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This entry was posted by Sulav Shrestha on July 9, 2011 at 2:11 pm and filed under
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Anatomy of Appendix and Appendicitis


July 9, 2011 | 2:11 pm | Anatomy | No Comment

Also called as vermix, vermiform appendix is


a narrow vermin (worm shaped) tube arising from the posteromedial aspect of the cecum (a
large blind sac forming the commencement of the large intestine) about 1 inch below the
iliocecal valve. Small lumen of appendix opens into the cecum and the orifice is guarded by a
fold of mucous membrane known as valve of Gerlach. The 3 taenia coli (taenia libera,
taenia mesocoli and taenia omental) of the ascending colon and caecum converge on the base
of the appendix.
Although the appendix serves no digestive function, it is thought to be a vestigial remnant of
an organ that was functional in human ancestors.
The length varies from 2 to 20 cm with an average of 9 cm with diameter of about 5mm. It is
longer in children compared to adults. In the fetus it is a direct outpouching of the caecum,
but differential overgrowth of the lateral caecal wall results in its medial displacement.
The appendix is suspended by a small traignular fold of peritoneum, called the
mesoappendix.
Clinical

Inflammation of the appendix is known as the appendicitis. Acute appendicitis


is a common cause of abdominal pain requiring surgery, particularly in the
West where there is low roughage diet. Appendicitis usually follows
obstruction of the lumen with distal infection and ulceration. The usual
causes are: fecolith, calculi, foreign body, tumor, worms (Oxyuriasis
vermicularis), diffuse lymphoid hyperplasia, vascular occlusion, inadequate
dietary fiber intake, etc.

The lumen of the appendix is relatively wide in the infant and is frequently
completely obliterated in the elderly. Since obstruction of the lumen is the
usual precipitating cause of acute appendicitis it is not unnatural,therefore,
that appendicitis should be uncommon at the two extremes of life. It is seen
more commonly in older children and young adults.

Location of Appendix:

Right lower quadrant of abdomen and more specifically right iliac fossa.
McBurneys point lying at the junction of lateral one-third and the medial two-thirds
of the line joining the umbilicus to the right anterior superior iliac spine roughly
corresponds to the position of the base of the appendix.

McBurneys point is the site of maximum tenderness in appendicits.

Clinical

Examination of a case of acute appendicitis reveals following physical signs:


1. Hyperaesthesia in the right iliac fossa
2. Tenderness at McBurneys point
3. Muscle guard and rebound tenderness over the appendix

Appendicectomy is usually performed through a muscle-splitting incision in


the right iliac fossa. The caecum is delivered into the wound and, if the
appendix is not immediately visible, it is located by tracing the taeniae coli
along the caecumthey fuse at the base of the appendix. When the caecum is
extraperitoneal it may be difficult to bring the appendix up into the incision;

this is facilitated by first mobilizing the caecum by incising the almost


avascular peritoneum along its lateral and inferior borders.
Variations in Appendix position:
Although the base of the appendix is fixed, the tip can point in any direction. Hence, the

position of the appendix is


extremely variable.
The appendix is the only organ in the body which is said to have no anatomy. When
compared to the hour hand of a clock, the positions would be:
1. 12 o clock: Retrocolic or retrocecal (behind the cecum or colon)
2. 2 o clock: Splenic (upwards and to the left Preileal and Postileal)
3. 3 o clock: Promonteric (horizontally to the left pointing the sacral promontory)
4. 4 o clock: Pelvic (descend into the pelvis)
5. 6 o clock: Subcecal (below the cecum pointing towards inguinal canal)
6. 11 o clcok: Paracolic (upwards and to the right)
Most common position of appendix (75% of cases): Retrocecal
Second most common position of appendix (20% of cases): Subcecal
If the appendix is very long, it may actually extend behind the ascending colon and abut
against the right kidney or the duodenum; in these cases its distal portion lies
extraperitoneally.
Clinical
The location of the tip of the appendix determines early signs and symptoms of appendicitis.

Retrocecal: Extension of the hip joint may cause pain because the appendix is
disturbed by stretching of the psoas major muscle. Pain usually localizes in
the right flank.
Pelvic: Pain may be felt when the thigh is flexed and medially rotated,
because the obturator internus is stretched. Pelvic appendix may irritate the

bladder or rectum causing suprapubic pain, pain with urination, or feeling the
need to defecate.

Retroileal: In some males, it can irritate the ureter and cause testicular pain.

Pregnancy: the appendix can be shifted and patients can present with RUQ
(Right upper quadrant) pain.

Arterial Supply:
1. Appendicular artery: The mesoappendix, containing the appendicular branch of the
ileocolic artery (branch of superior mesenteric artery), descends behind the ileum.
2. Accessory appendicular artery: An accessory appendicular artery can branch from
the posterior cecal artery which is also a branch of ileocolic artery.
Clinical

Acute infection of the appendix may result in thrombosis of the appendicular


artery with rapid development of gangrene and subsequent perforation.
The accessory appendicular artery can lead to significant intraoperative and
postoperative hemorrhage and should be searched for carefully and ligated
once the main appendicular artery is controlled.

Venous drainage:
Appendicular vein > Ileocolic vein > Superior mesenteric vein > Portal vein
Lymphatic drainage:

There is abundant lymphoid tissue in its walls.


From the body and apex of the appendix 8-15 vessels ascend in the mesoappendix and
are ocasionally interrupted by one or more nodes > unite to form 3 or 4 larger vessels
> inferior and superior ileocolic nodes

A few of them pass indirectly through the appendicular nodes situated in the
mesoappendix.

Clinical
Appendicular dyspepsia: Chronic appendicits produces dyspepsia resembling disease of
stomach, duodenum or gall bladder. It is due to passage of infected lymph to the subpyloric
lymph nodes which causes irritation of pylorus.

Nerve supply:
1. Sympathetic nerves: T9 and T10 spinal segments through the celiac plexus
2. Parasympathetic nerves: Vagus
Clinical
Both the appendix and the umbilicus are innervated by segment T10 of the spinal cord and
hence the pain caused by appendicitis is first felt in the region of umbilicus (referred pain).
With increasing inflammation pain is felt in the right iliac fossa due to involvement of the
parietal peritoneum of the region which is sensitive to pain in contrast to pain insensitive
visceral peritoneum.
Histology: Inside to outside

1. Mucosa:

No villi
Epithelium invaginates to form crypts of Liberkuhn but the crypts do not occur as
frequently as in the colon

Muscularis mucosae is ill defined

2. Submucosa:

Large accumulations of lymphoid tissue in the lamina propria and submucosa. Hence
appendix is also called abdominal tonsil.
There is often fatty tissue in the submucosa.

3. Muscularis externa:

Thinner than in the remainder of the large intestine


Comprises 2 layers: Inner circular muscle layer and Outer longitudinal muscle layer

Outer longitudinal smooth muscle layer does not aggregate into taenia coli

4. Serosa and peritoneum


Clincial:
The submucosal lymphoid follicles enlarge, peak from 12-20 years, and then decrease. This
correlates with the incidence of appendicitis. Enlarged or hyperplastic lymhoid follicles
contribute to the obstruction of small lumen of appendix.
Pathology:
In acute appendicitis, the microscopy of cross section of appendix reveals:
1. Fibrin on peritoneal surface
2. Neutrophil exudate in lumen
3. Neutrohpil exudate spreads in submucosa and soon affects all layers
Tags: Appendicitis, Appendix

Last updated: July 9, 2011


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