Appendicitis

1. Submitted By
PALLABI SAHOO
3rd year BHMS
Roll No. 0111BHMS021
U.H.M.C.,Rourkela-769010
Under the guidance of
Dr. P. K. PATTNAIK
(H. O. D., Department of Surgery)
U.H.M.C., Rourkela-769010

2. CONTENTS
1. What is appendicitis?
2. Causes of appendicitis
3. Symptoms and signs of appendicitis.
4. Diagnosing appendicitis
5. Investigation
6. Differentials Diagnosis
7. Complications
8. Treatment
9. Surgical procedure
10.Medicinal Treatment
11.Conclusion
12. References

3. The appendix is a small dead end pouch, like a little tube, that comes off the caecum. The
caecum is the first part of the large intestine (large bowel) just before the colon. The small
intestine digests and absorbs food. The parts of the food that are not digested begin to be formed
into faeces (motions) in the caecum. It is normally about 5-10 cm long and quite thin and appears
to have no function.
Location of the appendix in the digestive system
Appendicitis means inflammation of the appendix. The inflamed appendix becomes infected
with bacteria (germs) from the intestine. The inflamed appendix gradually swells and fills with
pus. Eventually, if not treated, the swollen appendix might perforate (burst). This is very serious,
as the contents of the intestine then spill into the abdominal cavity. This can cause a serious
infection of the membrane that lines the abdomen (peritonitis), or an abscess in the abdomen. So,
if appendicitis is suspected, early treatment is best before it bursts.
Mortality/Morbidity:
 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.

4.  Perforation rates are higher in patients younger than 18 years and in patients older than
50 years, possibly because of delays in diagnosis. Appendiceal perforation is associated
with an increase in morbidity and mortality rates.
Sex:
 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.
Age:
 Incidence of appendicitis gradually rises from birth, peaks in the late teen years, and
gradually declines in the geriatric years.
 Although rare, cases of neonatal and even prenatal appendicitis have been reported.

5. Inflammation of the appendix is usually the result of blockage causing an infection. The
appendix is open at one end where it connects to the large intestine. If the open end of the
appendix gets plugged for some reason, either because of swelling or because something from
the large intestine gets stuck in the opening, then the appendix starts to swell because of the
secretions from the lining. The swelling shuts off the blood supply and the appendix tissue dies.
An operation to remove the swollen appendix (an appendectomy) is the only way to fix this
problem.
Acute appendicitis
The blockage in appendix may also occur if lymph nodes in the appendix swell. Less common
causes of blockage are vegetable and fruit seeds, stomach worms, and thickened barium from
prior X-rays. In seniors, appendicitis is occasionally caused by a tumor (cancer) of the colon.

7. The main symptoms of appendicitis are encrypted in the following.
 Pain in the abdomen (tummy pain) is usually the main symptom. The initial typical pain
is diffuse and dull and is situated in the umbilical or lower epigastric region. Intermittent
cramping pain may also be there. Gradually the pain is localized in the right lower
quadrant.
 Anorexia is complained of in case of appendicitis.
 Nausea is present in 9 out 10 patients with appendicitis. Vomiting is frequently found in
children and teenagers whereas it is absent in adults.
 Many patients give history of constipation before the onset of abdominal pain. Diarrhea
occurs in some patients particularly in young children.
The common physical signs are
 Appendicitis may cause rise of temperatures. Temperature elevation is usually restricted
from 99˚ to 100 ˚ F (39 ˚C).
 Pulse rate is usually normal or slightly elevated. Pulse rate increases in proportion with
the temperature of the patient.
Inspection
 The patient looks anxious in pain and tongue is dry.
 In acute condition it may disclose some limitations of the respiratory movement of the
lower half of the abdomen.
Palpation
Presence of peritoneal inflammation can be suspected if cough or percussion on the abdominal
wall elicits pain.
 Systemic gentle palpation will detect an area of maximum tenderness that corresponds to
the position of the appendix and is usually located in the right lower quadrant at or near
McBurnet’s point.
 Rebound tenderness:- The classic method of demonstrating peritoneal inflammation is
rebound tenderness. In this case the gentle pressure is exerted on the inflamed area and

8. sudden release of the hand will cause extreme pain of the patient at the inflamed area.
This is called rebound tenderness.
 Rovsing’s sign:- Pain in the right lower quadrant is complicated of when palpation
pressure is exerted in the left lower quadrant. It is also called ‘referred rebound
tenderness’.
 Psoas sign:- This test is performed by having the patient lie on his left side. The
examiner then slowly extends the patients right thigh, thus stretching the iliopsoas
muscle. This will produce pain to make the sign positive.
 Obturator test:- Passive internal rotation of flexed right thigh with the patient in supine
position will elicit pain. This positive obturator sign is diagnostic of pelvic appendicitis.
 Percussion:- Light percussion on McBurnet’s point will elicit pain in case of early
appendicitis.
 Auscultation:- It will reveal mearge or no bowel movement on the right iliac fossa.
 Rectal examination:- This is important and should be performed in every patient
suspected of suffering from appendicitis. In case of pelvic appendicitis there may not be
any tenderness on the anterior abdominal wall. Rectal examination is very essential to
exclude such appendicitis.

9. Appendicitis is usually a clinical diagnosis and needs to be determined by a doctor. The doctor
will perform a number of tests that may also provide information on the extent and location of
inflammation. After a physical examination, a blood test may be done to check for infection. A
doctor might also take a urine sample to rule out a urinary tract infection, because symptoms can
be similar to those of appendicitis.
Sometimes an ultrasound will be performed to help with the diagnosis. An abdominal CT scan is
occasionally needed for people when other tests do not give clear results.
Other diseases that can be confused with appendicitis include colitis, Crohn's disease, gastritis,
gastroenteritis, tubal pregnancy, and ovary problems.
Tests for appendicitis or peritonitis
The test for appendicitis or peritonitis may be done in the following way.
Here a person have cough and see if this causes sharp pain in the belly or slowly but forcefully,
press on the abdomen a little above the left groin until it hurts a little. Then quickly remove the
hand
 If a very sharp pain (rebound pain) occurs when the hand is removed, appendices or
peritonitis is likely.
 If no rebound pain occurs above the left groin, try the same test above the right groin.

10.  80-85% of adults with appendicitis have a WBC count greater than 10,000.
 Neutrophilia greater than 75% occurs in 78% of patients.
 Fewer than 4% of patients with appendicitis have a WBC count less than 10,000 and
neutrophilia less than 75%.
 C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver in response
to bacterial infection. Serum levels begin to rise within 6-12 hours of acute tissue
inflammation. A rapid assay is widely available.
 In adult patients who have had symptoms for longer than 24 hours, a normal CRP has a
negative predictive value of approximately 100% for the presence of appendicitis.
 Two other studies in adults found that a combination of a WBC count of less than 10,500,
neutrophilia less than 75%, and a normal CRP had 100% negative predictive value for the
diagnosis of acute appendicitis.
 Abdominal CT has become the most important imaging study in the evaluation of
patients with atypical presentations of appendicitis. Several studies have shown a
decrease in negative laparotomy rate and appendiceal perforation rate when abdominal
CT is used in selected patients with suspected appendicitis.
 Advantages of CT scanning include superior sensitivity and accuracy compared with
other imaging techniques, ready availability, noninvasiveness, and potential to reveal
alternative diagnoses.
 If graded compression ultrasonography of the right lower quadrant is positive for
appendicitis, appendectomy should be performed.
 If negative, this finding is not sufficiently sensitive to rule out the possibility of
appendicitis. Consideration should be given to further observation and focused helical CT
with rectal contrast.
 Kidneys-ureters-bladder (KUB) view used typically.
 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 radiography is insensitive, nonspecific, and
not cost-effective.
 A single contrast study can be performed on an unprepared bowel.
 Non-filling or incomplete filling of the appendix coupled with pressure effect or spasm in
the cecum suggests appendicitis.
Except for high specific gravity due to dehydration, routine urine examination will usually reveal
normal result in case of appendicitis.

12.  Acute cholecystitis
 Enterocolitis
 Amoebic colitis
 Meckel’s diverticulitis
 Acute pancreatitis
 Intestinal obstruction
 Crohn’s disease
 Perforated peptic ulcer
 Carcinoma of the caecum
 Salpingitis
 Ectopic gestation
 Ruptured ovarian follicle
 Twisted right ovarian cyst
 Right ureteric colic
 Right sided acute pyelonephritis
 Torsion of testis
 Haematoma
 Basal pneumonia
 Pleurisy

13.  Appendicular rupture
 Appendicular mass (Phlegmon)
 Appendicular abscess
 Supportive pylephlebitis
 Wound infection
 Intra-abdominal abscess
Treatment guidelines for patients with suspected acute appendicitis include the following:
 Establish IV access and administer aggressive crystalloid therapy to patients with
clinical signs of dehydration or septicemia.
 Do not give anything by mouth to patients with suspected appendicitis.
 Consider ectopic pregnancy in women of childbearing age and obtain a qualitative
beta-hCG in all cases.
 This may be useful when appendectomy is not accessible or when it is temporarily a
high-risk procedure.
 Preoperative antibiotics.

14. An operation to remove the inflamed appendix is usually done quite quickly once the
diagnosis is made. It is much better to remove an inflamed appendix before it bursts. The
inflamed appendix is found and cut off the caecum. The hole left in the caecum is stitched up
to stop any contents from the gut leaking out. Antibiotic medicine is given just before the
operation to reduce the risk of an infection developing at the site of the operation.
In most cases, the operation is done before the appendix perforates. This is usually a
straightforward and successful operation needing just a short recovery. However, surgery can
be more difficult and you will take longer to recover if the appendix has perforated.
Surgery is commonly done by a keyhole operation, as the recovery is quicker compared to
having an open operation. The keyhole operation is performed through three tiny cuts, the
largest of which is only around 1.5 cm in size. There are usually no long-term complications
after the operation. As with any operation, there is a small risk of complications from the
operation itself and from the anesthetic. However, if you don't have an operation, an inflamed
appendix is likely to perforate and cause a serious infection in the abdomen (peritonitis)
which can be life-threatening.
Open surgery Laparoscopic appendectomy

15. The goals of therapy are to eradicate the infection and prevent complications.
Medicine acute intest. conditions, colic
 Abdominal pains, violent; come and disappear suddenly. Are squeezing; clawing; as
if griped by nails; violent pinchings. "Violent colic, intense cramping pain, face red as
fire." Tenderness of abdomen, worst least jar. Frequent urging to stool, little or no
result (Nux).
 Spasmodic contraction of sphincter ani. Great pain in ileo-caecal region: cannot bear
slightest touch, even of bedclothes (early appendicitis. Local external applications to
abort). Typical Bell. has red, hot face; big pupils: is sensitive to pressure draughts, jar.
Special remedies of appendix and caecum
 Years ago, when making diagrams to show the action of remedies on parts of the
body, one grasped the fact that two drugs seemed to share the honours in this area-
Belladonna and Mercurius corrosivus. And one knows that Bell. has earned a great
reputation for early, simple inflammation of appendix. Among its symtoms are: Great
pain in right ileo-caecal region.
 Cannot bear the slightest touch, not even of bed covers. Tenderness aggravated by
least jar. (KENT says, "The jar of the bed will often reveal to you the remedy"). Bell.
has much swelling. Its inflammations throb : feel bursting. Kent also says, "There are
instances where Bell. :is the remedy of all remedies in appendicitis".
 There are instances where Bell. is the remedy in appendicitis. Belladonna has
dysenteric troubles. Pain in the region of the caecum.
Medicine acute intest. conditions, colic.
Peculiar bruised sensation about caecum and along transverse colon. Tender to pressure.
Appendicitis. (Bell). Painful bloody discharges (from rectum) with vomiting. Tenesmus,
persistent, incessant, with insupportable cutting, colicky pains. Diarrhoea dysentery with
terrible straining before, with, and after stool. Merc. cor. is almost specific for dysentery.
Very distressing tenesmus, getting worse and worse: nothing blood.
Special remedies of appendix and caecum
This drug down in black type for appendicitis. Merc. corr. is violent and active. Has far more
activity, excitement and burning. Caecal region and transverse colon painful. Bloated
abdomen. Characteristic : Great tenesmus of rectum, the "never-get-done" remedy. Abdomen
bruised, bloated, tender to least touch. Tenesmus of bladder, also. Hot urine passed drop by
drop. Clinical.
 Appendicitis.

16.  A girl, 16, had perforating appendicitis, operation having been delayed too long in
consequence of opposition of friends.
Special remedies of appendix and caecum
 Appendicitis : peritonitis. Must keep very still; stools hard, dry, as if burnt. Pain in a
limited spot: dull, throbbing or sticking. Bry. is better lying on painful side, for
pressure and to limit movement. Lies knees drawn up. Better for heat to inflamed part.
 Sensitive abdomen; appendicitis. Constipation; hard, dry stool.
Special remedies of appendix and caecum
 "It acts on appendix and has been used for appendicitis. But remember, it promotes
suppuration, and a neglected appendix with pus formation would probably rupture
sooner under its use". -Another condition to which Natrum sulph. patients are prone is
a fairly acute attack of appendicitis, with extreme pains in the cecal region.
 Lymphatic inflammation; crushing injuries. Compare: Iris florentina-Orris-root-
(delirium, convulsions, and paralysis); Iris factissima (headache and hernia); Iris
germanica-Blue Garden Iris-(dropsy and freckles); Iris tenax -1.minor-(dry mouth;
deathly sensation at point of stomach, pain in ileo-caecal region; appendicitis. Pain
from adhesions after).
 Echinacea angustifolia - Clinical - Appendicitis.
Digestive drugs
 Apparently, it is a retro-cecal appendix, because they always complain of extreme
pain going right round to the back, rather than of pain ore McBurney's Point. It is the
type of appendix which is associated with a degree of jaundice. Some of the most
striking results from Natrum sulph. have been in cases of appendix abscesses, where
there has been a retro-cecal appendix and a tendency for the inflammation to track up
and conditions suggesting a sub-phrenic. There is one other rather interesting point
about this remedy, and it has no connection with the digestive system. Natrum sulph.
is sometimes very well indicated in acute his joints, particularly when it is the right
hip which is affected. The pain is very similar in character to that experienced in cases
of appendicitis, and if there are any Natrum sulph. indications, it is worthwhile to
consider its use. Two cases in hospital cleared up remarkably well on Natrum sulph.,
and it is apt to be forgotten for this condition.
 It has cured many cases resembling the first stage of appendicitis. Pain and tenderness
in the whole abdomen. Flatulence; colic; rending, tearing, cutting pains throughout the
abdomen; stitching pains in the abdomen; violent neuralgic pains in the abdomen;
inflammation of the bowels, of the peritoneum; appendicitis.
Abdomen
Flatulence with distention. Shifting, flatulent pain along colon several hours after meals.
Frequent, loose, yellow, painful stools, with burning of flatulence. Chronic appendicitis.
Relationship

17.  Compare: Hyd.; Nux.; Rhamnus Californica (tincture for constipation; tympanites and
appendicitis and especially rheumatism).
 Acts on vermiform appendix thus has been used for appendicitis, but remember it
promotes suppuration and a neglected appendicitis with pus formation would
probably rupture sooner under its use.
clinical
Appendicitis. Stitches in the caecum at 7 p.m., alternating with pains elsewhere.
Characteristics
This should make it appropriate in some cases of appendicitis. Appendicitis. As an external
application in the form of compresses, Lime-water has an ancient repute in allaying
inflammation of many kinds.
Characteristics
It has rapidly dispelled all inflammatory action in cases of appendicitis; and has removed all
suffering in an aggravated case of phagedaenic piles.
Clinical
 Appendicitis. Acute pain in liver extending towards stomach," though contrary to the
general "left to right" direction, is characteristic, as I can testify.
 Lach. is also one of the most prominent remedies in appendicitis.
Clinical
Appendicitis.
Characteristics
Although he deemed it useless he was persuaded to operate, and found a large abscess behind
the colon, freely communicating with the peritoneal cavity.
Clinical
Appendicitis.
Clinical
Appendicitis. Colic. Constipation Diarrhoea. Tympanites. Typhlitis. The ileo-caecal
symptoms seem to point to it as a possible remedy in cases of appendicitis.
Clinical
Anus, itching of. Appendicitis.
Clinical
Appendicitis. Appetite, lost.

18. Clinical
 Appendicitis. Breast, tumours of. Colic. Colic just below navel and some griping in
the side in afternoon. Griping below navel, 7 a.m. (after a slight vexation). Pain in
sigmoid flexure.
 Dull, heavy, periodic pain < when abdomen compressed, legs extended. (Appendicitis
as a local remedy. -R. T. C.). Several stools daily with tenesmus. Albuminuria.
Clinical
Appendicitis. "Sensitive to music" was observed in one of Nebel's patients; another had pains
in the region of the appendix vermiformis, which should lead to serviceable action in
appendicitis cases.
Clinical
Albuminuria. Appendicitis.
Do not forget the symptoms of Arnica in appendicitis if we know Bryonia, Rhus tox.,
Belladonna, Arnica and similar remedies. The homoeopathic remedy will cure these cases,
and, if we know it, you need never run after the surgeon in appendicitis except in recurrent
attacks.
If we do not know remedies, we will succumb to the prevailing notion that it is necessary to
open the abdomen and remove the appendix. It is only deplorable ignorance that causes
appendicitis to be surrendered to the knife.
"Great pain in the ileo-caecal region; cannot bear the slightest touch, even the bed clothes."
Yellow, brown spots on the abdomen; petechiae over the abdomen during typhoid fever. Pale
face in pleura/peritoneum-disease, red face in articular affections.
Belladonna Echinacea Purpurea
Bryonia alba Alfalfa plant

19. In this project the appendicitis disease is presented. Here various sections viz. what is
appendicitis, causes, symptoms and sign of appendicitis are given, which may give the
overall understanding of the disease. Further investigation of the disease and its diagnosis are
given. Both the surgical and medicinal treatment of this disease is broadly discussed.
1. S. Craig, Appendicitis, Medscape, Jul 2011.
2. D. J. Humes, J. Simpson; Acute appendicitis. BMJ. 2006 Sep 9.
3. A. Kentsis, Y. Y. Lin, K. Kurek, Discovery and Validation of Urine Markers of Acute
Pediatric Appendicitis Using High-Accuracy Mass Spectrometry, Ann Emerg Med.
2009, Jun 25.
4. http://chealth.canoe.ca
5. http://en.wikipedia.org/wiki/Appendicitis