Dr A.

Badrek-Amoudi FRCS

ABA-The Appendix- 4th year

Lectures
 A 15 year old girl presents with a right lower abdominal
pain.
A 6 year old boy with a history of sore throat presents
with lower abdominal pain
A 45 year old man presents with a sudden onset of
epigastric pain localised to RIF

1. How do you diagnose appendicitis.

2. What are the classical and atypical features of
appendicitis
3. Are investigations always needed and what is their role
4. How do you prepare your patient prior to surgery
5. What are the surgical approaches
6. How do you care for your patient after surgery

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Introduction
1889 Mac Burney described location,
the clinical features of appendicitis and
the importance of operative intervention
and muscle-splitting incision.

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Surgical Anatomy
Surface anatomy
Development: diverticulum of ceacum appearing
in the 8th week of life
Positions: constant base, tip varies (retroceacal,
pelvic, subcaecal, preileal, pericolic)
Blood supply
Location during surgery
Surrounding anatomical structures
Part of the gut lymphoid tissue.

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Acute Appendicitis
Epidemiology
Most common surgical emergency.
Slightly more common in men.
Incidence are falling from 100 to 50 in 100 000 (1975-1991).
1 in 6 of the population will have an appendectomy.
In Saudi Arabia incidence are comparable to western figures
? More common in European societies (Diet).
? Relation to class status.
Age > 2 yrs, (associated with lymphoid development).
Up to 16% of appendicectomies are normal 75% are in women

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Acute Appendicitis
Pathology I
Luminal obstruction.
Lymphoid hyperplasia 60%
Faecolith 35%.
Inspissated barium.
Fruit seeds. }<4%
Worms. < 1%
Extra-luminal obstruction eg Ca Cecum

Raised intra-luminal pressure

Mucus accumulation
Multiplication of bacteria.
( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)
Venous and lymphoid congestion and.

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Acute Appendicitis
Pathology II
Impaired arterial flow, thrombosis and gangrene.
Perforation may occur through devitalized tissue.

Histological terms used:

Catarrhal appendicitis
Suppurative ;;;
Necrotic ;;;
Gangrenous ;;;
Perforated ;;;
Appendicular mass

The risk of perforation is not inevitable.

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Clinical Features I
Full History Duration, severity, onset, System review.
and examination: General, throat, chest..etc

Only 55% have classical features.

Atypical 45%
History 24-36 hours
Abdominal pain:
(diffuse and periumbilical, localizing to the RIF)
Anorexia (almost always).
Vomiting (75%).
Low grade fever.
If >38 suspect perforation
Tenderness, guarding and rebound: Be gentle
Rovsings, psoas, obturator signs: unreliable and late
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Clinical Features II
Tender Appendicular mass
Atypical:
(loin, high RUQ, deep pelvic)
Diarrhea ( not always gastroenteritis)
Urinary frequency
The Extremes of Age:
Children < 5 rapid progression
Pain in the elderly is less intense

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Investigations
White cell count: high sensitivity 96%, low specificity
Urine analysis
Plain Xray, nonspecific
Ultrasound highly sensitive (80-90%), excludes
other pathologies.
Computer Tomography: More superior to USS in diagnostic
accuracy.
Barium enema: Good accuracy, but technically
difficult and false positives are common.
Laparoscopy
Active observation
Computer aided diagnosis.
Peritoneal lavage

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The Very Young
Diagnosis may be more difficult to
establish, WBC is likely to be normal
(12% are normal).

Children are more likely to progress to

perforated appendix
(? Under-developed Greater Omentum).

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The Very Old
Greater morbidity and mortality
Less typical presentation
Cancer may be a possibility as an
underlying cause.
Perforation of 50% and mortality of
20% has been reported

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The Pregnant
Implications: Clinical Findings, Lab Ix, Surgery
1: 2000 pregnancies.
More common in the first two trimesters
The appendix is pushed superiorly and laterally
WBC > 15
Premature Labor 10-15% with surgery
Perforated appendix leads to fetal death in 20%
Rapid diagnosis and treatment is advised.

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In AIDS Patients
Be aware of CMV or Kaposi sarcoma as
the underlying cause

WBC may not rise

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The Management
Preop:
IVI,
analgesia,
IV antibiotics
Conventional appendicectomy
Types of incisions
Laparoscopic appendicectomy:
(questions regarding pain, hospital stay, operation
time, to daily activity, wound infection)

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Post-Operative
1. Check the vitals
2. Check the abdominal signs and bowel
movement
3. Check the wound
4. Advise on mobilization
5. In OPD:
1. Check wound
2. Check the Histology

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Prognosis
Mortality: from 0.2% to 1%
Complications increase with perforation
Morbidity:
Wound abscess,
Wound infection (less with MacBurneys incision),
Wound dehiscence
Intra-abdominal abscess,
Faecal fistula,
Intestinal obstruction,
Adhesive band,
inguinal hernia.
Fertility

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Problems
Mass palpable pre-operatively

Appendix is normal at operation

Tumor is found in appendix

Prophylactic appendicectomy

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The Appendix Chronic Appendicular Conditions
Chronic Appendicitis

A loose term referring to a multitude of

conditions associated with RIF pain and
in which pathology of the appendix has
been found.

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Appendicular Mass
Results from either:
1. Localized by edematous, adherent omentum
and loops of small bowel
2. Appendicular abscess
Incidence is 10%
Higher in children
Management controversy:
Interval vs Immediate appendicectomy

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Tumors of The Appendix
Carcinoid:
Arise from Kluchitsky cells
Mean age 20-40
Yellow bulbar mass
In F>M
In third decade of life
Usually lies near the tip
In the absence of LN spread with <2 cm in
diameter appendicectomy is sufficient. Otherwise
a R hemicolectomy is necessary.
Adenocarcinoma and Lymphoma.
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