APPENDIX

BLOCK-5
GROUP-2
ANATOMY AND PHYSIOLOGY
OF THE APPENDIX
 ANATOMY
• It is a blind intestinal true diverticulum, located in the posterio-
medial aspect of caecum. The average length is 6-9 cm.
• The outer diameter varies between 3 and 8 mm, whereas the
luminal diameter varies between 1 and 3 mm.
• The appendix, along with the ileum and the colon, develops from
the midgut and first appears at 8 weeks of gestation.
• As the gut rotates medially, the cecum becomes fixed in the right
lower quadrant, thus determining the final position of the
appendix.
• The appendix is intraperitoneal and retrocecal in location, but it
can be pelvic (30%) and retroperitoneal (7%).
• The base of the appendix can be located by following
longitudinally oriented tinea coli to their confluence to the cecum.
 BLOOD SUPPPLY
• Appendix receives its arterial supply from
the appendicular branch of the ileocolic
artery.
• This artery originates posterior to the
terminal ileum.
• It runs near the free margin of
the mesoappendix and ends in branches to
supply the appendix.
• Venous drainage from the cecum and
appendix flow through a tributary of SMV,
ileocolic vein.
 NERVE SUPPLY LYMPHATIC
DRAINAGE
• Innervation of the appendix is derived from The lymphatic drainage of the appendix flows
sympathetic elements contributed by the into lymph nodes that lie along the ileocolic
superior mesenteric plexus (T10-L1). artery.
• Parasympathetic innervation via the vagus
nerves.
 PHYSIOLOGY
• Appendix is an immunologic organ that actively participates in the secretion of
immunoglobulins, particularly immunoglobulin A.
• Previously considered a vestigial organ, the appendix is now linked to the development and
preservation of gut-associated lymphoid tissue (GALT) and to the maintenance of
intestinal flora.
• The appendix may function as a reservoir to recolonize the colon with healthy bacteria.
• It has been suggested that appendectomy is associated with increased Clostridium difficile
infections and increased subsequent cancer (colon, oesophageal) as a result of microbial
alteration.
• The protective effect of an early appendectomy against development of ulcerative colitis
has been proposed to be mechanistically linked to the release of dimeric forms of IgA from
plasma B cells and the Th2 response mediated by IL-13–producing natural killer T cells.
 PRESENTATION
OF SYMPTOMS IN
APPENDICITIS
AND THEIR
RATIONALE
 SYMPTOMS IN APPENDICITIS
• 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
haematuria.
• The etiology of appendicitis is perhaps due to luminal obstruction that occurs as a result of
lymphoid hyperplasia in paediatric populations;
• In adults, it may be due to fecaliths, fibrosis, foreign bodies (food, parasites, calculi), or
neoplasia.
• Early obstruction leads to bacterial overgrowth of aerobic organisms in the early period, and
subsequently, it leads to mixed flora.
• Obstruction generally leads to increased intraluminal pressure and referred visceral pain to
the periumbilical region.
• It is postulated that this leads to impaired venous drainage, mucosal ischemia leading to
bacterial translocation, and subsequent gangrene and intraperitoneal infection.
• Escherichia coli and Bacteroides fragilis are the most common aerobic and anaerobic
bacteria isolated in perforated appendicitis.
 PRESENTATION,
DIAGNOSTIC
STRATEGY AND
TREATMENT OF
PATIENTS PRESENTING
WITH - RLQ
ABDOMINAL PAIN
• Patient 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,
diarrhoea, small bowel obstruction, and haematuria.
PHYSICAL EXAMINATION
• 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.
• 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.
 MANEUVERS
• 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).
• In addition, pain with rectal or cervical examinations
is also suggestive of pelvic appendicitis.
 DIFFERENTIAL
DIAGNOSIS FOR A
VARIETY OF PATIENTS
PRESENTING WITH RLQ
ABDOMINAL PAIN
• Causes of acute abdominal pain that are often confused with
acute appendicitis include acute mesenteric adenitis, cecal
diverticulitis, Meckel’s diverticulitis, acute ileitis, Crohn’s
disease, acute pelvic inflammatory disease, torsion of ovarian
cyst or graafian follicle, and acute gastroenteritis.

• Frequently, no organic pathology is identified.

• Obtaining an antecedent history of a viral infection (mesenteric

adenitis or gastroenteritis) and a cervical exam in women

(exquisite tenderness with motion in pelvic inflammatory

disease) are essential before planning any intervention.

• Detailed menstrual history can distinguish mittel schmerz (no

DIFFERENT DIAGNOSTIC TESTS
 LABORATORY FINDINGS

• Patients with appendicitis usually have leukocytosis of 10,000 cells/mm3 , with a higher

leukocytosis associated with gangrenous and perforated appendicitis (∼17,000 cells/mm3 ).

• C-reactive protein, bilirubin, IL-6, and procalcitonin have all been suggested to help in

the diagnosis of appendicitis, specifically in predicting perforated appendicitis.

• White blood cell (WBC) count and a C-reactive protein are two appropriate lab tests to

obtain in the initial work up of appendicitis;

• A pregnancy test is also essential in women of childbearing age.

• Lastly, a urinalysis can be valuable in ruling out nephrolithiasis or pyelonephritis

 IMAGING CT SCAN
•Purpose of Imaging: Confirms •CT Scan Accuracy: Sensitivity and specificity of 0.96
appendicitis; acceptable negative for diagnosing acute appendicitis.
•
operation rates: <10% in males, •Suggestive Features: Enlarged lumen (>6 mm), wall
<20% in females. thickening (>2 mm), periappendiceal fat stranding,
•Impact: Routine cross-sectional appendiceal wall thickening, appendicolith.
imaging reduces negative •Radiation Exposure: Low-dose CT (2–4 mSv) slightly
laparotomies. above background radiation (3.1 mSv); does not affect
•Appropriate Use: For unclear clinical outcomes despite lower resolution.
diagnoses or high-risk patients (e.g., •Intravenous Contrast: Preferred
pregnant or with comorbidities). but avoid in allergies or low GFR
•Modalities: CT, ultrasound (US), (<30 mL/min/1.73 m²).
MRI. •Comparison: CT is more sensitive
and specific than ultrasound for appendicitis diagnosis.
ULTRASOUND
. MRI
• Ultrasound Accuracy: Sensitivity 0.85, • MRI Accuracy: Sensitivity 0.95, specificity 0.92 for
specificity 0.90. acute [Link] Case: Preferred for patients
• Graded Compression: Measures avoiding ionizing radiation (e.g., pregnant,
anteroposterior appendix diameter. pediatric).Limitations: Expensive, requires expertise.
• Rule-Out Criterion: Compressible appendix
<5 mm.
• Suggestive Features:
 Diameter >6 mm.
 Pain with compression.
 Appendicolith presence.
 Increased fat echogenicity
and periappendiceal fluid.
 DIFFERENCE BETWEEN
UNCOMPLICATED, COMPLICATED,
NEGATIVE, AND CHRONIC
APPENDICITIS AND THEIR
TREATMENT STRATEGIES
 UNCOMPLICATED APPENDICITIS
• Pathology:
 Early stage, mild periappendiceal inflammation.
 Acute appendicitis: Neutrophil infiltration in muscularis propria without purulent exudate.
 Suppurative appendicitis: Purulent exudate in lumen ± abscess.
 Gangrenous appendicitis: Wall necrosis without perforation.
• Symptoms: Sudden onset, severe, within 24–48 hours.
• Management:
 Preferred: Appendectomy.
 Nonoperative: IV antibiotics → oral antibiotics (e.g., fluoroquinolone + metronidazole or
amoxicillin/clavulanic acid).
o Recurrence: 26.5% require appendectomy within 1 year.
o Higher adverse events and risk of complicated appendicitis on recurrence.
 COMPLICATED APPENDICITIS
• Types: Perforated, gangrenous, with abscess/phlegmon.
• Presentation:
 Often after 24 hours (20% within 24 hours).
 Symptoms: Acute illness, dehydration, potential abscess (right lower quadrant or
retroperitoneal).
 Untreated: Risk of liver/psoas abscess, fistulas, pylephlebitis.

• Management:
 Septic patients: Immediate surgery → higher complication risk (abscess, fistula).
 Non-septic:
o Resuscitation + IV antibiotics.
o Percutaneous drainage for longstanding abscess.
o Surgery for failed conservative management or free perforation.
 COMPLICATED APPENDICITIS
Surgical Approaches
•Laparoscopic Appendectomy: Shorter hospital stay, faster recovery, fewer wound infections
(especially in obese).
 Open Appendectomy: Shorter operative time, lower intra-abdominal infection risk.
 Costs: Comparable due to offset by shorter LOS in laparoscopic cases.
 Increasing use of laparoscopic approach in the U.S.
INTERVAL APPENDECTOMY
Perforated Appendicitis:
• 80% resolve with drainage + antibiotics.
• Debate on interval appendectomy (6–8 weeks later):
 Recurrent appendicitis: 7.4%–8.8% and
 Appendiceal neoplasms: Benign 0.7%, malignant 1.3%.
 OPERATIVE INTERVENTION
PREOPERATIVE PREPARATION

• Timing: Operate expeditiously; resuscitation if dehydrated.

• Antibiotics:
 Administer 30–60 min before incision.
 Uncomplicated: Cefoxitin, ampicillin/sulbactam, cefazolin + metronidazole.
 Allergy: Clindamycin + fluoroquinolone, gentamicin, or aztreonam.
 Perforated: Piperacillin/tazobactam or cephalosporin + metronidazole.
 Post-op: <4 days if source control achieved (STOP-IT trial).
 OPERATIVE INTERVENTION
OPEN APPENDECTOMY
• •Procedure:
 General or regional anesthesia.
 Incision: McBurney’s point (oblique or transverse), or midline for perforated cases.
 Muscle-splitting approach for peritoneum access.
 Position: Trendelenburg with left side down.
 Mesentery ligation early for better exposure.
 Viable appendix base: Ligation acceptable.
 OPERATIVE INTERVENTION
LAPAROSCOPIC APPENDECTOMY
• Positioning: Supine, left arm tucked; Trendelenburg with the left side down.
• Access to Peritoneum:
• Techniques: Hasson (periumbilical), Verees, or optical trocar (LUQ).
• Ports: 5-mm ports in suprapubic and LLQ (optional RUQ).
• Procedure:
 Grasp appendix → elevate → create window between mesoappendix & cecum.
 Divide mesoappendix (cautery, clip, or bipolar energy).
 Divide appendix base (endoscopic stapler or endoloop).
 Nonviable base: Staple through cecum (avoid ileocecal valve).
 Retrieve appendix in specimen bag if lesion suspected.
 Periappendiceal phlegmon: Carefully separate bowel; convert to open
surgery if needed.
 OPERATIVE INTERVENTION
NOVEL TECHNIQUES
• Single Incision Appendectomy: No improved outcomes; higher incisional hernia rate.
• NOTES Surgery: Better cosmetic outcome & less pain; limited use due to contamination
risks.
• Robotic Appendectomy: Superior ergonomics; costly, larger ports, limited adoption.

NEGATIVE EXPLORATION
• If no appendicitis found during laparoscopy/laparotomy, explore peritoneum for other
pathologies.
• Remove normal appendix to prevent future diagnostic confusion.
 OPERATIVE
INCIDENTAL APPENDECTOMY
INTERVENTION
• Prophylactic Appendectomy:
 Performed during other surgeries to prevent future appendicitis.
 Common in:
o Children on chemotherapy.
o Compromised hosts with unclear physical exams.
o Crohn’s disease with normal cecum.
o Travelers to remote areas.
o Ovarian cancer surgeries.
 Risks:
o Higher risk of adhesions, complications, and economic costs.
o No clear evidence of long-term benefits.
 Current Stance: Not routinely recommended.
SPECIAL CIRCUMSTANCES IN
APPENDIX THAT MAY BE
ENCOUNTERED
 APPENDICITIS IN CHILDREN
•Incidence: 1 in 8 children undergo workup for appendicitis.

•Age-related Presentation:

 Infants/young children: High perforation rates (51%-100%).

 School-age children: Lower perforation rates.

 Neonates: Abdominal distension, lethargy, irritability.

•Pediatric Appendicitis Score:

 Max score: 10 points.

 Score ≥7: High chance of appendicitis (78%-96%).

 APPENDICITIS IN CHILDREN
• Differential Diagnoses: Intussusception, gastroenteritis, malrotation, pregnancy,
mesenteric adenitis, ovarian/testicular torsion.

• Management:

 Early Appendicitis: Laparoscopic appendectomy preferred.

 Complicated Appendicitis: Urgent appendectomy (laparoscopic).

 Perforated Appendicitis: Post-op antibiotics (3-5 days).

 Nonoperative Management: Safe for early cases, limited inflammation, no

rupture (88%-92% success). Recurrence rate: 22% at 1 year.
 APPENDICITIS IN OLDER ADULTS
• Presentation: Often with perforation/abscess due to diminished inflammation.
• Management:
 Higher risk for complications.
 Diagnostic imaging preferred before surgery.
 Laparoscopic appendectomy is safe and effective.
 APPENDICITIS IN PREGNANCY
• Incidence: 1 in 800-1000 pregnancies, mostly in 1st/2nd trimesters.
• Symptoms: Heartburn, bowel irregularity, displaced tenderness.
• Imaging:
 Ultrasound: Preferred, sensitivity 67%-100%, specificity 93%-96%.
 MRI: Sensitivity 94%, specificity 97%.
 CT: Avoided unless necessary due to fetal radiation risk.
• Surgical Considerations: Higher fetal loss with perforation (up to 36%).
 Laparoscopic appendectomy safe but higher fetal loss rate (7% vs. 3% for
open).
 Nonoperative management has high failure rates (25%).
 CHRONIC/RECURRENT
APPENDICITIS
•Presentation: Recurrent RLQ pain, appendicolith, or dilated appendix.

•Management: Appendectomy often resolves symptoms.

•Prophylactic Appendectomy: Not recommended without imaging abnormalities.

OUTCOMES AND
POSTOPERATIVE
COURSE FOR
APPENDICITIS
 OUTCOMES AND
POSTOPERATIVE COURSE
• Appendectomy Complications
• Adverse Events:
 Common: Soft tissue infections (superficial/deep), wound infections
(periumbilical ports in laparoscopic cases).
 Wound Infection: Managed by opening, packing; delayed primary closure
not beneficial.
 Abscesses: Managed with percutaneous drainage and antibiotics.
 Fistulas: Managed conservatively (appendicocutaneous/appendicovesicular).
 Bowel Obstructions & Infertility: Rare but reported.

• Postoperative Antibiotics:
 Uncomplicated Appendicitis: No further antibiotics.
 Perforated Appendicitis: 3-7 days antibiotics (4 days per STOP-IT trial).
 OUTCOMES AND
POSTOPERATIVE COURSE
STUMP APPENDICITIS

• Cause: Incomplete excision of appendiceal stump (>0.5 cm).

• Management: Re-excision of the appendiceal base.

• Diagnosis: Requires careful patient history, physical exam, and imaging.

• Prevention: Proper identification and ligation of appendiceal base during

initial surgery
 OUTCOMES AND
POSTOPERATIVE COURSE
APPENDICEAL NEOPLASMS

• Incidence: 1% of appendectomy specimens, commonly gastroenteropancreatic

neuroendocrine tumors (GEP-NETs), mucinous neoplasms, 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.
 OUTCOMES AND
POSTOPERATIVE COURSE
GASTROENTEROPANCREATIC NEUROENDOCRINE TUMORS (GEP-NETS OR
CARCINOID)

• Appendiceal Carcinoid Tumors:

 Submucosal rubbery masses, often detected incidentally.

 Indolent but can metastasize to lymph nodes or liver.

 Rarely associated with carcinoid syndrome (2.9% with liver metastasis).

 OUTCOMES AND
POSTOPERATIVE COURSE
GOBLET CELL CARCINOMAS
• Misdiagnosed as Goblet Cell Carcinoids:
 Adenocarcinoid with both adenocarcinoma and neuroendocrine features.
 Worse prognosis than carcinoids but slightly better than adenocarcinomas.
 High risk of peritoneal recurrence.
• Management:
 Systematic peritoneal surveillance and documentation of peritoneal cancer index if
disease present.
• Without metastatic disease: Right hemicolectomy recommended.
• For tumors ≥2 cm: Right colectomy may be advocated.
 OUTCOMES AND
POSTOPERATIVE COURSE
LYMPHOMAS

• Appendiceal Lymphomas:
 Rare (1-3% of lymphomas, mostly non-Hodgkin's).
 Difficult to diagnose preoperatively, can have appendiceal diameter >2.5 cm.

• Management:
 Most cases require appendectomy.
 OUTCOMES AND
POSTOPERATIVE COURSE
ADENOCARCINOMA OF THE APPENDIX

• Rare neoplasm with 3 histologic subtypes: mucinous adenocarcinoma, colonic

adenocarcinoma, and adenocarcinoid.

• Presentation: Commonly presents as acute appendicitis, but also with ascites, palpable
mass, or during unrelated surgery.

• Treatment: Right hemicolectomy recommended for all patients.

• Prognosis: Early perforation common, but not linked to worsened prognosis.

• Survival: 55% 5-year survival, varying with stage and grade.

• Risk: High risk for synchronous and metachronous neoplasms, especially GI tract-related.
 OUTCOMES AND
POSTOPERATIVE COURSE
APPENDICEAL MUCOCELES AND MUCINOUS NEOPLASMS
• Definition: Mucus-filled appendix, caused by neoplastic (mucinous cystadenomas,
cystadenocarcinomas) or non-neoplastic conditions.
• Presentation: Often incidental, but 1/3 present with appendicitis.
• Imaging: Well-capsulated, round cystic mass with possible irregularities suggesting
neoplastic process.
• Management:
 Surgical excision without rupture.
 Laparoscopic excision acceptable if no nodularity or dissemination.
 In cases with peritoneal spread: Biopsies and documentation of disease burden
required.
 Appendectomy with lymphadenectomy is sufficient if no mesenteric or peritoneal
involvement.
 OUTCOMES AND
POSTOPERATIVE COURSE
PSEUDOMYXOMA PERITONEI (PMP) SYNDROME
• Cause: Often due to appendiceal mucinous neoplasms, but can occur with gastric, ovarian,
pancreatic, and colorectal tumors.
• Prognosis: Varies, with treatment ranging from curative to palliative.
• Standard Treatment: Cytoreductive surgery and HIPEC (Hyperthermic Intraperitoneal
Chemotherapy).
• Technique: Involves peritonectomies and intraperitoneal heated chemotherapy (e.g.,
mitomycin).
• Minimizing morbidity: Early detection and low-volume disease allow laparoscopic
procedures with similar morbidity to major GI surgeries
CASE REPORT
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.
CHIEF COMPLAINT:
Abdominal pain
HISTORY OF PRESENT ILLNESS:
UPON EXAMINAYION AT GP:
● Mild tenderness in the periumbilical area
● Normal temperature and urine dip
6 HOURS LATER AT GP:
● Symptoms were unchanged
● Temperature of 37.6°C
4 HOURS LATER AT THE LOCAL HOSPITAL:
● RLQ pain was reported
● No diarrhea, (+) anorexia and vomiting after the abdominal pain is noted in 12 hrs, no change
in bowel habit
● RLQ tenderness with rebound tenderness.
● Temperature was 38.5°C.
● Blood tests- elevated inflammatory markers and no anemia.
1. What further data should be obtained from the patient’s history and explain?
PRESENT HISTORY PAST HISTORY
• How long has the pain been present? • Is there a history of travel?
• Is it too painful, rate it in the scale of 1 to 10? • Is there a history of hospitalization?
• Can you describe your pain (colicky, stabbing, • Is there a past history of similar pain?
crampy)?
• Is there any allergy?
• Has it changed? If so, over what time frame?
• How long there has there been a fever? • Is there any history of past surgery?
• At what times do you have fever? • Is there any adulthood illness?
• Do you have head ache? Epilepsy episodes? • Is any of your family members have same kind
• Does eating affect the pain? of medical condition?
• Is the pain radiating to other parts?
• What makes it worse? What makes it better?
• Are there any episodes of vomiting?
• Is there any pain during urination?
• Do you have normal bowel habit?
• Are you sexually active?
• Any pain or bleeding during/after recent sexual
activity?
• Any episodes of irregular menses?
• Any episodes of halitosis?
• Did you have blood in your feces?
• Are you able to pass gas?
• Is there a history of travel or hospitalization?
• Is there a past history of similar pain?
• Is there any allergy?
• Is there any history of past surgery?
• Is there any adulthood illness?
• Is any of your family members have same kind of
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 appendicitis.

● 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.
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)
4. Enumerate and explain the different Scoring systems to diagnose Acute Appendicitis?
FINDINGS POINTS
1. ALVARADO SCORE
MIGRATORY RIGHT ILIAC 1
FOSSA PAIN
ANOREXIA 1
NAUSEA OR VOMITING 1
TENDERNESS-RIGHT 2
SCORE ILIAC FOSSA
<3 Likelihood of appendix REBOUND TENDERNESS 1
4-6 Further imaging is required RIGHT ILIAC FOSSA
>= 7 High likelihood of appendix FEVER ≥36.3◦C 1
LEUKOCYTOSIS ≥ 2
10×CELLS/L
SHIFT TO THE LEFT OF 1
NEUTROPHILS
2. APPENDICITIS INFLAMMATORY RESPONSE SCORE:
FINDINGS POINTS
VOMITING 1
PAIN IN THE RIGHT 1
INFERIOR FOSSA
REBOUND TENDERNESS

LIGHT 1

MEDIUM 2
SCORE PROBABILITY
STRONG 3 0-4 low probability (outpatient follow up)
BODY TEMPERATURE 1 5-8 intermediate group (active observation
≥38.5◦C or diagnostic laparoscopy)
9-12 high probability (surgical exploration)
POLYMORPHONUCLEAR
LEUKOCYTES
1
70%-84%
2
≥85%
WHITE CELL COUNT

10.0-14.9× CELLS /L 1

≥15.0×cells/L 2
C-REACTIVE PROTEIN
CONCENTRATION
1
10-49g/l
2
5. What are your differential diagnoses and explain how you can rule in or rule out these conditions?
DIFFERENTIAL DIAGNOSIS RULE IN RULE OUT
● RLQ tenderness

APPENDICITIS ● vomiting • NONE

● nausea
● anorexia
● Fever
● RLQ pain ● Diarrhea

ACUTE MESENTERIC ADENITIS ● Vomiting ● Viral infection

● Rebound tenderness ● Weight loss

● Lower abdominal pain ● Associated with STIs

PELVIC INFLAMMATORY DISEASE ● Temperature higher than ● Bilateral lower quadrant

38.3°C tenderness
● Cramping abdominal pain ● Cobblestone mucosa

CROHNS DISEASE ● Low-grade fever ● weight loss

● prolonged diarrhea
● Nausea ● Abdominal pain most
commonly in LLQ
DIVERTICULITIS ● Vomiting
● Fever and Abdominal pain ● Change in the bowel habit
6. Enumerate and explain the significance of the different diagnostic tests/ imaging
and how to interpret them?
● Physical exam to assess your pain. A gentle pressure on the painful area to assess rebound
tenderness and the different maneuvers.
● Lab tests: To help confirm the diagnosis of appendicitis and rule out other causes of abdominal
pain.
● Blood tests: Blood tests can show a high white blood cell count, a sign of infection. Blood tests
also may show dehydration or fluid and electrolyte imbalances.
● Urinalysis: Urinalysis is testing of a urine sample to rule out a urinary tract infection or a
kidney stone.
● Pregnancy test: For women, this test is often required
● Imaging tests:
 Abdominal ultrasound/Magnetic resonance imaging (MRI): can show signs of a
blockage in the appendiceal lumen, a burst appendix inflammation, other sources of
abdominal pain.
 Used as the first imaging test for possible appendicitis in infants, children, young adults, and
pregnant women.
 CT scan: CT scans use x-rays and computer technology to create images. Patients don’t
 ▪ an appendiceal abscess
▪ a blockage in the appendiceal lumen
 Women of childbearing age should have a pregnancy test before having a CT scan. The
radiation from CT scans can be harmful to a developing fetus and ultrasound is preferred
over this for pregnant women
7. What therapy or treatment will you recommend and explain?

● Appendectomy

o Open appendectomy: For early non-perforated appendicitis, a Mcburney or Rocky-

Davis incision may be made.

o Laparoscopic appendectomy: increasingly utilized in the US. Shorter length of hospital

stays, faster return to work, lower superficial wound infection rates (especially in obese
patients), but intra- abdominal infection rates are higher than in open appendectomy.

o Non-surgical treatment: Antibiotics- IV antibiotics followed by fluoroquinolone and

metronidazole, or Amoxicillin with clavulanic acid. Not recommended, due to more side
effects, and risk of recurrence (according to a study, 26.5% of the patients treated with
THANK
YOU