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ACUTE APPENDICITIS

M. IQBAL RIVAI
ANATOMY
a blind muscular tube with mucosal, submucosal,
muscular and serosal layers.

At birth short and broad at its junction with


the caecum
childhood
caecum rotates the appendix into a retrocaecal but
intraperitoneal position
Anatomy
Mesoappendix peritoneal fold containing
fat & appendicular artery
Appendicular artery a branch of the lower
division of the ileocolic artery passes behind
the terminal ileum to enter the mesoappendix

end artery

Thrombosis

Necrosis

gangrenous appendicitis
Commonly:
behind the caecum (Retrocaecal)
On psoas muscle at or below pelvic brim (Pelvic)

Rarely:
Pre-ileal Post-ileal Paracaecal
Microscopic Anatomy
Aetiology
There is no unifying hypothesis regarding the
aetiology of acute appendicitis.

Decreased dietary bre and increased consumption


of rened carbohydrates may be important.

associated with bacterial proliferation within the


appendix

Obstruction of the appendix lumen by a faecolith


or a stricture, tumour, parasites.
Pathology
Lymphoid hyperplasia narrows the lumen of the
appendix leading to luminal obstruction mucus
secretion and inammatory exudation increase
intraluminal pressure obstructing lymphatic drainage

Oedema and mucosal ulceration develop with bacterial


translocation to the submucosa further distension of
the appendix venous obstruction and ischaemia of
the appendix wall bacterial invasion occurs through
the muscularis propria and submucosa acute
appendicitis
Peritonitis a result of free migration of bacteria
through an ischaemic appendicular wall

Risk factors for perforation of the appendix:


Extremes of age
Immunosuppression
Diabetes mellitus
Faecolith obstruction
Pelvic appendix
Previous abdominal surgery
Clinical diagnosis
History
begin with poorly localised colicky abdominal pain.
Periumbilical colic
Pain shifting to the right iliac fossa
Anorexia
Nausea

Signs
Pyrexia
Localised tenderness in the right iliac fossa
Muscle guarding
Rebound tenderness
Signs to elicit in appendicitis
Pointing sign
Rovsings sign
Psoas sign
Obturator sign
Special features, according to position of the
appendix
Special features, according to age
Infants
Appendicitis rare in infants < 36 months diagnosis is often
delayed incidence of perforation and postoperative morbidity
is higher than in older children.
Diffuse peritonitis can develop rapidly because of the
underdeveloped greater omentum

Children
It is rare to nd a child with appendicitis who has not vomited.
Children with appendicitis usually have complete aversion to food.

The elderly
Gangrene and perforation occur much more frequently inelderly
patients.
The obese
Obesity can obscure and diminish all the local signs of acute
appendicitis Delay in diagnosis

Pregnancy
Appendicitis the most common extrauterine acute
abdominal condition in pregnancy
the caecum and appendix are progressively pushed to the right
upper quadrant of the abdomen as pregnancy develops during
the second and third trimesters non-specic symptoms
Differential diagnosis
Investigation

Clinical examination
alvarado score
Abdominal x-ray
Barium enema
Abdominal ultrasound
Contrast-enhanced CT
scan
Treatment
Appendicectomy
Conventional appendicectomy
Removal of the appendix

Retrograde appendicectomy
Laparoscopic appendicectomy

Problems encountered during appendicectomy


Appendicitis complicating Crohns disease
Appendix abscess
Pelvic abscess
Conventional appendicectomy
Removal of the appendix
Laparoscopic appendicectomy
Postoperative complications
Wound infection
Intra-abdominal abscess
Ileus
Respiratory
Venous thrombosis and embolism
Portal pyaemia (pylephlebitis)
Faecal fistula
Adhesive intestinal obstruction
Neoplasms of the appendix
Carcinoid tumours
Other appendiceal tumours
Mucinous cystadenoma