is approximately 1.4 times
greater in men than in women

 The incidence of primary appendectomy is approximately

equal in both sexes
 EPIDEMIOLOGY [cont’d]
 Age:
 Appendicitis may occur at all ages, but is most commonly
seen in the 2nd and 3rd decades of life
 The incidence of appendicitis gradually rises from birth,
peaks in the late teen years, and gradually declines in the
geriatric years
 Although rare, neonatal and even prenatal appendicitis
have been reported in literature
 The emergency physician must maintain a high index of
suspicion in all age groups
 AETIOLOGY
 Etiological factors for appendicitis include:-
 Appendiceal luminal obstruction
 Diet
 Social status
 Familial susceptibility
 Appendiceal luminal obstruction
 Luminal causes
 Feacolith
 Lymphoid follicle hyperplasia
 Worms e.g. ascaris
 Foreign body
 In the wall
 Stricture
 Neoplasms
 Outside the wall
 Adhesions
 kinks
 Diet
 Low intake of dietary fiber is associated with
increased incidence of appendicitis
 Dietary fiber is thought to decrease the viscosity of
feces, decrease bowel transit time, and discourage
formation of fecaliths that predispose individuals to
obstructions of the appendiceal lumen
 Familial tendency

 Appendicitis tends to run in certain families

may be due to peculiar position of the organ
which predisposes to infection
 CLASSIFICATION

 Clinical classification
 Pathological classification
 Clinical classification
 Acute appendicitis
 Subacute appendicitis
 Recurrent appendicitis
 Chronic appendicitis
 Pathological classification

 Obstructive appendicitis
 Non-obstructive appendicitis
 PATHOPHYSIOLOGY

 Two types:-
 Obstructive appendictis
 Non-obstructive appendicitis
 Obstructive appendicitis
 Luminal obstruction and mucus production result in
increased intraluminal pressure
 Bacteria trapped within the appendiceal lumen begin to
multiply, and the appendix becomes distended
 Luminal distention stimulates visceral nerve endings
concerned with pain [visceral pain]
 This produce dull aching pain felt periumbilically
according to nerve supply of the appendix (T10) 
referred pain
 Venous congestion and edema follow next, and by 12 hours
after onset, the inflammatory process may become
transmural
 Obstructive appendicitis[ cont]

 Peritoneal irritation then develops

 If the obstruction is left untreated, arterial blood
flow to the appendix is compromised, and this
leads to tissue ischemia and necrosis
 This stimulates parietal nerve endings→ shift of
pain to the RIF
 Full thickness necrosis of the appendiceal wall
leads to perforation with the release of fecal and
suppurative contents into the peritoneal cavity
 Obstructive appendicitis [cont]
 Depending on the duration of the disease process,
either a localized walled-off abscess or mass occurs,
or if the pathologic process has advanced rapidly, the
perforation is free in the peritoneal cavity and
generalized peritonitis occurs
 The commonest bacterial growth from inflamed
appendices include Escherichia coli, Kleblesiella
spp., Proteus spp and Bacteroids
 Non-obstructive appendicitis
 This is less dangerous type
 Inflammation commences in the mucous membrane or in the
lymphoid follicles and gradually spread to the submucosa
 As there is no obstruction there is not much distension, but
when the serosa is involved localizing peritonitis develops
and the patient c/o RIF pain
 Such inflammation terminates either by:-
 Suppuration
 Gangrene
 Fibrosis
 Resolution
 Many of the sub-acute appendicitis, recurrent appendicitis
and chronic appendicitis develop from this variety
 CLINICAL PRESENTATION
 History: classic symptoms include:-
 Periumbilical pain [visceral pain] which shifts and
localize to the RIF [parietal or somatic pain]
 Periumbilical pain is colicky in nature in obstructive type
and is dull aching and constant in non-obstructive type
 RIF pain is sharp intense and well localized to the RIF
 Anorexia
 Nausea & Vomiting
 CLINICAL PRESENTATION [cont’d]

 Physical examination
 Pyrexia
 RIF tenderness
 Muscle guarding
 Rebound tenderness
 Special test to elicit in appendicitis
 Pointing sign
 Rovsing’s sign [RIF pain with palpation of the LIF ]
 Psoas sign [RIF tenderness with internal rotation of the flexed
right hip]
 Obtrurator sign [RLQ pain with hyperextension of the right hip ]
 DIFFERENTIAL DIAGNOSIS

 Abdominal disorders
 Gynecological disorders
 Retroperitoneal disorders
 Thoracic disorders
 Others
 Abdominal disorders
 Acute cholecytitis
 Perforated peptic ulcers
 Entecolitis
 Intestinal obstruction
 Carcinoma caecum
 Crohn’s diseases
 Amoebic colitis
 Meckel’s diverticulitis
 Acute pancreatis
 Gynecological disorders

 PID
 Ectopic pregnancy ®
 Twisted ovarian cyst ®
 Ruptured ovarian follicles ®
 Retroperitoneal disorders

 Right ureteric colic

 Right sided acute pyelonephritis
 Right sided testicular torsion
 Retroperitoneal haematoma
 Thoracic disorders

 Basal pneumonia
 Pleurisy
 Miscellaneous

 Henoch-Schoenlein purpura
 Porphyria
 Diabetic abdomen
 WORK UP

 Lab investigations
 Complete blood cell count
 Leucocytosis
 Neutrophilia greater than 75%
 C-reactive protein test
 Urinalysis
 WORK UP [cont’d]
 Imaging investigations
 Abdominal radiography
 The kidneys-ureters-bladder (KUB) view is typically used
 Visualization of an appendicolith in a patient with symptoms
consistent with appendicitis is highly suggestive of appendicitis,
but this occurs in fewer than 10% of cases
 The consensus in the literature is that plain radiographs are
insensitive, nonspecific, and is not cost-effective

•
WORK UP [cont’d]
 Abdominal Ultrasonography
 An outer diameter of greater than 6 mm,
noncompressibility, lack of peristalsis, or
periappendiceal fluid collection characterizes an
inflamed appendix
 The normal appendix is not visualized
 It’s noninvasive, short acquisition time, lack of
radiation exposure, and potential for diagnosis of
other causes of abdominal pain, particularly in the
subset of women of childbearing age
 However it is operator dependent
 WORK UP [cont’d]
 Computed tomography
 Abdominal CT has become the most important imaging study in the
evaluation of patients with atypical presentations of appendicitis
 Advantages of CT scanning include
 Sensitivity and accuracy compared with those of other imaging
techniques
 Readily available

 Noninvasive

 potential to reveal alternative diagnoses

 Disadvantages
 lengthy acquisition time if oral contrast is used

 patient discomfort if rectal contrast is used

 Exposure to radiation

 It is really required to make diagnosis of acute appendicitis

 DIAGNOSTIC SCORING SYSTEM
 Various scoring systems have been devised to aid diagnosis
of appendicitis
 Although many diagnostic scores have been advocated,
most are complex and difficult to implement in the clinical
situation
 The Alvarado score, is a simple scoring system that can be
instituted easily
 The Classic Alvarado score [1986] is based on three
symptoms, three signs and two laboratory findings and has
a total score of 10
 Classic Alvarado Score [1986]
Features Score
Symptoms
 Migratory RIF pain 1
 Anorexia 1
 Nausea & vomiting 1
Signs
 Pyrexia 1
 Tenderness RIF 1
 Rebound tenderness RIF 2
Lab investigations
 Leucocytosis 2
 left shift of neutrophil maturation 1

Total 10
 Diagnostic Scoring System [cont]
 Kalan et al [1994] omitted one lab parameter [left
shift of neutrophil maturation] which is not
routinely available in many laboratories, and
produced a modified score which have only one
lab findings
 A modified Alvarado score [1994] is based on three
symptoms, three signs and one laboratory findings
[total score of 9]
 MAS is commonly used
 Modified Alvarado Score [1994]
Features Score
Symptoms
Migratory RIF pain 1
Anorexia 1
Nausea & vomiting 1

Signs
Pyrexia 1
Tenderness RIF 1
Rebound tenderness RIF 2
Lab investigation 2
leucocytosis

Total 9
 MASS- interpretation
 A score of 1-4:[ discharging group] The diagnosis
of acute appendicitis is unlikely
 A score of 5-6: [observing group] Probable to have
appendicitis but not convincing to have urgent
appendicectomy
 A score of 7-9: [emergency group] Regarded as
probable to have acute appendicitis and needs
emergency appendicectomy
TREATMENT

 The treatment of appendicitis is appendicectomy

 Appendicectomy can be elective, emergency or
interval
 Two types of appendicectomy:-
 Conventional open appendicectomy
 Laparoscopic appendicectomy
Preoperative care
 Iv fluid
 Analgesics
 Preoperative antibiotics with broad spectrum
antibiotics
 Check Hb, blood grouping and crossmatching
 Shaving
 Written informed consent
 Pre-anaesthetic visit
 Intraoperative care

 Open appendicectomy
 Incisions
 Grid-iron sss
 Rurtherford Morrison’s
 Lanz’s [transverse skin crease]
 SUMI when the diagnosis is not clear
 Rt lower paramedian
 Midline incision
 Intraoperative care cont’d
 Appendiceal locations of the tip
 Retrocaecal appendix [70%]
 Pelvic appendix [25%]- the tip hangs in the pelvic brim
 Subcaecal appendix [2%]
 Splenic appendix [1%]- either pre- or post-ileal i.e anterior or
posterior to the terminal ileum
 Paracaecal appendix [1%]
 Paracolic appendix [1%]-either to the right or left of ascending
colon, the tip in the extraperitoneal tissue
 Location of the base-is constant, being found at
confluence of 3 taeniae coli of the caecum which fuse to
form the outer longitudinal muscle coat of the appendix
 Post operative care

 Iv fluids
 Analgesics
 Antibiotics
 Monitor-
 Vital signs
 Discharge home in 2-3 days postoperatively
 COMPLICATIONS

 Complications of acute appendicitis

 Postoperative complications
i. Complications of acute appendicitis

 Appendicular mass
 Appendicular abscess
 Recurrent appendicitis
 Perforation peritonitis
Treatment of complications

 Appendicular abscess
 Appendicular mass
 Peritonitis
 Recurrent appendicitis
 a.Appendicular mass

 Use conservative Ochsner-Sherren regime

 Iv fluid
 NGT
 Analgesics
 Antibiotics –parenteral
 Mark the limits of the mass on the abdominal wall
using a skin pencil
 Monitor- vital sign, size of the mass, input/output chart
 Clinical improvement is expected in 24-48 hours
Appendicular mass [cont]

 Criteria for stoping OSR

 Increased pulse rate
 Increasing or spreading abdominal pain
 Increasing the size of the mass
 Vomiting or increasing gastric contents
b.Appendicular Abscess

 I&D
 Antibiotics
c.Recurrent appendicitis

 Elective appendicectomy
 ii.Postoperative complications
 Wound infections
 Intrabdominal abscess
 Paralytic ileus
 Feacal fistula
 Adhesive intestinal obstruction
 Portal pyaemia due to septicemia in the portal venous
system
 Respiratory complications
 DVT embolism
 RIH due to damage to iliopogastric / ilioinguinal
nerves
 Incisional hernia