Acute Appendicitis

ACUTE APPENDICITIS
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ACUTE APPENDICITIS 2
• Appendicitis is defined as an inflammation of

the inner lining of the vermiform appendix
that spreads to its other parts. This condition
is a common and urgent surgical illness.
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Mc Burneys point 3
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Variations in topographic
position of the appendix 4
From its base at the cecum, the appendix may extend (A) upward, retrocecal and
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retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to
the left, ileocecal (may pass anterior or posterior to the ileum)
Incidence
5
• The lifetime rate of appendectomy is 12% for men and 25% for women, with
approximately 7% of all people undergoing appendectomy for acute
appendicitis during their lifetim
• Despite the increased use of ultrasonography, computed tomography (CT),
and laparoscopy, the rate of misdiagnosis of appendicitis has remained
constant (15.3%), as has the rate of appendiceal rupture.
• The percentage of misdiagnosed cases of appendicitis is significantly higher
among women than among men
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Etiology 6
• Obstruction of the lumen is the dominant

etiologic factor in acute appendicitis.
• – Faecolith / faecal stasis
– Submucosal lymphoid hyperplasia
• – Vegetable/fruit seeds
• – Worms (Entrobius vermicularis
• – Tumours of caecum/appendix
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Pictorial Explanation
7
Distention
causing
Ischemia
obstruction
Distention
Gangrene
Appendiceal Appendiceal Irritation of parietal Perforation,

obstruction/early distension peritoneum localised/generalised
appendicitis – (localised) peritonitis, mass
visceral peritoneal
irritation
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8
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Symptoms 9
1-Abdominal pain is the prime symptom of acute appendicitis. Classically,

pain is initially diffusely centered in the lower
epigastrium or umbilical area, is moderately severe, and is steady, sometimes with
intermittent cramping superimposed.
After a period varying from 1 to 12 hours, but usually within 4 to 6 hours, the pain
localizes to the right lower quadrant
2-Anorexia nearly always accompanies appendicitis. It is so constant that

the diagnosis should be questioned if the patient is
not anorectic.
3-vomiting occurs in nearly 75% of patients

4-obstipation beginning before the onset of abdominal pain
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10
The sequence of symptom appearance has great
significance for the differential diagnosis. In >95% of
patients with acute appendicitis, anorexia is the first
symptom, followed by abdominal pain, which is
followed, in turn, by vomiting (if vomiting occurs). If
vomiting precedes the onset of pain, the diagnosis of
appendicitis should be questioned.
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SIGNS 11
• Temperature elevation is rarely >1°C

• Pulse rate is normal or slightly elevated
• Tenderness often is maximal at or near the
McBurney point
• Direct rebound tenderness
• indirect rebound tenderness
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12
• The Rovsing sign—pain in the right lower quadrant when
palpatory pressureis exerted in the left lower quadrant
• Muscular resistance to palpation of the abdominal wall
roughly parallels the severity of the inflammatory
process
• psoas sign - indicates an irritative focus in proximity to
that muscle
• -obturator sign of hypogastric pain on stretching the
obturator internus indicates irritation in the pelvis. The
test is performed by passive internal rotation of the
flexed right thigh with the patient supine.
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iNVESTIGATIONS 13
• IPPA (Physical examinations)

• Blood test (TWDC, RBC)
• Urine test
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Appendiceal Rupture 14
Immediate appendectomy has long been the recommended treatment for acute
appendicitis because of the presumed risk of progression to rupture. The overall rate of
perforated appendicitis is 25.8%. Children <5 years of age and patients >65 years of
age have the highest rates of perforation (45 and 51%, respectively)
delays in presentation are responsible for the majority of perforated appendices.
Appendiceal rupture occurs most frequently distal to the point of luminal obstruction
along the antimesenteric border of the
appendix. Rupture should be suspected in the presence of fever with a temperature
of >39°C (102°F) and a white blood cell
count of >18,000 cells/mm3
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Differential Diagnosis
15
The differential diagnosis of acute appendicitis depends on four 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 ADENITIS
2-Pelvic Inflammatory Disease
3-Ruptured Graafian Follicle

4-Twisted Ovarian Cyst
5-Ruptured Ectopic Pregnancy
6-ACUTE GASTROENTERITIS
Treatment 16
Once the decision to operate for presumed acute appendicitis has been made, the
patient should be prepared for the operating room. Adequate hydration should be
ensured, electrolyte abnormalities should be corrected, and pre-existing cardiac,
pulmonary, and renal conditions should be addressed. A large meta-analysis has
demonstrated the efficacy of preoperative antibiotics in lowering the infectious
complications in appendicitis.
Most surgeons routinely administer antibiotics to all patients with suspected
appendicitis
Appendetomy :
1-open appendectomy
2-Laparoscopic appendectomy
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Open appendetomy 17
• For open appendectomy most surgeons use either a

McBurney (oblique) or Rocky-Davis (transverse) right lower
quadrant muscle-splitting incision in patients with suspected
appendicitis. The incision should be centered over either the
point of maximal tenderness or a palpable mass
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Laparoscopic appendetomy 18
• Laparoscopic appendectomy usually requires the use of three
ports. Four ports may occasionally be necessary to mobilize a
retrocecal appendix. The surgeon usually stands to the
patient's left. One assistant is required to operate the
camera. One trocar is placed in the umbilicus (10 mm), and a
second trocar is placed in the suprapubic position. Some
surgeons place this second port in the left lower quadrant.
The suprapubic trocar is either 10 or 12 mm, depending on
whether or not a linear stapler will be used.
• The placement of the third trocar (5 mm) is variable and
usually is either in the left lower quadrant, epigastrium, or
right upper quadrant.
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TQ 19
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Acute Appendicitis

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ACUTE APPENDICITIS

• Appendicitis is defined as an inflammation of

• Obstruction of the lumen is the dominant

Appendiceal Appendiceal Irritation of parietal Perforation,

1-Abdominal pain is the prime symptom of acute appendicitis. Classically,

2-Anorexia nearly always accompanies appendicitis. It is so constant that

3-vomiting occurs in nearly 75% of patients

• Temperature elevation is rarely >1°C

• IPPA (Physical examinations)

1-ACUTE MESENTERIC ADENITIS

2-Pelvic Inflammatory Disease

3-Ruptured Graafian Follicle

• For open appendectomy most surgeons use either a

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