ACUTE

APPENDICITIS
 Appendicitis
is nonspecific
inflammation of the inner
lining of the vermiform
appendix that spreads to
its other parts
 History
 Amyan performed an appendectomy in 1735
without anesthesia
 Melier in 1827 correctly ascribed the
inflammation of the appendix
 Reginald H. Fitz, an anatomopathologist at
Harvard, described appendicitis in 1886 and
advocated early surgical intervention
 The first surgeon who correctly diagnosed
acute appendicitis, performed appendectomy
and had the patient recover was Senn from
Canada, but his case was not reported until
1961
In 1889 McBurney described diagnostic and
therapeutic management of acute appendicitis
At the end of the 19th century the English
surgeon H. Hancock successfully performed
appendectomy in a patient with acute
appendicitis
Since 1987, many surgeons have begun to
treat appendicitis laparoscopically. This
procedure has been improved and
standardized
 Problem
 Acute appendicitis is one of the more
common causes of acute abdominal pain
 Acute appendicitis is the most common
acute surgical disease of the abdomen
 Statistics report that 1 of 5 cases of
appendicitis is misdiagnosed
 A normal appendix is found in 15-40% of
patients after an emergency appendectomy
The mortality is about 0.2% - 0.3%
The mortality rate is less than 1% if
appendicle perforation exists
Elderly patients have a mortality rate
that approaches 5%
Mortality rate 1-4% is reported in infants
because of the high frequency of
perforation caused by delayed diagnosis
related to the difficulties in distinguishing
appendicitis from other conditions in the
differential diagnosis
 Frequency
 The incidence of acute appendicitis is around
7% of the population in the United States and
in European countries
 In Asian and African countries, the incidence
is probably lower because of the dietary habits
 Рersons of any age may be affected, with
highest incidence occurring during the second
and third decades of life
 Appendicitis occurs more frequently in males
than in females, with a male-to-female ratio of
1.7:1
 Anatomy
The appendix is a wormlike extension of the
cecum, and its average length is 8-10 cm
(ranging from 2-20 cm). This organ appears
during the fifth month of gestation, and its
wall has an inner mucosal layer, 2 muscular
layers, and a serosa. Several lymphoid
follicles are scattered in its mucosa. The
number of follicles increases when
individuals are aged 8-20 years
 Various anatomical positions
 Retrocaecal position (commonest irregular
position —70%) — the appendix lies behind the
caecum although in majority of cases in an
intraperi­toneal location. Only in case of long
retrocaecal appendix the tip of the appen­dix
remains in me retroperitoneal tissue close to the
ureter
 Pelvic position (second most common irregular
position —25%)
 SubCaecal (2%)
 Subhepatic (3 %) — that means the tip of the
appendix is towards the liver
 Etiology
Appendicitis is caused by obstruction of the
appendical lumen
 The causes of the obstruction include lymphoid hyperplasia
secondary to irritable bowel disease (IBD) or infections (more
common during childhood and in young adults), fecal stasis and
fecaliths (more common in elderly patients), parasites (especially in
Eastern countries), or, more rarely, foreign bodies and neoplasms

 Lymphoid hyperplasia of the appendix may be related to Crohn

disease, mononucleosis, amebiasis, measles and respiratory
infections
 Etiology
 The bacteriology flora, customarily found in
acute appendicitis, is a mixed colonic flora
with both aerobic and anaerobic organisms.
 Most frequently seen organisms are Esch.
coli, enterococci, bacteroides (gram-
negative rod), non-haemolytic streptococci,
anaerobic streptococci and CI. Welchii
 Appendicitis usually has
3 stages
 Edematous stage. Appendicitis may have spontaneous
regression or may evolve to the second stage. The
mesoappendix is commonly involved with
inflammation
 Purulent (phlegmonous) stage. Spontaneous regression
rarely occurs. Appendicitis usually evolves beyond
perforation and rupture. Peritonitis may be possible
 Gangrenous stage. Spontaneous regression never
occurs
 Сlassification
As a result inflammation
process develop from
simple ( catarrhal or superficial)
appendicitis till
destructive appendicitis
(phlegmon, gangrene ) and
complicated appendicitis
 In our clinic we use Kolesov's
classification (1972)

 appendicular colic
 destructive appendicitis:

a) phlegmonic, b) gangrenous,
c) perforated
 complicate: a) appendicular mass, b)
appendicular absces, c) peritonitis, d)
pylephlebitis
 Clinical
 The disease begins with a sudden pain in the
abdomen. It is localized in a right iliac area,
has moderate intensity, constant character
and not irradiate. With 70 % of patients the
pain arises in epigastric area or other part
of abdominal cavity - it is an “epigastric
phase” of acute appendicitis. In 2–4 hours it
moves to the place of appendix existence
(the Kocher’s sing).
 Palpation
 Presence of peritoneal inflammation can be suspected
if cough or percussion on the abdominal wall causes
pain
 Systemic palpation will detect an area of maximum
tenderness which corresponds to the position of the
appendix and is usually located in the right lower
quadrant at or near McBurney's point
 Muscle guarding or resistance to palpation roughly
parallel to the severity of the inflammatory process
 Blumberg sign
 After pressing by fingers on a front
abdominal wall from the place of pain
quickly, but not acutely, the hand is
taken away. Strengthening of pain is
considered as a positive symptom in
that place.
 Rovsing 's sign
 Pain in the right lower quadrant is
complained of when palpation pressure
is exerted in the left lower quadrant.
Retrograde displacement of the colonic
gas strikes the base of inflamed
appendix.
 Psoas ( Roup's )sign
 This test is performed by having the patient
lie on his left side. The examiner men slowly
extends the patient's right thigh, thus
stretching the iliopsoas muscle. This will
produce pain to make the sign positive. This
indicates presence of irritative inflamed
appendix in close proximity to the psoas
muscle. This is possible in retrocaecal
appendicitis
 Obturator test
 Passive internal rotation of flexed right
thigh with the patient in supine
position will elicit pain. This positive
obturator sign is diagnostic of pelvic
appendicitis
 Rozdolsky’s sign
 Light percussion on McBurney's
point will elicit pain in case of early
appendicitis
 Sitkoysky’s sign
 Strengthening pain in the right
lover square in the position of
patient on the left side
 Dunphy sign
 Additional signs such as increasing
pain with cough
 Lab Studies
Complete blood cell count
 A mild elevation of WBCs (ie, >12,000/mL) is a common
finding in patients with acute appendicitis. In these
patients, leukocytosis occurs. Otherwise, the WBC count
has low specificity for appendicitis, and a number of
bacterial and viral diseases may also lead to leukocytosis
 In infants and elderly patients, a WBC count is especially
unreliable because these patients may not mount a normal
response to infection
 In pregnant women, the physiologic leukocytosis renders
the CBC count useless for the diagnosis of appendicitis
 Urine examination
 Urinalysis may be useful in differentiating
appendicitis from urinary tract conditions.
 Mild pyuria may occur in patients with
appendicitis because of the relationship of
the appendix with the right ureter
 Proteinuria and hematuria suggest
genitourinary diseases or hemocoagulative
disorders
 C-reactive protein

 C-reactive protein (CRP) has been reported

to be useful in the diagnosis of appendicitis.
This protein is physiologically produced by
the liver when bacterial infections occur
and rapidly increases within the first 12
hours
 Imaging Studies
Abdomen plain film
 There is no pathognomonic sings of
appendicitis in X-ray examination
 Plain films may show a faecolithat the
appendicular region
 A distended loop of small bowel in the right
lower quadrant may be seen
 Chest film
 It may be performed to exclude any
disease of the base of the right lung as
disease in this area may irritate the
spinal nerve to simulate the symptoms
of appendicitis
 Ultrasound
 A healthy appendix usually cannot be viewed
with ultrasound (US). When appendicitis
occurs, the US typically demonstrates a
noncompressible tubular structure of 7-9 mm
in diameter.
 Vaginal ultrasound alone or in combination
with transabdominal scan may be useful to
determine the diagnosis in women of
childbearing age.
 False-positive results may occur in patients
with Crohn disease. False-negative results are
frequent in patients with retrocecal appendix
 Diagnostic laparoscopy
It may be useful in selected cases (e.g.
infants, elderly patients, female
patients) to confirm the diagnosis
 If findings are positive, such
procedures should be followed by
definitive surgical treatment at the
time of laparoscopy
 Appendicular mass
 In majority of cases as soon as the appendix becomes
gangrenous, omentum and coils of small intestine
coyer the mflarned appendix all around. There is no
discrete collection pf pus inside. This is an attempt of
the nature to prevent general peritonitis even if
rupture of the ap­pendix occurs. Usually such
appendicular mass develops on die 3rd day after the
commencement of an attack of acute appendicitis. This
is a tender mass on the right iliac fossa. This mass
usually resolves by conservative treatment. In
untreated cases of when the patient does not react to
the conservative treatment such appendicular mass
may turn into an appendicular abscess and becomes
larger in size
 Apendicular abscess
 A progressive suppurative process in an ap­pendicular
mass forms an appendicular abscess walled off by the
omentum, inflamed caecum and coils of small intestine.
Such abscess may follow rupture of the appendix with the
expulsion of small content of the appendix distal to the
obsffuction. The caecal contents cannot come out due to
the occluding fee-coiitii. In such appendicular abscess there
may be variable pyrexia and slight increase in the pulse
rate. There is definite increase of the leucocyte count with
relative increase of polymorphonuclear cells. The
commonest site of the ab­scess is in the lateral pah of the
iliac fossa (from retrocaecal appendicitis). The second
common position is in the pelvis. In untreated cases lethal
form of peri­tonitis is produced by secondary rupture of
appendicular abscess
 Peritonitis
 Spreading peritonitis is the principal
cause of continuing mortality from
appendicitis and requires careful and
energetic treatment
 Pylephlebitis
 Ascending septic trombophlebitis portal venous
system (pylethrombophlebitis) is a grave but rare
complication of gangre­nous appendicitis. Septic
Clots from involved mesenteric veins produce
multiple pyogenic abscess in the liver. It is
heralded by chills, spiking fever, right upper
quadrant pain and jaundice. In infants and young
children, in young women, during pregnancy and
in the elderly appendicitis has got distinctive
clinical settings with some peculiarities which will
influence management of such cases of
appendicitis. So these cases and their peculiarities
are mentioned herewith
 Postoperative complications
 wound infection especially in patients
with gangrenous or perforated
appendicitis
 adynamic ileus

 cecal fistulas

 pelvic or abdominal abscess

 Follow-up care
 After hospital discharge, patients must have
a light diet and limit their physical activity
for a period of 2-6 weeks based on the
surgical approach (i.e., laparoscopic or open
appendectomy).
 The patient should be evaluated by the
surgeon in the clinic to determine
improvement and to detect any possible
complications