APPENDIX MODULE

THANDAYUTHAPANI VINOTH KUMAR

19-1167-155
Block 11, Group 2

1
Anatomy and physiology

● the appendix is now linked to the development

and preservation of gut-associated lymphoid
tissue (GALT) and to the maintenance of
intestinal flora
● appendix is a true diverticulum of the cecum as
it contains all the histological layers of the
colon
● The average appendix measures 6 to 9 cm
Anatomy and physiology
● The appendix is intraperitoneal and
retrocecal in location, but it can be
pelvic (30%) and retroperitoneal (7%).
● Grossly, the appendiceal base can be
identified by tracing the convergence of
the cecal taeneia
○ The three taeniae coli converge at the
junction of the cecum with the
appendix
Anatomy and physiology
● Blood supply
○ appendicular branch of the
ileocolic artery

● Visceral innervation
○ superior mesenteric plexus
(T10-L1) and the vagus
nerves.
 HISTOLOGY

● The histologic features of the appendix are

contained within the-
○ Serosa(which is an extension of the
peritoneum)
○ Muscularis layer
○ Submucosa
○ Mucosa
● Lymphoid aggregates occur in the
submucosal layer and may extend into
the muscularis mucosa.

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Acute appendicitis

● Inflammation of the appendix

● Etiology

○ it is perhaps due to the lumen becoming blocked (luminal obstruction) by a

fecalith, fibrosis, foreign bodies and neoplasm (in adults); or lymphoid
hyperplasia (in pediatric population). Early obstruction leads to bacterial
overgrowth of aerobic organisms. Obstruction generally leads to increased
intraluminal pressure and referred visceral pain to the periumbilical region.
This also leads to impaired venous drainage, mucosal ischemia leading to
bacterial translocation, and subsequent gangrene and intraperitoneal
infection.
CLINICAL FEATURES

• Starts with periumbilical and diffuse pain that eventually localizes to the right
lower quadrant as the peritoneal lining gets irritated.
• GI symptoms-nausea, vomiting and anorexia after the onset of
pain obstipation prior to the onset of pain and
• Patient feels that defecation will relieve their abdominal pain.
• Diarrhea may occur in association with perforation, especially in children.
• Early in presentation the vital signs may be minimally altered.
• The body temperature and pulse rate may be normal or slightly elevated.

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Clinical Diagnosis
● History
○ Abdominal migratory pain -classical sign of appendicitis; due
inflammation of the visceral peritoneum usually progresses to
the parietal peritoneum.
○ anorexia
○ nausea, vomiting
○ fever
Clinical Diagnosis

● Physical Examinations
○ Most patients lay quite still due to parietal peritonitis.
○ Patients are generally warm to the touch (with a low-grade fever, ∼38.0°C
[100.4°F]) and demonstrate focal tenderness with guarding.
○ Localization of appendix:
■ Rovsing’s sign, pain in the right lower quadrant after release of gentle
pressure on left lower quadrant (normal position);
■ Dunphy’s sign, pain with coughing (retrocecal appendix);
■ Obturator sign, pain with internal rotation of the hip (pelvic appendix);
■ Iliopsoas sign, pain with flexion of the hip (retrocecal appendix)
McBurney’s Point
Clinical Diagnosis

• Alvarado score is the most common scoring

system for the diagnosis of acute appendicitis.
• A score of
1. 9-10: almost certain
2. 7-8: high likelihood of appendicitis
3. 4-6: consider further imaging
4. <3: low likelihood of appendicitis.
Clinical Diagnosis

• The Appendicitis Inflammatory

Response Score is the better
alternative for the scoring of acute
appendicitis.
• A score of
1. 9-12 yields high probability – the
need to explore
2. 5-8: intermediate – observe or
diagnostic follow-up
3. 0-4 is low probability which allows the
patient to do out-patient follow-up
diagnostic tests/ imaging
● Laboratory Test
○ Complete Blood Count
■ Leukocytosis of 10,000 cells/mm3, with a higher leukocytosis associated
with gangrenous and perforated appendicitis
○ C-reactive Protein (CRP) Test
■ help in the diagnosis of appendicitis
○ Pregnancy Test
■ essential in women of childbearing age.
○ Urinalysis
■ urinalysis can be valuable in ruling out nephrolithiasis or pyelonephritis.
diagnostic tests/ imaging
● Imaging Tests
○ CT Scan (contrast-enhanced)
■ enlarged lumen and double wall thickness (greater than 6 mm), wall thickening
(greater than 2 mm), periappendiceal fat stranding, appendiceal wall thickening,
and/or an appendicolith.
○ Ultrasound
■ An easily compressible appendix <5 mm in diameter generally rules out appendicitis.
■ Diameter of greater than 6 mm, pain with compression, presence of an appendicolith,
increased echogenicity of the fat, and periappendiceal fluid rules in appendicitis.
○ MRI
■ recommended in patients for whom the risk of ionizing radiation outweighs the relative
ease of obtaining a contrast CT scan, i.e., pregnant or pediatric patients
Differential Diagnosis
Acute Appendicitis
Acute mesenteric adenitis
Pelvic Inflammatory Disease
Rule In Rule Out
(+)Nausea and Vomiting preceding - Cannot be ruled out
Abdominal Pain
(+)Anorexia
(+) Fever of 38.5°C
(+) Migratory Right Lower Quadrant
Tenderness
(+) Rebound Tenderness
(+) Elevated Inflammatory Markers
(+)Nausea and Vomiting After No antecedent history of viral or
Abdominal Pain bacterial infection especially
(+) Fever of 38.5°C Yersinia infection
(+) Anorexia (-) Diarrhea
(+) Right Lower Quadrant Tenderness (-)Rectal tenderness
(+) Rebound Tenderness
● 25-years old No sexual history
● Female (-)Adnexal tenderness
(+) Anorexia (-)Cervical motion tenderness
(+) Fever of 38.5°C (-) Uterine tenderness
(+) Abdominal pain (+) Right lower quadrant pain
(+) Elevated inflammatory markers
Differential diagnosis

Rule In Rule Out

Acute gastroenteritis (+) Fever of 38.5°C No antecedent history of

(+) Anorexia viral infection
(+) Nausea & Vomiting (-) Diarrhea
(+)Abdominal pain

Crohn’s Disease (+) Fever of 38.5°C (-) Diarrhea

(+) Right lower quadrant (-) Weight loss
pain
(+) Anorexia
(+) Nausea and Vomiting
(+) Right lower quadrant
pain
Uncomplicated Appendicitis

● Preferred approach: Appendectomy.

● Approach of Surgery
○ laparoscopic appendectomy
■ shorter length of stay (LOS)
■ faster return to work
■ lower superficial wound infection rates
○ Open appendectomy
■ shorter operative times
■ lower intra-abdominal infection rates
Complicated Appendicitis
● Complicated conditions: Perforated and gangrenous appendicitis and appendicitis with
abscess or phlegmon formation
● perforated appendicitis usually present after 24 hours of onset
● Perforated appendicitis can be managed either operatively or nonoperatively.
● Immediate surgery is necessary in patients that appear septic
● Patients are resuscitated and treated with IV antibiotics.
● Patients with longstanding perforation are better treated with adequate
percutaneous image-guided drainage
Negative Appendicitis
● Upon performing a laparoscopy or laparotomy for suspected
appendicitis, if one finds no evidence of appendicitis, a thorough
exploration of the peritoneum must be performed to rule out
contributing pathology.
● A normal appendix is often removed to reduce future diagnostic
dilemma
Chronic or Recurrent Appendicitis

● Patients with recurrent right lower quadrant abdominal pain not associated with a febrile illness with
imaging findings suggestive of an appendicolith or dilated appendix
● Patients often report resolution of symptoms with an appendectomy. In the absence of imaging
abnormalities, prophylactic appendectomy is not encouraged
 SPECIAL CIRCUMSTANCES

Appendicitis in Children
● infants and young children are most likely to present with perforated disease
● neonates can also present with abdominal distension and lethargy or irritability
● The Pediatric Appendicitis Score
○ similar to the Alvarado Score and is scored of 10 points, with maximum weight (2
points each)
■ right lower quadrant tenderness and pain with cough, percussion or hopping.
○ A score of 7 or greater: has a high chance of having appendicitis
● early appendicitis: laparoscopic appendectomy
● complicated appendicitis: urgent appendectomy is advocated in the setting of no
abscess or mass.
Appendicitis in Children
● In the setting of a perforation, antibiotics are continued after surgery for at least 3
days, and preferably 5 days (APSA guidelines)
● Management of perforated appendicitis with abscess is similar to adults,
● Nonoperative management of appendicitis has also been studied in children.
○ It may be safe for children with early presentation (less than 48 hours), limited
inflammation , appendicoliths, and no evidence of rupture on imaging.
● administered IV antibiotics until inflammation reduces and then transitioned to
oral antibiotics.
Appendicitis in Older Adults

● Older adult patients can have diminished inflammation and thus present
with perforation or abscess more frequently.
● higher risk for complications, and it is more prudent to obtain definitive
diagnostic imaging prior to taking patients to the operating room.
● Laparoscopic appendectomy is safe and might allow patients to
reduce pain and their hospital stay
Appendicitis in Pregnancy
● rare in the antepartum state, and it can occur in the postpartum state in geriatric pregnancies
● patients can also present with heartburn, bowel irregularity, flatulence, or a change in bowel
habits.
● Ultrasonography is the preferred imaging modality
● An alternative imaging modality: MRI
● While CT can be performed in pregnancy, the risk of fetal irradiation leads many
practitioners to avoid it unless other modalities are inconclusive.
● Laparoscopic appendectomies can be safely performed in pregnant patients, although
studies suggest a variable but reproducible higher rate of fetal loss than open
techniques.
 Outcomes and postoperative course

● Appendectomy is a relatively safe procedure with an extremely low mortality

rate (less than 1%).
● Patients with uncomplicated appendicitis do not require further antibiotics
after an appendectomy, while patients with perforated appendicitis are treated
with 3 to 7 days of antibiotics
● Patients with deep space abscesses are managed with percutaneous
drainage and antibiotics.
Stump Appendicitis

● uncommon complication after surgery is the development of appendicitis

in an incompletely excised appendiceal stump
● Optimal management requires reexcision of the appendiceal base,
but diagnosis can be difficult and requires careful assessment of the
patient’s history, physical exam, and imaging studies.
Appendiceal Neoplasms

● Neoplasms that occur in the appendix are predominantly

gastroenteropancreatic neuroendocrine tumors (or GEP-NETs, previously
called carcinoids), mucinous neoplasms, or adenocarcinomas.
● Almost one-third of the neoplasms of the appendix present with acute
appendicitis, while the others are often incidentally detected or are
detected after regional spread of disease
Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs or Carcinoid)

● Appendiceal carcinoid tumors are submucosal rubbery masses that are detected
incidentally on the appendix
● Upon incidental findings of a suspected carcinoid, the surgeon must evaluate the nodal
basin along the ileocolic pedicle and also examine the liver for any signs of metastases.
● For lesions that are <1 cm
○ negative margin appendectomy is adequate.
● For tumors 2 cm or larger,
○ right hemicolectomy is recommended.
● For lesions 1 to 2 cm in size
○ there is no consensus on a completion colectomy.
● A right colectomy is often performed for mesenteric invasion, enlarged nodes, or positive
or unclear margins
Goblet Cell Carcinomas
● mistakenly called goblet cell carcinoids
● worse prognosis than carcinoids
● There is a high risk of peritoneal recurrence in such cases.
● For incidentally detected lesions, a systematic surveillance of the peritoneum must be performed,
and a peritoneal cancer index score must be documented if disease is present.
● In the absence of metastatic disease, a right hemicolectomy is generally appropriate, although
some advocate for a right colectomy only for tumors 2 cm or larger.
Lymphomas Appendiceal lymphomas

● rare (1%–3% of lymphomas, usually non-Hodgkin’s) and difficult to

diagnose preoperatively (appendiceal diameter can be 2.5 cm or
larger).
● Management includes an appendectomy in most cases.
Adenocarcinoma
● rare neoplasm
● three major histologic subtypes:
○ mucinous adenocarcinoma
○ colonic adenocarcinoma
○ adenocarcinoid.
● Patients also may present with ascites or a palpable mass, or the
neoplasm may be discovered during an operative procedure for an
unrelated cause.
● The recommended treatment: formal right hemicolectomy.
● Overall 5-year survival is 55% and varies with stage and grade
Appendiceal Mucoceles and Mucinous Neoplasms of the Appendix

● term appendiceal mucocele

● The most common form of presentation is incidental
● It is important to carefully assess for the presence of ascites,
peritoneal disease, and scalloping of the liver surface on imaging
upon initial evaluation
● An appendectomy is acceptable if the patient has acute appendicitis,
but suboptimal debulking is discourage
Pseudomyxoma Peritonei Syndrome

● This can occur in gastric, ovarian, pancreatic, and colorectal primary tumors as well.
● Patients with this syn-drome can have varied prognosis ranging from curative to pal-
liative.
● Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) are
considered the standard of care for patients with PMP syndrome from appendiceal
primaries.
● Early detection and management of limited peritoneal dis-ease is favorable and
preferred as opposed to extensive intra-peritoneal mucin development.
● The surgical technique involves parietal and visceral peritonectomies, and
intraperitoneal administration of heated (42oC [108oF]) chemotherapy (usually
mitomycin) in the abdomen.
 CASE
● A 25-year-old woman presented to her GP with a 12-hour history of vague central abdominal
pain associated with nausea and anorexia.
● On examination, her GP noted mild tenderness in the periumbilical area. Normal temperature
and urine dip were recorded. The GP asked the patient to return six hours later for review. At
the time of review, the patient reported that her symptoms were unchanged. She was noted to
have a temperature of 37.6°C. The GP arranged a review in the local hospital that evening.
● Four hours later, she was assessed by the surgical resident, when she complained that the car
journey to the hospital was uncomfortable when driving over speed bumps and that she had not
eaten all day. At this time, she reported that her pain was in the RLQ.
● On direct questioning, she said she had no diarrhea but with anorexia and vomiting after the
abdominal pain is noted in 12 hrs, but denied any change in her bowel habit. On examination,
she was noted to have RLQ tenderness with rebound tenderness. Her temperature was 38.5°C.
Blood tests revealed elevated inflammatory markers and no anaemia.

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 1. What further data should be obtained from the patient’s history and explain ?

⮚Information that should be obtained from the patient’s history for the management and
evaluation plan:
• Onset – When did you first experience the pain? sudden vs gradual?
• Location - Is pain localized to a specific area of the abdomen? Which quadrant of the stomach is
most associated with the pain.
• Duration – Time of its presentation in terms of minutes / hours / days / weeks / months / years
• Character – What kind of pain is noted? Is it sharp / dull ache / burning
• Associated symptoms – Other symptoms related to pain (e.g. fever, diarrhea)
• Radiation – does the pain move anywhere else?
• Time course – worsening / improving / fluctuating

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• Exacerbating / Relieving factors – does anything make the pain worse or better?
• Severity of the pain – on a scale of 0-10 how severe is the pain? 0 being least painful and 10 being
the most painful.
• Pain during urination/defecation?
• Did the patient miss any periods/ menstrual irregularities if any?
• Does the patient have irregular bowel movements as of recent?
• Did the patient undergo any surgical procedure recently/ in the past?
• Past medical history of the patient. As any past disease / disorder can speak of any underlying
condition & in turn either increase or decrease the possibilities of certain conditions.
• Can the patient pass gas?
• Familial history of disorders in the patient, just for ruling out purposes.
• Does the patient have any headaches?
• Were there episodes of epilepsy in the patient?
• What medications does a patient take? If any?
• Are there any scars/ contours/ irregularities in the abdominal region whilst examination/ inspection?
 2. Enumerate the classic presentation in terms of medical history and physical
examination of acute appendicitis. Explain these findings in terms of the
pathophysiology of acute appendiditis?

• Inflammation of the visceral peritoneum usually progresses to the parietal peritoneum, presenting
with migratory pain, which is a classic sign of appendicitis.
• Inflammation can often result in anorexia, nausea, vomiting, and fever. Regional inflammation can
also present with an ileus, diarrhea, small bowel obstruction, and hematuria.
• Most patients lay quite still due to parietal peritonitis. Patients are generally warm to the touch and
demonstrate focal tenderness with guarding.
• McBurney’s point, which is found one-third of the distance between the anterior superior iliac spine
and the umbilicus, is often the point of maximal tenderness in a patient with an anatomically normal
appendix.
• The patient in the case had vague central abdominal pain associated with nausea and anorexia,
mild tenderness in the peri- umbilical area and pain in the RLQ. She also had rebound tenderness
suggesting peritonitis and low-grade fever.
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 3. Enumerate and describe the different maneuver and signs that can be found in
acute appendicitis?

• Rovsing’s sign: pain in the right lower quadrant after release of gentle pressure on
left lower quadrant (normal position);
• Dunphy’s sign: pain with coughing (retrocecal appendix);
• Iliopsoas sign: pain with flexion of the hip (retrocecal appendix).
• Obturator sign: Performed by passive internal rotation of flexed right thigh with the
patient is supine position (positive if with hypogastric pain on stretching obturator
internus muscle)
•

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 4. Enumerate and explain the different Scoring systems to diagnose Acute
Appendicitis?

• The Alvarado Score is the most widespread scoring system, with maximum weight (2
points each) for right lower quadrant tenderness and pain with cough, percussion or
hopping.
• Used for ruling out appendicitis and selecting patients for further diagnostic workup.
• A score of 7 or greater indicates that the patient has a high chance of having
appendicitis (78%–96% percent)

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5. What are your differential diagnosis and explain how you can rule in or rule out
these conditions?

Differential diagnosis Rule in Rule out

Pelvic inflammatory ∙ Usually bilateral
disease ∙ Tender periumbilical area
∙ Motion tenderness
∙ Nausea
∙ Low grade fever
∙ No abnormal discharge
from vagina
∙ Motion of the cervix is
exquisitely painful

Ovarian torsion ∙ Nausea ∙ No abnormal

∙ Right lower quadrant pain bleeding(anemia)
∙ Rebound tenderness ∙ No Palpable adenexal
∙ Fever mass

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Gastroenteritis ∙ Inflammation markers in ∙ No dehydration
BT ∙ Pain specific to RLQ
∙ fever and tenderness
∙ Abdominal tenderness ∙ No diarrhea
∙ Vomiting ∙ Iron deficiency anemia

Appendicitis ∙ Nausea
∙ Loss of appetite
∙ Fever;
∙ Elevated inflammatory
markers
∙ Right lower quadrant pain
rebound tenderness
∙ Pain increased by
movement
 6. Enumerate and explain the significance of the different diagnostic tests/
imaging and how to interpret them?
∙ Mentural history
✔ To distinguish mittelschmerz (no fever or leukocytosis, mid-menstrual cycle pain)
∙ Pregnancy test
✔ to rule out ectopic pregnancy
• child bearing age , pain usually appears in the lower abdomen or pelvic region
∙ CBC
✔ WBC count : complicated appendicitis.
? Normal range : in blood 4,500-11,000 WBCs per microliter.
? Normal range : in urine 0-5 WBCs per high power field (wbc/hpf).
? leukocytosis (10,000 cell/mm) : uncomplicated appendicitis
? High leukocytes (∼17,000 cells/mm3 ) :associated with gangrenous and perforated appendicitis
✔ C-reactive protein, bilirubin, Il-6, and procalcitonin : may be due to perforated appendicitis.
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∙ Urinalysis:
✔ Done to rule out urinary tract infection
✔ ruling out nephrolithiasis or pyelonephritis
✔ Bacteriuria generally not seen in appendicitis

∙ Pelvic examination
✔ To check and differential cause of abdominal pain
? acute mesenteric adenitis
• right lower quadrant abdominal pain
• pain in other part of body as well
• pain is felt both in the periumbilical region and in the right iliac fossa
• the area of pain and Tenderness tends to shift (in contrast with the more fixed area of
tenderness in appendicitis)
? cecal diverticulitis
• Left lower quadrant pain (M/C 70% of patients)
• Right-sided diverticulitis with right lower quadrant pain
• localized abdominal tenderness (m/c)
• In complicated diverticulitis a tender palpable mass may be noted (20% of cases)
? torsion of ovarian cyst or graafian follicle
? acute gastroenteritis
• Mild to moderate pain in the presence of active peristalsis of normal pitch
∙ Imaging
✔ computerized tomography (CT) : more sensitive and specific
? CT scan that suggest appendicitis include enlarged lumen and double wall thickness (greater
than 6 mm) wall thickening (greater than 2 mm), periappendiceal fat stranding, appendiceal wall
thickening, and/or an appendicolith
? A contrast-enhanced CT scan has a sensitivity of 0.96 (95% confidence interval [CI] 0.95–0.97)
and specificity of 0.96 (95% CI 0.93–0.97) in diagnosing acute appendicitis
• but it can be avoided in patients with allergies or low estimated glomerular filtration rate (less than
30 mL/minute for 1.73 m2 )
✔ ultrasound (US)
? Ultrasonography has a sensitivity of 0.85 (95% CI 0.79–0.90) and a specificity of 0.90 (95% CI
0.83–0.95)
? to identify the anteroposterior diameter of the appendix.
? Suggest of appendicitis : wall thickened of a diameter of greater than 6 mm, pain with
compression, presence of an appendicolith, increased echogenicity of the fat, and periappendiceal
fluid
? To differential diagnosis of Meckel’s diverticulitis
• a thickened noncompressible tubular structure may be seen.
? Pros : it does not expose patients to ionizing radiation,
? Cons : Utility decrease in obese patients
✔ magnetic resonance imaging (MRI).
? MRI of the abdomen has a sensitivity of 0.95 and specificity of 0.92 for identification of acute
appendicitis
? recommended in patients for whom the risk of ionizing radiation : pregnant or pediatric patients
∙ Radiograph:
✔ Plain films of abdomen:
? Identify obstruction
? Identify free gas
• To identify and differentiate Crohn’s diasease : where pain is lower right abdominal
quadrant with abdominal bloating
? Abdominal radiograph: fecalith in RLQ associated with gangrenous acute appendicitis
? to rule out bowel malignancy
 7. What therapy or treatment will you recommend and explain?

⮚ Appropriate resuscitation followed by expedient appendicectomy is the treatment of choice.

⮚ All patients should receive broad spectrum perioperative antibiotics (one to three doses), as they
have been shown to decrease the incidence of postoperative wound infection and intra-abdominal
abscess formation.
⮚ Followed by a course of a fluoroquinolone and metronidazole, or oral amoxicillin/clavulanic acid
⮚ Conservative therapy is considered in exceptional cases or if findings are unclear (soft signs)
⮚ Bowel rest (keep patient NPO), IV fluid therapy, observation
⮚ Analgesia
⮚ According to the case our patient comes under uncomplicated appendicitis, so the preferred
approach to manage patients with uncomplicated appendicitis is an appendectomy.
Surgical approach may be laparoscopic or open and is decided on a case-by-case basis

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Surgery-Appendicectomy
⮚ Gridiron incision: Incision is placed perpendicular to the right spinoumbilical line at the McBurney’s
point (i.e. at the junction of lateral one-third and medial two-third of spinoumbilical line).
⮚ Rutherford Morison’s muscle cutting incision (Muscles are cut upwards and laterally).
⮚ Lanz crease incision centering at McBurney’s point— cosmetically better.
⮚ Right lower paramedian incision/lower midline incision— when in doubt or when there is diffuse
peritonitis.
⮚ Fowler-Weir approach by cutting muscle medially over the rectus
⮚ In difficult cases—Retrograde appendicectomy can be done. In presence of pus or burst
appendix, the peritoneal cavity is drained.
⮚ Laparoscopic approach: Becoming popular and better, which uses several smaller incisions and
special surgical tools fed through the incisions to remove the appendix and also leads to fewer
complications.
⮚ Postoperatively, IV fluids, antibiotics are given. Once bowel sounds are heard, oral diet is given.

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REFERENCE:

Schwartz, Seymour I., Brunicardi, F. Charles., eds. Schwartz's Principles Of Surgery: ABSITE And
Board Review. New York: McGraw-Hill Medical, 2011.

THANK YOU!

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