Appendix, APPENDICITIS

ACUTE APPENDICITIS
 ►LEARNING OBJECTIVES

Acute appendicitis

• What is it?

• What are the symptoms of it?

• How is it diagnosed?

• Why can it be difficult to diagnose appendicitis?

• What other conditions mimic appendicitis?

• How is appendicitis treated?

 APPENDICITIS, ACUTE

►INTRODUCTION
BACKGROUND
Appendicitis is a common and urgent surgical illness
with protean manifestations
 Appendicitis, Acute

►INTRODUCTION
BACKGROUND
No single sign, symptom, or diagnostic test
accurately confirms the diagnosis of appendiceal
inflammation in all cases
 APENDICITIS, ACUTE
BACKGROUND
INCIDENCE (FREQUENCY)

► Incidence of appendicitis is lower in cultures with a

higher intake of dietary fiber

• AGE
Incidence of appendicitis gradually rises from birth, peaks
in the late teen years, and gradually declines in the
geriatric years
 APENDICITIS, ACUTE

BACKGROUND
INCIDENCE (FREQUENCY)

SEX
The incidence of appendicitis is approximately
1.4 times greater in men than in women
Anatomy recall: lateral anterior wall of
abdomen, and vermiform appendix
 RIGHT LOWER QUADRANT

• CECUM
• APPENDIX
• RIGHT OVARY AND TUBE
• RIGHT URETER
 WHAT’S APPENDIX
• Located in the RLQ . Out pouching • Narrow tube • Rises
from the cecum. 2.5 cm below the ileocecal junction •
worm shaped • Generally 6-10 cm long, 1.5 cm wide

• The taeniae coli converge at the base of the

appendix • Wall contained lymphatic follicles
 APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY
• Appendicitis:
• What is it?
• Appendicitis means inflammation of the appendix

• What is inflammation?
A basic way in which the body reacts to infection,
irritation or other injury, the key feature being
redness, warmth, swelling and pain
How is appendicitis happened?
• Obstruction of the appendiceal lumen is the primary
cause of appendicitis
• *Obstruction of the lumen leads to distension of the
appendix due to accumulated intraluminal fluid
• * Ineffective lymphatic and venous drainage allows
bacterial invasion of the appendiceal wall. perforation
and spillage of pus into the peritoneal cavity
 APPENDICITIS, ACUTE
• ►PATHOPHYSIOLOGY

• ► Causes:
• The blockage (obstruction) may be due:

1) to thick mucus within the vermiform appendix

2) to stool (hard, fecalith) that enters the appendix from

the cecum

3) the lymphatic tissue in the appendix may swell and

block the appendix
 APPENDICITIS, ACUTE

• ►PATHOPHYSIOLOGY
• ► Causes:
• ► Parasites: e.g. :Schistosomes species
• Strongyloides species
• ► Diseases: Tuberculosis, and Tumors
 APPENDICITIS, ACUTE
► CLINICAL DIAGNOSIS

• HISTORY: Common symptoms of appendicitis

Typically history, begins with anorexia and

periumbilical pain followed by:

• Low-grade fever 38ºC or more , nausea, right lower

quadrant (RLQ) pain, and vomiting occurs in only 50%
of cases

► Migration of pain from the periumbilical area to the RLQ

is the most discriminating feature of the patient's
history
 APPENDICITIS, ACUTE
► CLINICAL DIAGNOSIS
• HISTORY
• Remember
• When vomiting occurs, it nearly always follows the onset
pain

• Vomiting that precedes pain is suggestive of intestinal

obstruction, and the diagnosis of appendicitis should be
reconsidered

• Absence of fever or high fever can occur

 APPENDICITIS, ACUTE
• ► CLINICAL DIAGNOSIS
• HISTORY:
• Remember
• Nausea is present in 61-92% of patients
• Anorexia is present in 74-78% of patients

• Diarrhea or constipation is noted in as many as 18%

of patients and should not be used to discard the
possibility of appendicitis
 APPENDICITIS, ACUTE
• ► CLINICAL DIAGNOSIS
HISTORY:
Remember
• Duration of symptoms is less than 48 hours in
approximately 80% of adults but tends to be
longer in elderly persons

• Approximately 2% of patients report duration of

pain in excess of 2 weeks

• A history of similar pain is reported in as many

as 23% of cases
 APPENDICITIS, ACUTE
• ► CLINICAL DIAGNOSIS

PHYSICAL EXAMINATION

► General Appearance (Inspection)

► Patient’s well built or not

► well or poorly nourished

► Mental state: Normal

► Facial expression: feel uncomfortable

► Skin and mucous membranes: pallor, Cyanosis, Eruptions,

Pigmentation
.
 APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Abdomen:
• INSPECTION
• Symmetric or not
• Postoperative scars (or not)
• Respiratory movements
• Visible peristalsis or not
• Dilatation of superficial veins (or not)
• Inguinal regions on both sides
 PHYSICAL EXAMINATION
• ► Palpation:
Gentle palpation (beginning at a site distant from the pain)

• RLQ tenderness is present in 96% of patients, but this is a

nonspecific finding (McBurney' Point)

• Rarely, left lower quadrant (LLQ) tenderness has been the

major manifestation in patients with *situs inversus or

• in patients with *a lengthy appendix that extends into the LLQ

 APPENDICITIS, ACUTE

• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Palpation
• The most specific physical findings are:
► Rebound tenderness
► Pain on percussion
► Guarding (tensing of the abdominal wall muscles)
 APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION
• ► Other confirmatory peritoneal signs
• The Rovsing sign
• ► RLQ pain with palpation of the LLQ
 Other confirmatory peritoneal signs
• The psoas sign: Pain on passive extension of the right
thigh (► retroperitoneal retrocecal appendix)
• Patient lies on left side
• Examiner extends patient's right thigh while applying
counter resistance to the right hip (asterisk)
 Other confirmatory peritoneal signs

The obturator sign Pain on passive internal rotation of the

flexed thigh (►pelvic appendix)
Examiner moves lower leg laterally
while applying resistance to the lateral side of the knee
(asterisk) resulting in internal rotation of the femur
 APPENDICITIS, ACUTE
• CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION

• ► Confirmatory peritoneal signs

• Dunphy’s sign: increased pain with coughing

• Flank tenderness: in lower quadrant (retroperitoneal retrocecal

appendix)
 APPENDICITIS, ACUTE
CLINICAL DIAGNOSIS
• PHYSICAL EXAMINATION

• ► Percussion:
• Point tenderness (RUQ)

• ► Auscultation
• Not helpful in making diagnosis

► Rectal examination
Is helpful in making clinical diagnosis of localized and
generalized peritonitis
 APPENDICITIS, ACUTE

• ► Differential Diagnosis
• The differential diagnosis of appendicitis is broad
• Gastrointestinal, Gynecologic, Pulmonary,
Genitourinary, Systemic and other diseases can
mimic appendicitis.

► Gastrointestinal: e.g. (Abdominal pain: cause

unknown, Cholecystitis, Crohn's disease, Diverticulitis,
Duodenal ulcer, Gastroenteritis, Intestinal obstruction
Intussusception, Meckel's diverticulitis and etc… )
 APPENDICITIS, ACUTE
• ► Differential Diagnosis
• ► Gynecologic: e.g.
• Entopic pregnancy, Endometriosis, Ovarian torsion, Pelvic
inflammatory disease, Ruptured ovarian cyst and etc…

► Systemic e.g.:
Diabetic, ketoacidosis, Porphyria ,Sickle cell disease etc..

• ► Pulmonary e.g.: Pleuritis, Pulmonary infarction

 APPENDICITIS, ACUTE

• ► Differential Diagnosis
• ► Genitourinary e.g.: Kidney stone , Prostatitis
Pyelonephritis, Testicular torsion, Urinary tract infection
etc..
• ► Other e.g.: Parasitic infection, Psoas abscess
Rectus sheath hematoma
 APPENDICITIS, ACUTE

► Laboratory Tests (studies) (white blood cell )

• The white blood cell (WBC) count is elevated
(greater than 10,000 per mm3) in 80% of cases
with Appendicitis

• Unfortunately, the WBC is elevated in up to 70%

of patients with other ► causes of right lower
quadrant pain

• Thus, an elevated WBC has a low predictive

value
 APPENDICITIS, ACUTE
• ► Laboratory Tests (Blood C-reactive protein
level)

• An elevated C-reactive protein level (greater than

0.8 mg per dL) is common in appendicitis
• Not sensitive and specific

Elevated C-reactive protein level in combination

with an elevated WBC are highly sensitive (97 to
100 percent)

• If all these findings are absent, the chance of

appendicitis is low
 APPENDICITIS, ACUTE
• Laboratory Studies (Tests) (Urinalysis)
• ► The test may demonstrate changes such as:
• Mild pyuria
• Proteinuria
• Hematuria
• This test serves more to exclude urinary tract
causes of abdominal pain than to diagnose
appendicitis
• ► Imaging Studies (Radiologic Evaluation)
• The options for radiologic evaluation of patients with
appendicitis have expanded in recent years

A) Computer tomography scan

B) Ultrasonography (US scan)
C) Plain film (visualization of appendicolith)

Other test: Barium enema

Radionuclide scanning

Diagnostic Laparatomy
 SB
>3cm

C
Ileocecal valve
APPENDICITIS!
• ► Imaging Studies (Radiologic Evaluation)
• Abdominal CT- most important

1- Appendix > 6 mm diameter in diameter

2- Superior sensitivity- 97-100%
3- Specificity- 91-99%
4- Non invasive
5- Ability to detect alternative Dx’s
6- Dicrease negative laparatomy rate and appendiceal
perforation
• ► Imaging Studies (Radiographic Evaluation)

• Ultrasonography (US)
• 1) Outerdiametre > 6 mm
• 2) Noncompressibility
• 3) Presence of peritoneal fluid collection
• 4) Normal appendix usually not visualized
• ► Imaging Studies (Radiographic Evaluation)

• Plain Films-KUB
• 1) Visualization of appendicolith (10% of cases)

• Consensus is that:
• 2) Not sensitive
• 3) Nonspecific
• 4) Not cost effective
 APPENDICITIS, ACUTE

• Special Considerations
• young children
• While appendicitis is uncommon in young children, it
poses special difficulties in this age group

• 1) Young children are unable to relate a history

• 2) Often have abdominal pain from other causes and
• 3) May have more nonspecific signs and symptoms

• These factors contribute to a perforation rate

 APPENDICITIS, ACUTE
• Special Considerations
Pregnancy
1) In pregnancy, the location of the appendix begins to shift
significantly by the fourth to fifth months of gestation

2) Common symptoms of pregnancy may mimic appendicitis

3) The leukocytosis of pregnancy renders the WBC count less

useful

4) As in nonpregnant patients, appendectomy is the standard

for treatment
• Special Considerations
• Elderly
Elderly patients have the highest mortality rates

1) The usual signs and symptoms of appendicitis may be:

diminished
atypical or
absent in the elderly
which leads to a higher rate of perforation

2) More frequent perforation combined with a higher incidence of

other medical problems and less reserve to fight infection
contribute to a mortality rate
 APPENDICITIS, ACUTE
• Treatment
• The standard for management of nonperforated
appendicitis remains appendectomy

• Because prompt treatment of appendicitis is important in

preventing further morbidity and mortality

• Appendectomy may be performed by:

* laparotomy (Open) (usually through a limited right

lower quadrant incision) or

* laparoscopy
• Complications
• Appendiceal rupture
• Accounts for a majority of the complications of appendicitis
• (peritonitis)

• Factors that increase the rate of perforation are:

• Delayed presentation to medical care

• Age extremes (young and old)

• Hidden location of appendix

 APPENDICITIS, ACUTE
• Complications
• A periappendiceal abscess
• It may be treated immediately by:
Surgery or by
Nonoperative management
• Nonoperative management consists of:
Parenteral antibiotics with observation or
US or CT-guided drainage

• followed by interval appendectomy six weeks to three

months later
• Complications
• Hemorrhage
• Gangrene
•
Thanks