PATHOPHYSIOLOGY

APPENDIX
The appendix is a small, finger-like appendage about 10 cm (4in) long that is
attached tothe cecum just below the ileocecal valve. The appendix fills with food and
empties regularly intothe cecum. Because it empties inefficiently and its lumen is small,
the appendix is prone toobstruction and is particularly vulnerable to infection.
Although it's commonly referred to as the "appendix," the real name for it
is"vermiform appendix." In the past, the appendix was considered an evolutionary
leftover. Nowhowever, scientists acknowledge that the appendix helps support the
immune system in twoways. It helps tell lymphocytes where they need to go to fight an
infection and it boosts the largeintestine's immunity to a variety of foods and drugs. The
latter helps keep your gastrointestinaltract from getting inflamed in response to certain
food and medications you ingest.

PATHOPHYSIOLOGY of APPENDICITIS
The main thrust of eventsleading to the development of acute appendicitis lies in the
appendix developing a compromised blood supply due to obstruction of its lumen and
becoming very vulnerable to invasion by bacteria found in the gut normally.Obstruction
of the appendix lumen by fecalith, enlarged lymphnode, worms, tumor, or indeed foreign
objects, brings about a raised intra-luminal pressure, which causes the wall of the
appendix to become distended. Norma lmucus secretions continue within the lumen of
the appendix, thus causing further build up of intra-luminal pressures. This in turn leads
to the occlusion of the lymphatic channels, then the venous return, and finally the
arterial supply becomes undermined. Reduced blood supply to the wall of the appendix
means that the appendix gets little or no nutrition and oxygen. It also means a little or no
supply of white blood cells and other natural fighters of infection found in the
blood being made available to the appendix. The wall of the appendix will thus start to
break up and rot. Normal bacteria found in the gut gets all the inducement needed to
multiply and attack thed ecaying appendix within 36 hours from the point of luminal
obstruction, worsening the process of appendicitis. This leads to necrosis and
perforation of the appendix. Pus formation occurs when nearby white blood cells are
recruited to fight the bacterial invasion. A combination of dead white blood cells,
bacteria, and dead tissue makes up pus. The content of the appendix (fecalith, pus and

mucus secretions) are then released into the general abdominal cavity, bringing causing
peritonitis.

Symptoms of appendicitis include:

lower right side abdominal pain
loss of appetite
nausea
vomiting
diarrhea
constipation
inability to pass gas
abdominal swelling
low grade fever
a sense you might feel better after passing stool
Appendicitis pain may start off as mild cramping. It often becomes more steady
and severe with time. You will not necessarily notice changes in your bowel habits.
However, sometimes appendicitis can affect urination.
If you have right side tenderness along with any of these other symptoms, talk to
a doctor. Appendicitis can quickly become a medical emergency. Rupture rarely
happens within the first 24 hours of symptoms. However, up 80 percent of people who
have symptoms for 48 hours will end up with a ruptured appendix.
A perforated appendix can be fatal. The risk of death is highest in infants and the
elderly.
CLINICAL MANIFESTATION OF APPENDICITIS
Lower right quadrant pain usually accompanied by low-grade fever, nausea, and
sometimes vomiting.
At McBurney's point (located halfway between the umbilicus and the anterior spine
of the ilium), local tenderness with pressure and some rigidity of the lower portion of
the right rectusmuscle.
Rebound tenderness may be present; location of appendix dictates
amount of tenderness, muscle spasm, and occurrence of constipation or diarrhea.

 Rovings sign (elicited by palpating left lower quadrant, which paradoxically causes
pain in right lower quadrant).
If appendix ruptures, pain becomes more diffuse; abdominal distention develops
from paralytic ileus, and condition worsens.

COMPLICATION OF APPENDICITIS
The most frequent complication of appendicitis is perforation. Perforation of the
appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse
peritonitis (infection of the entire lining of the abdomen and the pelvis).

The major reason for appendiceal perforation is delay in diagnosis and treatment.
In general, thelonger the delay between diagnosis and surgery, the more likely is
perforation. The risk of perforation 36 hours after the onset of symptoms is at least
15%. Therefore, once appendicitis isdiagnosed, surgery should be done without
unnecessary delay.A less common complication of appendicitis is blockage of the
intestine. Blockage occurs whenthe inflammation surrounding the appendix causes the
intestinal muscle to stop working, and this prevents the intestinal contents from passing.
If the intestine above the blockage begins to fillwith liquid and gas, the abdomen
distends and nausea and vomiting may occur. It then may benecessary to drain the
contents of the intestine through a tube passed through the nose andesophagus and
into the stomach and intestine.A feared complication of appendicitis is sepsis, a
condition in which infecting bacteria enter the blood and travel to other parts of the
body. This is a very serious, even life-threateningcomplication. Fortunately, it occurs
infrequently.
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HOW IS APPENDICITIS DIAGNOSED?

Blood tests: You may need blood taken to show if you have an infection. The
blood may be taken from your hand, arm, or IV.

Urine test: You may need a urine test to check for a urinary tract infection or
kidney stone.

CT scan:
This test is also called a CAT scan.
An x-ray machine uses a computer
to take pictures of your abdomen.
You may be given dye in your IV
before the pictures are taken. The
dye will help your caregivers see
the pictures better. People who are
allergic to iodine or shellfish (crab,
lobster, or shrimp) may be allergic
to some dyes.

Abdominal ultrasound: This test is done so caregivers can see the tissues and
organs of your abdomen. Gel will be put on your abdomen and a small sensor will
be moved across your abdomen. The sensor uses sound waves to send pictures of
your abdomen to a TV-like screen.

Abdominal x-ray

Ultrasound

Barium Enema

HOW IS APPENDICITIS TREATED?

Medicines:
o

Pain medicine: You may be given medicine to take away or decrease pain. Do
not wait until the pain is severe before you take your medicine.

Antibiotics: This medicine is given to help treat or prevent an infection caused

by bacteria.

Laparoscopy
Newer techniques for removing the appendix
involve the use of the laparoscope.
Thelaparoscope is a thin telescope attached to
a video camera that allows the surgeon to
inspect theinside of the abdomen through a
small puncture wound (instead of a larger
incision). If appendicitis is found, the appendix
can be removed with special instruments that
can be passedinto the abdomen, just like the
laparoscope, through small puncture wounds.
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The benefits of the laparoscopic technique

include less post-operative pain (since much of
the post-surgery paincomes from incisions) and
a speedier return to normal activities. An
additional advantage of laparoscopy is that it
allows the surgeon to look inside the abdomen
to make a clear diagnosis incases in which the
diagnosis of appendicitis is in doubt.

Appendectomy: This is surgery to remove your appendix. During a laparoscopic

appendectomy, small incisions are made in your abdomen. A small scope and
special tools are inserted through these incisions. A scope is a flexible tube with a
light and camera on the end. If your appendix has burst, you may need an open
appendectomy. This is when a single, larger incision is made to remove your
appendix and clean out your abdomen.

If the appendix is not ruptured (perforated) atthe time of surgery, the patient generally
issent home from the hospital after surgery inone or two days. Patients whose appendix
has perforated are sicker than patients without perforation, and their hospital stay often
is prolonged (four to seven days), particularly if peritonitis has occurred.
Intravenousantibiotics are given in the hospital to fightinfection and assist in resolving
any abscess.
Occasionally, the surgeon may find a normal-appearing appendix and no other cause
for the patient's problem. In this situation, the surgeon mayremove the appendix. The
reasoning in these casesis that it is better to remove a normal-appearingappendix than
to miss and not treat appropriately anearly or mild case of appendicitis

COMPLICATION OF APPENDECTOMY
The most common complication of appendectomy is infection of the wound, that
is, of thesurgical incision. Such infections vary in severity from mild, with only redness
and perhaps sometenderness over the incision, to moderate, requiring only antibiotics,
to severe, requiringantibiotics and surgical treatment. Occasionally, the inflammation
and infection of appendicitisare so severe that the surgeon will not close the incision at
the end of the surgery because of concern that the wound is already infected. Instead,
the surgical closing is postponed for severaldays to allow the infection to subside with
antibiotic therapy and make it less likely for infectionto occur within the incision.
Wound infections are less common with laparoscopic surgery.
Another complication of appendectomy is an abscess, a collection of pus in the area of
theappendix. The major complication is perforation of the appendix, which can lead to
peritonitis or anabscess. Perforation generally occurs 24 hours after onset of
pain (symptoms include fever (37.7C[100F] or greater), toxic appearance, and
continued pain or tenderness).

GLOSSARY
Abdomen: The belly, that part of the body that contains all of the structures between
the chest and the pelvis. The abdomen is separated anatomically from the chest by the
diaphragm, the powerful muscle spanning the body cavity below the lungs.
Abdominal: Relating to the abdomen, the belly, that part of the body that contains all of
the structures between the chest and the pelvis. The abdomen is separated
anatomically from the chest by the diaphragm, the powerful muscle spanning the body
cavity below the lungs.
Abdominal pain: Pain in the belly (the abdomen). Abdominal pain can come from
conditions affecting a variety of organs. The abdomen is an anatomical area that is
bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below,
and the flanks on each side. Although abdominal pain can arise from the tissues of the
abdominal wall that surround the abdominal cavity (the skin and abdominal wall
muscles), the term abdominal pain generally is used to describe pain originating from
organs within the abdominal cavity (from beneath the skin and muscles). These organs
include the stomach, small intestine, colon, liver, gallbladder, and pancreas.
Abnormal: Not normal. Deviating from the usual structure, position, condition, or
behavior. In referring to a growth, abnormal may mean that it is cancerous or
premalignant (likely to become cancer).
Abscess: A local accumulation of pus anywhere in the body. The following are some
examples of abscesses:
1. A skin abscess is better known as a common boil;
2. A peritonsillar abscess is a persistent collection of pus behind the tonsils; and
3. A perianal abscess is a pool of pus that forms next to the anus, often causing
considerable tenderness and swelling in that area and pain on sitting down and
on defecating.
Appendectomy: Removal by surgery of the appendix, the small worm-like appendage
of the colon (the large bowel). An appendectomy is performed because of probable
appendicitis, inflammation of the wall of the appendix generally associated with
infection.
Appendiceal: Relating to the appendix. As, for example, an appendicealabscess.
Perforation of the appendix can lead to a periappendiceal abscessor diffuse peritonitis
(infection of the entire lining of the abdomen and the pelvis).
Appendiceal perforation: Rupture of appendix.
Appendicitis: Inflammation of the appendix, the small worm-like projection from the
first part of the colon. Appendicitis usually involves infection of the appendix by bacteria
that invade it and infect the wall of the appendix. Appendicitis can progress to produce
an abscess (a pocket of pus) and even peritonitis (inflammation of the lining of the
abdomen and pelvis).

Appendix: A small outpouching from the beginning of the large intestine (the ascending
colon). Formally called the vermiform appendix because it was thought to be wormlike.
Bacteria: Single-celled microorganisms which can exist either as independent (freeliving) organisms or as parasites (dependent upon another organism for life).
Barium enema: A series of x-rays of the lower intestine (colon) and rectum that are
taken after the patient is given an enema with a white, chalky solution that contains
barium. The barium outlines the intestines on the x-rays. These x-rays permit the
detection of colon and rectal abnormalities including diverticulosis, diverticulitis,
abnormal colon movement, dilation (widening) of the colon, polyps and cancers of the
colon and rectum.
Cancer: An abnormal growth of cells which tend to proliferate in an uncontrolled way
and,
in
some
cases,
to
metastasize
(spread).
Cecum: The cecum (also spelled caecum), the first portion of the large bowel, situated
in the lower right quadrant of the abdomen.
Complication: In medicine, an additional problem that arises following a procedure,
treatment or illness and is secondary to it. A complication complicates the situation.
Computerized tomography: Pictures of structures within the body created by a
computer that takes the data from multiple X-ray images and turns them in pictures.
CT scan: Computerized tomography scan. Pictures of structures within the body
created by a computer that takes the data from multiple X-ray images and turns them
into pictures on a screen. CT stands for computerized tomography.
Enema: Liquid injected into the rectum. An enema may be used for therapeutic (such
as to stimulate evacuation of the bowels) or diagnostic (such as imaging studies of the
gastrointestinal tract - barium enema) purposes.
Fecalith: A hard stony mass of feces. A fecalith can obstruct the appendix, leading
to appendicitis. Fecaliths also can obstruct diverticuli. Called also a coprolith and
stercolith. From fecal + -lith for stone.
Fever: Although a fever technically is any body temperature above the normal of 98.6
degrees F. (37 degrees C.), in practice a person is usually not considered to have a
significant fever until the temperature is above 100.4 degrees F (38 degrees C.).
See the entire definition of Fever
Incision: A cut. When making an incision, a surgeon is making a cut.
Infection: The growth of a parasitic organism within the body. (A parasitic organism is
one that lives on or in another organism and draws its nourishment therefrom.) A person
with an infection has another organism (a "germ") growing within him, drawing its
nourishment from the person.
Inflammation: A basic way in which the body reacts to infection, irritation or other
injury, the key feature being redness, warmth, swelling and pain. Inflammation is now

recognized
as
a
type
of
nonspecific
immune
response.
See the entire definition of Inflammation
Innervate: To supply with nerves. It is a little known fact that the cornea is the most
densely innervated tissue in the body.
Laparoscope: An instrument through which structures within the abdomen and pelvis
can be seen. A small surgical incision (cut) is made in the abdominal wall to permit the
laparoscope to enter the abdomen or pelvis. A diversity of tubes can be pushed through
the same incision or other small incisions permitting the introduction of probes and other
instruments. In this way, a number of surgical procedures can be performed without the
need for a large surgical incision.
Laparoscopy: A type of minimally invasive surgery in which a small incision (cut) is
made in the abdominal wall through which an instrument called a laparoscope is
inserted to permit structures within the abdomen and pelvis to be seen. The abdominal
cavity is distended and made visible by the instillation of absorbable gas, typically,
carbon dioxide. A diversity of tubes can be pushed through the same incision in the
skin. Probes or other instruments can thus be introduced through the same opening. In
this way, a number of surgical procedures can be performed without the need for a
large surgical incision. Most patients receive general anesthesia during the procedure.
Mucus: A thick slippery fluid produced by the membranes lining certain organs such as
the nose, mouth, throat, and vagina. Mucus is the Latin word for "a semifluid, slimy
discharge from the nose." Note that mucus is a noun while the adjective is mucous.
Nausea: Nausea, is the urge to vomit. It can be brought by many causes including,
systemic illnesses, such as influenza, medications, pain, and inner ear disease. When
nausea and/or vomiting are persistent, or when they are accompanied by other severe
symptoms such as abdominal pain, jaundice, fever, or bleeding, a physician should be
consulted.
Pain: An unpleasant sensation that can range from mild, localized discomfort to agony.
Pain has both physical and emotional components. The physical part of pain results
from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it
can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by specific nerve
fibers that carry the pain impulses to the brain where their conscious appreciation may
be modified by many factors.
Pelvic: Having to do with the pelvis, the lower part of the abdomen, located between
the hip bones.
Pelvis: The lower part of the abdomen located between the hip bones.
Peri-appendiceal: See: Periappendiceal.
Peritoneum: The membrane that lines the abdominal cavity and covers most of the
abdominal organs. (From the Greek peri- meaning around + tonos meaning a stretching
= a stretching around).
Peritonitis: Inflammation of the peritoneum (The peritoneum is the tissue layer of cells
lining the inner wall of the abdomen and pelvis). Peritonitis can result from infection
(such as bacteria or parasites), injury and bleeding, or diseases (such as systemic lupus
erythematosus).

Pus: A thick whitish-yellow fluid which results from the accumulation of white blood cells
(WBCs), liquified tissue and cellular debris. Pus is commonly a site of infection or
foreign material in the body.
Rupture: A break or tear in any organ (such as the spleen) or soft tissue (such as
the achilles tendon). Rupture of the appendix is more likely among uninsured and
minority children when they develop appendicitis.
Scan: As a noun, the data or image obtained from the examination of organs or regions
of
the
body
by
gathering
information
with
a
sensing
device.
Symptom: Any subjective evidence of disease. Anxiety, lower back pain, and fatigue
are all symptoms. They are sensations only the patient can perceive. In contrast, a sign
is objective evidence of disease. A bloody nose is a sign. It is evident to the patient,
doctor, nurse and other observers.

XI.
APPENDIX

A.

Statistics
1. Harrisons Principles of Internal Medicine states that appendicitis is the most
common medical emergency in the United States.
2. In the United States, appendicitis occurs in 7% of the U.S. population, with an
incidence of 1.1 cases per 1000 people per year. Some familial predisposition
exists.
3. Incidence of appendicitis is lower in cultures with a higher intake of dietary fiber.
Dietary fiber is thought to decrease the viscosity of feces, decrease bowel transit
time, and discourage formation of fecaliths, which predispose individuals to
obstructions of the appendiceal lumen.
4. The over-all mortality rate of 0.2-0.8% is attributable to complications of the
disease rather than to surgical intervention
5. Mortality rate rises above 20% in patients older than 70 years, primarily because
of diagnostic and therapeutic delay.
6. Perforation rate is higher among patients younger than 18 years and patients
older than 50 years, possibly because of delays in diagnosis. Appendiceal
perforation is associated with a sharp increase in morbidity and mortality rates
7. Appendicitis occurs most often between the ages of 10 and 30. It is more common
in men than in women . The incidence of appendicitis is approximately 1.4 times
greater in men than in women.
8. Incidence of appendicitis gradually rises from birth, peaks in the late teen years,
and gradually declines in the geriatric years. The median age at appendectomy is

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22 years. Although rare, neonatal and even prenatal appendicitis have been
reported.

9. More than 250,000 appendectomies are performed annually. The incidence of

primary appendectomy is approximately equal in both sexes.
10. In the Philippines , which has an estimated population of 86,241,6972, the
incidence of appendicitis was reported to be 215,604

B.

References

Books
1. MIMS PHILIPPINES, ver. 2, 2010
Internet sites:
emedicine.medscape.com
kids.yahoo.com/reference/dictionary/english/entry/dictionary
http:wikianswers.com
http://www.medicinenet.com/
http://www.medicinenet.com/
www.rightdiagnosis.com
www.myhealthyfeeling.com

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