3. Dfn
• Appendicitis is the inflammation of the
vermiform appendix
• Surgical emergency
• When treated promptly most patients
recover without any difficulty
4. dfn
• Appendicitis (or epityphlitis) is a
condition characterized by inflammation of
the appendix[1]. While mild cases may
resolve without treatment, most require
removal of the inflamed appendix, either
by laparotomy or laparoscopy. Untreated,
mortality is high, mainly due to peritonitis
and shock.[2
6. diagnosis
• Although the model described above is
traditionally taught in medical schools,
histories of patients operated for
appendicitis do not often correlate well
with such a single disease progression.
Specifically, those with atypical histories
have findings at surgery that are
consistent with a suppurative process that
starts at the onset of symptoms and then
smolders.
7. diagnosis
• Patients with typical histories may have
findings suggesting resolution. Histories to
suggest rupture of the appendix while
patients are being diagnostically observed
are exceedingly rare.
8. diagnosis
• Thus appendicitis is now considered by some to
behave as two distinct disease processes,
typical and atypical (or suppurative).
Approximately two-thirds of patients with
appendicitis have typical histories, and findings
suggest a virus or mild obstruction as a cause.
In the third with atypical histories, an early
suppurative process begins at the clinical onset,
and severe unremitting obstruction is the likely
cause. In any case, early surgical removal is the
best treatment for either type of appendicitis.
(Hobler,K., 1998)
9. diagnosis
• Appendicitis’ apparently idiopathic nature
has led to many different theories
explaining its occurrence. One theory
regarding the cause of appendicitis,
sometimes facetiously referred to as "the
porcelain throne theory”, was proposed by
Dr. Denis Burkitt, who developed the
theory after observing low rates of
appendicitis in Uganda.
10. diagnosis
• He proposed two causes for this: one, the
Africans ate a diet high in fiber, and two,
they used squat toilets rather than seat
toilets. Most health practitioners accept Dr.
Burkitt's first cause as a contributing
factor, but are unfamiliar with the second
one, which has never been tested.
11. diagnosis
• A third hypothesis, which has gained less
attention, proposes that a lack of adequate
sanitary facilities in the developing world may
actually have a protective effect against later
appendicitis. This theory, proposed by Baker in
1985, hypothesized that infants in the developed
world are exposed to fewer enteric organisms,
which modifies their immune response to virus
infections, which might then cause appendicitis.
This is also unverified. [1]
12. diagnosis
• Appendicitis can be classified into two
types, typical and atypical. The pain of
typical acute appendicitis usually starts
centrally (periumbilical) before localising to
the right iliac fossa (the lower right side of
the abdomen). There is usually associated
loss of appetite (anorexia) and fever.
Nausea, or vomiting may or may not occur
13. diagnosis
• These classic signs and symptoms are
more likely in younger patients. Older
patients (beyond their teenage years) may
present with only one or two. Diagnosis is
easier in typical acute appendicitis and
surgery removes a swollen appendix with
little or no suppuration (pus) if operated
early (within 24 hours of onset).
14. diagnosis
• Atypical histories are not unusual and are more
often associated with suppurative appendicitis.
This condition often starts with right lower
quadrant pain and may smolder with non-
specific symtoms (e.g.,malaise,lethargy and/or
fever) for several days before a diagnosis of
appendicitis can be made. Diarrhea, a symptom
of gastroenteritis, may occur if the appendiceal
inflammation irritates adjacent intestine.
Diagnosis is more difficult and surgery removes
an appendix that is suppurative, gangrenous or
ruptured.
15. diagnosis
• There is typically pain and tenderness in
the right iliac fossa in both typical and
atypical (suppurative) appendicitis.
Rebound tenderness may be present
suggesting that there is some element of
peritoneal irritation.
16. diagnosis
• Asking the patient to cough gently and
point to the tender spot is the least painful
way to localize the area of peritonitis. If the
abdomen is involuntarily guarded (rigid),
there should be a strong suspicion of
peritonitis requiring urgent surgical
intervention.
17. Diagnosis
• Diagnosis is based on history and physical
examination backed by an elevation of
neutrophilic white cells, and other infection
markers on blood testing and imaging.
18. diagnosis
• The classical history in appendicitis is
diffuse pain in the periumbilical region
which then localizes as pain and
tenderness at McBurney's point
(associated with an inflamed appendix
coming in contact with the surrounding
parietal peritoneum
19. diagnosis
• This point is located on the right-hand side
of the abdomen one-third of the distance
between the anterior superior iliac spine
and the navel. Here, on gentle palpation,
the abdominal muscles often feel firm to
rigid because of involuntary spasm, and a
cough also produces a localized soreness.
20. diagnosis
• Other physical findings include right-side
tenderness on a digital rectal exam. Since
the appendix normally lies on the right, if a
finger is inserted into the rectum and there
is tenderness when pressure is applied
toward the right, this indicates an
increased likelihood that the patient has
appendicitis
21. diagnosis
• Other signs used in the diagnosis of
appendicitis are the psoas sign (useful in
retrocecal appendicitis), the obturator sign
(specifically the obturator internus
muscle), Blumberg's sign, and
Rovsing's sign. Ultrasonography and
Doppler sonography also provide useful
means to detect appendicitis, especially in
children. In some cases (15%
approximately),
22. diagnosis
• ultrasonography of the iliac fossa does
not reveal any abnormalities despite the
presence of appendicitis. This is especially
true of early appendicitis before the
appendix has become significantly
distended and in adults where larger
amounts of fat and bowel gas make
actually seeing the appendix technically
difficult
23. diagnosis
• Despite these limitations, in experienced
hands sonographic imaging can often
distinguish between appendicitis and other
diseases with very similar symptoms such
as inflammation of lymph nodes near the
appendix or pain originating from other
pelvic organs such as the ovaries or
fallopian tubes.
24. diagnosis
• In places where it is readily available,
CT scan has become the diagnostic test
of choice, especially in adults. A properly
performed CT scan with modern
equipment has a detection rate
(sensitivity) of over 95% and a similar
specificity.
25. diagnosis
• Signs of appendicitis on CT scan include lack of
contrast (oral dye) in the appendix and direct
visualization of appendiceal enlargement
(greater than 6 mm in diameter on cross
section). The inflammation caused by
appendicitis in the surrounding peritoneal fat (so
called "fat stranding") can also be observed on
CT, providing a mechanism to detect early
appendicitis and a clue that appendicitis may be
present even when the appendix is not well
seen.
26. diagnosis
• Thus, diagnosis of appendicitis by CT is made
more difficult in very thin patients and in
children, both of whom tend to lack significant fat
within the abdomen.
• In most cases, however, appendicitis is a
clinical diagnosis and, due to the high radiation
dose involved, CT scans are only used when the
diagnosis is in doubt (e.g. atypical history) or if
there are other considerations involved.
27. Alvarado
• Alvarado appendicitis score: Score: 0
Appendicitis less likely
Score Interpretation
• under 5 Appendicitis less likely
• 5-6 Possible appendicitis
• 7-8 Probably appendicitis
• over 8 Very probably appendicitis
29. T reatment
• Appendicitis can be treated by removal of
the appendix through a surgical procedure
called an appendicectomy (also known as
an appendectomy). The incision of
appendectomy can be a Gridiron incision,
a Lanz incision, or the midline incision
30. Treatment
• Often now the operation can be performed
via a laparoscopic approach, or via small
incisions with a camera to visualize the
area of interest in the abdomen. If the
findings reveal suppurative appendicitis
with complications such as rupture,
abscess, adhesions, etc., conversion to
open laparotomy may be necessary
31. T reatment
• Antibiotics are often given intravenously to
help kill remaining bacteria and thus
reduce the incidence of infectious
complication in the abdomen or woun d
32. Prognosis
• Most appendicitis patients recover easily with
treatment, but complications can occur if
treatment is delayed or if peritonitis occurs.
• Recovery time depends on age, condition,
complications, and other circumstances but
usually is between 10 and 28 days.
• Recovery time depends on age, condition,
complications, and other circumstances but
usually is between 10 and 28 days
33. prognosis
• The real possibility of life-threatening
peritonitis is the reason why acute
appendicitis warrants speedy evaluation
and treatment. The patient may have to
undergo a medical evacuation.
• Appendectomies have occasionally been
performed in emergency conditions (i.e.
outside of a proper hospital), when a
timely medical evacuation was impossible
34. prognosis
• Typical acute appendicitis responds quickly to
appendectomy and occasionally will resolve
spontaneously. If appendicitis resolves
spontaneously, it remains controversial whether
an elective interval appendectomy should be
performed to prevent a recurrent episode of
appendicitis. Atypical appendicitis (associated
with suppurative appendicitis) is more difficult to
diagnose and is more apt to be complicated
even when operated early.
35. prognosis
• In either condition prompt diagnosis and
appendectomy yield the best results with
full recovery in two to four weeks usually.
Mortality and severe complications are
unusual but do occur, especially if
peritonitis persists untreated.
