The appendix

 Anatomy of the appendix:

• The appendix is an intraperitoneal, narrow, muscular tube attached to the posterior medial
surface of the cecum, 2.5 cm below the ileocecal valve.
• Length= 7.5 -10 cm.
The appendix has many locations in relation to the cecum, which are:

1-Retrocecal (64-70%).
2-Pelvic (32%).
3-Subcecal (2%).
4-Preileal (1%).
5-Postileal (0.5%).

• The location of the appendix affects the presenting symptoms and physical findings. So, you
may ask why there are different sites for the appendix?
• Answer: At birth, the appendix is short and broad at its junction with the caecum, but
differential growth of the caecum produces the typical tubular structure by about the age
of 2 years. During childhood, continued growth of the caecum commonly rotates the
appendix into a retrocecal but intraperitoneal position. In approximately one-quarter of
cases, rotation of the appendix does not occur, resulting in a pelvic, subcecal or paracecal
position.
• Arterial supply of the appendix: from the appendicular artery.
Abdominal aorta >>> SMA >>> ileocolic artery >>> posterior cecal artery >>> appendicular
artery (passes behind the terminal ileum).
• Venous drainage: to the posterior cecal vein >>> SMV >>> portal vein >>> hepatic sinusoids >>
central veins >>> hepatic veins >>> IVC.
• Question: during a surgery, if the appendix is not found, what can the surgeon do to locate
the appendix?
Answer: use the base of the appendix as a guidance, because the position of the base of the
appendix is constant, being found at the confluence of the three taeniae coli of the caecum,
which fuse to form the outer longitudinal muscle coat of the appendix, and by gentle traction
on the taeniae coli, particularly the anterior taenia, this will lead the operator to the base of
the appendix.

 Appendicitis:
 appendicitis is the most common acute surgical emergency and appendectomy is the most
 common surgical procedure.
-Causes of appendicitis:
1-Fecalith (more common in adults).
2-Lymphoid hyperplasia (more common in children).
3-Tumor of the appendix (particularly carcinoma) >> in middle-aged and elderly.
4-Seeds of fruits or vegetables.
5-Intestinal parasites (Oxyuris vermicularis).

-Pathophysiology of appendicitis:
If obstruction occurs >>> continued mucus secretion and inflammatory exudation increase
intraluminal pressure >>> obstructing lymphatic drainage >>> edema and mucosal ulceration
develop with bacterial translocation to the submucosa (resolution may occur at this point
either spontaneously or in response to antibiotic therapy) >>> If the condition progresses >>>
further distension of the appendix may cause venous obstruction and ischemia of the
appendix wall >>> With ischemia, bacterial invasion occurs through the muscularis propria
and submucosa, producing acute appendicitis >>> finally ischemic necrosis of the appendix
wall produces gangrenous appendicitis, with free bacterial contamination of the peritoneal
cavity.

• Diagnosis of acute appendicitis:

1-History:
a-Begin with poorly localized colicky abdominal pain (in the periumbilical region, if you ask the
patient where is the pain, he will point to the periumbilical region rather than a specific point).
b-Anorexia: you can use hamburger sign by asking the patient what is his/her favorite meal and
whether he/she wants to eat it now >>> used to rule out appendicitis.
c-Nausea: very common symptom that accompanies abdominal pain regardless of the underlying
pathology.
d-Usually one or two episodes of vomiting that follow the onset of pain: common in children and
in obstructed appendix.
e-Pain shifted to RIF. so why pain is firstly felt in the periumbilical region then migrates to the
RIF?
Answer: because the appendix is a midgut structure, and midgut structure pain is felt in the
periumbilical region (visceral pain). when irritation of parietal peritoneum occurs, the pain shifts
to the RIF (somatic pain), and now the patient can point to a specific point when you ask him
about pain. Also, the patient may avoid coughing or moving because they may exacerbate the
pain.

f-Other symptoms:
1-Constipation: in middle aged and elderly.
2-Diarrhea: occurs in:
a-Pelvic appendicitis due to irritation of the rectum (with tenesmus).
b-Pre or post-ileal appendicitis due to irritation of the terminal ileum.
3-Bloating: with inability to pass wind due to inflammation.
4-Urinary symptoms: when the tip of the appendix is in contact with the bladder, it can lead to
frequency and dysuria. Also, retrocecal appendicitis can cause right ureter irritation and urinary
symptoms.
5-In females: you must ask about the following:
a-Menstrual cycle: to rule out gynecological causes
b-Missed period: it could mean ectopic pregnancy.
c-PID.
d-Vaginal discharge, backpain: they could be signs of endometriosis.
*Note: The shifting of the pain from the periumbilical region to the RIF is present in only half the
cases of acute appendicitis. There may be an atypical presentation that include pain that is
predominantly somatic or visceral and poorly localized. Atypical pain is more common in the
elderly, in whom localization to the right iliac fossa is unusual.
2-Physcial examination (signs): the diagnosis of appendicitis rests more on thorough clinical
examination of the abdomen than on any aspect of the history or laboratory investigation. The
cardinal features are those of:
1-Unwell patient that is lying flat and doesn’t move to prevent pain and flexing the right leg to
relax the psoas muscle (to prevent irritating the appendix).
2-Localised abdominal tenderness, muscle guarding and rebound tenderness (gentle superficial
palpation of the abdomen, beginning in the left iliac fossa and moving anticlockwise to the right
iliac fossa, will detect muscle guarding over the point of maximum tenderness, classically
McBurney’s point (which is 1/3 of the distance from ASIS to the umbilicus) + asking the patient to
cough or gentle percussion over the site of maximum tenderness will elicit rebound tenderness).
3-Inspection of the abdomen may show limitation of respiratory movement in the lower
abdomen.
4-You may ask the patient to point to where the pain began and where it moved (the pointing
sign).
5-Low-grade pyrexia (37.5-38.5) >>> if it’s higher, think of 2 things:
a-Another pathology. b-Complicated appendicitis.
*Notes about point 2:
1-Guarding occurs in any inflamed intraabdominal organ.
2-Rigitidy usually indicates generalized peritonitis secondary to perforation.
3-If the appendix is not in the location (McBurney’s point), the area of tenderness may be located
in other sites, such as:
a-Lower inguinal / suprapubic areas: in pelvic appendix (when the appendix is located entirely in
the pelvic region >>> there is usually complete absence of abdominal rigidity, and often
tenderness over McBurney’s point is also lacking).
b-RUQ / subhepatic pain: rarely, the cecum doesn’t migrate to its normal position during
development (to the RIF) >>> in these circumstances, the appendix may be found near the
gallbladder >>> causes RUQ / subhepatic pain.
c-LIF pain: in case of intestinal malrotation >>> appendix may be found in the LIF.
d-VERY IMPORTANT: in cases of pregnancy >>> the appendix is pushed to the RUQ as pregnancy
develops during the 2nd and 3rd trimesters >>> so, tenderness may be felt in RUQ rather than
McBurney’s point (don’t forget that in pregnancy you are dealing with 2 lives >>> the risk of fetal
loss is 4% and the risk of premature delivery is 10%).
-Special signs and maneuvers to elicit in appendicitis:
1-Cough (Dunphy’s sign): ask the patient to cough while lying down and see where the pain
localizes (in appendicitis it should localize to McBurney’s point).
2-Rovsing’s sign: if palpation of the left lower quadrant of a person's abdomen increases
the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing's
sign and may have appendicitis.
-Question: Why this occurs?
Answer: the abdomen is a tight compressed space, when you press in the LIF you will move
the content to the right, this will move the ileocecum and appendix with it which will hit
the abdominal wall causing pain if it’s inflamed.
3-Psoas sign: The psoas muscle originates from the transverse process of L1-4 and inserts in
the lesser trochanter of the femur. So, if the appendix is retrocecal, it will rest on this
muscle. If you stretch this muscle it will hit the appendix and elicit pain. it’s elicited by
having the patient lie on his or her left side while the right thigh is extended (flexed
backward). (https://www.youtube.com/watch?v=m4ldpvIYEDM)
4-Obturator sign: Pelvic appendix might be in contact with obturator internus muscle, so
it’ll elicit pain if we move it and the appendix is inflamed. Elicited by flexion of the hip
and internal rotation. (https://www.youtube.com/watch?v=6LrL4ysi_AE)
*Note: digital rectal exam (DRE) is important when you suspect a pelvic appendicitis
(tenderness is lower than Mcburney’s pint, usually at the pubic symphysis and
accompanied by tenesmus and diarrhea).
-Alvarado score: clinical scoring system used in the diagnosis of appendicitis.

3-Investigation: order the following tests:

a-CBC: leukocytosis with left shift + neutrophilia.
b-Urine analysis: to rule out UTI.
c-Pregnancy test (β-HCG): to rule out ectopic pregnancy.
d-Imaging:
1-US: at McBurney’s point, it will show blind-ended edematous tubular structure that is not
compressible (tender).
2-CT: to confirm or exclude the diagnosis of appendicitis and helps to find out if there is another
pathology in the pelvis (it’s more used nowadays).
*Note: contrast-enhanced standard dose CT is especially useful in patients in whom there is
diagnostic uncertainty, particularly older patients, where acute diverticulitis, intestinal
obstruction and neoplasm are likely differential diagnoses.
-Differential diagnosis of acute appendicitis:
1-Mesentric lymphadenitis: enlarged mesenteric lymph nodes in ileocecal region leading to
similar findings to acute appendicitis. Common in children, and during spring and autumn
(seasons of viral infections) which is similar to appendicitis.
-Question: how can you differentiate between acute appendicitis and mesenteric
lymphadenitis?
Answer: by using the differentiating test [Shifting tenderness]: On lying flat, both acute
appendicitis and mesenteric lymphadenitis are tender at McBurney’s point. When the
patient is turned to his left side tenderness is slightly shifted to the left in mesenteric
lymphadenitis because mesentery is mobile, but in acute appendicitis, tenderness remains at
McBurney’s point because the cecum is fixed.
2-Meckel’s diverticulitis: Meckel’s diverticulum is a remnant of the vitello-intestinal
tract that extends from the terminal ileum to the umbilicus which is 2-feets from
ileocecal region, 2 inches long, and found in 2% of the population (Rule of 2). When the
diverticulum gets inflamed it leads to similar findings to acute appendicitis.
3-Crhon’s disease: Increasing in incidence with similar findings to acute appendicitis. On
endoscopy, you’ll fine thickened ileum and mesentery.
4-Leaking duodenal ulcer: due to perforation, duodenal content goes below the liver, seep into
the right paracolic gutter reaching the right iliac fossa causing localized tenderness [Valentino
appendicitis].
5-Female pathology: take a careful history of the menstrual period, vaginal discharge, back pain.
Some differential diagnosis: ruptured ectopic pregnancy, twisted ovarian cyst, ovarian tumor,
etc.
6-Familial Mediterranean Fever (FMF): Medical disease (non-surgical) that presents with similar
symptoms of acute appendicitis.

-Complications of acute appendicitis:

1-Perforation: leading to localized or generalized peritonitis. Early perforation may
occur, mainly in children (because the omentum is not well developed) and elderly
(because the omentum is atrophic), and therefore must be diagnosed and dealt with
them very early.
2-Appendicular mass: tender mass in the right iliac fossa. Due to micro-perforation; the
appendix, omentum, cecum, and terminal ileum get together. (No peritonitis, late
diagnosis).
3-Appendicular abscess.
4-Portal pyemia (which is infection of the portal vein): venous drainage of abdomen goes
to the portal circulation. If there was a bacterium, it may lead to infection/abscess, which
may occur in appendicitis and diverticulitis, but now this is rarely seen due to better
diagnosis and stronger antibiotics.
5-Mucocele: goblet cells secreting mucous in an obstructed appendix >>> bad because if
ruptured during surgery, malignant mucous cells become precipitated all over the
peritoneum leading to what is called [pseudomyxoma peritonei] that presents with
recurrent obstructions, adhesions, etc.
*Notes about complications:
1- Complications are more at the extremes of age.
2-Difficult diagnosis:
a-When the appendix is located at the subhepatic location (due to incomplete rotation of
bowel (cecum directly below liver)).
b-Obesity: finding will not be clear  late diagnosis & treatment  higher risk of
complications.
c-Diabetes: due to neuropathy.
d-Analgesics intake.
-Treatment of appendicitis:
1-Appendicetomy for acute appendicitis:
open or laparoscopic, but laparoscopic is
better.
2-For appendicular mass: Oschner-Sherren
regimen, which includes the written in the pic
on the right.
3-For appendicular abscess: drainage.

*Notes about treatment:

1-Always use broad spectrum antibiotics (cephalosporins + flagyl [metronidazole]
because Bacteroides are a common cause of appendicitis).
2-If the patient is responsive to conservative treatment (general condition improvement,
decreased pain and mass size, no fever, vomiting or tachycardia), then an [Interval
appendectomy] is performed, that is; you discharge the patient and the surgery will be
scheduled on 8-weeks after initial onset.
3-If the patient did not improve on conservative treatment (increased temperature,
constant pain, vomiting, obstructed and increased mass size), then it is considered as an
abscess and confirmed by CT scan that shows a collection of pus within the mass, and a
CT or US guided percutaneous drainage is applied alongside the antibiotics.
4-If a right iliac fossa mass persists (more than 2-3 weeks) after conservative treatment,
consider the possibility of cancer of the cecum or Crohn's disease.
 -Question: What to do if the appendix is found to be normal at surgery?
1-We always remove the appendix, because if the patient comes back again complaining of RIF
pain, the doctors will think that the appendix is removed when they see the scar.
2-Inspect 2 feet of the terminal ileum (to rule out Meckel’s diverticulum or Crohn's disease).
3-Look for any pelvic pathology (females).
4-Ensure that there is no pus in the peritoneal cavity (perforation).
*Note: there may be an accidental finding regarding the appendix which is carcinoid tumor of
the appendix (secretes serotonin) >>> the approach depends on the size and location of the
tumor:
1-If it’s 1cm or less and located at the tip of the appendix >>> appendectomy.
2-If it’s 2 cm or more and located at the base of the appendix >>> right hemicolectomy.

-Read only notes from the doctor’s slides:

1- Stump Appendicitis: when the appendix isn’t totally removed (around 60 reported
cases) >>> symptoms usually occur 9 years after surgery >>> results from inflammation
of a long stump.
2- Incidental Appendectomy: in:
a-Children about to go to chemotherapy.
b-Disabled patients who cannot describe their symptoms.
c-Crohn's disease when the caecum is not involved.
d-Travel to remote areas.
3- HIV and Appendicitis: higher incidence than the normal population + higher incidence
of early perforation + do not manifest leukocytosis.
4- Amyand’s Hernia: the cecum is adherent to the wall of hernial sac.