ACUTE APPENDICITIS

OBJECTIVES
1. Introduction
2. Etiology
3. Pathophysiology
4. Clinical presentation
5. Physical Examination
6. Investigations
7. Differentials
8. Management
9. Complications

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APPENDICITIS

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 INTRODUCTION
• Acute appendicitis is an inflammation of the
vermiform appendix.

 Most common surgical emergency.

 Slightly more common in men.
 Incidence are falling
 1 in 6 of the population will have an appendectomy

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 ETIOLOGY
Luminal obstruction.
• Lymphoid hyperplasia 60%
(Lymphoid hyperplasia is a rapid increase in the number of
normal cells (called lymphocytes))
• Faecolith 35%.
• Inspissated (thickened) barium.
• Fruit seeds. }<4%
• Worms. < 1%
• Mucus accumulation
• Multiplication of bacteria.
( E.Coli, Bacteroids, peptostreptococcus,
Psuedomonas)
Extra-luminal obstruction e.g. Ca Cecum

Venous and lymphoid congestion and Impaired arterial flow,

thrombosis and gangrene.
Perforation may occur through devitalized tissue.
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Pathophysiology
The appendix fills with food and empties regularly
into the cecum. Because it empties inefficiently
and its lumen is small, the appendix is prone to
obstruction and is particularly vulnerable to
infection (i.e., appendicitis).

Once this obstruction occurs the appendix

subsequently becomes filled with mucus and
swells, Increasing pressures within the lumen and
the walls of the appendix, resulting in thrombosis
and occlusion of the small vessels, and stasis of
lymphatic flow

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 Clinical presentation
Atypical 45%
Only 55% have classical features.
History 24-36 hours
Location of McBurney's point (1), located two thirds the distance from the
umbilicus (2) to the anterior superior iliac spine (3).

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 ALVARADO SCORE
• It is based on a number of clinical and laboratory scoring systems to
assist diagnosis.
• Symptoms
• Migratory right iliac fossa pain 1 point
• Anorexia 1 point
• Nausea and Vomiting 1 point

• Signs
• Right iliac fossa tenderness 1 points
• Rebound tenderness 2 point
• Fever 1 point
• Laboratory
• Leucocytosis 2 points
• Shift to left (segmented neutrophils) 1 point
• Total score 10 points

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 PHYSICAL EXAMINATION

• 1. Pain localized in a right iliac area.

• In 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of
acute appendicitis. In 2-4 hours it migrates to the area of appendix (the Kocher’s
sign).
• 2. Single nausea and vomiting.
• 3. Fever to 37.5-380C.
• 5. Muscular tension in a right iliac area.
• Rovsing's sign - pain in right lower quadrant during palpation of left lower
quadrant
• Sitkovsky’s sign - increase of pain in a right iliac area when the patient lies on the
left side
• Bartomier’s sign - the increase of pain intensity during the palpation of right iliac
area when the patient lies on the left side.
• Dunphy's sign-increased pain with coughing
• .Vaginal examination for women.
• . Rectal examination for men WAA MICHAELNGOD 8
 INVESTIGATIONS
• White cell count: high sensitivity 96%, low specificity
• Urine analysis
• Plain X-ray, nonspecific
• Ultrasound highly sensitive (80-90%), excludes other
pathologies.
• Computer Tomography: More superior to USS in
diagnostic accuracy.
• Barium enema: Good accuracy, but technically
difficult and false positives are common.

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DDs ??

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 MANAGEMENT
 Preoperative
 Intra-Venous Infusion,
 analgesia,
 I.V antibiotics
 NPO
 Monitor the vitals
 Mass is marked to identify the progression and
regression

 appendicectomy is the definitive treatment

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 POST OPERATIVE
1. Check the vital signs
2. Check the abdominal signs and bowel movement
3. Check the wound
4. Advise on mobilization
5. In OPD:
1. Check wound
2. Check the Histology

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 COMPLICATIONS
Complications increase with perforation
• peritonitis
• Wound abscess,
• Wound infection (less with MacBurney’s incision),
• Wound dehiscence
• Intra-abdominal abscess,
• Faecal fistula,
• Intestinal obstruction,
• Adhesive band,
• inguinal hernia.
• Fertility

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THE END

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