1.

Review the pathophysiology of abdominal pain

2. Compare the contrast between somatic pain and visceral abdominal pain
3. Explain the developmental anatomy of appendix
4. Explain the definition of appendicitis
5. Explain the histopathological features of appendicitis including acute chronic, and acute
exacerbation on chronic appendicitis
6. Explain the histopathological features of carcionoid of the appendix
7. Discuss the pathophysiology of appendicitis
8. Compare and contrast the histopathology features and clinical picture between acute
appendicitis and chronic appendicitis, acute exacerbation on chronic appendicitis
9. Describe the natural course and complication of acute appendicitis
10. Describe the sign and symptoms of acute appendicitis
11. Discuss the differential diagnosis of acute appendicitis
12. Appraise the steps taken to diagnose acute appendicitis
13. Explain the role of abdominal imaging in diagnosing appendicitis
14. Describe the management of simple acute appendicitis and complicated appendicitis
15. Describe the anatomy of peritoneum and peritoneal cavity including the basic principle of
abdominopelvic cavity and the division of peritoneum and peritoneal cavity
16. Describe the physiology of peritoneum
17. Explain the concept of peritonitis, sepsis, and systemic inflammatory response syndrome
18. Describe the etiology and classification of secondary peritonitis
19. Explain the pathophysiology of secondary peritonitis
20. Discuss the complication of peritonitis
21. Explain the sign and symptoms of primary and secondary peritonitis
22. Appraise the steps taken to diagnose secondary peritonitis
23. Discuss the differential diagnosis of secondary peritonitis
24. Interpret plain abdominal X-ray of acute abdomen
25. Discuss the supportive and definitive treatment of secondary peritonitis
26. Ethical issue on surgical complication
27. Formulate research problem of the case
Anatomy and histology
Large intestine

Appendix
is a blind intestinal diverticulum (6–10 cm in length) that contains masses of lymphoid tissue. It arises
from the posteromedial aspect of the cecum inferior to the ileocecal junction. The appendix has a short
triangular mesentery, the mesoappendix, which derives from the posterior side of the mesentery of the
terminal ileum. The mesoappendix attaches to the cecum and the proximal part of the appendix. The
position of the appendix is variable, but it is usually retrocecal.

Base of appendix is located 2cm beneath ileocecal valve. Its position within the abdomen corresponds to
a point on the surface known as McBurney’s point (1/3 bawah garis serong yang menghubungkan
umbilicus dan SIAS)

A: SMAileocolic a. appendicular a.

V: ileocolic v SMV portal vein

Lymphatic: ileocolic LN superior mesenteric LN

Innervation: superior mesenteric plexus

Sympathetic: lower thoracic

Parasympathetic: vagus nerve

Afferent fibers: accompany sympathetic nerve to T10

Histology

1. Mucosa: penetrated throughout its length by tubular intestinal glands, lines by goblet and
colonocytes.

Colonocytes: irregular microvilli and dilated intercellular space

Goblet cells: produce mucus.

Stem cells located 1/3 lower of each gland

Lamina propria rich in lymphoid cells and lymphoid nodule extend into submucosa. Organized lymphoid
nodule (peyer’s patches)

Appendix has no absorptive function

2. Submucosa
3. Muscularis: longitudinal and circular layer. with fibers of the outer layer gathered in three separate
longitudinal bands called teniae coli
4. Serosa: intraperitoneal portion, protuberance of adipose tissue
Peritoneum
Serous membrane that forms the lining of abdominal cavity. It covers most of intrabdominal organs, and
is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum
supports the abdominal organs and serves as a conduit for their blood vessels, lymph vessels, and
nerves

 Intraperitoneal: structures within intraperitoneal space

 Retroperitoneal: behind
 Subperitoneal/infraperitoneal: below

Two types of peritoneum

 Outer layer, parietal peritoneum, is attached to the abdominal wall and pelvic wall
 Inner layer, visceral peritoneum, is wrapped around visceral organs, thinner than parietal

Potential space between 2 layer is peritoneal cavity, filled with peritoneal fluid

Mesentery: refer to a double layer of visceral peritoneum. There are often blood vessels, nerves, and
other structures between these layers. The space between these two layers is technically outside of the
peritoneal sac, and thus not in the peritoneal cavity.

Intraperitoneal organs

Stomach, First part of the duodenum [5 cm], jejunum, ileum, cecum, appendix, transverse colon,
sigmoid colon, rectum (upper 1/3), Liver, spleen, pancreas (only tail), In women: ovaries

Physiology
Appendix
1. Immune function
 Contain Peyer’s patches. Peyer's patches are covered by a special epithelium that
contains specialized cells called microfold cells (M cells) which sample antigen directly
from the lumen and deliver it to antigen-presenting cells (located in a unique pocket-like
structure on their basolateral side). T cells, B-cells and memory cells are stimulated
upon encountering antigen in Peyer's patches. These cells then pass to the mesenteric
lymph nodes where the immune response is amplified. Activated lymphocytes pass into
the blood stream via the thoracic duct and travel to the gut where they carry out their
final effector functions. The maturation of B-lymphocytes takes place in the Peyer's
patch.
 A group of researchers from Osaka University, The University of Tokyo, Kinki University,
and Riken have found that lymph tissue in the appendix, commonly misconceived as an
unnecessary organ, was an important location for generating IgA that plays a crucial role
in mucosal immunity and that it was involved in the regulation of intestinal bacterial
flora. They found that in the appendectomized mice the number of IgA-producing cells
in the large intestine was reduced and balance of intestinal bacterial flora was changed.
 IgA is an important antibody for maintaining a balance in intestinal bacterial flora. Thus,
they demonstrated that the appendix is an important organ in the suppression of
inflammatory bowel disease caused by a disturbed balance of intestinal bacterial flora.
2. Maintaining gut flora
The appendix serves as a haven for useful bacteria when illness flushes those bacteria from the
rest of the intestines. This proposal is based on a new understanding of how the immune system
supports the growth of beneficial intestinal bacteria, in combination with many well-known
features of the appendix, including its architecture, its location just below the normal one-way
flow of food and germs in the large intestine, and its association with copious amounts of
immune tissue. Research performed at Winthrop University-Hospital showed that individuals
without an appendix were four times more likely to have a recurrence of Clostridium difficile
colitis. The appendix, therefore, may act as a "safe house" for commensal ("good") bacteria. This
reservoir of gut flora could then serve to repopulate the digestive system following a bout of
dysentery or cholera.

Peritoneum
1. Contain tPA, high fibrinolytic activity, prevent adhesion
2. The peritoneal surface area is a semipermeable membrane with an area comparable to that of
the cutaneous body surface. Nearly 1 m2 of the total 1.7 m2 area participates in fluid exchange
with the extracellular fluid space at rates of 500 mL or more per hour. Normally, there is less
than 50 mL of free peritoneal fluid, a transudate with the following characteristics: specific
gravity below 1.016, protein concentration less than 3 g/dL (predominantly albumin), white
 blood cell count less than 3000/μL (50% lymphocytes, 40% macrophages, a few eosinophils,
mast cells), complement-mediated antibacterial activity, and lack of fibrinogen-related clot
formation. The circulation of peritoneal fluid is directed toward lymphatics in the undersurface
of the diaphragm. There, particulate matter—including bacteria up to 20 μm in size—is cleared
via stomas in the diaphragmatic mesothelium and lymphatics and discharged mainly into the
right thoracic duct.
3. Peritoneal fluid is also produced as a transudate which coats the serosal surface of viscera to
facilitate frictionless movement e.g. during peristalsis. The fluid is constantly being produced
and resorbed through the large surface area of the peritoneum, for this reason drugs are
sometimes administered by intraperitoneal injection. Bacterial toxins are also absorbed readily
and can cause inflammation of the peritoneum; peritonitis.
4. The peritoneal fluid diffuses everywhere within the cavity and is continuously renewed; in fact, a
turnover of 5ml per 24 h has been calculated. It flows upward into subphrenic recesses, where
the intraperitoneal hydrostatic pressure in lower (-30mmH2O in comparison with 0 mmH2O in
the pelvic spaces) and the reabsorption is more active.
5. Peritoneal reabsorption is favored by the respiratory activity, because the pumping effect of the
diaphragmatic movements; therefore, every condition that increases respiratory rhythm, and
thus intraperitoneal and thoracic pressure, stimulate this reabsorption and vice versa.
6. Peritoneointestinal reflex
Irritation of peritoneum, strongly inhibits the excitatory enteric nerves and thereby can cause
intestinal paralysis, especially in patient with peritonitis.

Embryology of midgut

Appendicitis

Colon cancer

Microbiology

Systemic inflammatory response syndrome

Severe sepsis and septic shock