Basics of Acute Appendicitis

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Acute AppendicitisAcute Appendicitis
Presented by :Presented by :
Seyed Morteza MahmoodiSeyed Morteza Mahmoodi
Anatomy project
Year 2005-06
Supervised by:
Dr. Aziz Aziz

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ContentsContents
 IntroductionIntroduction
 HistoryHistory
 IncidenceIncidence
 Etiology and pathologyEtiology and pathology
 CaseCase
 Signs and symptomsSigns and symptoms
 Clinical diagnosisClinical diagnosis
 Differential diagnosisDifferential diagnosis

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IntroductionIntroduction
 Appendicitis can be tricky diagnosis, even forAppendicitis can be tricky diagnosis, even for
skilled physicianskilled physician
 Acute appendicitis is the most common cause ofAcute appendicitis is the most common cause of
intraabdominal infectionintraabdominal infection
 Appendicectomy is the most commonAppendicectomy is the most common
emergency surgical operationemergency surgical operation..
 Variations in the position of the appendix, ageVariations in the position of the appendix, age
of the patient, and degree of inflammation makeof the patient, and degree of inflammation make
the clinical presentation of appendicitisthe clinical presentation of appendicitis
notoriously inconsistentnotoriously inconsistent..

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HistoryHistory
 Recognition as clinical entityRecognition as clinical entity
Reginald Fitz ‘perforatingReginald Fitz ‘perforating
inflammation of the vermiforminflammation of the vermiform
appendix’appendix’
 Charles McBurney describedCharles McBurney described
the clinical manifestation thethe clinical manifestation the
point of max. tenderness in thepoint of max. tenderness in the
right iliac fossaright iliac fossa

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IncidenceIncidence
 Relatively rare in infantsRelatively rare in infants
 Common in childhood and adult lifeCommon in childhood and adult life
3-4/1000/year3-4/1000/year
 Peak incidence in teens and early 20sPeak incidence in teens and early 20s
 After middle age the risk is quit smallAfter middle age the risk is quit small
 Before puberty the incidence is equal amongstBefore puberty the incidence is equal amongst
males and femalesmales and females
 In teenagers and young adults the ratio ofIn teenagers and young adults the ratio of
male:female is 3:2 at the age of 25male:female is 3:2 at the age of 25
 Thereafter the incidence in males declinesThereafter the incidence in males declines
 approximately 1 in 7 people will undergo anapproximately 1 in 7 people will undergo an
appendicectomy during their lifetimeappendicectomy during their lifetime

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EtiologyEtiology
 No unifying hypothesisNo unifying hypothesis
 Bacterial proliferationBacterial proliferation
 Initiating event is controversialInitiating event is controversial
 Obstruction of appendix lumenObstruction of appendix lumen
 Faecolith or fibrotic strictureFaecolith or fibrotic stricture
 TumorTumor
 Intestinal parasitesIntestinal parasites
 No luminal obstructionNo luminal obstruction

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Pathological sequencePathological sequence

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Pathological sequencePathological sequence

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Pathological sequencePathological sequence

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PathologyPathology
 Continued mucous secretion andContinued mucous secretion and
inflammatory exudation intraluminalinflammatory exudation intraluminal
pressure obstructing lymphatic drainage.pressure obstructing lymphatic drainage.
 Edema and mucosal ulceration develop withEdema and mucosal ulceration develop with
bacterial translocation to submucosa .bacterial translocation to submucosa .
 Further distention may cause venousFurther distention may cause venous
obstruction and ischcemia of the appendixobstruction and ischcemia of the appendix
wall.wall.
 Bacterial invasion through muscularisBacterial invasion through muscularis
externea producing acute appendicitis.externea producing acute appendicitis.
 Ischaemic necrosis of appendicular wallIschaemic necrosis of appendicular wall
gangrenous appendix bacterial contaminationgangrenous appendix bacterial contamination
of peritoneal cavity.of peritoneal cavity.

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Pathology cont.Pathology cont.
 Greater omentum becomesGreater omentum becomes
adherent to inflamedadherent to inflamed
appendix paracaecalappendix paracaecal
abscessabscess
 Extremes of ageExtremes of age
 ImmunosuppressionImmunosuppression
 Faecolith obstructionFaecolith obstruction
 Pelvic appendixPelvic appendix
 Previous abdominalPrevious abdominal
surgerysurgery

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Pathology cont.Pathology cont.

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Pathology cont.Pathology cont.

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Case reportCase report
 Colicky periumblical painColicky periumblical pain
 Migrated to the right lower quadrantMigrated to the right lower quadrant
 Initial nauseaInitial nausea
 Increasing emesis and anorexiaIncreasing emesis and anorexia
 Abdominal guarding and reboundAbdominal guarding and rebound
tendernesstenderness
 Rigid anterior abdominal wall in RLQRigid anterior abdominal wall in RLQ
 Low grade fever and rising WBC countLow grade fever and rising WBC count

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Clinical signsClinical signs

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Clinical signsClinical signs

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Abdominal painAbdominal pain
 Visceral abdominal painVisceral abdominal pain
 Somatic abdominal painSomatic abdominal pain
 referred abdominalreferred abdominal

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Visceral abdominal painVisceral abdominal pain
 Visceral abdominal pain, organs, visceralVisceral abdominal pain, organs, visceral
peritoneum, mesenteryperitoneum, mesentery
1-distention of a hollow viscus1-distention of a hollow viscus
2-ischemia to a viscus2-ischemia to a viscus
3-inflammation3-inflammation
Referred to midline embryologicalReferred to midline embryological
developmentdevelopment

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Colicky painColicky pain
 Colicky pain form of visceral painColicky pain form of visceral pain
rhythmic pain resulting from smoothrhythmic pain resulting from smooth
muscle spasm as a reaction to luminalmuscle spasm as a reaction to luminal
obstructionobstruction
 intestinal obstruction, passage ofintestinal obstruction, passage of
gallstone in biliary ducts, ureteric colicgallstone in biliary ducts, ureteric colic
 Often thought to be indigestion,Often thought to be indigestion,
constipation and is frequently ignored.constipation and is frequently ignored.
 Lasts for a variable period, usually fewLasts for a variable period, usually few
hours / 2 or 3 days, rarely longerhours / 2 or 3 days, rarely longer

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Referred painReferred pain
 The vague referred pain in the periumblicalThe vague referred pain in the periumblical
 stretching of the lumen or spasm.stretching of the lumen or spasm.
 The visceral innervation comes from theThe visceral innervation comes from the
10th thoracic spinal segment.10th thoracic spinal segment.
 Accompany the sympathetic nerves throughAccompany the sympathetic nerves through
the superior mesenteric plexus and thethe superior mesenteric plexus and the
lesser splanchnic nervelesser splanchnic nerve
 If the visceral innervation is higher, then theIf the visceral innervation is higher, then the
mid-line pain will be higher.mid-line pain will be higher.
 Testicular pain due to visceral referral ofTesticular pain due to visceral referral of
afferent nerve impulses to the same spinalafferent nerve impulses to the same spinal
segmentsegment

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Somatic painSomatic pain
 Skin, fascia, muscle and parietalSkin, fascia, muscle and parietal
peritoneumperitoneum
 Sever and precisely localizedSever and precisely localized
 Inflamed parietal peritoneum cutaneousInflamed parietal peritoneum cutaneous
hyperesthesia and tendernesshyperesthesia and tenderness
 The right iliac fossa pain is due to theThe right iliac fossa pain is due to the
irritation of parietal peritoneumirritation of parietal peritoneum
 somatic pain as opposed to earliersomatic pain as opposed to earlier
visceralvisceral..

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Guarding and rigidityGuarding and rigidity
 Guarding is the protective phenomenonGuarding is the protective phenomenon
 abdominal muscles increase in toneabdominal muscles increase in tone
 attempts to localize the inflammationattempts to localize the inflammation
 There is tenderness causing the patientThere is tenderness causing the patient
to constantly tense the abdominal wallto constantly tense the abdominal wall
muscles in palpationmuscles in palpation
 Voluntary guarding /apparent guardingVoluntary guarding /apparent guarding
 Involuntary guarding /true guardingInvoluntary guarding /true guarding
 Muscular spasm rigidityMuscular spasm rigidity
 localized initially progressing tolocalized initially progressing to
generalized with perforation orgeneralized with perforation or
increasing peritonitisincreasing peritonitis

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TendernessTenderness
 Tenderness:Tenderness:
localised over McBurney's pointlocalised over McBurney's point
not evident before later inflammation ofnot evident before later inflammation of
serosa and parietal peritoneumserosa and parietal peritoneum
often masked in obese due to inability tooften masked in obese due to inability to
displace viscusdisplace viscus
 Blumberg’s sign The pain is elicited withBlumberg’s sign The pain is elicited with
pressing the abdominal wall deeply withpressing the abdominal wall deeply with
fingers and abruptly releasing it.fingers and abruptly releasing it.

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ReflexesReflexes
 Visceral afferent fibers participate in reflexVisceral afferent fibers participate in reflex
activities. Reflex sweating, salivation,activities. Reflex sweating, salivation,
nausea, vomiting and tachycardia maynausea, vomiting and tachycardia may
accompany visceral pain.accompany visceral pain.
 Carried by autonomic nerve fibersCarried by autonomic nerve fibers

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SignsSigns
 lying still, with shallow breaths and reluctant tolying still, with shallow breaths and reluctant to
coughcough
 fever 37.5-38.5C, worsening with perforationfever 37.5-38.5C, worsening with perforation
 Foetor oris - halitosisFoetor oris - halitosis
 Furred tongueFurred tongue
 FlushedFlushed
 infrequently, diarrhoea:infrequently, diarrhoea:
 early and transient as a result of visceral painearly and transient as a result of visceral pain
 later if retroileal or pelvic involvement appendix; this islater if retroileal or pelvic involvement appendix; this is
typically prolonged and mucoidtypically prolonged and mucoid
 constipation - sometimes for a few days beforeconstipation - sometimes for a few days before
the attackthe attack

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Signs to elicit in appendicitisSigns to elicit in appendicitis
 Pointing signPointing sign
 Rovsing’s signRovsing’s sign
 Psoas signPsoas sign
 Obturator signObturator sign

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Pointing signPointing sign

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Psoas signPsoas sign

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Obturator signObturator sign

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Differential diagnosisDifferential diagnosis
ChildrenChildren
 GastroenteritisGastroenteritis
 Mesenteric adenitisMesenteric adenitis
 Meckel’s diverticulitisMeckel’s diverticulitis
 IntussusceptionIntussusception
 Henoch_Shonlein purpuraHenoch_Shonlein purpura
 Lobar pneumoniaLobar pneumonia

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Differential diagnosisDifferential diagnosis
AdultsAdults
 Terminal ileitisTerminal ileitis
 Ureteric colicUreteric colic
 Perforated peptic ulcerPerforated peptic ulcer
 Testicular torsionTesticular torsion
 Acute pancreatitisAcute pancreatitis
 Rectus sheath haematomaRectus sheath haematoma

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Differential diagnosisDifferential diagnosis
Adult femalesAdult females
 SalpingitisSalpingitis
 MittelschmerzMittelschmerz
 Torsion/hemorrhage of an overianTorsion/hemorrhage of an overian
cystcyst
 Ectopic pregnancyEctopic pregnancy
 EndometritisEndometritis

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Differential diagnosisDifferential diagnosis
ElderlyElderly
 Sigmoid diverticulitisSigmoid diverticulitis
 Intestinal obstructionIntestinal obstruction
 Carcinoma of the ceacumCarcinoma of the ceacum
 Aortic aneurismAortic aneurism

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InvestigationInvestigation
RoutineRoutine
 Full blood countFull blood count leukocytosis is generallyleukocytosis is generally
presentpresent
 Urinalysis assessment of dehydrationUrinalysis assessment of dehydration
Selected casesSelected cases
 Pregnancy testPregnancy test
 Urea and electrolytesUrea and electrolytes
 serum amylase - if pancreatitisserum amylase - if pancreatitis
suspectedsuspected

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InvestigationsInvestigations
 Supine abdominal X-raySupine abdominal X-ray
 Ultrasound abdomen/pelvisUltrasound abdomen/pelvis
 abdominal radiology - helpful toabdominal radiology - helpful to
distinguish:distinguish:
intussusceptionintussusception
renal stones (90%)renal stones (90%)
gallstones (10%)gallstones (10%)
localised ileuslocalised ileus

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X-ray signsX-ray signs
 Reported signs include:Reported signs include:
 increased soft tissue density in the right lowerincreased soft tissue density in the right lower
quadrantquadrant
 a faecolith in the right iliac fossaa faecolith in the right iliac fossa
 the majority are radio-opaquethe majority are radio-opaque
 occur in about 10% of those with appendicitisoccur in about 10% of those with appendicitis
 often mistaken for ureteric calculus or gallstonesoften mistaken for ureteric calculus or gallstones
 a gas-filled appendixa gas-filled appendix
 free intraperitoneal gasfree intraperitoneal gas

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X-raysX-rays

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CT-scanCT-scan

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UltrasoundUltrasound

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Color-flow UltrasoundColor-flow Ultrasound

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GastroenteritisGastroenteritis
 Gastroenteritis, orGastroenteritis, or inflammationinflammation of theof the
gastrointestinal tractgastrointestinal tract, is an illness caused by, is an illness caused by
an infectiousan infectious virusvirus,, bacteriumbacterium oror parasiteparasite..
 lasting less than 10 days and self-limitinglasting less than 10 days and self-limiting
 Sometimes it is referred to simply asSometimes it is referred to simply as
'gastro'.'gastro'.
 If the inflammation is limited to the stomach,If the inflammation is limited to the stomach,
the termthe term gastritisgastritis is used, and if the smallis used, and if the small
bowel alone is affected it is enteritis.bowel alone is affected it is enteritis.

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IntussusceptionIntussusception

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IntussusceptionIntussusception
 An intussusception prolapsing of part ofAn intussusception prolapsing of part of
intestine into another section of intestine,intestine into another section of intestine,
(collapsible telescope)(collapsible telescope)
 intussusceptum (The part which prolapsesintussusceptum (The part which prolapses
into the other),into the other),
 intussuscipiens (the part which receives it).intussuscipiens (the part which receives it).
The most frequent type ileum enters theThe most frequent type ileum enters the
cecum.cecum.
 Almost all intussusceptions occur with theAlmost all intussusceptions occur with the
intussusceptum having been locatedintussusceptum having been located
proximally to the intussuscipiens.proximally to the intussuscipiens.
 The reason for this is that peristaltic action ofThe reason for this is that peristaltic action of
the intestine "pulls" the proximal segment intothe intestine "pulls" the proximal segment into
the distal segment.the distal segment.

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Meckel’s diverticulumMeckel’s diverticulum

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Henoch-Schonlein purpuraHenoch-Schonlein purpura

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DiverticulitisDiverticulitis

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DiverticulitisDiverticulitis

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DiverticulitisDiverticulitis
 Diverticula small, pouches develop inDiverticula small, pouches develop in
the wall of the colon. (sigmoid colon).the wall of the colon. (sigmoid colon).
Many people develop diverticulaMany people develop diverticula
(called diverticulosis), after age 50,(called diverticulosis), after age 50,
and in most individuals they cause noand in most individuals they cause no
problem.problem.
 Diverticulitis (diverticula infected orDiverticulitis (diverticula infected or
inflamed) can cause pain, fever andinflamed) can cause pain, fever and
nausea. In rare cases, a pouch cannausea. In rare cases, a pouch can
rupture, spilling intestinal waste intorupture, spilling intestinal waste into
abdomen.

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BibliographyBibliography
 Clinical anatomy Richard SnellClinical anatomy Richard Snell
 Baily and Loves surgeryBaily and Loves surgery
 Schwasrts SurgerySchwasrts Surgery
 Handbook of general surgeryHandbook of general surgery
 Web sourcesWeb sources