APPENDICITIS AND

PERITONITIS

PREPARED BY :
• SUGASHSHINI SIVASAMY, 2160705
• NURUL SYAZANA BINTI MOHD ZULMAJDI CHEE, 2160001
• NUR AINA ATHIRAH BINTI AZIZAN, 2160709
 Anatomy of appendix
• a narrow muscular tube containing a large amount of lymphoid tissue.
• Its length is variable and ranges from 3 to 5 inches.
• The base of the appendix is attached to the cecum below the ileocecal junction, while the remainder
of it is free.
• It has a complete peritoneal covering, which attaches to the mesentery of small intestine by a short
mesentery of its own, called the mesoappendix.
• All the appendicular vessels and nerves pass through the mesoappendix to reach it.
• The appendix lies in the right iliac fossa. It relation to anterior abdominal wall, its base is situated at
the McBurney’s point. This point lies one third of the way up the line joining the right anterior superior
iliac spine to the umbilicus.
• Inside the abdomen, during surgical processes, the base of the appendix is easily found by finding the
teniae coli of the cecum and tracing them to the base of the appendix, where they converge to form a
continuous longitudinal muscle coat.
Blood supply of appendix:
1. Arteries
• The appendix receives its blood supply from the appendicular artery, which is a branch of lower
division of he ileocolic artery. It passes behind the terminal ileum and reach the base of the
appendix through mesoappendix.

2. Veins
• The appendicular vein corresponds to the appendicular artery and drains blood from vermiform
appendix. It is located in the mesoappendix and accompanies the appendicular artery. The
appendicular vein drains into the ileocolic vein.
3. Lymph drainage of appendix
• The lymphatics drain into one or two intermediate nodes lying in the mesoappendix and then
eventually drain into the superior mesenteric lymph nodes.

4. Nerve supply to appendix:

• The parasympathetic and sympathetic nerves are derived from the superior mesenteric plexus. The
afferent (sensory) fibers, which are concerned with the conduction of visceral pain from the
appendix, accompany the sympathetic nerves and enter the spinal cord at the level of tenth
thoracic segment.
 Various position of appendix

1. Retrocaecal
2. Pelvic
3. Paracaecal
4. Subcaecal
5.Preileal
6.Postileal
Special features according to position of appendix
1. Retrocaecal
• Deep tenderness in loin.
• Abdominal pain induced by hyperextension of hip joint.
• Can irritate ureter and cause urinary symptoms.
2. Pelvic
• Deep tenderness just above and to right of pubic symphysis.
• Tenderness at retrovesical pouch / pouch of Douglas (PR examination).
• Early diarrhea due to inflamed appendix being in contact with rectum.
• Can irritate the bladder and cause hematuria.
3. Post Ileal
• Tenderness is ill defined.
• Pain may not be shifted.
 Causes
1. Obstruction of the narrow appendiceal lumen
• lymphoid hyperplasia
• fecaliths
• parasites
• foreign bodies
• Crohn's disease
• primary or metastatic cancer
• carcinoid syndrome
Lymphoid hyperplasia is more common in children and young adults, accounting for the
increased incidence of appendicitis in these age groups.
HOW TO DIAGNOSE ?
1. History
2. Physical examination
3. General blood and
urine analyses
4. Vaginal examination
for women
5. Rectal examination
for men.
Clinical signs and symptoms

• Pain shifting to right iliac fossa

• Anorexia
• Nausea
• Vomitting
• Diarrhea
• Fever
 History
• More common at young adults and teenagers despite the gender.
• Begin with poorly localized colicky abdominal pain.
• Pain frequently noticed in periumbilical region.
• After a few hours or a few days , pain shifted to the right iliac fossa and
severity of pain increase
• Unable to sleep due to the pain
• History of nausea and vomiting , sometime diarrhea
• History of fever after few hours of abdominal pain
 Physical
examination
General appearance
• look unwell with flushed cheeks
• Low-grade pyrexia
• High temperature suggest general peritonitis associated with a ruptured appendix
• Pulse rate elevated as infection spreads
Head and neck
• Coated tongue
• Distinctive fetor oris
Chest
• lung examination findings normal
• exclude any signs of a right-sided basal pneumonia ( causes abdominal pain )
 Abdomen examination
Inspection.
• slightly distended, usually looks normal.
• The right hip may be kept slightly flexed if the appendix is lying against the psoas
major muscle.
• Coughing and sudden movements cause pain if peritonitis has developed.

Palpation.
• The right iliac fossa is tender on superficial and deep palpation, and the
overlying muscles show guarding.
• The maximum site of tenderness at Mc Burney’s point (gentle palpation)
• Appendix is lying in an unusual position – causes high or low tenderness
• May be rebound tenderness in the right iliac fossa.
• Pressure on the left iliac fossa may cause pain in the right iliac fossa (Rovsing’s
sign).
Percussion.
• This causes pain if peritonitis is
present.
• Dullness on percussion
- suggest of an underlying mass

Auscultation.
• Bowel sounds are present
unless
perforation and general
peritonitis have caused a paralytic
ileus.
Signs to elicit in appendicitis
• Pointing sign
• Rovsing’s sign
• Psoas sign
• Obturator sign
 Differential diagnosis
Children Adult Adult female :
• Gastroenteritis • Ureteric colic • Pelvic inflammatory
• Mesenteric adenitis • Perforated peptic ulcer disease
• Meckel’s diverticulum • Torsion of testis • Mittelshmerz
• Intussuseption • Rectus sheath • Pyelonephritis
• Henoch Scholein Purpura hematoma • Torsion/hemorrhage
• Lobar pneumonia • Pancreatitis of ovarian cyst
• ileitis • Ectopic pregnancy

Elderly :
• Diverticulitis
• Intestinal obstruction
• Abdominal CA
 Investigations
Laboratory :
• Full Blood Count – Leucocytosis
• Urinalysis – TRO UTI
• Amylase – TRO pancreatitis
• Pregnancy test – TRO ectopic pregnancy

Radiological :
• Ultrasound of abdominal pelvis – TRO renal stone
• Diagnostic laparoscopy – confirmation investigation
INTERPRETATION :

>7 suggest appendicitis

4-6 suspicious appendicitis

<4 not appendicitis

TREATMENT
 NON-OPERATIVE MANAGEMENT
• Patients with uncomplicated appendicitis .
• Bowel rest + IV antibiotics
• metronidazole , 3rd gen cephalosporin , ertapenem (broad antimicrobial , single daily dose )
• 90% with successful outcome but 10% develop recurrent appendicitis within 1 year thus
require surgery .
• Conservative treatment may be considered in well patient with limited sign / high operative
risk patient .
• >40 yo should be followed up to ensure there is no malignancy .
 OPERATIVE MANAGEMENT
• Pre-op preparation : IV fluids + antibiotics .
• Appendicectomy : Perform under general anaesthetic with supine position using open /
laparoscopic .
• Laparoscopic ( advantageous ) : rate of wound infection is lower .
• Laparoscopic : Bladder must be empty .

CONVENTIONAL APPENDICECTOMY
• Gridiron incision :ASIS to umbilics (McBurney’s Point)
• Rutherford Morision incision : cut internal oblique & tranversus muscle (para/retrocaecal
appendix)
• Lanz incision : 2cm below umbilicus centered on mid-clavicular mid-inguinal line . (better
exposure/easily extend)
 PROBLEMS ENCOUNTERED DURING
APPENDICECTOMY
1. Normal appendix : terminal ileitis,Meckel’s diverticulitis,tubal/ovarian causes .
2. Appendix cannot be found : trace taenia coli
3. Appendicular tumor : small (appendicectomy) , large ( hemicolectomy)
4. Appendix abscess : percutaneous drainage+antibiotics
5. Appendicitis complicating Crohn’s disease : conservative tx , iv corticosteroid , systemic
antibiotic
6. Pelvic abscess : percutaneous drainage
 MANAGEMENT OF APPENDIX MASS
• Satisfactory condition : conservative Ochsner-Sherren regime .
• Inflammation is localized , surgery is difficult and may be dangerous , may be
impossible to find the appendix , faecal fistula may form .

• CRITERIA FOR STOPPING CONSERVATIVE TREATMENT :

1. Rising pulse rate
2. Increase / spreading abdominal pain
3. Increase size of mass
• Contrast-enhanced CT of abdomen , antibiotic therapy .
• Abscess drain radiologically .
• Temp , pulse rate , fluid balance recorded .
• Clinical deterioration / peritonitis > early laparotomy .
• Clinical improvement is evident within 24-48 H .
• Mass does not resolve should suspect ca / Crohn’s disease .
 POST-OPERATIVE COMPLICATIONS
• Uncommon
• Reflect degree of peritonitis during operation and intercurrent diseases .
• Checklist for unwell ptx following appendicectomy :
-examine wound & abdomen for abscess
-perform rectal examination for pelvic abscess
-examine lungs for pneumonitis/collapse
-examine legs for venous thrombosis
-examine conjuctivae for icteric tinge
-examine liver for enlargement
-examine urine for organism ( pyelonephritis )
-suspect subphrenic abscess
Icterus conjuctivae Venous thrombosis
1) WOUND INFECTION
• Most common post-op complication
• Present with pain , erythema of the wound on 4/5 day .
• TX : wound drainage + antibiotics .
• Gram –ve bacilli & anaerobic bacteria ( bacteroides sp. & streptococci)

2) INTRA-ABDOMINAL ABSCESS
• Spiking fever , malaise , anorexia 5-7 D after op .
• Interloop , paracolic , pelvic , subphrenic sites .
• Dx : ab ultrasonagraphy , CT scan
• Tx : Percutaneous drainage , laparotomy ( intra-abdominal sepsis )
3) ILEUS
• Fever ,ileus persist >5 days indicate itra-abdominal sepsis .
• Richter’s type of hernia may occur at laparoscopic port insertion and confused with post-op ileus .
• CT scan to confirm .

4) RESPIRATORY
• RARE , except with concurrent pulmonary disease
• Adequate post-op analgesia , physiotherapy reduce the incidence .

5)VENOUS THROMBOSIS & EMBOLISM

• RARE , except Elderly , women on oral contraceptive pills .
6)PORTAL PYAEMIA
• RARE ,SERIOUS
• High fever , rigors , jaundice
• Septicaemia in portal venous system , dev of intrahepatic abscess .
• TX : percutaneous drainage + systemic antibiotics .

7) FAECAL FISTULA
• Fistula may follow appendicectomy in Crohn’s disease .
• Leakage from appendicular stump (rare) , may occur if caecal wall is inflamed/oedema

8) ADHESIVE INTESTINAL OBSTRUCTION

• Most common late complication .
• Chronic pain in right iliac fossa .
• Laparoscopy to confirm and allow division .
 RECURRENT ACUTE APPENDICITIS
• RARE
• Arise due to incomplete self-limiting obstruction of appendix lumen .
• Attacks vary in intensity , occur every few months ,culminate in severe appendicitis .
• Appendix is thickened and fibrosis present (previous inflammation) .
PERITONITIS
1.Anatomy & definition
2.Causes of peritoneal inflammation
3.Clinical Features of peritonitis
4.Investigation needed to be done
5.Management of peritonitis
6.Specific Treatment of the cause
7.Prognosis & complications
 ANATOMY
Peritoneum
- peritoneal membrane divided into visceral and parietal
- Beneath the peritoneal tissue lies a network of lymphatics
- and rich plexuses of capillary blood where absorbtion and exudation occurs
- Helps in immune responds,visceral lubrications and fibrinolytic activities

Parietal peritonium -
- Closed in men but has two openings in female; uterine tube
- Rich with nerve supply, causes severe pain that is accurately localized

Visceral peritoneum
- poorly supplied with nerves
- cause vague pain and usually located to the midline

Peritonial cavity
- There is small volume of peritoneal fluid acting as an lubricant containing lymphocytes and leucocytes
- Large surface area which facilitates in infection spreading
• Peritonitis – is the acute or chronic peritoneal inflammation with
characteristic local and general changesin the organism and severe
dysfunction of vital organs
Causes of peritoneal inflammation
1. Bacterial, gastrointestinal and non-gastrointestinal
(appendicitis)
2. Chemical ( bile,barium)
3. Allergic (starch peritonitis)
4. Traumatic ( operative handling)
5. Ischaemia (strangulated bowel,vascular occlusion)
6. Miscellaneous( familial Mediterranean fever)
 Microorganism in peritonitis
Gastrointestinal source Other sources

Escherichia coli Chlamydia trachomatis

Streptococci Neisseria gonorrhoea
Staphylococcus Haemolytic streptococci
Bacteroides Streptococcus pneumonia
Clostridium Mycobacterium tuberculosis
Klebsiella pneumonia Fungal infections
 Peritoneal infection
(bacteria from GI tract)
bacteria from GI tract
• Gram –ve contain endotoxins in cell wall that have multiple effects on host
• Other bacteria produce harmful exotoxins
• Bacteriodes commonly found in peritonitis
Non-gastrointestinal causes of peritonitis
• Pelvic infection via fallopian tube is high causes of infections
• Microorganism involved(chlamydia and gonococcus)
• This organism caused thinning layer of cervical mucus,thus lead to bacteria
from vagina to enter
 Localised peritonitis
eg.appendicitis,cholecystitis
• Anatomical
Greater sac divide into
1. Subphrenic spaces
2. Pelvis
3. Peritoneal cavity
4. Supracolic and infracolic
• Pathological
Adhesions form around affected organ> inflamed peritoneum> flakes fibrin appear >loops of
intestines become adherent to each other>outpouring of serous inflammatory exudate
(become turbid),if localised become frank pus
• Surgical
Drains placed during operations-exogenous infection
Diffuse peritonitis
eg:sudden perforation
• Factors cause development of this
1. Spread of peritoneal contamination
2. Stimulation of peristalsis or water hinders localization
3. Virulence of infecting organism
4. Young child small omentum
5. Distruption of localized collections
6. Deficient immune deficiency
 Clinical Features
Localised peritonitis Diffuse (generalised) peritonitis
Initial symptoms : Early Late
• Abdominal pain
• Malaise
• Anorexia
• Nausea
Inflammed : • Abdominal pain is severe • Circulatory failure (cold
• Abdominal pain, worse on • Tenderness and and clammy
movent, coughing and deep generalised guarding extremities, sunken
respiration. • Infrequent bowel sound eyes, dry tongue,
• Temperature and pulse • Pulse and temperature thready pulse, drawn
increase rise & anxious face
• Guarding, rebound tenderness, (Hipprocrartic facies)
rigidity
The Hippocratic facies in
terminal diffuse
peritonitis
Diagnostic Aids
Bedside Imaging
• Urine dipstick (UTI) • CXR
• Supine radiograph of the abdomen
• ECG if doubt/cardiac history
• Multiplanar computed tomography (CT)
Bloods
• Ultrasound scanning
• Baseline U&E treatment Invasive
• FBC (WBC) • Aspiration
• Serum amylase (Pancreatitis)
Management
• General Care :
1. Correction of fluid loss and circulating volume
2. Urinary catheterisation +/- gastrointestinal
decompression
3. Antibiotic therapy
4. Analgesia
5. Vital system support
 Specific Treatment of the cause
• if cause is amenable to surgery,such as appendicitis or peptic
ulcer operation must be carrried out as soon as patient fit for
anaestasia
• if due to pancreatitis or primary peritonitis of streptococcol
or pneumococcal origin ,non-operative treatment is preferred
Prognosis & Complications
• Mortality rate is about 10% reflecting the degree and duration of
peritoneal contamination, age, fitness and nature of underlying causes.
• Complications :
Systemic Abdominal
Bacteremic/endotoxixc shock Paralytic ileus

Systemic inflammatory response Residual/recurrent

syndrome (SIRS) abscess/inflammatory mass

Multiorgan dysfuntion syndrome Portal pyaemia/liver abscess

(MODS)

Death Adhesional small bowel obstruction