Dr.Dinesh.M.G Professor of Surgery J.J.M.M.C Davangere

1. Dr. Dinesh. M.G
Professor of Surgery
J.J.M.M.C.
Davangere

2. Introduction
 Considered by most to be a vestigial organ
 Its importance in surgery
 Acute appendicitis
 Carcinoid tumour

3. Anatomy
 Blind muscular tube
 Mucosa, submucosa, muscularis propria and serosa
 Positions
 Retrocaecal 74%
 Pelvic 21%
 Paracaecal 2%
 Pre ileal 1%
 Post ileal 0.5%
 Subcaecal 1.5%

4. Anatomy
 Appendicular artery runs in mesoappendix
 It is an ‘end-artery’ & a branch of ileocolic artery
 Microscopic anatomy
 Lined by columnar cell of colonic type
 Crypts are present in the mucosa in which lie the
argentaffin (Kultschitzsky) cells

5. Acute appendicitis
 Reginald Fitz first published paper on appendicular
perforation in 1886
 Charles McBurney described clinical features including
the point of maximum tenderness in Rt. iliac fossa
 McBurney’s point

6. Aetiology
 No definite single aetiology
 Obstruction of lumen by
 Faecolith
 Pin worms
 Carcinoma caecum etc.

7. Clinical features
Murphy’s triad
 Periumbilical pain shifting to Rt.iliac fossa
 Anorexia, nausea and vomiting
 Fever
Signs
 Tachycardia, pyrexia
 Tenderness or rebound tenderness in Rt. iliac fossa
 Guarding or rigidity
 Rovsing’s sign
 Positive ‘Psoas sign’
 Positive ‘Obturator test’

8. Psoas test

9. Obturator test

10. Differential diagnosis
 Children
 Acute gastroenteritis
 Mesenteric lymphadenitis
 Meckel’s diverticulitis
 Intussusception
 Lobar pneumonia and pleurisy
 Adults
 Right ureteric colic
 Rt. Acute pyelonephritis
 Perforated peptic ulcer
 Testicular torsion
 Acute pancreatitis

11. Differential diagnosis
Adult females
 Salpingitis
 Mittelschmerz
 Torsion /heamorrhage of an ovarian cyst
 Ectopic pregnancy
Elderly
 Carcinoma of caecum

12. Investigations
 CBC
 leucocytosis
 Urine analysis
 Serum creatinine and electrolytes
 X ray erect abdomen in diffuse peritonitis
 Usg abdomen
 CT abdomen
 Urine pregnancy test

13. Investigations
 Usg abdomen

14. CT scan

15. Treatment
 Appendicectomy
 Open
 Laparoscopic

16. Appendicular mass
 May form by 3rd day of acute appendicitis
 Consists of inflamed appendix, greater omentum,
oedematous caecal wall & oedematous coils of small
intestine
 It may form an abscess or resolve with treatment
 Differential diagnosis of appendicular mass
 Carcinoma caecum
 Ileocaecal tuberculosis

17. Management of appendicular mass
Ochsner-Sherren regimen
 Conservative treatment with
 Nil by mouth
 Ryle’s tube aspiration
 Antibiotic therapy
 Cephalosporins
 Aminoglycoside
 Metronidazole
 Recording of size of mass daily
 Recording of TPR chart 4hourly
 Input & output chart

18. Management of appendicular mass
 Interval appendicectomy if mass resolves after 6-8 weeks
 Early laparotomy if appendicular abscess develops
Management of appendicular abscess
 Controversial
 Early laparotomy and drainage of abscess with
appendicectomy in one sitting
 Percutaneous US or CT guided catheter drainage followed
by elective appendicectomy 8-12 weeks later

19. Complications of appendicitis
 Perforation
 Postoperative wound infection
 Intra abdominal and pelvic abscess
 Pyelephlebitis
 Enterocutaneous fistula
 Small bowel obstruction

20. Points to remember
 Diff. diagnosis of acute appendicitis in adult males include
 Right ureteric colic
 Rt. acute pyelonephritis
 Perforated peptic ulcer
 Testicular torsion
 Acute pancreatitis
 Diff diagnosis of acute appendicitis in adult females include
 Salpingitis
 ovarian torsion
 ectopic pregnancy

21. Points to remember
 Complications of acute appendicitis include
 Perforation
 Postoperative wound infection
 Intra abdominal and pelvic abscesses
 Pyelephlebitis
 Enterocutaneous fistula
 Small bowel obstruction
 Treatment of choice in acute appendicitis is
 Open or laparoscopic appendicectomy
 Regimen for conservative treatment of appendicular mass is
 Ochsner- Sherren regimen

22. Thank you