PGI Mae Caridad R. Martinquilla

Anatomy and Physiology• 8th week of embryologic

development

• The relationship of the base of the appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position

Anatomy and Physiology

• The three taeniae coli converge at the junction of the cecum with the appendix

• Length: <1 cm to >30cm• most appendices are 6 to 9

cm long• Mc Burney’s point- 1/3 of

the distance from the anterior superior iliac spine to the umbilicus.

Anatomy and Physiology• Appendicular artery -

branch from the lower division of the ileocolic artery

• The main artery approches the tip of the appendix, this one may be thrombosed in appendicitis gangrene and infarction

• Postcecal or ileocolic vein - and then into the superior mesenteric vein

Anatomy and Physiology

• Its connected by a short mesoappendix to the lower part of the ileal mesentery

• Small lumen opens into the caecum, sometimes this orifice is guarded by a semilunar mucosal fold forming a valve

• The lumen may be widely patent in early childhood; partially or wholly obliterated in the later decades of life

Anatomy and Physiology

• The appendix was erroneously viewed as a vestigial organ with no known function

• Now well recognized that the appendix is an immunologic organ that actively participates in the secretion of immunoglobulins, particularly immunoglobulin A

• Lymphoid tissue first appears in the appendix approximately 2 weeks after birth

Anatomy and Physiology

• Sympathetic and parasympathetic nerves from the superior mesenteric plexus

Acute Appendicitis

• 2nd- 4th decades of life• mean age of 31.3 years • median age of 22 years

• Slight male: female predominance (1.2 to 1.3:1)

• Rate of misdiagnosis of appendicitis has remained constant (15.3%) – higher among women than among men

Acute Appendicitis• Obstruction of the lumen- dominant etiologic

factor• Fecaliths-most common cause of appendiceal

obstruction• Less common causes:– Hypertrophy of lymphoid tissue– Inspissated barium from previous x-ray studies– Tumors– Vegetable and fruit seeds– Intestinal parasites

Pathophysiology

• Distention of the appendix stimulates the nerve endings of visceral afferent stretch fibers vague, dull, diffuse pain in the midabdomen or lower epigastrium

• Distention increases from continued mucosal secretion and from rapid multiplication of the resident bacteria of the appendix

Pathophysiology

• Distention of this magnitude reflex nausea and vomiting

• Capillaries and venules are occluded, but arteriolar inflow continues engorgement and vascular congestion

• inflammatory process soon involves the serosa of the appendix parietal peritoneum in the regioncharacteristic shift in pain to the right lower quadrant

Bacterial population

• The bacterial population of the normal appendix is similar to that of the normal colon

• The principal organisms seen in the normal appendix, in acute appendicitis, and in perforated appendicitis are Escherichia coli and Bacteroides fragilis

• Appendicitis is a polymicrobial infection

Antibiotic Coverage

• flora is known broad-spectrum antibiotics are indicated

• Antibiotic prophylaxis is effective in the prevention of postoperative wound infection and intra-abdominal abscess.– nonperforated appendicitis: coverage is limited to

24 to 48 hours – perforated appendicitis: 7 to 10 days of therapy is

recommended

Symptoms

• Abdominal pain is the prime symptom • pain is initially diffusely centered in the lower

epigastrium or umbilical area• After a period varying from 1 to 12 hours, but

usually within 4 to 6 hours, the pain localizes to the right lower quadrant

• Retrocecal appendix - flank or back pain• Pelvic appendix- suprapubic pain• Petroileal appendix- testicular pain

Symptoms

• Anorexia nearly always accompanies appendicitis

• Vomiting occurs in nearly 75% of patients• History of obstipation• Diarrhea occurs in some patients• >95% of patients anorexia is the first

symptom, followed by abdominal pain, which is followed, in turn, by vomiting (if vomiting occurs)

Signs• The classic right lower quadrant physical signs

are present when the inflamed appendix lies in the anterior position

• Direct tenderness often is maximal at or near the McBurney point

• Rebound tenderness• Referred or indirect rebound tenderness• Rovsing’s sign -indicates the site of peritoneal

irritation• Cutaneous hyperesthesia

Signs

• Muscular resistance to palpation of the abdominal wall roughly parallels the severity of the inflammatory process

• Early in the disease voluntary guarding• As peritoneal irritation progresses

involuntary guarding/true reflex rigidity – contraction of muscles directly beneath the

inflamed parietal peritoneum

Signs

• Signs of localized muscle irritation also may be present

• Psoas sign – lie on the left side as the examiner slowly extends the

patient's right thigh, thus stretching the iliopsoas muscle

– result is positive if extension produces pain• Obturator sign– irritation in the pelvis– passive internal rotation of the flexed right thigh with

the patient supine

Laboratory

• Mild leukocytosis, ranging from 10,000 to 18,000 cells/mm3 with moderate polymorphonuclear predominance acute, uncomplicated appendicitis

• Urinalysis can be useful to rule out the urinary tract as the source of infection– Although several white or red blood cells can be

present from ureteral or bladder irritation as a result of an inflamed appendix

Imaging

• Radiographic studies– abnormal bowel gas pattern nonspecific finding– presence of a fecalith highly suggestive of the

diagnosis

• Barium enema examination and radioactively labeled leukocyte scans– If the appendix fills on barium enema, appendicitis

is excluded; if the appendix does not fill, no determination can be made

Imaging

• Sonography– inexpensive, can be performed rapidly, does not

require a contrast medium, and can be used even in pregnant patients

– appendix is identified as a blind-ending, nonperistaltic bowel loop originating from the cecum

– presence of an appendicolith establishes the diagnosis– Thickening of the appendiceal wall and the presence

of periappendiceal fluid is highly suggestive– sensitivity of 55 to 96% and a specificity of 85 to 98%

Imaging

• High-resolution helical CT – inflamed appendix appears dilated (>5 cm) and the

wall is thickened. – evidence of inflammation, with "dirty fat," thickened

mesoappendix, and even an obvious phlegmon – Fecaliths– Arrowhead sign– CT scanning is also an excellent technique for

identifying other inflammatory processes masquerading as appendicitis

Appendicial Rupture

• Immediate appendectomy has long been the recommended treatment for acute appendicitis because of the presumed risk of progression to rupture

• rate of perforated appendicitis 25.8%• Children <5 years of age and patients >65

years of age have the highest rates of perforation (45 and 51%, respectively)

Appendicial Rupture

• Appendiceal rupture occurs most frequently distal to the point of luminal obstruction

• Fever with a temperature of >39°C (102°F) and a white blood cell count of >18,000 cells/mm3

• In the majority of cases, rupture is contained and patients display localized rebound tenderness

• Generalized peritonitis will be present if the walling-off process is ineffective in containing the rupture.

Appendicial Rupture

• Phlegmon- matted loops of bowel adherent to the adjacent inflamed appendix, or a periappendiceal abscess

• Phlegmons and small abscesses can be treated conservatively with IV antibiotics– well-localized abscesses can be managed with

percutaneous drainage– complex abscesses should be considered for

surgical drainage

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 Adenitis2.Gynecologic disorders3.Acute gastrointeritis4.Other intestinal disorders

Treatment

• Open appendectomy• Laparoscopic

appendectomy• Natural orifice

transluminal endoscopic surgery

• Interval appendectomy

Treatment

Thank you!