Surgery - Appendicitis

1. APPENDICITIS
M. Kamil (DP- Surgery)

2. Case
Mr. Y is a 20 year old Chinese male previously healthy who
presented to ED at 5.30 am due to sudden sharp abdominal
pain on RLQ since 3.00 am. The onset was at 11.00 pm but at
3.00 am the pain caused him to wake up from sleep. The pain
was sharp, continuous and non-radiating in nature. There was
nothing that can be done to relieve the pain. He rated the
pain during the attack as 7/10 in the scale 0 to 10. The pain
was also associated with dizziness and vomiting 3x (food
particles) but denied diarrhea. At ED he rated the pain as
8/10. He denied any abnormal stool.

3. ◦ PMH: Not significant
◦ No childhood/ adulthood illness.
◦ Allergy: NKDA
◦ Vaccination: cannot recall
◦ No prior h/o hospitalization and surgery.
◦ No h/o recent trauma.
◦ Family History: Not significant
◦ He is a second son out of 3. All his siblings are healthy.
◦ Mother: healthy
◦ Father: has diabetes and amputation of the big toe was done.
◦ Both his grandparents are healthy.

4. Physical examination findings.
◦ Vital signs: Normal
◦ BP: 120/78
◦ Pulse: 80
◦ RR: 20
◦ T: 37.1
◦ General:
◦ Alert, conscious, pink, not tachypnic, good hydration.
◦ Hand: No scar, no deputyrene contracture, no pallor, no palmar
erythema, joint- non tender, crt <2sec.
◦ Head: no scar. Forehead normal. Eye brows symmetry.

5. Physical examination findings.
◦Abdominal exam:
◦ Inspection: Shape- flat. No scar of prior surgery. Umbilicus
inverted. Flank not full. All quadrants moving symmetry with
breathing.
◦ Auscultation: bowel sound present but hypoactive. No renal
bruit.
◦ Palpation (light): Guarding, Tenderness at RLQ
◦ Percussion: resonance in all quadrants
◦ No rebound tenderness

6. Investigations.
◦ FBC:
◦ Hb 15.7 g/dL (13.5 – 17) Normal
◦ WBC 15.7 /L (4.5 – 10.0) Elevated
◦ Plt 328 mm3 (150 – 400) Normal
◦ Diagnosis
◦ Acute appendicitis
Plan:
◦ Admit to surgical
◦ NBM
◦ IV tramadol 50 mg TDS + IV maxalon 10 mg stat
◦ IV metronidazole 500 mg stat TDS
◦ IV cefuroxime 1.5 stat TDS
◦ IVD 4 pints NS/24H
◦ To inform surgical

7. Operation: Open appendectomy
◦ Intra-op finding:
◦ Normal cecum
◦ Normal small bowel
◦ No pus/ slough
◦ No Meckel's diverticulum
◦ Retrocecal appendix – grossly inflamed
Post – op plan:
◦ Allow clear fluid
◦ Continue abx
◦ T PCM 1 g QID
◦ WI D3

8. Acute appendicitis – Clinical presentation
◦ Acute appendicitis is inflammation of vermiform appendix.

9. Epidemiology
◦ Commonly occur between 10 to 20 year old and predominantly male (M: F,
1.4:1)
◦ Mortality rate:
◦ 20 fold decline from that reported 50 years ago.
◦ In general population: 4/1 000 000
◦ For infant increase to 9%,
◦ For patient above 65 year old is 15%
◦ For ruptured appendicitis: 4-5%
◦ For non-ruptured appendicitis: 0.1%
◦ For women, RIF pain with normal Gynae exam and normal leukocyte count,
the 90 - 99% of cases usually reveal acute appendicitis.

10. Differential Diagnosis
The differential diagnosis of acute appendicitis depends on 4 major
factors: the anatomic location of the inflamed appendix; the stage of the
process (i.e., simple or ruptured); the patient's age; and the patient's sex
1. Acute Mesenteric Adenitis (in kids)
2. Gynecologic disorders (female)
3. Acute gastroenteritis
4. Other intestinal disorders
5. Renal calculi

11. Classic presentation:
◦ Periumbilical abdominal pain which progress to intense pain over 24
hours,
◦ become constant,
◦ sharp and
◦ migrates to right iliac fossa and
◦ associated with:
◦ loss of appetite, (help to diagnose in pediatric group)
◦ nausea,
◦ vomiting and
◦ constipation

12. Other signs and symptoms
◦ Migrating pain - Pain in the umbilical
region that moves to the right iliac fossa
◦ Maximal tenderness at a McBurney’s point
◦ Rovsing’s sign – Palpation of LIF causes
pain in RIF

13. Other signs
◦ Psoas sign – Hip extension
◦ Obturator sign – Rotation of right flexed hip

14. Atypical presentation –
depend on the anatomic variations of location of appendix
◦ retrocecal appendix
◦ Absent of muscular rigidity and tenderness to deep
palpation.
◦ Exacerbation of pain on hip extension (psoas sign) may
occur.
◦ If the appendix is subcecal/pelvic
◦ Present of rectal or vaginal tenderness on right side.
◦ Absent of abdominal tenderness.
◦ If appendix is pre- ileal or post- ileal,
◦ The patient may present with vomiting or diarrhea
◦ Appendix can also be found on the left side in
0.2% of population.

15. Clinical prediction rules
◦ ALVARADO/MANTREL SCORE
• Migratory abdominal pain to RLQ (1)
• Anorexia (1)
• Nausea/vomiting (1)
• Tenderness in the right iliac fossa (2)
• Rebound tenderness (1)
• Elevated temp >37.5°C (1)
• Leukocytosis >10 (2)
• Left Shift (Neutrophils) (1)
Maximum score: 10
◦ 0-4: Low probability
◦ 5-6: Moderate probability
◦ >7: High probability
• 95% sensitivity, 83% diagnostic accuracy (M>F)
◦ PATIENT FROM THE CASE:
• Migratory abdominal pain to RLQ (1)
• Anorexia (1)
• Nausea/vomiting (1)
• Tenderness in the right iliac fossa (2)
• Rebound tenderness (1)
• Elevated temp >37.5°C (1)
• Leukocytosis >10 (2)
• Left Shift (Neutrophils) (1)
Score: 6 (Moderate probability)

16. Clinical algorithm for the management for suspected
acute appendicitis
History and physical examination
Refer to surgical unit
Admit: Observe and Serial abdominal examination
and r/o other differentials e.g. hernia, PID,
pregnancy, renal calculi etc ± diagnostic laparoscopy
Features persistent for
appendicitis
Refer to surgical unit
Possible appendicitis
A score: 5 to 6
Alvarado Score
Clinical appendicitis (possible)
A score: 7 to 10
Unlikely appendicitis
A score: 0 to 4
Discharge with advice or for
follow- up at appropriate clinic
e.g. Obgyn, Urology.
Features not persistent for
appendicitis
Appendectomy

17. Open appendectomy
1. Traditional approach is Gridiron incision over McBurney’s
point, at 90° to line from umbilicus to the anterior superior
iliac spine. Lanz incision is more horizontal in Langer’s lines
(skin creases) and gives a better scar.
2. Divide subcutaneous fat and superficial/Scarpa’s fascia.
Fibers of external oblique, internal oblique and transversus
abdominus divided with muscle splitting incision.
3. Incise pre-peritoneal fat and peritoneum to reveal caecum.
Deliver caecum through incision. Appendix located at
convergence of taenia coli.
4. Mesoappendix (blood vessels and mesentery) and
appendix divided, ligated and excised (stump may be
inverted).
5. In case of a normal looking appendix, excise (may be
histologically if not macroscopically inflamed); look for
Meckel’s diverticulum.
6. Wash, close in layers, dress wound.
Oxford, clinical medicine, 9th edition (2014)

18. References
◦ Alvarado, A (May 1986). "A practical score for the early diagnosis of acute appendicitis.". Annals of
emergency medicine 15 (5): 557–64
◦ Kyung Won, PhD. Chung (2005). Gross Anatomy (Board Review). Hagerstown, MD: Lippincott
Williams & Wilkins. p. 255.

19. THANK YOU 