Acute appendicitis is inflammation of the appendix that is commonly caused by obstruction. It occurs in about 10% of the population between ages 10-20 but can occur at any age. The obstruction leads to bacterial proliferation, invasion of the appendix wall, and damage from pressure necrosis. Initial pain is periumbilical but shifts to the right lower quadrant as the inflamed appendix touches the peritoneum. Signs include maximum tenderness, guarding, and rebound tenderness in the right iliac fossa. The Alvarado score is used to evaluate the likelihood of appendicitis. Treatment is antibiotic therapy and an appendectomy.

1. Acute Appendicitis
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K. Kavindya M. Fernando

2. What is acute appendicitis?
• Acute inflammation of the appendix
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3. How does this inflammation
occurs?
• Occurs due an obstruction
• Obstruction can occur by a
• Faecolith
• Foregin body
• Finbrous stricture from previous inflammation
• Enlarged lymphoid follicles
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4. How common it is?
• About 10% of the population will develop
acute appendicitis
(Benjamin IS, Patel AG; Managing acute appendicitis. BMJ. 2002 Sep 7;325(7363):505-6)
• Most common between the ages of 10 and 20
years but can occur at any age
• Appendicitis is more common in men
(Humes DJ, Simpson J; Acute appendicitis. BMJ. 2006 Sep 9;333(7567):530-4.)
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5. Why does acute appendicitis is
not common among extremes of
age?
• In infants lumen of the appendix is
• Wide mouthed & well drained
• In old age – lumen of appendix is
• Almost obliterated
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6. What happens after the
obstruction?
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Appendix acts as a closed loop
Bacteria proliferates in the lumen
Invade the appendix wall
Appendix is damaged by pressure
necrosis

7. What happens after the
obstruction?
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Vascular supply by end arteries
They get thrombosed
Gangrene formation
Perforation of appendix
Branches of the
appendicular branch of
ileocolic artery

8. JMJ 8
Can acute appendicitis occur
without getting it obstructed?
• Yes
• Direct infection of the lymphoid follicles
from the appendix lumen
• Hematogeneous infection
• More likely to resolve than obstructed cases
Ellis, H., Clane, S. R. & Watson, C., 2011. Acute Appendicitis. In: General Sugery Lecture Notes. pp. 199-
203.

9. Pathological course of
appendicitis
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Acute
appendicitis
Perforation
Localized
Generalized
Localized

10. History and
Examination
Signs and symptoms
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11. PAIN
• Pain commences as a central periumbilical
colic,
• Shifts after about 6 hours to the RIF
• According to the anatomical variations of
the position other symptoms may differ
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12. Anatomical variations of
appendix
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Retrocecal
Pre-ileal
Post-ileal
Pelvic
Paraceacal

13. Why does patient feel pain in
periumbilical region?
• Referred pain
• Normal visceral innervation of the appendix
• comes from the 10th thoracic spinal segment
• Corresponding dermatome
• Encircles the abdomen
• At the level of abdomen
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14. Why does the pain shifted to
the right iliac fossa
• Initial periumbilical pain – referred pain
• When the inflamed appendix touches the
peritoneum,
• Patient feels pain in right iliac fossa (over
the point where the inflamed appendix
touches the peritoneum)
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15. Other symptoms
• Anorexia
• Nausea / Vomiting
• Fever (low grade – unless perforated)
• Diarrhoea can occur when ileum is irritated
by the inflamed appendix
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16. JMJ 16
Typical history is
almost diagnostic
of acute
appendicitis

17. What are the signs which
suggest Acute appendicitis/
• Maximum tenderness
• Guarding
• Rigidity in the iliac fossa
• Rebound tenderness – cough can mimic it
• Tenderness and guarding would be
generalized if appendix has perforated
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18. What is guarding?
• When you try to touch the abdomen,
• Surrounding abdominal muscles, will go into a
spasm
• This spasm may cause pain
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19. What is rigidity?
• Due to the inflammation of the whole
abdomen,
• The abdominal walls have already went into a
spasm
• When you touch the abdomen, feeling of
• Board like rigidity
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20. Rovsing’s sign
• palpation of the left lower quadrant
increases the pain felt in the right lower
quadrant.
• This pressure stretches the entire
peritoneal lining, and so causes pain in any
location where the peritoneum is irritating
the muscle
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21. Psoas test
• extend the hip and abduct the thigh with
the patient on the left side
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Obturator test
• flex and internally rotate the right hip

22. How to detect pelvic and
retroceacle appendix?
• Rectal examination may reveal localised
tenderness as the only sign of an inflamed
retrocaecal or pelvic appendix
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23. What is Alvarado Score?
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SYMPTOMS Points allocated
• Migratory RIF pain 1
• Anorexia 1
• Nausea & Vomitting 1
SIGNS
• Tenderness in RIF 2
• Rebound tenderness 1
• Elevated temperature
(99.1 0F)
1
LABORATORY
• Leukocytosis (WBC>
10,000)
2
• Shift to left (neutrophil
preponderance)
1
TOTAL 10

24. Interpretation
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• Score <4 – strongly against a diagnosis of
appendicitis
• Score 5-6 – possible acute appendicitis
• Score >7 - probable acute appendicitis

25. Differential diagnosis 1/2
• Intra abdominal causes
• Meckle’s diverticulitis
• Acute intestinal obstruction – colicky pain,
vomiting, noisy bowel sounds, X-ray abdomen
• Gastroenteritis – diarhhoea, abdominal pain
• Acute colonic diverticulitis – solitary ceacal
diverticulum , sigmoid colon (mobile bowel)
• Crohn’s disease
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26. Differential diagnosis 2/2
• Gyanacological problems in females
• Ectopic pregnancy
• Ruptured or torted ovarian cyst – sudden severe
RIF pain radiating to loin
• Urogenital problems
• Ureteric colic – pain radiates from loin to groin
• Testicular torsion – periumbilical pain & vomiting
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27. Investigations
• Leucocyte count –
• A mild polymorph leukocytosis
• Normal level does not exclude the diagnosis
• UFR –
• To exclude UTI
• Urine for hCG
• In females to exclude the ectopic pregnancy
• USS abdomen
• where the diagnosis is doubtful and in the
assessment of an appendix mass or abscess
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28. Management
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29. Management
• Resuscitate the patient
• Intravenous fluid
• Antibiotics
• Opiate analgesia
• appendicectomy – treatment of choice
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30. Management
• Antibiotic prophylaxis – preoperatively
• Operation peritonitis – continue antibiotic
therapy
• Mrtranidazole
• Gentamycin or cephalosporins
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31. Appendicectomy
Acute appendicitis Appendicectomy
Acute appendicitis +
generalized peritonitis
Surgery  (intraperitoneal lavage
with N/S +AB)
Appendicectomy + drain
Appendicular mass –
inflammatory mass
Planned appendicectomy
Appendicectomy with next episode
Interval appendicectomy
Appendicular abscess Exploration + evacuation of pus
+/- appendicectomy
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32. Disadvantages of operating
first hand
• Dissemination of infected material
• Inflammation  vasodialatation 
hemmorrage
• Feacal fistula
• Post-op complications
• Wound infection
• Residual abscess
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33. Advices on discharge
• Clean and dressing after 5day
• Suture removal – 10 days
• R/V at clinic with histology report
• Come back if develop pain or fever
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34. Prognosis
• Appendicectomy is relatively safe with a
mortality rate for non-perforated
appendicitis of 0.8 per 1,000 and mortality
after perforation of 5.1 per 1,000
(Humes DJ, Simpson J; Acute appendicitis. BMJ. 2006 Sep 9;333(7567):530-4.)
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35. THANK YOU!!!!
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