Appendix

• An immunologic organ
– Secrete Ig; particularly IgA
• An integral component of GALT system
• Vermiform shape
 Appendix
• Derivate of the midgut
• The base is more medial
location (posteromedial wall
of the cecum) toward and
caudal to the ileocecal valve
 during both antenatal and
post natal development, the
growth rate of the cecum
exceeds that of the appendix
(unequal elongation of the
lateral wall of the cecum)
 Appendix
• The orifice is always at
the confluence of three
caecal taenia coll
converge at the junction
of the cecum with
appendix
Useful landmark to
identify the appendix
 Appendix
• The final location of the appendix is
determined by the location of the caecum
 The “normal” location of the appendix is
retrocecal but within the peritoneal cavity
(because the most inferior portion of the caecum is
within the peritoneal cavity), 65%
 Appendix
• The relationship of the base of the appendix to
the caecum remains constant, whereas the tip
can be found located in a variety of locations 
explains the myriad of symptoms, in the position:
– Retrocecal
– Pelvic
– Subcecal
– Preileal
– Right pericolic
 Incidence
• Lymphoid follicles in the submucosa gradually
increased through adolescence, then decrease
over time  peak incidence: late teens & 20s
The amount of lymphoid tissue increase throughout
puberty, remains steady for the next decade, and then
begins a steady decrease with age
After the age of 60 years, virtually no lymphoid tissue
remains within the appendix, and complete obliteration
of the appendiceal lumen is common
 Pathophysiology
Obstruction of the lumen is the dominant cause
• Fecalith
• Hypertrophy/swelling of the mucosal and
submucosal lymphoid tissue at the base of the
appendix
• Inspissated barium from previous x-ray studies
• Tumors
• Vegetable and fruit seeds
• Intestina parasites
 Pathophysiology
The proximal obstruction of the appendiceal lumen
A closed-loop obstruction

* Bacterial overgrowth
* Continued mucus secretion

* Distention of the lumen
* Increased intraluminal pressure

…..
 Pathophysiology
…..

 Stimulates nerve endings of visceral afferent stretch fibers,
producing visceral pain (vague, dull, diffuse pain) in the mid abdomen
or lower epigastrium
 Stimulates peristalsis  cramping
 Nausea and vomiting
 Pathophysiology
…..

Pressure in the organ increased

Lymphatic obstruction

Venous pressure is exceeded then obstructed

Capillaries and venules are occluded, arterial inflow continues

Engorgement and vascular congestion

…..
 Pathophysiology
…..

The inflammatory process soon involves the serosa of the appendix
and in turn parietal peritoneum; producing the characteristic shift in
pain to the right lower quadrant (i.e. somatic pain)


…..
 Pathophysiology
…..

As distention continue; arteriolar inflow occluded
Increase pressure in the appendiceal wall exceeds capillary pressure

*Elipsoidal infarcts (mucosal ischemia)
develop in the antimesenteric border,
the area with the poorest blood supply suffers most
*Integrity of mucosa compromised bacterial invasion

Acute inflammatory response ensues bacterial overgrowth
 edema

…..
 Pathophysiology
…..

The appendix becomes more edematous
 ischemic

Necrosis of the appendiceal wall
along with…
Translocation of bacteria through the ischemic wall

Perforation occurs
Usually through one of the infarcted areas on the antimesenteric borders
Perforation generally occurs just beyond the point of obstruction rather than at the tip
because of the effect of diameter on intraluminal tension

Gangrenous appendix
 Pathophysiology
Gangrenous appendix, without intervention

Will perforate

Spillage of the appendiceal contents into the peritoneal cavity
 Pathophysiology
If the sequence of events occurs slowly

The appendix is contained by the inflammatory response and the omentum
 
Localized peritonitis The body does not wall of the process
 
Appendiceal abscess Diffuse peritonitis
 Clinical Presentation
Appropriate sequence of symptoms:
Pain followed by nausea and vomiting with
fever and exaggerated local tenderness in the
position occupied by the appendix

(Murphy,
1905)
 Clinical Presentation Obstruction of
the appendiceal
lumen

The typical history/The classic pain sequence…

Generalized abdominal pain (crampy, dull, colicky, & intermittent) that difficult to localize
followed by anorexia and nausea

The pain then becomes most prominent diffusely centered in the lower epigastrium ,
moderately severe and is steady,
Transmural
sometimes with intermittent cramping superimposed inflammation of
the appendix
 leads to
inflammation of
Gradually moves toward the umbilicus the peritoneal
 lining of the RLQ
abdomen
After a period varying from 1-12 hours
Finally localizing in the right lower quadrant (sharp & constant pain)
Direct tenderness and muscle spasm in the right lower quadrant
Movement & Valsalva maneuver worsen the Pain

(the obstructed lumen of appendix cause
distention leads to the sensation of poorly
localized, usually periumbilical, crampy pain
via stimulation of the visceral afferent nerves)
(when the inflamed serosa contacts the
parietal peritoneum, the somatic nerves of the
peritoneum are stimulated and the previous
nonspecific pain becomes localized to the right
lower quadrant)
 Clinical Presentation
The process continues…
The amount of spasm increases
Muscular resistance to palpation of the abdominal wall roughly
parallels the severity of the inflammatory process
The appearance of rebound tenderness
The temperature is often mildly elevated/
low grade fever (38,30C)
Usually rises to higher levels in the event of perforation

Jadi urutan nyerinya…

nyeri tekan defans muskular nyeri lepas
 Clinical Presentation
Variation in the anatomic location of the appendix account for
many of the variations in the principal locus of the somatic phase
of the pain
• A long appendix with the inflamed tip in the left lower 
left lower quadrant pain
• A retrocecal appendix  right flank or back pain
• A pelvic appendix  suprapubic pain
• A retrocecal appendix  testicular pain
(presumably from irritation of the spermatic artery and ureter)
• Right upper quadrant pain
• Right-sided pelvic tenderness on rectal examination
 Clinical Presentation

The surgeon should systematically

examine the entire abdomen, starting
in the left upper quadrant away from
the patient’s described pain
 Clinical Presentation
Accompanied symptoms
• Anorexia
• Vomiting neural stimulation
the presence of ileus
neither prominent nor prolonged
only twice or once
If nausea and vomiting precede the pain, patients are
likely to have another cause for their abdominal pain, such
as GE
• Urinary or bowel frequency  appendiceal inflammation
irritating the adjacent bladder or rectum
 Clinical Presentation
The sequence of symptom
Anorexia
If the patient is not anorectic, the diagnosis of appendicitis should be questioned


Abdominal pain

Vomiting
If vomiting procedes the onset of pain, the diagnosis of appendicitis should be questioned
 Clinical Presentation
• RT dikerjakan bila pasien mengeluh nyeri perut tapi
saat kita periksa tidak ada NT Mc Burney
Karena bisa saja letak ujung appendiks di/
menuju rongga pelvis
Sehingga saat RT jari menekan peritoneum kavum
Douglaspasien mengeluh nyeri di suprapubik
rektum
 Clinical Presentation
• Right lower quadrant tenderness is THE MOST
consistent of all signs of acute appendicitis
• Its presence should always raise the specter of
appendicitis, even in the absence of other signs and
symptoms
 Clinical Presentation
Laboratory…
• Leucocytosis (12.000-18.000)
• Neutrophils  (“left shift”)
• Pyuria the proximity of the ureter to the inflamed appendix
 ureteral or baldder iritation as a result of an inflamed appendix
Clinical Presentation
 Physical Examination
Physical findings are determined principally by
The anatomic position of the inflamed
appendix
Whether the organ has already ruptured
when the patient is first examined
 Physical Examination
Rovsing’s sign
Elicited when pressure
applied in the left lower
quadrant reflects pain
in the right lower
quadrant
 Physical Examination
Psoas sign
Elicited by extension of
the right thigh with the
patient lying on the left
side, stretching of the
iliopsoas muscle
Pain suggests the
presence of an inflamed
appendix overlying the
psoas muscle
Indicates that the
inflamed appendix is
retrocaecal in orientation
 Physical Examination
Obturator sign/
Hypogastric pain
Elicited by passive
internal rotation of the
flexed right hip/thigh
with the patient in the
supine position, stretching
of the obturator internus
muscle
Indicates that the
inflamed appendix is
pelvic in orientation
 Imaging
Sonographic criteria
• Thickening of the appendiceal wall, 6 or 7 mm
• Noncompressible appendix of or greater in AP diameter
• The presence of an appendicolith
• Interruption of the continuity of the echogenic
submucosa
• Periappendiceal fluid or mass
• Increased echogenicity of the surrounding fat signifying
inflammation
• Loculated pericecal fluid
 Imaging
False-negative sonogram can occurs if:
• The appendicitis is confined to the appendiceal
tip
• Retrocecal location
• The appendix is markedly enlarged and
mistaken for small bowel
• The appendix is perforated and therefore
compressible
 Imaging
• Plain abdominal radiograph are neither
helpful nor cost effective and are not
recommended for the diagnosis of acute
appendicitis
• RLQ fecalith (appendocolith) was not
pathognomonic for acute appendicitis
 Differential Diagnosis
Depends upon 4 major factors:
• The anatomic location of the inflamed
appendix
• The stage of the process (i.e. simple or
ruptured)
• The patient’s age
• The patient’s sex
 Differential Diagnosis
(based on group of age)

Preschool children
• Intussusception
 Colicky-type pain
 < 3 y.o.
 Mass with no true peritonitis
• Meckel’s diverticulitis
 Pain localize to the periumbilical area
• Acute gastroenteritis
 Diarrhea
 Nausea
 Vomit
 Leukocytes in the stool
 No peritoneal signs
 Differential Diagnosis
(based on group of age)

School-age children
• Gastroenteritis
• Functional pain
• Constipation
• Omental infarction
Palpable mass
The pain does not migrate
 Differential Diagnosis
(based on group of age)

Adolescent boys and young adult men

• Chron’s disease
• Ulcerative colitis
• Epididimytis
 Differential Diagnosis
(based on group of age)

Adolescent Girls and young adult women

• PID
Onset in the lower abdomen
The pain is usually bilateral
Exacerbated on pelvic examination
• Ovarian cyst ruptured
torsion
No migration or changing symptoms
• UTI
 Differential Diagnosis
(based on group of age)

Eldery age group

• Malignancies GIT
reproductive system
• Diverticulitis
• Perforated ulcer
• Cholecystitis
Differential Diagnosis
 Differential Diagnosis
• Acute mesenteric adenitis
• Acute gastroenteritis viral
Salmonella
leucocyte count normal or 
Nausea and vomiting precede the abdominal pain
Diarrhea is a prominent symptoms
• Meckel’s diverticulitis
• Diseases of the male urogenital system
– Torsion of the testis
– Acute epididymitis
– Seminal vesiculitis
 Differential Diagnosis
• Intussusception
Children younger than age 2 years
A well-nourished infant
Suddenly doubled up by apparent colicky pain, between attacks
of pain the infant appears well, after several hours passes a
bloody mucoid stool
A sausage-shaped mass palpable in the right lower quadrant
• Crohn’s enteritis
Acutely inflamed distal ileum with no cecal involvement and a
normal appendix
Subacute course include fever
weight loss
pain
 Differential Diagnosis
• Colonic lesions
Should be considered in older patients
– Diverticulitis
Quicker progression to localized tenderness
Prodorme of an alteration in bowel habits
– Perforating carcinoma of
• The cecum
• That portion of the sigmoid that lies on the right side
• Appendicitis caused by a mass obstructing the appendiceal orifice
Guaiac-positive stools
Anemia
History of weight loss
 Differential Diagnosis
• Perforated peptic or duodenal ulcer, with fluid
tracking into the right paracolic gutter
• Yersiniosis
• Epiploic appedagitisinfarction of the colonic
appedage(s)torsion
 Differential Diagnosis
• Urinary tract infection; acute pyelonephritis (on the right side)
Chills
Right CVA tenderness
Pyuria
Bacteriuria
• Ureteral stone; if the calculus is lodged near the appendix
Pain referred to the labia
scrotum
penis
Hematuria
Absence of fever
leukocytosis
 Differential Diagnosis
• Primary peritonitis nephrotic syndrome
cirrhosis
endogenous/exogenous
immunosupression
• Henoch-Schönlein purpura
Beside abdominal pain, joints pain
purpura
nephritis
 Differential Diagnosis
• Foreign-body perforation of the bowel
• Closed-loop intestinal obstruction
• Mesenteric vascular occlusion
• Plueritis of the right lower chest
• Acute cholecystitis
• Acute pancreatitis
• Hematoma of the abdominal wall
 Differential Diagnosis
(Gynecologic Disorders)

• Pelvic inflammatory disease

Lower pain and tenderness
Pain of motion of the cervix
Purulent vaginal discharge
• Acute salpingitis
• Tubo-ovarian abscess
• Endometriosis
 Differential Diagnosis
(Gynecologic Disorders)

In women of childbearing years

Recent menstrual history
Pelvic examination
 Differential Diagnosis
(Gynecologic Disorders)

• Ruptured graafian follicle

Ovulation commonly results in the spillage of
sufficient amounts of blood and folicular fluid to
produce brief, mild, lower abdominal pain
Pain and tenderness are rather diffuse
Leukocytosis and fever are minimal or absent
Occurs at the midpoint of the menstrual cycle
(Mittel-Schmerz)
 Differential Diagnosis
(Gynecologic Disorders)

• Twisted ovarian cyst or tumor

rupture
torsion
Right lower quadrant pain, tenderness, rebound
Fever and leukocytosis
Palpable mass on vaginal exam
 Differential Diagnosis
(Gynecologic Disorders)

• Ruptured ectopic pregnancy

Abnormal menses
missing one or two periods
noting only slight vaginal bleeding
Pelvic mass
Elevated level of chorionic gonadotropin
Leukocyte counts rises slightly
Hematocrit level falls the intra-abdominal hemorrhage
Cervical motion and adnexal tenderness on vaginal
examination
The presence of blood and decidual tissue on culdocentesis
• Patients with a history, physical examination,
and laboratory studies classic for appendicitis
should undergo urgent appendectomy
• In those with an evaluation suggestive but not
convincing for appendicitis, further imaging is
indicated
– Pelvic US in women of childbearing age to
evaluate ovarian pathology
– Abdominopelvic CT to diagnosing other
intrabadominal pathology
 Appendiceal Ruptures
• Susceptible population:
– Children younger than age 5 years
– Patients older than age 65 years
Cannot express their symptoms
Delayed in presentation/present late in the course of their
disease
• Non operative treatment exposes the patient to the
increased morbidity and mortality associated with a
ruptured appendix
• Occurs most frequently distal to the point of luminal
obstruction along the antimesenteric border of the
appendix
 Appendiceal Ruptures
• Diminished inflammatory response:
– Less impressive  symptoms
 physical signs
– Longer duration of symptoms
– Decreased leukocytosis
 Appendiceal Ruptures
• Should be suspected in the presence of:
– 2 or more days of abdominal pain
The pain may be so severe that patients do not remember the
antecedent colicky pain
– Localized RLQ rebound tenderness  if the perforation has been
walled off by surrounding intra-abdominal structures including
the omentum
Generalized peritonitis if the walling-off process is ineffective in
containing the rupture
– High fever > 390C
– Rigors
– WBC > 18.000/mm3
– Poor oral intake
– Dehydration
 Periappendiceal Mass
• An ill-defined mass will be detected on
physical examination, this could represent a
phlegmon, consists of matted loops of bowel
adherent to the adjacent inflamed appendix,
or a periappendiceal abscess
• Have a longer duration of symptoms, usually
at least 5-7 days
When performing appendectomy,
if the appendicitis is not found
or normal appendix,
a methodical search for an alternative
diagnosis must be performed
• The cecum and mesentery should first be inspected
• Next, the small bowel is examined in a retrograde
fashion beginning at the ileocecal valve and extending
at least 2 feet
– Terminal ileum; terminal ileitis infectious causes
-Yersinia
-TB
Crohn’s disease
– Inflamed or perforated Meckel’s diverticulum
When performing appendectomy,
if the appendicitis is not found
or normal appendix,
a methodical search for an alternative
diagnosis must be performed
• In women, special attention should be paid to the
pelvic organs ovaries
fallopian tubes
uterus
• An attempts is also made to examine the upper
abdominal contents
• If purulent fluid is encountered, it is imperative
that the source be identified