Acute Appendicitis

Marah Marahleh

Objectives 1. 1.Anatomy of the appendix

2. 2. Acute Appendicitis

3.Epidemiology… Etilogy… Clinical presentation …

diagnosis

1. 4. Operative Intervention

2. 5. Post operative care

3. 6. Complications

The appendix is a narrow blind-ended tube that is attached to the posteromedial

end of the cecum.

Average length of 6 – 9 cm,Outer diameter 3-8mm and luminal diameter 1-3 mm.

• Blood supply of the appendix : the appendicular artery and vein which originate

from ileocolic artery and vein respectively.

• Lymphatic drainage : ileocolic lymph nodes.

• Innervation : Superior mesenteric plexuses T10-L1 and vagus nerve.

Histologically the appendix consist of three layers The serosa, muscularis layer and

submucosa Formed by lymphoid aggregates and neuroendocrine complexes.

The function of the appendix:

Immunological organ that secrete immunoglobulin particularly immunoglobulin A

and May function as a reservoir for healthy bacteria.

Anatomy

Epidemiology

The lifetime risk of developing appendicitis is 8.6% for males and 6.7% for

females, with the highest incidence in the second and third decades.

In the last few years, a decrease in frequency of appendicitis in Western

countries has been reported, which may be related to changes in dietary fiber

intake. In fact, the higher incidence of appendicitis is believed to be related to

poor fiber intake in such countries.

Etiology

Obstruction of the lumen due to fecaliths or hypertrophy of lymphoid tissue is

proposed as the main etiologic factor in acute appendicitis.

The proximal obstruction of the appendiceal lumen produces a closed-loop obstruction, and

continuing normal secretion by the appendiceal mucosa rapidly produces distension.

Distension increases from continued mucosal secretion and from rapid multiplication of the

resident bacteria of the appendix. This causes reflex nausea and vomiting, and the visceral pain

increases.

Capillaries and venules are occluded but arterial inflow continues, resulting in engorgement and

vascular congestion.

process soon involves the serosa of the appendix and in turn the parietal peritoneum. This

produces the characteristic shift in pain to the right lower quadrant.

As distension, bacterial invasion, compromise of the vascular supply, and infarction progress,

perforation occurs

Microbiology :

• The flora of the inflamed appendix differs from that of the

normal appendix. About 60% of aspirates of inflamed

appendices have anaerobes compared to 25% of

aspirates from normal appendices.

• Virtually all grow Escherichia coli and Bacteroides

species on culture.

• 62% Fusobacterium nucleatum/necrophorum

• Other usual species (Peptostreptococcus, Pseudomonas,

Bacteroides splanchnicus, Bacteroides intermedius,

Lactobacillus).

• Patients with gangrene or perforated appendicitis appear

to have more tissue invasion by Bacteroides.

Clinical Presentation

Symptoms

• Appendicitis usually starts with periumbilical and diffuse pain that eventually

localizes to the right lower quadrant.

• Nausea and vomiting

• Loss of appetite

• Atypical symptoms include

• Indigestion

• flatulence

• Constipation

• Diarrhea may occur in association with perforation, especially in children.

• Pelvic Appendicitis can present with suprapubic pain, dysuria and urinary

frequency.

Signs

• The body temperature and pulse rate may be normal or slightly elevated

low grade fever 38.3 C.

• Usually move slowly and prefer to lie supine due to the peritoneal

irritation.

• On abdominal palpation, there is tenderness with a maximum at or near

McBurney’s point.

• On deep palpation, one can often feel a muscular

resistance (guarding) in the right iliac fossa.

• Rebound tenderness

• Right-sided rectal tenderness in pelvic Appendicitis

Special signs

Rovsing’s sign –

Area of skin

hyperaesthesia bounded

by lines joining anterior

superior iliac spine,

the pubic

symphysis and umbilicus.

Laboratory Findings

No specific diagnostic test for appendicitis exists, but the judicious use of simple urine and

blood tests, particularly inflammatory response variables, should allow exclusion of other

pathologies and provide additional evidence to support a clinical diagnosis of appendicitis

• CBC : Mild leukocytosis accompanied by a polymorphonuclear prominence (white blood cell count >18,000 cells/mm3 raise the possibility of a perforated appendix

with or without an abscess And the opposite could be due to lymphopenia or septic reaction)

• C-reactive protein : elevated but can have up to a 12-hour delay.

• Urine analysis : to rule out the urinary tract infection. however, several white

or red blood cells can be present from irritation of the ureter or bladder.

A decreasing inflammatory response may

indicate spontaneous resolution.

Clinical Scoring Systems

Imaging Studies • Abdomenal x-ray : rarely helpful But can show the presence of a fecalith and fecal loading in the

cecum.

• Graded compression ultrasonography :

• computed tomography (CT) scan

- The inflamed appendix appears dilated (>5 mm), and the wall is

thickened.

- Periappendiceal phlegmon, and free fluid

- Periappendiceal fat stranding

- Thickened mesoappendix

- Fecaliths but their presence is not pathognomonic of appendicitis.

Ultrasonography. sensitivity of 55% to 96% and a specificity of 85% to

98%.

(CT) scan 92% to 97% sensitivity, 85% to 94% specificity

Differential Diagnosis

The most common findings in the case of an erroneous preoperative diagnosis of

appendicitis are, in descending order of frequency :

1. acute mesenteric adenitis,

2. no organic pathologic condition,

3. acute pelvic inflammatory disease,

4. twisted ovarian cyst or ruptured graafian follicle,

5. and acute gastroenteritis.

The differential diagnosis of acute appendicitis

depends on four major factors: the anatomic

location of the inflamed appendix; the stage of

the process (uncomplicated or complicated); the

patient’s age; and the patient’s gender.

Management

Uncomplicated Appendicitis

Operative versus Nonoperative Management of Uncomplicated Appendicitis

in line with treatment guidelines from the American College of Surgeons, Society of

American Gastrointestinal and Endoscopic Surgeons, European Association of Endoscopic

Surgery, and World Society of Emergency Surgery, all of which recommend appendectomy

as the treatment of choice for adult patients with nonperforated appendicitis

Patients pursuing nonoperative

management should be carefully

counseled regarding the risks of

treatment failure and recurrent

appendicitis.

Urgent versus Emergent Appendectomy for Uncomplicated Appendicitis

Emergent versus urgent operation for uncomplicated appendicitis is dependent on each institution

and surgeon

There was no statistically significant increase in the number of complicated appendicitis cases, rates

of surgical site infection, intra-abdominal abscesses or conversion to an open procedure, and

operative time showed no difference in the urgent group when compared to the emergent group

the emergent group had a time from presentation to the operat-ing room of <12 hours, whereas the

urgent group had a time from presentation to the operating room of 12 to 24 hours

Complicated Appendicitis

Complicated appendicitis typically refers to perforated appendicitis commonly associated

with an abscess or phlegmon.

Children less than 5 years of age and patients more than 65 years of age have the highest

rates of perforation (45% and 51%, respectively).

Rupture should be suspected in the presence of generalized peritonitis and a strong

inflammatory response.

OPERATIVE INTERVENTIONS FOR THE APPENDIx

Open Appendectomy Laparoscopic Appendectomy

General Anesthesia General Anesthesia

A right lower quadrant incision at McBurney’s point

with A McBurney (oblique) or Rocky-Davis

(transverse) right lower quadrant muscle splitting

incision If perforated appendicitis is suspected or

the diagnosis is in doubt, a lower midline

laparotomy can be considered

Typically uses three ports. Typically, a 10- or 12-mm

port is placed at the umbilicus, whereas two 5-mm

ports are placed suprapubic and in the left lower

quadrant.

Inc risk for surgical site infection Inc risk Of intra abdominal abscess

Decreased operative duration less pain, shorter length of stay, and quicker return

to normal activity

POSTOPERATIVE CARE AND COMPLICATIONS

Non perforated. After either open or laparoscopic appendectomy for nonperforated

appendicitis, patients may be started on a clear liquid diet and advanced as tolerated to a

regular diet. Antibiotics are not required postoperatively. Most patients are discharged within

24 to 48 hours of surgery. Same-day discharge is feasible, most commonly following a

laparoscopic appendectomy

perforated appendicitis often develop an ileus postoperatively regardless of the

surgical approach (open versus laparoscopic). Thus, diet should only be advanced as the

clinical situation warrants. Patients may be discharged once they tolerate a regular diet,

usually in five to seven days. Three to five days of intravenous antibiotics is recommended for

perforated appendicitis after appendectomy

COMPLICATIONS

The most common complication following appendectomy is surgical site infection, either a

simple wound infection or an intra-abdominal abscess Both typically occur in patients with

perforated appendicitis

Recurrent or stump appendicitis

Stump appendicitis is a form of recurrent appendicitis that is related to incomplete appendectomy that

leaves an excessively long stump after open or laparoscopic surgery, more commonly for perforated

appendicitis. To minimize stump appendicitis, the appendix should be transected no further than 0.5 cm

from its junction with the cecum and removed as a whole. In case stump appendicitis occurs, stump

resection can be performed open or laparoscopically. A perforated appendiceal stump, however,

typically requires a more extensive bowel resection to control

REFERENCES

• Schwartz’s Principles of Surgery Tenth Edition

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805616/#!po=51.3158

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1562475/#!po=28.333

• Acute appendicitis In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.

Thank you