Appendix

Joseph Angelo Kiat, MD

Medical Officer III, Surgery,
Veterans Memorial Medical Center
President, Philippine Association of General Surgery Residents Inc. - MMC
EMBRYOLOGY AND ANATOMY
1. With regard to the location of the appendix,
which of the following is true?
a. The base of the appendix can always be found at the
confluence of the cecal taenia.
b. In the majority of the cases, the tip of the appendix is
found in the pelvis
c. After the 5th gestational month of pregnancy, the
appendix shifted posteriorly and laterally by the
gravid uterus.
d. The position of the tip of the appendix in appendicitis
does not determine the symptoms of the patient.
• Appendix
– the development and preservation of gut-
associated lymphoid tissue (GALT);
– Maintenance of intestinal flora.
– Develops from the __________
– Appears at the 8th week of gestation.
• True diverticulum of the
cecum.
• Measurement: 6 to 9 cm
• Blood supply:
appendicular branch of
the ________________
• In pregnancy
– push superiorly and tip medially.
1. With regard to the location of the appendix,
which of the following is true?
a. The base of the appendix can always be found at the
confluence of the cecal taenia.
b. In the majority of the cases, the tip of the appendix is
found in the pelvis
c. After the 5th gestational month of pregnancy, the
appendix shifted posteriorly and laterally by the
gravid uterus.
d. The position of the tip of the appendix in appendicitis
does not determine the symptoms of the patient.
2. Which of the following regarding appendiceal
innervation is correct?
a. The innervation of the appendix is derived from both the
autonomic and somatic nervous systems.
b. In early appendicitis, the ANS is responsible for poorly
defined periumbilical pain
c. The somatic pain fibers are responsible for localization of
pain in the periumbilical region
d. Both autonomic and somatic nerve fibers follow a midgut
embryologic origin.
e. In the case of ruptured appendicitis, the somatic
innervation is disrupted and the patient is often rendered
pain free.
• Visceral innervation
– Derived from the Autonomic nervous system
(ANS), which follows a midgut embryologic origin.
– Occurs along the superior mesenteric plexus (T10-
L1) and the Vagus nerves.
– No somatic pain fibers are found.
– In early appendicitis, inflammation leads to poorly
localized pain that is referred to the periumbilical
region via the autonomic nerves.
• As the appendiceal inflammation worsens ->
irritation of the parietal peritoneum through
the somatic nerves.
• When it ruptures -> slight decrease in pain
ACUTE APPENDICITIS
3. Which of the following statements regarding the
pathogenesis of appendicitis is false?
a. The antimesenteric border has the poorest blood supply
and usually the site of perforation
b. Fecaliths are commonly responsible for appendicitis in
children
c. Viral and bacterial infections can preceed an episode of
appendicitis
d. Obstruction of the venous outflow and then arterial
inflow results in gangrene
e. Obstruction of the lumen may occur as a result of
lymphoid hyperplasia, inspissated stool or a foreign body.
 Increased in
Luminal Bacterial
intraluminal
Obstruction Overgrowth
pressure

Decreased Decreased
Bacterial
venous arterial
translocation
return inflow

Gangrene Perforation
4. What are the most common aerobic and
anaerobic bacteria isolated in perforated
appendicitis?
a. ________________________
b. ________________________
Which of the following statements regarding the
pathogenesis of appendicitis is false?
a. The antimesenteric border has the poorest blood supply
and usually the site of perforation - TRUE
b. Fecaliths are commonly responsible for appendicitis in
children – Lymphoid Hyperplasia
c. Viral and bacterial infections can preceed an episode of
appendicitis - TRUE
d. Obstruction of the venous outflow and then arterial
inflow results in gangrene - TRUE
e. Obstruction of the lumen may occur as a result of
lymphoid hyperplasia, inspissated stool or a foreign body.
- TRUE
 Salmonella, Shigella,
Infectious mononucleosis

can preceed appendicitis

 Clinical diagnosis
• Migratory pain
– Classic sign of appendicitis
• Inflammation can often result in:
– Anorexia
– Nausea / vomiting
– Fever
• Regional inflammation
– Ileus, small bowel obstruction, diarrhea, hematuria
Modified True or False:

5. Anorexia is fairly constant symptom, and the

diagnosis should be questioned if it is not
present.
6. Vomiting occurs in 95% of patients; typically it
precede pain.
Modified True or False:

5. Anorexia is fairly constant symptom, and the

diagnosis should be questioned if it is not
present. - TRUE
6. Vomiting occurs in 95% of patients; typically it
precede pain. - FALSE
7. Profuse and frequent vomiting with
abdominal pain: ________________________

8. Protracted diarrhea accompanied by

vomiting: ______________________________
 Physical Examination
• Warm to touch (low grade fever)
• (+) focal tenderness with guarding

9. In anatomically normal appendix, where is the

point of maximal tenderness?
_________________________________
McBurney’s point
 Physical Examination (10)
• Pain in the right lower A. Retrocecal
quadrant after release of B. Pelvic
gentle pressure on the left
lower quadrant C. Extraperitoneal
• Pain with coughing D. Ileal
• Pain with internal rotation E. In the LLQ
of the hip F. Peritoneal irritation
• Pain with flexion of the hip
• Pararectal/Paracervical
tenderness
 Admitting Impression: t/c Acute Appendicitis

11. What ancillaries will you request?

a. CBC
b. CRP
c. IL-6
d. Procalcitonin
e. Bilirubin
f. Urinalysis
g. CBC and urinalysis ONLY
ALVARADO SCORE
12. Upon assessment of a 28 year female, CP, who
came in due to RLQ pain, denies any migration of pain
(+) anorexia (-) nausea / vomiting, no fever episodes,
(-) dysuria/hematuria. On PE, abdomen is soft (+)
direct tenderness (-) rebound tenderness, RLQ. (-)
Rovsing’s (-) obturator (-) psoas (-) dunphy’s (-)
pararectal tenderness. CBC revealed leukocytosis.
Urinalysis is unremarkable. Which of the following
imaging studies is not a proved adjunct for the
diagnosis of appendicitis?
a. Abdominal obstructive xray series
b. Ultrasound
c. WAB CT Scan plain
d. Barium enema
e. Positron emission tomography
 Imaging
• To aid in the diagnosis of appendicitis
– A negative operation is acceptable in <10% of
male patients and in <20% of female patients.
– Reduces the rate of negative laparotomies
• Commonly used modalities
– Computed Tomography scan
– Ultrasound
– Magnetic Resonance Imaging
 CT Scan
• Sensitivity: 0.96 (95% CI 0.95-0.97)
• Specificity: 0.96 (95% CI 0.95-0.97)
• Positive predictive value: 85%
• Findings:
– Enlarged lumen and double wall thickness ( >
___mm)
– Thickened walls ( > ____ mm) target sign
– Periappendiceal fat stranding, fluid collection
– Appendicolith / fecalith
 Ultrasound
• Sensitivity: 0.85 (95% CI 0.70-0.90)
• Specificity: 0.90 (95% CI 0.83-0.95)
• To identify the anteroposterior diameter of the
appendix.
• Suggestive:
– Diameter > 6mm
– (+) pain with compression
– (+) appendicolith
– Increased echogenicity of the fat
– Periappendiceal fluid
CT vs US
 Magnetic Resonance Imaging
• Sensitivity: 0.95 (95% CI 0.88-0.98)
• Specificity: 0.92 (95% CI 0.87-0.95)
• More expensive
• Requires significant expertise
• Recommended in patients for whom the risk
of ionizing radiation outweighs the ease of
obtaining a contrast CT scan.
• Abdominal Xray • Barium Enema
Findings: – previously used
– Fecalith – Finding: partial filling of
– Ileus localized to RLQ the appendix
– Loss of peritoneal fat – About 10% of patients
strp – With equivocal findings
seen in about 40%
13. A 20 year old woman is operated on through
a right lower quadrant incision for presumed
appendicitis, but the appendix is normal. At this
point, as a surgeon, which of the following
would be an appropriate treatment?
a. Proceed with appendectomy if no other
pathology is found.
b. Exploration and treatment of any associated
pathologic condition, as indicated, without
appendectomy.
c. Exploration and diverticulectomy if a Meckel
diverticulum is present and is normal by
inspection and palpation
d. Exploration and, if no pathology is found,
closure without appendectomy.
e. Exploration and ileal resection if the terminal
ileum appears acutely inflamed
DIFFERENTIAL DIAGNOSIS
• Acute Mesenteric Adenitis
• Cecal Diverticulitis
• Meckel’s Diverticulitis
• Acute Ileitis
• Crohn’s disease
• Acute pelvic inflammatory disease
• Torsion of ovarian cyst or graffian follicle
• Acute gastroenteritis
 Acute Mesenteric Adenitis
• URTI precedes or is present at the onset of
diffuse abdominal pain.
• (+) Generalized lymphadenopathy or relatively
lymphocytosis
• Mesenteric lymph nodes examined via
histopathogy -> granuloma
• Tissue culture: Mycobacteria, Yersinia sp.
 Yersinia
Mesenteric adenitis
Ileitis
Colitis
Acute Appendicitis
 Acute Gastroenteritis
• Crampy abdominal pain followed by watery
stools, nausea and vomiting.
• Laboratory results: can be normal
• May request for stool culture
– Rule out bacterial infection
 Meckel Diverticulum
• If diverticulitis is present – RESECTION
• Asymptomatic and incidental finding during
laparotomy – SHOULD NOT BE necessarily
removed
 Epiploic Appendagitis
• Results from Infarction of the appendage
secondary to torsion.
• Pain is short-lived and well-localized
• Recovery is fairly rapid
• Patients do not appear ill
MANAGEMENT OF APPENDICITIS
Uncomplicated Appendicitis Complicated Appendicitis
• Appendectomy • Resuscitation
• Conservative Management • Surgery
• Antibiotics

14. What is the recommended approach to the surgical

management of acute appendicitis?
________________________________________________
15. Is antibiotic prophylaxis indicated for
uncomplicated appendicitis?
a. No, if immediate surgery will be performed.
b. Yes, to prevent surgical site infection for patients
who undergo appendectomy.
c. Yes, it is the standard modality.
d. No, since long-term implications of the
conservative strategy have not yet been
completely evaluated.
• Recommendation for prophylaxis in
uncomplicated appendicitis:
– Cefoxitin 2 grams IV single dose (Adults)
40 mg/kg IV single dose (children)
– Alternative:
• Ampicillin – Sulbactam 1.5 – 3 grams IV single dose
(Adults) 75 mg/kg IV single dose (children)
• Amoxicillin-clavulanate 1.2-2.4 grams IV single dose
(Adults) 45 mg/kg IV single dose (children)
• For patients allergic to beta-lactam
antibiotics:
– Gentamycin 80-120mg IV single dose plus
Clindamycin 600mg IV single dose (Adults)
– Gentamycin 2.5mg/kg IV single dose plus
Clindamycin 7.5-10mg/kg IV single dose (Children)
• Recommendation for prophylaxis in
complicated appendicitis:
– Adults: Ertapenem 1 gram IV q24hours
Tazobactam-pipearcillin 3.375 grams IV
q6h or 4.5 grams IV q8h
– (+) beta-lactam allergy:
• Ciprofloxacin 400 mg IV q12h plus Metronidazole 500
mg IV q6h
• Recommendation for prophylaxis in
complicated appendicitis:
– Pediatric: Ticarcillin-clavulanic acid 75 mg/kg IV
q6h
– Alternative:
• Imipenem-Cilastatin 15-25 mg/kg IV q6h
• For patients allergic to beta-lactam
antibiotics:
– Gentamycin 5mg/kg IV q24h plus Clindamycin
7.5-10mg/kg IV q6h (Children)
 Periappendiceal abscess
16. When is the optimal timing for surgery?
– As soon as the diagnosis is made. (EBCPG-PCS)
17. A patient suspected of having appendicitis
underwent exploration. Crohn’s disease was
found. Which of the following is true?
a. The normal appendix should always be
removed.
b. All grossly involved bowel, including the
appendix should be resected
c. An inflamed appendix, cecum and terminal
ileum should be resected.
d. Perforated bowel and advanced Crohn’s
disease with obstruction should be resected.
• If a normal appendix is found – EXPLORE and
other causes should be sought.
• If Crohn’s disease is encountered,
– Cecum and base of the appendix NORMAL: may
proceed with appendectomy
– If the base is involved, appendectomy should be
avoided
– (+) perforation or high grade obstruction, the
involved bowel should be resected.
 Negative Exploration
• No evidence of appendicitis -> thorough
EXPLORATION of the peritoneum must be
performed to rule out contributing pathology.
Management of Intraoperative Findings Mimicking Appendicitis
Ovarian Torsion
Crohn’s terminal ileitis
Meckel’s Diverticulitis
Appendiceal mass
Conservative management with
detorsion and oophoropexy
Appendectomy if base
uninflamed
Segmental bowel resection and
primary anastomosis
Laparoscopic aappendectomy /
ileocecectomy without capsular
disruption or spillage and
retrieval in a bag
 Incidental Appendectomy
• Children undergoing chemotherapy
• Compromised hosts with an unclear physical
exam
• Patients with Crohn’s disease with normal
cecum
• Traveling to remote places with no urgent care
• Patients undergoing cytoreductive operations
for ovarian malignancies.
SPECIAL CIRCUMSTANCES
 Appendicitis in Children
• Infants and young children – likely to present
with perforated appendicitis compared to
school-age children.
• May present with: abdominal distension and
lethargy (neonates)
• Differentials: Intussusception, AGE,
malrotation, pregnancy, mesenteric adenitis,
torsion of the omentum and ovarian /
testicular torsion
• Management: Laparoscopic appendectomy +
antibiotics
 Appendicitis in the Elderly
• More frequently presents with perforation
and abscess.
• Higher risk for complications
• Imaging
• Management: appendectomy
 Appendicitis in Pregnancy
• 1 in 800 – 1000 pregnancies.
• Mostly during 1st and 2nd trimester
• Can occur in the postpartum state in older
pregnancies
• May also present with heartburn, bowel
irregularity, flatulence or change in bowel
habits.
• Ultrasonography is preferred imaging modality
• MRI is an alternative
• CT Scan?

• Complication: risk of fetal loss

• Management: appendectomy vs. non-

operative management
 Chronic or Recurrent Appendicits
• Recurrent RLQ pain not associated with febrile
illness
• Imaging: Suggestive of an appendicolith or
dilated appendix
• Management: Appendectomy unless in the
absence of imaging abnormlities.
OUTCOMES AND POSTOPERATIVE
COURSE
 Stump Appendicitis
• Uncommon
• Incompletely excised appendiceal stump ( >
___cm stump length)
• Diagnosis is difficult.
• Management: Re-excision of appendiceal base
• “Appendiceal critical view”
• Prior appendectomy should not be an absolute
criterion in ruling out acute appendicitis
 Appendiceal Neoplasm
18. What type of appendiceal neoplasm are
predominantly encountered?
a. Adenocarcinoma
b. Mucinous neoplasm
c. GEP-NET
d. Squamous cell CA
 Gastroenteropancreatic neuroendocrine
tumors
• Formerly known as Carcinoids
• Submucosal rubbery masses
• Incidental
• Indolent but can develop nodal or hepatic
metastasis.
• Management:
– Tumors < 1 cm: a Negative margin appendectomy
is adequate
– Tumors < 2 cm or larger: Right hemicolectomy
– (+) Mesenteric invasion, enlarged nodes, or
positive or unclear margins: Right hemicolectomy
– Measure serum Chromogranin A
– Chemotherapy: 5FU and streptozocin
 Goblet Cell Carcinomas
• Both adenocarcinoma and neuroendocrine
features
• WORSE prognosis than carcinoids but BETTER
than adenocarcinoma
• High risk of peritoneal recurrence
• Surveillance of the peritoneum and a
peritoneal cancer index score
• Management: Right Hemicolectomy
 Lymphomas
• Rare (1-3& of lymphomas)
• Non-Hodgkin’s
• Appendiceal diameter: =/> 2.5 cm
• Management: Appendectomy, Chemotherapy
 Adenocarcinoma
• Mucinous adenocarcinoma
• Colonic adenocarcinoma
• Adenocarcinoid
• Presentation
– Acute appendicitis
– Ascites
– Palpable mass
– Incidental

Management: RIGHT HEMICOLECTOMY

Overall 5-year Survival: 55%
 Mucoceles and Mucinous
Neoplasm of the Appendix
• Mucocele
– Mucus-filled appendix
– Could be secondary to neoplastic or nonneoplastic
pathologies
– Incidental
– May present as appendicitis
– IMAGING: low attenuation, round, well
encapsulated cystic mass in the RLQ, wall
irregularity and soft tissue thickening
• NOTE:
– Assess for (+) ascites, peritoneal disease and scalloping of
the liver surface

MANAGEMENT: Excision of mucocele without capsular

disruption
- Homogenous cyst without nodularity or signs of
dissemination: Laparoscopic excision
- (-) mesenteric or peritoneal involvement: Appendectomy
with concurrent appendiceal lymphadenectomy
– (+) peritoneal seeding – obtain Biopsies

– SUBOPTIMAL debulking is discouraged

 Pseudomyxoma Peritonei Syndrome

• (+) appendiceal mucinous neoplasm develop

peritoneal dissemination.
• May occur in gastric, ovarian, pancreatic and
colorectal primary tumors as weel
• MANAGEMENT: cytoreductive surgery and
Hyperthermic intraperitoneal chemotherapy
(HIPEC)
• SURGERY:
– Parietal and visceral peritonectomies
– Intraperitoneal administration of heated
chemotherapy
THANK YOU.