APPENDICITI

S
Clerk Keith Coral
St. Lukes College of Medicine
Taguig-Pateros District Hospital
Dr. Cua Pardo

Appendicitis
Inflammation

of the inner lining of the

vermiform appendix that spreads to its
other parts
Common cause of acute abdominal pain
Clinical emergency

Anatomy

is a wormlike extension of cecum

vermiform appendix
Average length: 8-10cm
Appendix

 Exterior

layer:
longitudinal (derived
from taenia coli)
Interior layer: circular
Submucosal layer
contains
lymphoepithelial tissue
Mucosa columnar
epithelium with few
glandular elements and
neuroendocrine
argentaffin cells

Vasculature
Appendicular artery
terminal branch of
ileocolic artery
Venous drainage
ileocolic veins and right
colic vein into portal
vein
Lymphatic drainage
ileocolic nodes to celiac
nodes and cisterna chyli

Location
No

fixed position
1.7-2.5cm below termial ileum either in
a dorsomedial location (most common)
from the cecal fundus beside ileal orifice
or a funnel-shaped opening
Retroperitoneal location

Clinical Features

Clinical Features
Periumbilical

pain localizes to right

lower quadrant
Followed by nausea, vomiting, lowgrade fever, elevated WBC

 McBurneys

sign deep tenderness

noted at 2/3 of the distance from
umbilicus to the right anterior superior
iliac spine (McBurneys point)

Clinical Features

Abdominal pain most common symptom

Begins as periumbilical or epigastric pain then

migrates to RLQ
Lie down, flex their hips, draw their knees up to
reduce movements and to avoid worsening pain

Nausea 61-92%
Anorexia 74-78%
Vomiting follows onset of pain
Diarrhea/constipation 18%

Physical Examination

Rebound tenderness, pain on percussion, rigidity, guarding

RLQ tenderness 96%

Situs invertus
Lengthy appendix

Inflamed hemiscrotum
Pregnant

Non specific

LLQ tenderness

Most specific

RLQ 1st trimester

RUQ/right flank pain 2nd and 3rd trimester

Accdg to Sedlak et al (2008) No evidence that DRE provides

useful information in evaluation of appendicitis (failure to
perform DRE cited in successful malpractice claims)

Accessory signs

Rovsing sign
RLQ pain with palpation of LLQ
Peritoneal irritation
Dunphy sign
Sharp pain in RLQ elicited by voluntary cough
Localized periotonitis
Markle sign
Pain elicitied in a certain area of abdomen when the standing
patient drops from standing on toes to the heels with a jarring
landing

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Obturator sign
RLQ pain with internal and
external rotation of flexed
right hip
Right hemipelvis

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Psoas sign
RLQ pain with extension of
right hip or flexion of right hip
against resistance
(Right psoas muscle)

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Bloomberg Sign
Rebound tenderness
Deep palpation of viscera over
inflamed appendix followed by
sudden release of pressure
causing pain

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McBurneys
sign
Palpate RLQ over McBurneys
point
Tenderness (+)

Epidemiology
Most

common in adolescents and young

adults
Lifetime risk = 7%
M>F

 Diagnosis

can be difficult to confirm

Differential Diagnoses

Mesenteric lymphadenitis (secondary to

Yersinia or Viral enterocolitis)
Acute salpingitis
Ectopic pregnancy
Mittelscherz (pain associated with
ovulation)
Meckel diverticulitis
Urinary Tract Infection
Acute Gastroenteritis

 Ureterolithiasis
Cholecystitis
Pancreatitis
Acid-related

disease (Ulcer)

Pathophysiology

Pathophysiology
Initiated

by progressive increases in
intraluminal pressure that compromises
venous outflow
Obstruction of appendiceal lumen
50-80%: associated with overt luminal
obstruction:

Fecalith
Gallstone
Tumor
worms

Pathophysiology
Obstruction

causes an increase in pressure within

the lumen
Continuous secretion of fluids and mucus from
mucosa
Intestinal bacteria multiply reading to recruitment
of WBC and formation of pus and subsequent
higher intraluminal pressure rises above the
appenciceal veins venous outflow obstruction
Ischemia
Loss of epithelial integrity and bacterial invasion of
appenciceal wall

Pathophysiology
Within

a few hours, localized condition

may worsen because of thrombosis of
appendicular artery and veins
Leading to perforation and gangrene
Periappendicular abscess or peritonitis

Etiology

Etiology
Caused

by obstruction of appendiceal lumen

Most common causes of obstruction:

Lymphoid hyperplasia secondary to IBD or

infection
Fecal stasis
Fecalith (calcium salt + fecal debris
Parasite (Schistosoma, Stongyloides)
Foreign body
Neoplasms

 Ischemic

injury
Stasis of luminal contents

Favor bacterial proliferation

Trigger inflammatory response
Tissue

edema
Neutrophilic infiltration of lumen, muscular
wall, perappendiceal soft tissue

 Subserosal

vessels congested
Perivascular neutrophilic infiltrate
Erythematous serosa
Diagnosis requires neutrophilic
infiltration of muscularis propria

Stages
Early

stage

Obstruction of appendiceal lumen leads to

mucosal edema, ulceration, bacterial
diapedesis, appendiceal distention due to
accumulated fluid and increasing
intraluinal pressure
Visceral afferent nerve fibers are
stimulated, and pateint perceives visceral
periumbilical or epigastric pain

Stages
Suppurative

Increasing intraluminal pressure exceed capillary

perfusion pressure associated with obstructed
lymphatic and venous drainage and allows
bacterial and inflammatory fluid invasion of the
tense appendiceal wall
Transmural spread of bacteria causes
suppurative appendicitis
Inflamed serosa comes in contact with parietal
peritoneum, patients experience classic shift of
pain to RLQ

Stages
Gangrenous

Intramural venous and arterial

thromboses

Stages
Perforated

Persisting tissue ischemia

Infraction and perforation
Peritonitis

Stages
Phlegmonous

(abscess)

Inflamed or perforated appendix walled

off by adjacent greater omentum or bowel
loops
Focal

abscess

Stages
Chronic

Patient has a history of RLQ pain of at

least 3 weeks without alternative
diagnosis
After appendectomy, relief of symptoms
Symptoms proven to be result of chronic
inflammation (histopathologically)

Diagnosis

Diagnosis

CBC

WBC >10,500
Neutrophilia

CRP
Liver and Pancreatic function tests
Urinalysis
Urinary beta-HCG
Urinary 5-hydroxyindoleacetic acid (5-HIAA)

Increase
acute

inflammation

Decrease
inflammation

shifts to necrosis
early warning of perforation of appendix

Imaging
CT

scan

With contrast
Most important imaging study

Ultrasound

Safer alternative
Healthy appendix cannot be visualized
Noncomprerssible tubular structure of 79mm: appendicitis

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Diagnostic
Scoring

Review of 150 patients

0-3

Discharged without imaging

4-6

(32%)

Imaging (CT scan evaluation)

>7

(3.6%)

(78%)

Surgical consultation

 However,

Schneider et al concluded that

MANTRELS scoring was not sufficiently
accurate

 None

has been shown prospectively to

improve on clinicians judgment

Management

Management
IV access
NPO
Parenteral analgesisc and antiemetic as
needed

Previously discouraged and criticized because

they render PE findings less reliable
8 RCTs = safe
No study has shown that analgesics adversely
affect accuracy of PE

Antibiotics
Antibiotic

prophylaxis must be
administered before every appendectomy
Broad-spectrum gram-negative and
anaerobic coverage is indicated
Cefotetan and Cefoxitin
Carbapenems
Antibiotic treatment may be stopped when
the patient becomes afebrile and WBC
count normalizes

 Appendectomy

Only curative treatment of appendicitis

Appendectomy

 Phlegmon/small

IV antibiotics
Interval appendectomy after 4-6 weeks
later

Larger

abscess

well-defined abscess

Percutaneous drainage
IV antibiotcs

Prognosis
Most common reason for emergency
abdominal surgery
Complication rate 4-15%
Mortality rate 0.2-0.8%
Patients older than 70 years: >20%
because of diagnostic and therapeutic
delay
Appendiceal perforation increased
morbidity and mortality

Thank you