Overview of the appendix, its clinical

significance
and acute appendicitis

Prepared by Dr. Robert Bancod

Associate Professor
 Appendix
Abstract:
Background: The vermiform appendix now referred to as the appendix is a true
diverticulum of the colon, a wormlike extension of the cecum that arises from
the posteromedial wall, about 2 cm below the ileocecal junction. The appendix,
therefore, may act as a “safe house” for beneficial bacteria. Acute appendicitis
is a common condition that almost always requires emergency surgery
however, in early acute appendicitis, antibiotics are the option. Its decision to
operate is based on clinical findings which specifically involved the parietal
peritoneum. The regular re-assessment of patients and making use of the
investigative options available will meet the standard of care expected by
patients with early acute appendicitis and acute appendicitis. The diagnosis is
clearer when the patient presents with classic symptoms. However, if the
presentation is atypical due to variations in the position and length of the
 Appendix
Methods:
Review and synthesis of pertinent literature and guidelines pertaining
to clinical appendix and acute appendicitis
CASE REPORT 1
A 23-year-old male presented with complaints of pain in the right upper quadrant with a few episodes
of vomiting, mild fever, and bowel symptoms for 2 days. The pain was moderate in intensity, non-
radiating and continuous with minimal associated bowel and urinary symptoms. Pain was mainly
aggravated by standing or coughing. There was no history of other chronic abdominal pain, fever or loss
of appetite, dyspeptic symptoms, or renal colic.
On clinical examination, there was tenderness in rt. upper quadrant and minimal tenderness in other
abdominal sites. A mild increase in temperature was noted in the same quadrant with sluggish bowel
sounds. No significant tenderness was there at Mc Burney’s point with negative Blumberg’s sign. The
rest of the examinations were essentially normal.
His routine investigations were within normal range except for raised total leucocyte count. All blood
serology reports were negative. Ultrasonography revealed a small collection with an echogenic
comment in the right iliac fossa with tail artifact noted in the upper limits of the right.
After confirming the diagnosis, the patient was taken for surgery. Informed consent, including risk,
benefit, and alternatives given to the patient and family & documented. Open appendectomy through
Mc Burney’s incision was planned, on exploration after extending the Gridiron incision appendix was
found near the inferior border of the liver in the posterior abdominal wall with pulled up caecum with
empty right iliac fossa. The appendectomy was done and the abdominal drain was kept in situ. The
specimen was sent for histopathological examination which reveals acute inflammation of the appendix.
The patient recovered well and was discharged with no untoward complications after surgery.
 CASE REPORT 2
A previously healthy 28-year-old woman presents to the emergency department
with a 2-day history of abdominal pain that began in the umbilical area and
migrated to the right lower abdomen. She is a single mother who works remotely
and is raising a 5-year-old child. Her temperature is 37.8°C; other vital signs are
normal. She rates her pain at 7 on a scale of 1 to 10, with 10 representing the
worst possible pain. Examination reveals tenderness in the right lower quadrant,
with a moderate localized rebound. The result of a pregnancy test is negative, as
is the result of a polymerase-chain-reaction assay for severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2). Her white cell count is 12,500 per cubic
millimeter. Computed tomography (CT) performed after the intravenous
administration of contrast material shows a dilated, inflamed appendix with
appendicolith.
Introduction:
Appendix
Appendix
• wormlike extension of the cecum
• arises from the posteromedial wall of
the cecum
• Tip of the anterior taenia coli
(Taenia libera)
• About 2cm below the ileocecal
junction
• It is supported by the mesoappendix,
a fold of mesentery which suspends
the appendix from the terminal ileum
• Pelvic position is the normal position
of the appendix and is the most
frequently seen female population.
 Appendix
Location
• Lies at the junction of the
lateral 1/3 and medial 2/3
of the line joining the right
anterior superior iliac spine
to the umbilicus, this is
called Mc Burney’s point
• The anterior cutaneous
branch of the
iliohypogastric nerve is
found also near McBurney’s
point
 Appendix
The component parts of the
appendix are the base, body,
and tip. BASE
• The base is attached to the
posteromedial wall of the
cecum.
BODY
• The body is narrow and
tubular just between the base
and the tip is the least vascular
distal and blind end of the
appendix which is a common TIP
area of ruptured appendicitis.
 Appendix
The length of the
appendix:
• Normal appendix
length is between 6
and 9 cm
• Normal appendix width
is between 5.6 and 6.6
mm
 Appendix
Position
 Firstly, the Retrocecal position is also called the 11 to 12 0’clock position.
It is the commonest type and is seen in approximately greater than 60% of
cases.
 Secondly, the Paracolic position which is also called the 10 0’clock
position. The appendix lies below the cecum and the tip ascends on the
right side of the ascending colon; it is seen in about 2% of cases.
 Splenic or preileal position which is the 2 0’clock position. Here appendix
tip passes upwards and medially in front of the terminal part of the ileum or
behind the terminal part of the ileum.
 Sub-ileal position is also called the 3 0’clock position. Here the appendix
tip is directly horizontal towards the sacral promontory.
 Pelvic position, which is the 4 0’clock position and is the second
commonest position. Here the appendix tip passes downwards and medially
and crosses the pelvic brim to enter the pelvis.
 Lastly mid inguinal, also known as the 6 0’clock positions. The appendix
tip here passes vertically downwards below the cecum and is pointed
towards the inguinal ligament.
 Appendix
Neurovascular supply
• The appendix is supplied by the
appendicular artery which is
the branch of the inferior
division of the ileocolic artery
• The sympathetic branch of
the vagus nerve and
parasympathetic branch of
the ileocolic branch of the
superior mesenteric plexus
innervate the appendix.
 Appendix
Venous drainage
• Appendicular vein
↓
• Ileocolic vein
↓
• Portal vein
 Appendix
Lymphatic drainage:
• lymphatic fluid from the
appendix drains into lymph
nodes within the
mesoappendix and into
the ileocolic lymph nodes
which surround the
ileocolic artery.
 Appendix
Normal histology
• Appendix wall is composed of the
same layers as the colon:
• Mucosa
• Muscularis mucosa

• Submucosa (Germinal center)

• Muscularis Externa
• Serosa/subserosa
• Can see in figure 1 a prominent
appendicular lymphoid hyperplasia
• Especially in younger persons
• In the older age group having
submucous fibrosis appendicitis
 Appendicitis
Inflammation of the appendix
known as appendicitis
The broad category of Appendicitis
is based on signs and symptoms
and diagnostic modalities:
• Uncomplicated appendicitis
• Early Acute appendicitis
• Typical or classical appendicitis
• Atypical appendicitis
• Acute Appendicitis
• Complicated Appendicitis
• Recurrent appendicitis
• Chronic appendicitis
Etiology
• In the young, it is mostly due Appendicitis
to an increase in lymphoid
tissue size (lymphoid
hyperplasia), which occludes
the lumen
• From 20 years old onwards, it
is more likely to be blocked
due to a faecolith, parasitic
infection, bacterial infection,
Inflammatory bowel disease,
viruses, and neoplasm.
• Organism
• Gram Negative and Anaerobic
Bacteria
 Appendix
High Risk:
• Young age
• Elderly
• Pregnancy
 Appendicitis
Pathogenesis of Appendicitis

Fecalith
If symptoms and signs persist within 24 hours
1. Early typical or classical appendicitis.
• Sudden pain that begins around your navel for
about 4-6 hours and often shifts to the lower
Appendicitis
right abdomen after 24 hours
• Pointing sign – asking the patient to point to
where the pain started and where it has moved to
which usually starts at the Periumbilical region
and moves to the right lower abdomen
• Pain worsens if the patient cough, walks, or
makes other jarring movements.
• Loss of appetite
• Nausea and Vomiting
• Low-grade fever
2. Early atypical acute appendicitis
• Abdominal bloating
• Diarrhea or constipation occurs in 10-20%
• Flatulence
• Body malaise - generalized feeling of being
unwell
• Renal colic
• Urinary frequency- feeling like urinating often
and more quickly
Morphology of mucosal appendicitis
• If signs may be seen 24 to 48 hours.

Appendicitis
• This is the stage of Acute appendicitis.
• Major cause: Localized irritation in the lining of
parietal peritoneum at RLQ
• As the appendix swell, it irritates the parietal
peritoneum which produces positive sign findings:
• McBurney sign guarding and tenderness
• Rovsing sign (RLQ pain with palpation of the LLQ):
Suggests peritoneal irritation
• Obturator sign (RLQ pain with internal and
external rotation of the flexed right hip): Suggests
the inflamed appendix is located deep in the right
hemipelvis
• Psoas sign (RLQ pain with extension of the right
hip or with flexion of the right hip against
resistance): Suggests that an inflamed appendix is
located along the course of the right psoas muscle
• Blumberg sign signed rebound tenderness at RLQ
• Dunphy sign (sharp pain in the RLQ elicited by a
voluntary cough): Suggests localized peritonitis
• Hyperesthesia within Sherren Triangle
• Markle sign - having a patient stand on his or her
toes and suddenly drop down onto the heels with
an audible thump
Morphology of Suppurative appendicitis
 Appendicitis
• If signs persisted on the 3rd day and
beyond.
• This is the stage of Complicated
appendicitis.
• Major cause: Generalized irritation in the lining of
the parietal peritoneum all over the abdomen
(Peritonitis)
• Sign and symptoms
Morphology of Complicated appendicitis:
• Gangrene appendicitis
• Perforation appendicitis
• Appendicular abscess
• Appendicular mass
• Carcinoid appendicitis
• Mucocele appendicitis
TIMELINE of APPENDICITIS
1st Day or 24 Hours
• Typical Appendicitis – Pain around the navel or umbilicus associated with loss of appetite, nausea, vomiting, and low-
grade fever. The pointing sign is a pathognomonic feature.
• Atypical Appendicitis – right lower quadrant associated with diarrhea, abdominal bloating, constipation, flatulence,
body malaise, and urinary frequency.
• Reclinical examination and observation
• Morphology seen are mucosal appendicitis and Submucous fibrosis appendicitisPreclinical

2nd Day or 48 Hours

• Full-blown appendicitis – involved irritation of parietal peritoneum at right lower quadrant
• Physical examination: McBurney point, Rovsing sign. Obturator sign, Psoas sign, Blumberg sign, Dunphy sign,
Hyperesthesia, and Markle sign
• Morphology: grossly the appendix is swollen and the serosa will be dull and may be covered by exudates
(Suppurative appendicitis or phlegmonous appendicitis).

3rd Day or 72 Hours

• Complicated appendicitis – involved generalized irritation in the lining of the parietal peritoneum
• The sign and symptoms are increased pulse, increased blood pressure, high-grade fever, decreased bowel sound,
board-like abdomen, abdominal distension, and increased WBC
• Morphology of complicated appendicitis: Gangrene appendicitis, perforation appendicitis, appendicular abscess,
carcinoid appendicitis, and mucocele appendicitis.
 Differential Diagnosis
• Mesenteric adenitis
• Parasitism
• Pelvic inflammatory disease
• Mittelschmerz
• Ovarian cyst
• Ectopic gestation
• Curtiz-Hugh syndrome
• Crohn disease
• Enterocolitis
• Carcinomas
• Lymphomas
• Tuberculosis
 Acute Appendicitis
Investigations
• Complete blood count
• White blood cell count, which
points to an infection
• WBC count greater than
10,500 cells/µL.
Neutrophilia greater than
75% occurs in 78% of
patients.
• CRP levels >1 mg/dL are
common in patients with
appendicitis
 Appendicitis
Alvarado Scoring
 Acute Appendicitis
Confirmation test
• Ultrasound scan
• Abdominal CT scan
• MRI
• Laparoscopy
 Appendicitis
Treatment:
Early Typical Appendicitis/atypical appendicitis
• Establish IV access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration.
• Nil by Mouth
• Administer parenteral analgesic and antiemetic as needed for patient comfort
• Antibiotics
 Antibiotic prophylaxis should be administered
 Preoperative antibiotics should be administered
 Broad-spectrum gram-negative and anaerobic coverage is indicated
 Cefotetan and cefoxitin seem to be the best choices of antibiotics
 In penicillin-allergic patients, carbapenems are a good option
 Appendicitis
Treatment of Acute appendicitis
• WE should establish IV access
• Administer aggressive crystalloid therapy like normal saline to correct
dehydration.
• Patient should be nil by mouth.
• Administer parental analgesia like morphine and antiemetics like
promethazine.
• Give intravenous antibiotics
• Do appendectomy within 36 hours from symptom onset when the patient
presented at the hospital.
 Appendicitis
Treatment of complicated appendicitis depends on the age group
• The young and elderly appendicular rupture should be immediate
laparotomy thru midline incision
• The young adult age group who has appendicular mass, and
appendicular abscess should approach in conservative Ochsner-
Sherren regimen
 Acute Appendicitis
Different types of incision
• McBurney incision or Gridiron incision
• The incision is made through this point oblique
to this line (McBurney-McArthur). The incision
extends 3-5 cm along skin creases.
• Lanz or Langer’s incision
• The incision is made through this point
horizontal to this line (McBurney-McArthur). The
incision extends 3-5 cm along skin creases
• Rockey-Davis incision
• Skin incision is based on the McBurney point which
is oriented transversely allowing for better
cosmetics
• Fowler-weir extension medially
• Rutherford Morrison incision laterally
• Mid-line incision or vertical incision
• Transverse Incision (newborn and infants)
 Appendiceal Rupture
• Appendiceal rupture occurs most
frequently distal to the point of luminal
obstruction along the antimesenteric
border of the appendix
• the risk of rupture rises 48–72
hours after symptoms begin
• Presence of muscle guarding and
rebound tenderness of the abdomen
• Rupture in the presence of fever and
WBC>18,00 cells/mm3
• Chest X-ray
• Presence of pneumoperitoneum
• Treatment
• Laparotomy
 Appendicular abscess
Appendicular abscess
• It is a collection of pus resulting from necrosis
of the tissue superimposed with infection in an
inflamed appendix
 Appendicular abscesses can arise either in the
peritoneal cavity or the retroperitoneal space. 
 The collection often contains air, not infrequently
(~50 %) a fecalith, and is surrounded by inflamed
non-compres­sible fatty tissue. 
 The latter not only represents the omentum
(“policeman of the belly”) but also the fatty epiploic
appendages and fatty mesentery. 
• Together with neighboring bowel loops, this
represents the -often successful- walling-off of
the appendiceal abscess in an attempt to
prevent the spill of pus to the peritoneal cavi­ty
 Appendicular abscess

Treatment of Appendiceal Abscess

• Percutaneous aspiration or Drain placement if signs
and symptoms are deteriorating.
• Intravenous antibiotics are continued until the
patient
• Afebrile
• Return to normal gastrointestinal function
• Normal WBC count with a normal differential count
• At this time, patients are switched to oral
antibiotics for a total antibiotic course of 10-14 days
• Interval appendectomy is performed 6-8 weeks
later.
.
 Appendicular mass
• An appendiceal mass is an
inflammatory tumor consisting of the
inflamed appendix, its adjacent
viscera-like bowel loops including the
edematous cecal wall and ileum, and
the greater omentum
• Can felt a mass be characterized as
tender, smooth, firm, and not mobile in
the right iliac fossa
• Treatment
• Conservative Ochsner-Sherren regimen
 Gangrenous Appendicitis
Gangrenous Appendicitis
• Is characterized by destructive
changes to the entire wall of the
appendix
• Appendix is thickened, earthy-grey,
with purulent and fiber-like
depositions
• Its wall is flabby and can be easily
perforated
• Parietal peritoneum is often
edematous, infiltrated, and covered
by fibrin
• Treatment is Appendectomy
 Appendicitis
Postoperative Complication
• Bowel obstruction (generalized
ileus)
• Wound infection/dehiscence
• Intraperitoneal Abscess
Summary
The appendix is a wormlike structure protruding from the caecal wall. Its purpose in
the young age group as an immune system while in the older age group they become
a vestigial organ. The human appendix is usually 5.6 - 6.6 mm in diameter and length
between 6 and 9 cm. It has variant positions attached with different signs and
symptoms. Appendicitis is the common surgical abdomen and the incidence is more
among males than females and seen in young adults than the elderly. The most
common appendicitis caused is due to obstruction of fecalith. Uncomplicated
appendicitis and complicated appendicitis are the main classifications based on signs
and symptoms and diagnostic modalities however recurrent appendicitis and chronic
appendicitis can be added too. Differentiating acute appendicitis from other causes
of abdominal pain requires careful diagnostic examination. Critical phasing of
appendicitis will give us a way in assessing diagnosis and the right approach to
treatment. Patients with early acute appendicitis should be treated with antibiotics
and appendectomy should remain the mainstay of treatment in acute appendicitis
and complicated appendicitis.
Conclusion

A precise history of acute appendicitis may indicate the

pathology and physical examination. However, the
ability to identify the presence of peritoneal irritation
probably has the greatest influence on the final surgical
decision. The best policy is to give antibiotics for early-
stage of acute appendicitis and appendectomy for
acute appendicitis.
 References:
1. Randal Bollinger R et al (2007). Biofilms in the large bowel suggest an apparent function of the human vermiform appendix. J Theor Biol. 2007 Dec 21;249(4):826-31. [PubMed]
2. Naraynsingh et al (2003). McBurney's point: are we missing it? Surgical and Radiologic Anatomy. 2003;24(6):363–365
3. Bulut et all (2016) in Modifying Cave-Wallbridge classification
4. Ugur Ekici et al (2018) used a radiological finding to examine the relationship between appendix length and width ratio with acute appendicitis perforation
5. Deshmukh S, Verde F et al (2014). Anatomical variants and pathologies of the appendix. Emergency Radiology 2014 Oct;21(5):543-52) [PubMed].
6. Brooke E Kania et al (2021) on a pyogenic liver abscess secondary to appendicitis
7. Appendicular lymphoid hyperplasia
8. Sun-Ju Choi MD (2014)
9. Reginald H. Filz, at Harvard, first described the disease in 1886
10. Addiss et al The epidemiology of appendicitis and appendectomy in the United States)
11. Jörg C Hoffmann et al (2021) Classification of acute appendicitis (CAA)
12. Gomes et al Laparoscopic grading system of acute appendicitis
13. Shahram Lotfipour, MD, MPH, et al 2018
14. National Council on Radiation Protection and Measurements (NCRP)
15. Comparing Outcomes of antibiotic Drugs and Appendectomy (CODA) trial and an
updated treatment guideline for appendicitis from the American College of Surgeons
(2021
16. Fitz Maurice GJ et al (2011) Antibiotics versus appendectomy in the management of acute
appendicitis
17. Macroscopic appearance of the appendix is abnormal and best established by laparoscopy,
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