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1. Surgical pathology of
the appendix
Acute appendicitis
Chronic appendicitis
Tumors of the appendix

2. Appendix
Functions – not clear in humans
- it may have a significance in immune
defense – abundance of lymphoid follicles
- removal of the appendix may be a cause for
an increase in colonic cancer incidence - not
supported by controlled studies
- endocrine function

3. “Normal” Anatomy

4. Typical position
2.5 cm bellow the ileo-cecal valve (base
of appendix) the only fix region –
important when trying to find the
appendix
Taeniae converge at the base of the
appendix
84% free mobile in any possible location
16% fixed retrocecal

5. Acute apendicitis
Essentials of diagnosis
Abdominal pain
Anorexia, nausea, vomiting
Localized abdominal tenderness
Low grade fever
Leukocytosis

6. General considerations
= acute inflammation of the appendix wall that
starts in the mucosa and may extend to
adjacent organs
70% of cases present obstruction of the
proximal lumen:
Fibrous bands, fecaliths, foreign bodies
Tumors, parasites, lymphoid hyperplasia
External compression
Inflammation starts in the mucosa with
ulcerations and secondary bacterial infection

7. Close tube
Blood supply affected as disease
progresses
Infection in the wall
Increased pressure
Puss formation inside the lumen
Wall destruction: gangrene + perforation
Bacterial peritonitis may be limited by
adhesions (plastic peritonitis)

8. Clinical findings
Protean
manifestation: may
mimic a variety of
conditions
Progression of
symptoms is
essential

9. Clinical findings
Onset: vague abdominal discomfort
Followed:
Nausea, anorexia, indigestion
Vomiting
Pain, mild, localized in the epigastrum
Pain: localized in RLQ +
Pain or discomfort (moving, walking,
coughing)

10. Examination
At this moment:
Tenderness on coughing, localized in RLQ
Localized tenderness on palpation
Slight muscular rigidity
Rebound tenderness referred to the same
area
Rectal and pelvic examination NORMAL
Low fever (<38 degrees)

11. Examination –
retrocecal appendicitis
Poorly localized pain (retrocecal position –
protected from the abdominal wall)
No discomfort on coughing, walking etc.
Diarrhea
Urinary symptoms (hematuria, urinary
frequency)
Pain in the flank – tenderness on one finger
examination

12. Examination – pelvic
appendicitis
May simulate gastroenteritis
Nausea, vomiting and diarrhea are
more prominent (adjacent appendix to
pelvic colon)
Negative abdominal examination
IMPORTANT – repeated pelvic (rectal)
examination

13. Aberrant positions
Left side appendix – confusion with
diverticulitis (malrotation)
RUQ – cecum in abnormal position may
mimic cholecystitis or perforated
duodenal ulcer
Normal cecum – long appendix –
anything is possible

14. Lab workup
High leukocyte count: average
15.000/μl, 90% more the 10.000 with
more then 75% neutrophils.
10% have normal formula
Urinalysis typically normal, few
leukocytes or eritrocytes.
Retrocecal or pelvic
– special attention

15. X-Ray findings
Plain X-Ray films are usually not
contributory
Air-fluid levels or isolated ileus
Fecaliths
Free air in the peritoneum
Signs of peritonitis

16. CT scan

17. Ultrasound scan

18. Appendicitis in
pregnancy
Same frequency as in non-pregnant
Difficult diagnosis
High position of the appendix
All usual signs are present
Difficult to interpret leukocytosis
Appendectomy is mandatory and urgent

19. Differential diagnosis

20. Differential diagnosis
Difficult in young and elderly – highest
incidence of perforation
High incidence of false positive
appendicitis: women 20-40 PID and
other genital conditions

21. Differential diagnosis
Local inflammatory conditions
(enterocolitis, urinary infections, urinary
stones, pelvic inflammatory disease)
Distant digestive diseases (compliacted
duodenal ulcer, billiary stones)
Distant non-digestive diseases
(penumonia, myocardial infarction,
porphyria, lead poisoning)

22. Complications
PERFORATION
More severe pain
Fever >38
Typically in the first 12 hours
In 50% of patients the appendix is
perforated at the time of diagnosis

23. Complications
PERITONITIS
Localized – microscopic
perforation
Increased tenderness, rigidity
Abdominal distension
Ileus
Fever high and toxicity
Douglas pouch very sensible
Generalized – classic
presentation

24. Complications
APPENDICEAL ABSCESS
(appendiceal mass)
Localized peritonitis
Walled off by peritoneum
Symptoms of appendicitis + mass in RLQ
US + CT characteristical

25. Complications
APPENDICEAL ABSCESS
Treatment: ATB + diet low in residue
Drainage of abscess +/- appendectomy
Postponed appendectomy 8-12 weeks
Differential diagnosis:
Carcinoma of the cecum
Tumors of the appendix
Genital pathology

26. Complications
Pylephlebitis: suppurative
thrombophlebitis of pportal vein
Chills, high fever, jaundice + hepatic
abscess formation.
Serious septic problems
CT scan + US: thrombosis and gas in
portal system
Treatment: ATB + surgery urgent

27. Treatment

31. CHRONIC
APPENDICITIS

32. Chronic abdominal pain
In the RLQ
Possible recurrent attack of acute
appendicitis
Other problems
Many do not consider chronic
appendicitis a reality

33. = chronic inflammation in the wall due to
multiple acute attacks
Pathology – retractions of appendix and
mesoappendix and adhesions
Examination – dispepsia + pain
Workup – to exclude another pathology
Tratament – appendectomy - debatable
Chronic appendicitis

34. Tumors of the
appendix

35. Classification
Benign – fibroma
- leyomioma
- lypoma
Malignant – carcinoma
Bordeline - carcinoid
- mucocele

36. Benign tumors
Very rare
Occasionally may obstruct the lumen
and cause acute apendicitis
May arise as a mass in RLQ

37. Carcinoma
Rare and never diagnosed
preoperatively
Most typical presents as
acute appendicitis or RLQ
abscess
Prognosis: bad – 10% wide
spread MTS at time of
diagnosis. Rapid lymph node spread and
local spread through peritoneal cavity (ovary)
Treatment: right hemicolectomy + lymph node
dissection

38. Carcinoid tumor
The most common location of carcinoid
in the digestive tract
Slow growth (<2 cm) and rarely MTS.
3% MTS in lymph nodes
Carcinoid sdr: attacks of vasodilation,
diarrhea, abdominal colical pain,
tachicardia, hipotension MTSMTS
Examination: RLQ pain + mass

39. Carcinoid
Lab workup:
Urinary 5HIA
US, CT, arteriography, bronchoscopy
Treatment:
Appendectomy
Right hemicolectomy (>2cm, invasion of
cecum, invasion mesoappendix, nodes)
MTS – enucleation (<4) +/or chemotherapy

40. Mucocele
Not true tumors:
Chronic distension of the appendix plus continuous
mucus secretion.
Flattened epithelial cells
Cystadenoma – columnar epithelium (low grade
adenocarcinoma). Do not infiltrate the wall and do not
produce MTS
Clinical examination:
RLQ discomfort
Mass
Rupture in peritoneum: pseudomixoma peritonei

41. Mucocele
Treatment: appendectomy

42. MUCINOUS CHIST-ADENOMA - APENDICULARMUCINOUS CHIST-ADENOMA - APENDICULAR