University of Guyana

Faculty of Health Sciences

School of Medicine

Appendicitis
Anetha Jodhan
Ravindra Singh

MED 1201 – Descriptive Anatomy II

Lecturer: Dr. Roberta R. Martin
16/04/18
Outline
I. Introduction IV. Diagnosis
I. Appendix V. Treatment
II. Appendicitis VI. Complications
II. Etiology VII. Prognosis
III. Clinical Presentations VIII. References
Appendix
• Hollow, muscular, closed-
ended tube
• 2-20cm (avg 10cm) in length

• Arises from the posteromedial

cecum about 3cm from the
ileocecal valve

• Unclear function
Appendix: Locations and Positions
Arterial Supply
Appendicular artery

Origin: Ileocecal artery

Course: Passes between

layers of the mesoappendix

Distribution: Appendix
Venous Drainage

Appendicular Vein, drains

into Ileocolic vein
Tributary of Superior
Mesenteric Vein
Lymphatic Drainage
Lymph nodes in the meso-
appendix and to the Ileocolic
lymph nodes that lie along the
Ileocolic artery

Efferent lymphatic vessels

pass to the superior
mesenteric lymph nodes
Innervation
Sympathetic and parasympathetic
nerves from the Superior
Mesenteric Plexus.

Sympathetic: Lesser thoracic spinal

cord
Parasympathetic: Vagus Nerves

Afferent fibers from appendix

accompany sympathetic nerves to
T10 segment of spinal cord
Appendicitis
Appendicolith Inflammation of
Stone, Tumor Appexdix; most
Enlarged LN common cause of
Foreign body abdominal pain

Obstructed
Appendix Appendicitis
lumen
Etiology
• Obstruction of appendicular lumen
• Fecalith, Undigested seeds, Pinworm infections, Tumors, Lymphoid
hyperplasia

• Mucous secreted by lumen builds up due to obstruction causing an

increase in pressure and swelling of the appendix which presses on
nearby nerve fibers and abdominal pain is felt.

• Bacteria naturally present in the gut are trapped and begin to

multiply which triggers and immune response causing pus to
accumulate in the appendix.
Acute Vs Chronic

• Acute: most common and fast

developing
• Most common surgical emergency; 10%
population develops

• Chronic: Rare and slow developing

Epidemiology

• 7% will develop appendicitis at some point

in lifetime (1 in 10)

• Men> women

• Young> old
Symptoms
Diagnosis
• Localization of pain; right lower
quadrant
• Begins peri-umbilical

• McBurney’s point: 2cm from the

anterior superior iliac spine
• Pain in other locations? - location of
appendix

• Significant increase in pain may be

Differential Diagnosis
GI Pathology GU Pathology

Merkel’s Diverticulum
Meckel’s Diverticulum Ectopic
Ectopic Pregnancy
Pregnancy
Epiploic
Epiploic appendagitis
appendagitis PID
PID
Crohn’s
Crohn’s flare
flare Pyelonephritis
Pyelonephritis
Intussusception
Intussusception Ovarian
Ovarian Torsion
Torsion or
or cyst
cyst
Volvulus
Volvulus Renal
Renal Colic
Colic
Special Exam Maneuvers
Rebound or
Obturator
Rosving’s Sign Psoas Sign Involuntary
Sign
guarding
Abdominal
pain w/
extension of
Pain w/ right hip
Pain on right
internal or Peritoneal
w/ palpitation
external sign
on left
rotation of hip Assess for
guarding and
rebound
Special Exam Maneuvers
Obturator
Sign
Pain w/
internal
or
external
rotation
of hip
Special Exam Maneuvers
Psoas
Sign
Abdominal
pain w/
extension of
right hip

Assess for
guarding and
rebound
tenderness
Special Exam Maneuvers
Blumberg’
s Sign
Rebound
or
involuntary
guarding

Peritoneal
sign
Laboratory Tests
Elevated White blood cell count (>10,000-12,000/mm²)
Elevated C-reactive protein (>8-10 mg/L)
• non-specific systemic inflammatory marker. Predict
severity

Consider imaging:
• Ultrasound
• Magnetic Resonance Imaging
• CT Scan
Ultrasound Non-compressible,
dilated appendix;
fecalith
6-7 mm
Benefits

No ionizing radiation Lower specificity

exposure Operator dependent
Rapid diagnosis Obese body habitus
Cheap Pain
Readily available Overlying bowel gas

Downsides
Imaging for Pediatric Patient

• Ultrasound is better imaging modality for children

• There is a lower incidence of obesity

• A higher risk is associated with radiation exposure

CT Scans 1. Enlarged appendiceal
diameter with wall
thickening
2. Appendicolith
Benefits

3. Fat Stranding
Test of choice for Ionizing radiation
non-pregnant exposure
patients
Greater sensitivity
and specificity
Help find alternative

Downsides
Dx
 1. Enlarged
MRI appendiceal
diameter with wall
IV gadolinium harmful to fetus thickening
2. Signs of
Benefits

inflammation
Pregnant Cost adjacent to the
females Lack of appendix
Non-ionizing availability
radiation

Downsides
Alvarado Score (MANTRELS) Paediatric Appendicitis Score
Diagnostic criteria Value Diagnostic criteria Value
Migrating pain to RLQ 1 Migrating pain to RLQ 1

Anorexia/ acetone in urine 1 Anorexia 1

Nausea – Vomitting 1 Nausea/ emesis 1

Tnderness in RLQ 2 Tenderness in RLQ 2
Rebound Pain 1 Cough/ percussion tenderness 2

Temperature >= 37.3 C 1 Pyrexia (not defined) 1

Leucocytosis (>1-x103/L) 2 Leucocytosis (>10x103/L) 1
Leucocyte shift to left (>75%) 1 Neutrophilia 1

Total Score 10 Total Score 10

Treatment Surgery

• Laparoscopic VS. Open

Antibiotics
surgical Treatment
• less invasive and faster
• GN and Anaerobic Coverage recover times/ better
outcomes
• Ertapenem
• Non-perforated:
• Ciprofloxacin + Metronidzole OR Supportive Care
Ampicillin-Sulbactam
• NPO
• Perforated: • IV Fluids
• Piperacillin-tazobactam OR Cefepime
• Pain Control - Opiods
Treatment
Prognosis
• Prognosis is generally good

• If imaging negative or inconclusive but patient is still

symptomatic
• Consider admission to observation unit for serial
abdominal examinations

• Provide patient with return precautions on discharge

Case 1
• A young man sought medical care
because of central abdominal pain that
was diffuse and colicky. After some
hours, the pain began to localize in the
right iliac fossa and became constant. He
was referred to an abdominal surgeon,
who removed a grossly inflamed
appendix. The patient made an
uneventful recovery.
References
Text Books:
1. Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. Lippincott Williams & Wilkins; 2013 Feb 13.
2. Drake R, Vogl AW, Mitchell AW. Gray's Anatomy for Students E-Book. Elsevier Health Sciences; 2009 Apr 4.
3. Netter FH. Atlas of Human Anatomy, Elsevier Health Sciences; 2014 May 20.
4. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2017.

Journals:
5. Petroianu A. Diagnosis of acute appendicitis. International Journal of Surgery. 2012 Jan 1;10(3):115-9.
6. Mostbeck G, Adam EJ, Nielsen MB, Claudon M, Clevert D, Nicolau C, Nyhsen C, Owens CM. How to diagnose acute
appendicitis: ultrasound first. Insights into imaging. 2016 Apr 1;7(2):255-63.

Websites:
7. Kenhub. (2018). Appendicitis. [online] Available at: https://www.kenhub.com/en/library/anatomy/appendicitis [Accessed 06
Mar. 2018].
8. TeachMeAnatomy. (2018). The Cecum and Appendix. [online] Available at:
http://teachmeanatomy.info/abdomen/gi-tract/cecum-appendix/ [Accessed 06 Mar. 2018].
9. Alvarado Score for Acute Appendicitis - MDCalc [Internet]. Mdcalc.com. 2018 [cited 30 April 2018]. Available from:
https://www.mdcalc.com/alvarado-score-acute-appendicitis
10. MANTRELS score of 10 [Internet]. Emergency Diagnostic Radiology. 2018 [cited 30 April 2018]. Available from:
https://emergencyradiology.wordpress.com/2009/02/05/mantrels-score-of-10/
Surgery Videos
Ruptured Appendicitis
https://www.youtube.com/watch?v=VrvOhM9euns
https://www.youtube.com/watch?v=VrvOhM9euns
Open Appendectomy
https://www.youtube.com/watch?v=zPP8sy1C6-4

Laparoscopic Appendectomy
https://www.youtube.com/watch?v=Qx2GtOdObB4