4th Surgery Dr.

Mohammed
Stage Gastrointestinal Lecture. 1

Appendix & Appendicitis

Objectives : To understand
• The Incidence , aetiology pathology and surgical anatomy of acute
appendicitis.
• The clinical symptoms & signs and differential diagnoses of appendicitis.
• The investigation of suspected appendicitis.
• Evolving concepts in management of acute appendicitis.
 Special features, according to position of the appendix
 Special features, according to age , Obese , Pregnant.
 Differential diagnosis in children

Acute Appendicitis
Incidence:
- Rare in infants, increasingly common in childhood and early adult life, peak
incidence in the teens and early 20s.
- Before puberty males = females.
- In teenagers and young adults the male : female ratio = 3:2
- Thereafter, the greater incidence in males declines.

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Aetiology
No definite cause, But:
1. Decreased dietary fibre and increased consumption of refined carbohydrates
(Low fiber diet).

2. Bacterial proliferation within the appendix, No single organism is responsible

(mixed growth of aerobic and anaerobic organisms ).

3. Obstruction of the appendix lumen:

- Lymphoid hyperplasia
- Faecolith (composed of inspissated faecal
material, calcium phosphates, bacteria and
epithelial debris
- Stricture
- Foreign body(rare)
- Tumour, particularly carcinoma of the
caecum(middle age and elderly)
- Intestinal parasites, particularly Oxyuris
vermicularis

Pathology
- Lymphoid hyperplasia narrows the lumen  luminal obstruction.

- Continued mucus secretion and inflammatory exudation  increase

intraluminal pressure  obstructing lymphatic drainage  Oedema

- Mucosal ulceration

- Bacterial translocation to the submucosa.

- Resolution may occur (spontaneously/antibiotic therapy).

Or
- Condition progresses, more distension  venous obstruction & wall
ischaemia  bacterial invasion through the muscularis propria and
submucosa, producing acute appendicitis.

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 - Ischaemic necrosis  gangrenous appendicitis  free bacterial
contamination of the peritoneal cavity (peritonitis).

• Alternatively, the greater omentum and loops of small bowel become

adherent to the inflamed appendix, walling off the spread of peritoneal
contamination, and resulting in a phlegmonous mass or paracaecal abscess.

• Rarely, appendiceal inflammation resolves, leaving a distended mucus-filled

organ termed a ‘mucocoele’ of the appendix .

Risk factor foe perforation

 Extremes of age
 Immunosuppression
 Diabetes mellitus
 Faecolith obstruction of the appendix lumen
 Free-lying pelvic appendix
 Previous abdominal surgery

Diffuse peritonitis occurs as a result of:

- free migration of bacteria through an ischaemic appendicular wall
- frank perforation of a gangrenous appendix
- delayed perforation of an appendix abscess.
- In these situations, a rapidly deteriorating clinical course is accompanied by
signs of diffuse peritonitis and systemic sepsis syndrome.

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Clinical Diagnosis
History:
Symptoms:
1. Pain:
- In the beginning Poorly localised, colicky abdominal pain (midgut visceral
discomfort in response to appendiceal inflammation and obstruction).
- Then pain in periumbilical region.
- Central abdominal pain + anorexia, nausea and usually one or two episodes of
vomiting that follow the onset of pain.

With progressive inflammation of the appendix:

Shifting of pain: from central abdominal pain to right
iliac fossa (irritation of RIF parietal peritoneum) i.e.
visceral to somatic pain which is :
- More intense
- Constant
- Localized to right iliac fossa

Typically, coughing or sudden movement

exacerbates the right iliac fossa pain.

2. Anorexia
- Constant clinical feature, particularly in children.

Family history
- 1/3 of children with appendicitis have a first-degree relative with a similar
history .
- One half of acute appendicitis  classic visceral–somatic sequence of pain .

Signs
Temperature and pulse rate:
- After 6 hours, slight pyrexia (37.2–37.7°C) with a corresponding increase in
the pulse rate to 80 or 90 is usual.
- Changes of greater magnitude may indicate complications.
- Unwell patient with low-grade pyrexia
- Inspection of the abdomen limitation of respiratory movement in the lower
abdomen.
- localised abdominal tenderness

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 - Maximum at McBurney’s point.
- Muscle guarding.
- Rebound tenderness.

Asking the patient to cough or gentle

percussion over the site of maximum
tenderness will elicit rebound tenderness .

Pointing sign: The patient is asked to

point to where the pain began and where it
moved .

Rovsing’s sign: Deep palpation of the left

iliac fossa may cause pain in the right iliac fossa.

Psoas sign : passive extension of hip or

active flexion of hip against resistance pain. The patient will lie with the right hip
flexed for pain relief.

Obturator sign : hip flexion and internal rotation cause pain in the
hypogastrium (the obturator test).

Cutaneous hyperaesthesia may be demonstrable in the right iliac fossa

Two clinical syndromes of acute appendicitis:

1- Acute catarrhal (non-obstructive) appendicitis
2- Acute obstructive appendicitis:
- more acute course (abrupt).
- generalized abdominal pain from the start.
- Temperature normal.
- vomiting common.

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Special features according to position of the appendix
1- Retrocaecal appendicitis
- Rigidity is often absent.
- Application of deep pressure may fail to elicit tenderness
(silent appendix)
- Deep tenderness is often present in the loin, and rigidity
of the quadratus lumborum.
- Psoas spasm leading to flexion of the hip joint.
- Hyperextension of the hip joint may induce abdominal
pain (Psoas sign +ve).

2- Pelvic appendicitis
- More common in children
- Early diarrhoea (inflamed appendix in contact with the rectum).
- Complete absence of abdominal rigidity.
- Tenderness over McBurney’s point is also lacking.
- Deep tenderness can be made out just above and to the right of the
symphysis pubis.
- Rectal examination reveals tenderness in the rectovesical pouch or the pouch
of Douglas, especially on the right side.
- +ve Psoas & Obturator signs.
- Frequency of micturition (inflamed appendix in contact with the bladder).

3- Postileal appendicitis
The inflamed appendix lies behind the terminal ileum
(difficult to diagnose)
- Pain may not shift.
- Diarrhea is a feature.
- Marked retching.
- Tenderness, if any, is ill defined, although it may be
present immediately to the right of the umbilicus.

Special features according to age

Infants:-
- Rare in infants under 36 months of age.
- The patient is unable to give a history. Diagnosis is often delayed.
- Higher incidence of perforation and postoperative morbidity than older
children.

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 - Diffuse peritonitis can develop rapidly because of the under developed
greater omentum.

Children :-
- Vomiting is more common.
- Complete aversion to food.

The elderly
- Gangrene and perforation occur much more frequent.
- The abdominal clinical picture is not obvious even in the presence of
gangrenous appendicitis (lax abdominal walls or obesity)
- Clinical picture may simulate subacute intestinal obstruction.
- Higher mortality (coincident medical conditions plus the previous factors)

The obese
- Obesity can obscure and diminish all the local signs of acute appendicitis.
- Midline abdominal incision
- (Delay in diagnosis + technical difficulty of operating in the obese)
- Laparoscopy is particularly useful in the obese.

Pregnancy
Appendicitis is the most common extrauterine acute abdominal condition in
pregnancy.

- Delay in presentation:-
 Early non-specific symptoms often attributed to pregnancy).

 The physiologic leukocytosis of pregnancy (high as 16,000 cells/mm3).

 Obstetric teaching has been that the caecum and appendix are
progressively pushed to the right upper quadrant of the abdomen as
pregnancy develops during the second and third trimesters.

- Pain in the right lower quadrant of the abdomen remains the cardinal feature
of appendicitis in pregnancy.

- Fetal loss occurs in 3–5 % of cases, increasing to 20 % if perforation is found at

operation.

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Differential diagnosis
Children
1- Acute gastroenteritis and mesenteric lymphadenitis:
- The pain is diffuse, and tenderness is not sharply localized and cervical lymph
nodes might be enlarged.

2- Meckel’s diverticulitis:
- Signs may be central or left sided.

3- Intussusception:
- Appendicitis is uncommon before the age of two years, whereas the median
age for intussusception is 18 months.

4- Henoch–Schönlein purpura:
- Preceded by a sore throat or
respiratoryinfection.
- Abdominal pain can be severe.
- Ecchymotic rash, affecting the
extensor surfaces of the limbs and
on the buttocks.
- The face is usually spared.
- Microscopic haematuria is common.

5-Lobar pneumonia and pleurisy,

- Especially at the right base
- Abdominal tenderness is minimal.