APPENDIX

1. Introduction

A. Appendix is a worm shaped tube which arise from posterior medial wall of the caecum about 2
cm below the ileocecal junction.
B. It is situated in Right Ilaic Fossa.
C. The length of the caecum is variable which can vary from 2 to 20 cm.
D. The average length of appendix is about 9 cm.
E. It is longer in children and shorter in adults and length of appendix become shorter with ageing.

2. Different part of appendix

A. Bace : It is attached to caecum.

B. Body : It is intermediate part which has has a lumen or canal within it.
C. Tail : It is distal part of the appendix and is movable in nature.
3. Peritonial Relation
1. Appendix is covered by peritoneum on all as per the covering known as mesoappendix.
2. Appendix vessel enters into the one so appendix for the supply of blood to the appendix and
its covering.

4. Different position of appendix

The base of the appendix is fixed but the tip can move in different direction. Thus various types
of positions of appendix takes place.
A. 11’O Clock position :
1. In this type the appendix lies below and behind the caecum aand the tip passes along with the
colon.
2. It is also known as subceacal or 11’O Clock position.

B. 12’O Clock position :

1. It is retrocaecal type.
2. Appendix passes vertically upward and behind the caecum directing towards the ascending
colon.
3. This position is most common type of position.
4. This is present in more than 60% of the cases.

C. 2’O Clock position :

1. It is also known as splenic type.
2. The tip of the appendix is directed upwards and medially. It passes either in front of ileum or
behind the ileum.
3. It is also called preileal / postileal position. It is dangerous position because, during the
appendicitis there is infection from the inflammation of the appendix.

D. 3’O Clock position :

1.In this position tip is directed horizontally.

E. 4’O Clock position :

1. It is also known as pelvic postion and the tip of the appendix is directed towards the pelvic
beam.
2. It is 2nd most common postion of appendix and occurs in 30% of the cases.
F. 6’O Clock position :
1. It is also known as mid-inguinal type in which the tip of appendix is downwards.
2. This is very rare position.
5. Artery Supply ( Blood Supply )
Appendix is supplied by appendicular artery which is branch of inferior Ileocolic artry which is
derived form superior mesenteric artery.
 APPENDICITIS
Appendicitis is an inflammation of the appendix, which is the worm-shaped pouch attached to
the cecum, the beginning of the large intestine. The appendix has no known function in the body,
but it can become diseased. Appendicitis is a medical emergency, and if it is left untreated the
appendix may rupture and cause a potentially fatal infection.

Types of appendicitis
There are four type of of appendicitis as follows :
1. Acute appendicitis
2. Subacute appendicitis
3. Recurrent appendicitis
4. Chronic appendicitis

 Acute appendicitis
Acute appendicitis is the most common acute surgical condition of the abdomen. Acute
appendicitis may occur at all ages but is most commonly seen in twenties and thirties of age.
It is disease of inflammation of vermiform appendix. It is a common cause if acute abdomen.

Aetiology :
1. Weakness of muscle coat.
2. Due to end arteries.
3. Infestation by the intestional parasites i.e. roundworm, hookworm.
4. Constriction of the lumen.
5. Fmilial factor.
6. Infection of upper respiratory tract etc.
7. Rich in protein intake.
Pathology :
1. The organs looks red and swollen.
2. The peritoneal surface may be smooth or roughened due to loss of endotheium and deposit of
lumph.
3. The nucleus membrane with polymorph is thickened, enlarged and infiltrarted with polymorph
and at place erosion are present.
4. If the process is checked healing occurs after a time and is often associated with fibrosis.
5. It may show itself aas generalized sclerosis of the whole appendix.
6. A structure of the lumen or complete obliteration may occur.
7. More severe infection leads to supurration in various forms. Mucous and pus gets collected in
lumen and may lead to perforation.

Clinical Feature : ( Usually 10-30 years )

Symptoms
1. Pain : Colicky in obstruction type that start in early morning in other cases dull aching first
around the umbilical then gets shifted to M C Burney’s point.
2. Disgestive disturbance : Constipation.
3. Nausea and vomiting.
4. Tempearture : Usually 99-101℉.
5. Within 2 or 3 days a tender and fixed lump develops at the site of the appendix.

On Examination
1. Tachycardia
2. Respiration : High
3. Coated tongue
4. Temperature
5. Toxic : not much
Local
Temperature raised, tenderness present, muscle guard, M C Burney’s sign positive, Rovsing sign
positive, Rebound sign positive.
( pain, vomiting and temperature is known as murphy’s syndrome )

Diagnosis
1. Blood test : High leukocytosis, polymorph raised.
2. Rovsing’s Sign : Pressure on left iliac fossa, pain in the Right Iliac fossa.
3. Psoas test : Passive extension of hip is painful in Retrocaceal appendix in contact with psoas
muscle.
4. Obturator test : Passive internal rotation of hip is painful if the appendix is in contavt with
obsurator internus.
5. Barium enema : To visulise changes in the mucosal pattern and presence of faecoliths or
foreign bodies.
6. Stool test : Occult blood suggest erosion and ulceration.
7. C.T. Scan

Differential Diagnosis
1. Intestinal colic
2. Acute gastroenteritis
3. Meckers diverticulitis
4. Amoebic typhitis (inflammation of the caecum)
5. Perforated duodenal ulcer
6. Iliac lymphadenitis
7.Rt ureteic colic
 In Female: 1. Ruptered tubal pregnancy
2. Acute salpingitis
3. Rupture of a Graafian follicle
4. Twisted ovarian cyst etc.

Progonosis
In case of early diagnosis and proper treatment the prognosis is favourable.

Cause of death
1. Untreated intraperitoneal abseces.
2. Diffuse peritonitis.
3. E.coli infection (Septicaemia)

Management
1. Without probable lump : Immediate appendiscectomy.
2. With a lump
A. In case of resolution : proper up position, antibiotics, small quantities of liquid
food, no purgative, close observation of pulse rate, temperature, papation of size of the
lump(whether increasing or decreasing), if any rigidity or tenderness, any vomiting, any
distortion etc.
B. In case of non-resolution : appendiscectomy
3. Treatment of post-operative complication.
4. Treatment of apeendicular abscess -Intervention and drainage : Appendix may be
removed if it comes on the way but never search for it.
5. Laproscopic Appendisectomy : It is possible to remove the appendix laproscopially.
Especially if the organ is normal or mildly inflamed. In skilled hands this may be the procedure
of choice for easy appendicitis. It should not be used when there is peritonitis or if the diagnosis
is in doubt.
  Chronic appendicitis
Chronic appendicitis is a long-standing inflammation or fibrosis of the appendix that presents
clinically as prolonged or intermittent abdominal pain. It is often a challenging diagnosis and
might result in complications such as intra-abdominal infections or bowel obstruction or
perforation.

Types of chronic appendicitis

There are three types of chronic appendicitis
1. Chronic recurrent appendicitis : They are recurrent attacks of acute appendicitis.
2. Chronic simple appendicitis : There is chronic vague pain in the Rt. Iliac fossa, which may
be difficult to be diagnosed from amoebic colitis.
3. Appendicular dyspepsia : A patient of chronic appendicitis may present with features of
duodenal ulcer. In these case there is no tenderness at the duodena but pressure on the MC
Burney’s point causes the pain over the epigastrium.

Pathology
Chronic Inflammation : Appendix is slightly congested with deposition of subserous fat.
Microscopic appearance – cest of chronic inflammation present.

Clincal Features Present

1. Slight pain or tenderness in the Rt. Iliac fossa.
2. Indigestion
3. General weakness
4. Malaise
5. Coated tongue due to absorption of toxin.
6. Epigastrium pain, acidity, heart burn (appendicular dyspepsia).

Management
The treatment for any form of chronic appendicitis appendicectomy.
 Homeopathic Remedy (Treatment)
1. Aconite
i. Attack is sudden, pain is intense and there is fear of death.

2. Belladonna
i. Pain and tenderness in the MC Burney’s point.
ii. Associated with fever.
iii. Headache, vomiting, slightest touch cannot be bourne.
iv. Worse from jar motion of bed or turning of body and lies on back.
v. Sudden and violent pain in the Rt ileo-caecal region.
vi. Throbbing or cutting or burning sensation of the affected region, can’t bear the least
touch, not even the pressure of the cover and above all the least jar.
vii. Its constrained to lie motionless on back.

3. Broynia
i. Abdomen very sore and sensitive.
ii. Swelling
iii. Used as a laxative to relieve constipation.

4. Arsenicum album
i. Burning pain, sweeling in caecum region.
ii. Anguish and restlessness prostration.
iii. Fever and thrist for small quantities of water at short intervals.

5. Lachesis
i. Sudden onset, abdomen highly sensitive to touch with burning pain.
ii. Cutting and teasing pain on the right side of abdomen associated with distension.
iii. Sensitive, irritability, nausea and constipation.
iv. Feels worse after sleep.

6. Hepar Sulph
i. Deep circumscribed swelling in the ileo-caecal region.
ii. Lies on back, with right knee drawn at easiest position.
iii. Great sensitiveness to slightest touch.
iv. Cold sweat on hand.

7. Colochium
i. Ileo-caecal region is extremely sensitive to touch and pressure.
ii. Distension of abdomen with gripping, teasing, cutting, stitching pains.
iii. Motion exictes vomiting and pain.
iv. Cold feeling in abdomen.
v. Aversion to food, loathing even the sight or even more, the smell of it.

8. Nitric Acid
i. Great sensitiveness to touch, lightest jar or movement.
ii. Sticking or pricking pain.
iii. Usually thristless, anxiety about recovery and fear of death.

9. Rhus Tox
i. Hard painful swelling of right side of abdomen.
ii. Pain worse from sitting or when stretching the right leg.
iii. Impossibility of lying on left side when lying on back with right leg drawn up.

10. IRIS Tenax

i. Fearful pain in ileocaecal region, great tenderness to pressure on one point and deathly
sensitive at pit of the stomach.
ii. Vomiting and fever associated with constipation.

11. Cinchona officinalis

i. Vomiting of indigested food particles, heaviness in the pit of stomach due to flatulence.
ii. Nausea and vomiting with sour taste in mouth.
iii. Throbbing type of headache with flushes in vertex, pressure in eyes.
iv. Sudden crying and tossing.
v. Ideas crowd in mind, so sleepless.

12. Gratiola
i. Recurrent attacks of appendicitis, especially in female candidate.
ii. Thick white coated tongue with nausea and vertigo after meals.
iii. There are severe cramps in the abdomen after and during meals.
iv. Distension of the abdomen after taking food followed by insomnia.
13. Kali Bichromicum
i. Catarrhal condition of appendix, inflammation of appendix with nausea and vomiting
followed by diarrhoea due to bad effects of alcohol.
ii. Weak digestion and assimilation , patient vomits out undigested food particle and stringy
mucous.
iii. Tongue is smooth, shiny or thickly white coated, cracks are present.
iv. Dryness of mouth with discharge of stringy mucous.

14. Phosphorus
i. Intense tenderness over Mac burney’s point.
ii. Great burning in the stomach.
iii. Violent shooting oain in the Right Iliac Fossa.
iv. Nausea and excessive salvation.
v. Coliky type of pain in the whole of the abdomen.

15. Pulsatilla
i. Abdominal discomfort due to fatty and undigested rich food.
ii. Heaviness of the abdomen due to flatulence.
iii. Pains worse after taking food.
iv. Water brash with offensive taste and smell in mouth.
v. Chronic constipation with with urge of passing the stools.
vi. Dry mouth without thrist.