APPENDICITIS

By : Norfarhana binti Azahri 1301-1211-3535

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ANATOMY

Vermiform appendix. Length : 8-10 cm. Vascularization :

Ileocolic artery appendicular artery. Ileocolic vein, right colic vein portal vein. Ileocolic nodes.

Venous drainage :

Lymphatic drainage :

DEFINITION
Appendicitis

is the swelling (inflammation) of the inner lining of the vermiform appendix. The appendix is a small pouch attached to the beginning of the large intestine.

PATHOPHYSIOLOGY
Lumen obstructed (infection, foreign body, neoplasm, fecalith) Increased pressure within lumen Continuous secretion of fluids and materials from the mucosa Stagnation, multiplication of bacteria Recruitment of WBCs Formation of pus

STAGES OF APPENDICITIS
EARLY STAGE OF APPENDICITIS Mucosal edema. Mucosal ulceration. Bacterial diapedesis. Appendiceal distention due to accumulated fluid. Increasing intraluminal pressure. Mild visceral periumbilical or epigastric pain, which usually lasts 4-6 hours.

STAGES OF APPENDICITIS
SUPPURATIVE APPENDICITIS Classic shift of pain from the periumbilicus to the right lower abdominal quadrant (RLQ). Continuous and more severe than the early visceral pain.

STAGES OF APPENDICITIS
GANGRENOUS APPENDICITIS Intramural venous and arterial thromboses ensue, resulting in gangrenous appendicitis. PERFORATED APPENDICITIS Localized or generalized peritonitis.

STAGES OF APPENDICITIS
PHLEGMONOUS APPENDICITIS OR ABSCESS
SPONTANEOUSLY RESOLVING APPENDICITIS RECURRENT APPENDICITIS

CHRONIC APPENDICITIS

History of RLQ pain of at least 3 weeks duration without an alternative diagnosis. After appendectomy, the patient experiences complete relief of symptoms. Histopathologically, the symptoms were proven to be the result of chronic active inflammation of the appendiceal wall or fibrosis of the appendix.

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APPENDICITIS

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ANAMNESIS
History

taking :

Pain typically starts at the mid-abdominal region and later (1-12 hours) shifts to the right lower quadrant. Pain is usually constant with intermittent abdominal cramps. Pain becomes worse on movement and coughing

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ANAMNESIS
Location

of pain vary depends on location of appendix :

Retrocaecal appendix flank or back pain Retroileal appendix testicular pain due to irritation of the spermatic artery or ureter Pelvic appendix suprapubic pain A long appendix with tip inflammation in the left lower quadrant may cause pain to that region.

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ANAMNESIS
Other

accompanied symptoms :

Anorexia. Nause and vomiting. Severe constipation late feature

Sequences

of presentations : :

Anorexia abdominal pain vomiting Nausea, vomiting, local peritonitis

Pregnancy

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PHYSICAL EXAMINATION
INSPECTION Body temperature may slightly increased. PALPATION Classic signs :

Right lower quadrant abdominal tenderness (McBurney's sign). Localised rebound tenderness. Pain in the right lower quadrant after compressing the left lower quadrant (Rovsing's sign).

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PHYSICAL EXAMINATION
AUSCULTATION Decreased bowel sound. OTHERS Pain when :

Patient lying on their left side and slowly extending the right thigh to cause a stretch in the iliopsoas muscle (psoas sign). Internal rotation of the flexed right thigh (obturator sign) inflamed appendix is located deep in the right hemipelvis.

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MANTRELS SCORING
Scores

0-3

Discharged without imaging. CT evaluation.

4-6

7-10

Surgical consultation.

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FURTHER INVESTIGATIONS
Rectal

examination tenderness on the right side of rectum. USG/abdominal CT scan. Urinalysis exclude any UTIs/renal colic.

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TREATMENT
Appendectomy
Granular roughened serosa with marked congestion at tip (yellow arrow). Grey yellow purulent exudate on the surface (green arrows). Marked increase in diameter.

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COMPLICATIONS
Abnormal

connections between abdominal organs or between these organs and the skin surface (fistula). Abscess. Blockage of the intestine. Infection inside the abdomen (peritonitis). Infection of the surgical wound.

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