appendicitis dr phillip bmc

1. APPENDICITIS
Dr Phillipo Leo Chalya
M.D. (Dar); M.Med Surg (Mak)
Specialist surgeon - Bugando Medical Centre

2. FORMAT
 Definition
 A historical perspective
 Epidemiology
 Aetiology
 Classification
 Pathophysiology
 Clinical presentation
 Differential Diagnosis
 Work up
 Treatment
 Complications

3. DEFINITION
 Appendicitis refers to inflammation of the vermix
appendix

4. A HISTORICAL PERSPECTIVE
 First described by Reginald Fitz in 1886 who
also was the first to advocate appendicectomy
as the cure
 In 1889 Charles McBurney described the
clinical findings of acute appendicitis including
the point of maximum tenderness in RIF which
bears his name

5. EPIDEMIOLOGY
 Incidence:
 The incidence is higher in developed countries and in
developing countries which are adopting a more refined
western type diet
 Incidence of appendicitis is lower in cultures with a higher
intake of dietary fiber

6. EPIDEMIOLOGY [cont’d]
 Mortality/Morbidity:
 The overall mortality rate of 0.2-0.8% is attributable to
complications of the disease rather than to surgical intervention
 Mortality rate rises above 20% in patients older than 70 years,
primarily because of diagnostic and therapeutic delay
 Perforation rate is higher among patients younger than 18 years
and patients older than 50 years, possibly because of delays in
diagnosis
 Appendiceal perforation is associated with an increase in
morbidity and mortality rates

7. EPIDEMIOLOGY [cont’d]
 Sex:
 The incidence of appendicitis is approximately 1.4 times
greater in men than in women
 The incidence of primary appendectomy is approximately
equal in both sexes

8. EPIDEMIOLOGY [cont’d]
 Age:
 Appendicitis may occur at all ages, but is most commonly
seen in the 2nd
and 3rd
decades of life
 The incidence of appendicitis gradually rises from birth,
peaks in the late teen years, and gradually declines in the
geriatric years
 Although rare, neonatal and even prenatal appendicitis
have been reported in literature
 The emergency physician must maintain a high index of
suspicion in all age groups

9. AETIOLOGY
 Etiological factors for appendicitis include:-
 Appendiceal luminal obstruction
 Diet
 Social status
 Familial susceptibility

10. Appendiceal luminal obstruction
 Luminal causes
 Feacolith
 Lymphoid follicle hyperplasia
 Worms e.g. ascaris
 Foreign body
 In the wall
 Stricture
 Neoplasms
 Outside the wall
 Adhesions
 kinks

11. Diet
 Low intake of dietary fiber is associated with
increased incidence of appendicitis
 Dietary fiber is thought to decrease the viscosity of
feces, decrease bowel transit time, and discourage
formation of fecaliths that predispose individuals to
obstructions of the appendiceal lumen

12. Familial tendency
 Appendicitis tends to run in certain families
may be due to peculiar position of the organ
which predisposes to infection

13. CLASSIFICATION
 Clinical classification
 Pathological classification

14. Clinical classification
 Acute appendicitis
 Subacute appendicitis
 Recurrent appendicitis
 Chronic appendicitis

15. Pathological classification
 Obstructive appendicitis
 Non-obstructive appendicitis

16. PATHOPHYSIOLOGY
 Two types:-
 Obstructive appendictis
 Non-obstructive appendicitis

17. Obstructive appendicitis
 Luminal obstruction and mucus production result in
increased intraluminal pressure
 Bacteria trapped within the appendiceal lumen begin to
multiply, and the appendix becomes distended
 Luminal distention stimulates visceral nerve endings
concerned with pain [visceral pain]
 This produce dull aching pain felt periumbilically
according to nerve supply of the appendix (T10) 
referred pain
 Venous congestion and edema follow next, and by 12 hours
after onset, the inflammatory process may become
transmural

18. Obstructive appendicitis[ cont]
 Peritoneal irritation then develops
 If the obstruction is left untreated, arterial blood
flow to the appendix is compromised, and this
leads to tissue ischemia and necrosis
 This stimulates parietal nerve endings→ shift of
pain to the RIF
 Full thickness necrosis of the appendiceal wall
leads to perforation with the release of fecal and
suppurative contents into the peritoneal cavity

19. Obstructive appendicitis [cont]
 Depending on the duration of the disease process,
either a localized walled-off abscess or mass occurs,
or if the pathologic process has advanced rapidly, the
perforation is free in the peritoneal cavity and
generalized peritonitis occurs
 The commonest bacterial growth from inflamed
appendices include Escherichia coli, Kleblesiella
spp., Proteus spp and Bacteroids

20. Non-obstructive appendicitis
 This is less dangerous type
 Inflammation commences in the mucous membrane or in the
lymphoid follicles and gradually spread to the submucosa
 As there is no obstruction there is not much distension, but
when the serosa is involved localizing peritonitis develops
and the patient c/o RIF pain
 Such inflammation terminates either by:-
 Suppuration
 Gangrene
 Fibrosis
 Resolution
 Many of the sub-acute appendicitis, recurrent appendicitis
and chronic appendicitis develop from this variety

21. CLINICAL PRESENTATION
 History: classic symptoms include:-
 Periumbilical pain [visceral pain] which shifts and
localize to the RIF [parietal or somatic pain]
 Periumbilical pain is colicky in nature in obstructive type
and is dull aching and constant in non-obstructive type
 RIF pain is sharp intense and well localized to the RIF
 Anorexia
 Nausea & Vomiting

22. CLINICAL PRESENTATION [cont’d]
 Physical examination
 Pyrexia
 RIF tenderness
 Muscle guarding
 Rebound tenderness
 Special test to elicit in appendicitis
 Pointing sign
 Rovsing’s sign [RIF pain with palpation of the LIF ]
 Psoas sign [RIF tenderness with internal rotation of the flexed
right hip]
 Obtrurator sign [RLQ pain with hyperextension of the right hip ]

23. DIFFERENTIAL DIAGNOSIS
 Abdominal disorders
 Gynecological disorders
 Retroperitoneal disorders
 Thoracic disorders
 Others

24. Abdominal disorders
 Acute cholecytitis
 Perforated peptic ulcers
 Entecolitis
 Intestinal obstruction
 Carcinoma caecum
 Crohn’s diseases
 Amoebic colitis
 Meckel’s diverticulitis
 Acute pancreatis

25. Gynecological disorders
 PID
 Ectopic pregnancy ®
 Twisted ovarian cyst ®
 Ruptured ovarian follicles ®

26. Retroperitoneal disorders
 Right ureteric colic
 Right sided acute pyelonephritis
 Right sided testicular torsion
 Retroperitoneal haematoma

27. Thoracic disorders
 Basal pneumonia
 Pleurisy

28. Miscellaneous
 Henoch-Schoenlein purpura
 Porphyria
 Diabetic abdomen

29. WORK UP
 Lab investigations
 Complete blood cell count
 Leucocytosis
 Neutrophilia greater than 75%
 C-reactive protein test
 Urinalysis

30. WORK UP [cont’d]
 Imaging investigations
 Abdominal radiography
 The kidneys-ureters-bladder (KUB) view is typically used
 Visualization of an appendicolith in a patient with symptoms
consistent with appendicitis is highly suggestive of appendicitis,
but this occurs in fewer than 10% of cases
 The consensus in the literature is that plain radiographs are
insensitive, nonspecific, and is not cost-effective
•

31. WORK UP [cont’d]
 Abdominal Ultrasonography
 An outer diameter of greater than 6 mm,
noncompressibility, lack of peristalsis, or
periappendiceal fluid collection characterizes an
inflamed appendix
 The normal appendix is not visualized
 It’s noninvasive, short acquisition time, lack of
radiation exposure, and potential for diagnosis of
other causes of abdominal pain, particularly in the
subset of women of childbearing age
 However it is operator dependent

32. WORK UP [cont’d]
 Computed tomography
 Abdominal CT has become the most important imaging study in the
evaluation of patients with atypical presentations of appendicitis
 Advantages of CT scanning include
 Sensitivity and accuracy compared with those of other imaging
techniques
 Readily available
 Noninvasive
 potential to reveal alternative diagnoses
 Disadvantages
 lengthy acquisition time if oral contrast is used
 patient discomfort if rectal contrast is used
 Exposure to radiation
 It is really required to make diagnosis of acute appendicitis

33. DIAGNOSTIC SCORING SYSTEM
 Various scoring systems have been devised to aid diagnosis
of appendicitis
 Although many diagnostic scores have been advocated,
most are complex and difficult to implement in the clinical
situation
 The Alvarado score, is a simple scoring system that can be
instituted easily
 The Classic Alvarado score [1986] is based on three
symptoms, three signs and two laboratory findings and has
a total score of 10

34. Classic Alvarado Score [1986]
Features Score
Symptoms
 Migratory RIF pain 1
 Anorexia 1
 Nausea & vomiting 1
Signs
 Pyrexia 1
 Tenderness RIF 1
 Rebound tenderness RIF 2
Lab investigations
 Leucocytosis 2
 left shift of neutrophil maturation 1
Total 10

35. Diagnostic Scoring System [cont]
 Kalan et al [1994] omitted one lab parameter [left
shift of neutrophil maturation] which is not
routinely available in many laboratories, and
produced a modified score which have only one
lab findings
 A modified Alvarado score [1994] is based on three
symptoms, three signs and one laboratory findings
[total score of 9]
 MAS is commonly used

36. Modified Alvarado Score [1994]
Features Score
Symptoms
Migratory RIF pain
Anorexia
Nausea & vomiting
1
1
1
Signs
Pyrexia
Tenderness RIF
Rebound tenderness RIF
Lab investigation
leucocytosis
1
1
2
2
Total 9

37. MASS- interpretation
 A score of 1-4:[ discharging group] The diagnosis
of acute appendicitis is unlikely
 A score of 5-6: [observing group] Probable to have
appendicitis but not convincing to have urgent
appendicectomy
 A score of 7-9: [emergency group] Regarded as
probable to have acute appendicitis and needs
emergency appendicectomy

38. TREATMENT
 The treatment of appendicitis is appendicectomy
 Appendicectomy can be elective, emergency or
interval
 Two types of appendicectomy:-
 Conventional open appendicectomy
 Laparoscopic appendicectomy

39. Preoperative care
 Iv fluid
 Analgesics
 Preoperative antibiotics with broad spectrum
antibiotics
 Check Hb, blood grouping and crossmatching
 Shaving
 Written informed consent
 Pre-anaesthetic visit

40. Intraoperative care
 Open appendicectomy
 Incisions
 Grid-iron sss
 Rurtherford Morrison’s
 Lanz’s [transverse skin crease]
 SUMI when the diagnosis is not clear
 Rt lower paramedian
 Midline incision

41. Intraoperative care cont’d
 Appendiceal locations of the tip
 Retrocaecal appendix [70%]
 Pelvic appendix [25%]- the tip hangs in the pelvic brim
 Subcaecal appendix [2%]
 Splenic appendix [1%]- either pre- or post-ileal i.e anterior or
posterior to the terminal ileum
 Paracaecal appendix [1%]
 Paracolic appendix [1%]-either to the right or left of ascending
colon, the tip in the extraperitoneal tissue
 Location of the base-is constant, being found at
confluence of 3 taeniae coli of the caecum which fuse to
form the outer longitudinal muscle coat of the appendix

42. Post operative care
 Iv fluids
 Analgesics
 Antibiotics
 Monitor-
 Vital signs
 Discharge home in 2-3 days postoperatively

43. COMPLICATIONS
 Complications of acute appendicitis
 Postoperative complications

44. i. Complications of acute appendicitis
 Appendicular mass
 Appendicular abscess
 Recurrent appendicitis
 Perforation peritonitis

45. Treatment of complications
 Appendicular abscess
 Appendicular mass
 Peritonitis
 Recurrent appendicitis

46. a.Appendicular mass
 Use conservative Ochsner-Sherren regime
 Iv fluid
 NGT
 Analgesics
 Antibiotics –parenteral
 Mark the limits of the mass on the abdominal wall
using a skin pencil
 Monitor- vital sign, size of the mass, input/output chart
 Clinical improvement is expected in 24-48 hours

47. Appendicular mass [cont]
 Criteria for stoping OSR
 Increased pulse rate
 Increasing or spreading abdominal pain
 Increasing the size of the mass
 Vomiting or increasing gastric contents

48. b.Appendicular Abscess
 I & D
 Antibiotics

49. c.Recurrent appendicitis
 Elective appendicectomy

50. ii.Postoperative complications
 Wound infections
 Intrabdominal abscess
 Paralytic ileus
 Feacal fistula
 Adhesive intestinal obstruction
 Portal pyaemia due to septicemia in the portal venous
system
 Respiratory complications
 DVT embolism
 RIH due to damage to iliopogastric / ilioinguinal
nerves
 Incisional hernia