2. FACTS
 Acute appendicitis is the most common
surgical emergency of the abdomen
 Appendectomy is one of the most
frequently performed surgical procedures

3. FACTS
Mortality rate from perforated appendicitis:
 near certain death a century ago
 10-20 per cent 50 years ago
 5 per cent during the 1960s
 1 per cent or less from the 1970s to the present

4. FACTS
“Rates of unnecessary appendectomies and
perforation have remained relatively high
despite gaining a century of clinical experience
with acute appendicitis”
“The dramatic expansion of diagnostic testing
options and the introduction of innovative
surgical approaches during the last decade has
actually caused even more debate and
disagreement than resolution of issues.”

5. OPERATIONAL DEFINITIONS
Uncomplicated Appendicitis:
 Includes the acutely inflamed, phlegmonous,
suppurative, or mildly inflamed appendix with
or without peritonitis

6. OPERATIONAL DEFINITIONS
Complicated Appendicitis:
 Includes gangrenous appendicitis, perforated
appendicitis, localized purulent collection at
operation, generalized peritonitis and
periappendiceal abscess

7. OPERATIONAL DEFINITIONS
Equivocal Appendicitis:
 A patient with right lower quadrant
abdominal pain who presents with an atypical
history and physical examination and the
surgeon cannot decide whether to discharge or
to operate on the patient

12. Adult size 9 cms length ; 1-3 mm lumen
Base constant = confluence of taenia coli
Blood supply – appendicular branch of
ileocolic artery
Lymphatics – follows the blood supply

13. HISTOLOGIC FEATURES
- Muscular layer not well defined
- Lymphoid aggregates in submucosa and
mucosa
- Mucosa is like colon, but irregular shaped
crypts

14. PHYSIOLOGY
-Serotonin – mediates pain arising from
non inflamed appendix
- “ carcinoid tumors”
- Immune surveillance
- Secretes mucin, fluid & proteolytic
enzymes

15. DISEASES OF THE VERMIFORM
APPENDIX
I. Acute appendicitis
Etiology & Pathogenesis:
A.Role of environmental: Diet and
Hygiene
Western Diet (Low fiber, High fat)
Change in motility, flora, lumen –
fecalith formation

16. B. Role of obstruction
- anatomical
- hyperplasia of lymphoid
- neoplasm/foreign body

17. Sequence of events:
Increase mucus & fluids inc intraluminal
pressure – obstructed outflow of blood (venules)
& lymph inc P appendiceal wall obstructs
arterial supply mucosal ischemia,
inflammation, stasis, necrosis of muscularis
PERFORATION

18. Observation:
Impacted fecalith – no local inflammation
(50%)
C. Role of colonic flora
- 60% Anaerobes – inflammed AP
- 25% Anaerobes – non-inflammed AP
Lumen – source of microorganism
(E.coli/Bacteroides)
Pieper et al – inc antibody titer to Bacteriodes
Gangrene & perforation

19. NATURAL HISTORY
Temple et al(1995) Prospective study Ann.
Surgery
- 20% perforation < 24 hrs after onset of
symptoms
- 1 patient <10 hrs
- average time to perforate 64h

20. CLINICAL PRESENTATIONS:
Symptoms:
Abdominal pain – crampy colicky, initial
response of muscularis of appendix to
obstruction
Vomiting, nausea, loss of appetite

21. CLINICAL PRESENTATIONS:
Signs:
Tenderness – local inflammatory response; tip of
appendix touching parietal peritoneum
Fever rarely occurs (38.2o
C)

22. 3 CLASSIC MANEUVERS:
• Rovsing sign – peritoneal irritation
• Psoas sign – irritation of psoas muscle
• Obturator sign – irritation of obturator
muscle
“OVERALL CLINICAL PICTURE COUNTS”

23. Laboratory:
Leukocytes count – serial
Urinalysis – exclude ureteral stone/UTI
Liver enzymes/amylase – R/O HBT dse
BHCG – Pregnancy

24. Imaging studies:
• Plain film- abnormal gas pattern
-(+) fecalith/ rule out other dse.
• Graded compression USG- A-P> 6mm
- sensitivity (55-96%), spec (85-98%)
• CT scan – dilated AP(>5cm),thickened
- wall,(92% sensitive, 94% spec)
BHCG – Pregnancy
Imaging studies

25. Alvarado scale for the diagnosis of AP
Migration of pain(1),anorexia(1), N/V(1)
RLQ pain (2),rebound (1),fever (1)
Leukocytosis (2), left shift (1)
• 9-10 = almost certain/no labs
• 7-8 = high likelihood
• 5-6 =compatible with but not diagnostic

26. Acute appendicitis is essentially a clinical
diagnosis; there is no laboratory or
radiologic test yet devised that is 100%
diagnostic of this condition

27. EVALUATION
Hx and PE – serial PE, one examiner, rectal
exam, speculum, bimanual examination,
urinalysis, pregnancy test
MANAGEMENT:
a. preop – fluids/antibiotics (2nd
gen)
b. Operative – open/laparoscopy
c. Postop - antibiotics

28. COMPLICATIONS
• Perforation
• Abscess formation
• Intestinal obstruction
• Bacteremia
• Sepsis
• Fistula
• Liver abscess
• Pyelophlebitis

29. Differential diagnosis:
Acute mesenteric adenitis, AGE, dse of male
urogenital system
Meckel’s diverticulitis, intessusception,
perforated peptic ulcer, colonic lesion,
epiploic appendagitis
UTI, gynecologic dse, Henoch-Schonlein
purpura

30. Special consideration:
Lifetime risk- 12%( males )
25%( females )
Mean age – 31.3 y/o
2nd
- 4th
decade of life
Rate of misdiagnosis- 15% (higher in females,
22.3 vs 9.3%)
Negative appendectomy women- 23.2%

31. Special consideration:
Advance age – 50-70% perforation
Use of imaging modalities like CT scan
Pregnancy – location of appendix base on AOG
- ultrasound

32. II. Neoplasm
> 0-5% incidence
> AdenoCA, Cystic neoplasm, carcinoid, mets,
lymphoma, leiomyosarcoma
> Treatment: Right hemicolectomy
> 5 yr. survival- 55%