Appendix

1. PGI Mae Caridad R. Martinquilla

2. Anatomy and Physiology
•8
th
week of embryologic
development
•The relationship of the
base of the appendix to
the cecum remains
constant, whereas the tip
can be found in a
retrocecal, pelvic,
subcecal, preileal, or right
pericolic position

3. Anatomy and Physiology
•The three taeniae coli
converge at the junction of
the cecum with the
appendix
•Length: <1 cm to >30cm
•most appendices are 6 to 9
cm long
•Mc Burney’s point- 1/3 of
the distance from the
anterior superior iliac spine
to the umbilicus.

4. Anatomy and Physiology
• Appendicular artery
-branch from the lower
division of the ileocolic
artery
•The main artery approches
the tip of the appendix, this
one may be thrombosed in
appendicitis gangrene
and infarction
•Postcecal or ileocolic vein -
and then into the superior
mesenteric vein

6. Anatomy and Physiology
•Its connected by a short mesoappendix to the
lower part of the ileal mesentery
•Small lumen opens into the caecum,
sometimes this orifice is guarded by a
semilunar mucosal fold forming a valve
•The lumen may be widely patent in early
childhood; partially or wholly obliterated in
the later decades of life

9. Anatomy and Physiology
•The appendix was erroneously viewed as a
vestigial organ with no known function
•Now well recognized that the appendix is an
immunologic organ that actively participates
in the secretion of immunoglobulins,
particularly immunoglobulin A
•Lymphoid tissue first appears in the appendix
approximately 2 weeks after birth

10. Anatomy and Physiology
•Sympathetic and parasympathetic nerves
from the superior mesenteric plexus

11. Acute Appendicitis
•2
nd
- 4
th
decades of life
•mean age of 31.3 years
•median age of 22 years
•Slight male: female predominance (1.2 to
1.3:1)
•Rate of misdiagnosis of appendicitis has
remained constant (15.3%)
–higher among women than among men

12. Acute Appendicitis
•Obstruction of the lumen- dominant etiologic
factor
•Fecaliths-most common cause of appendiceal
obstruction
•Less common causes:
–Hypertrophy of lymphoid tissue
–Inspissated barium from previous x-ray
studies
–Tumors
–Vegetable and fruit seeds
–Intestinal parasites

13. Pathophysiology
•Distention of the appendix stimulates the
nerve endings of visceral afferent stretch
fibers vague, dull, diffuse pain in the
midabdomen or lower epigastrium
•Distention increases from continued mucosal
secretion and from rapid multiplication of the
resident bacteria of the appendix

14. Pathophysiology
•Distention of this magnitude  reflex nausea
and vomiting
•Capillaries and venules are occluded, but
arteriolar inflow continues engorgement
and vascular congestion
•inflammatory process soon involves the
serosa of the appendix parietal peritoneum
in the regioncharacteristic shift in pain to
the right lower quadrant

15. Bacterial population
•The bacterial population of the normal
appendix is similar to that of the normal colon
•The principal organisms seen in the normal
appendix, in acute appendicitis, and in
perforated appendicitis are Escherichia coli
and Bacteroides fragilis
•Appendicitis is a polymicrobial infection

17. Antibiotic Coverage
•flora is known broad-spectrum antibiotics
are indicated
•Antibiotic prophylaxis is effective in the
prevention of postoperative wound infection
and intra-abdominal abscess.
–nonperforated appendicitis: coverage is limited to
24 to 48 hours
–perforated appendicitis: 7 to 10 days of therapy is
recommended

18. Symptoms
•Abdominal pain is the prime symptom
•pain is initially diffusely centered in the lower
epigastrium or umbilical area
• After a period varying from 1 to 12 hours, but
usually within 4 to 6 hours, the pain localizes to
the right lower quadrant
•Retrocecal appendix - flank or back pain
•Pelvic appendix- suprapubic pain
•Petroileal appendix- testicular pain

19. Symptoms
•Anorexia nearly always accompanies
appendicitis
•Vomiting occurs in nearly 75% of patients
•History of obstipation
•Diarrhea occurs in some patients
•>95% of patients  anorexia is the first
symptom, followed by abdominal pain, which
is followed, in turn, by vomiting (if vomiting
occurs)

20. Signs
•The classic right lower quadrant physical signs are
present when the inflamed appendix lies in the
anterior position
•Direct tenderness often is maximal at or near the
McBurney point
•Rebound tenderness
•Referred or indirect rebound tenderness
•Rovsing’s sign -indicates the site of peritoneal
irritation
•Cutaneous hyperesthesia

21. Signs
•Muscular resistance to palpation of the
abdominal wall roughly parallels the severity
of the inflammatory process
•Early in the disease voluntary guarding
•As peritoneal irritation progresses
involuntary guarding/true reflex rigidity
– contraction of muscles directly beneath the
inflamed parietal peritoneum

22. Signs
•Signs of localized muscle irritation also may be
present
•Psoas sign
–lie on the left side as the examiner slowly extends the
patient's right thigh, thus stretching the iliopsoas
muscle
–result is positive if extension produces pain
•Obturator sign
–irritation in the pelvis
–passive internal rotation of the flexed right thigh with
the patient supine

24. Laboratory
•Mild leukocytosis, ranging from 10,000 to
18,000 cells/mm
3
with

moderate
polymorphonuclear predominance

 acute,
uncomplicated appendicitis
•Urinalysis can be useful to rule out the urinary
tract as the source of infection
–Although several white or red blood cells can be
present from ureteral or bladder irritation as a
result of an inflamed appendix

25. Imaging
•Radiographic studies
–abnormal bowel gas pattern nonspecific finding
–presence of a fecalith  highly suggestive of the
diagnosis
•Barium enema examination and radioactively
labeled leukocyte scans
–If the appendix fills on barium enema, appendicitis
is excluded; if the appendix does not fill, no
determination can be made

27. Imaging
•Sonography
–inexpensive, can be performed rapidly, does not
require a contrast medium, and can be used even in
pregnant patients
–appendix is identified as a blind-ending, nonperistaltic
bowel loop originating from the cecum
–presence of an appendicolith establishes the
diagnosis
–Thickening of the appendiceal wall and the presence
of periappendiceal fluid is highly suggestive
– sensitivity of 55 to 96% and a specificity of 85 to 98%

29. Imaging
•High-resolution helical CT
–inflamed appendix appears dilated (>5 cm) and the
wall is thickened.
–evidence of inflammation, with "dirty fat," thickened
mesoappendix, and even an obvious phlegmon
–Fecaliths
–Arrowhead sign
–CT scanning is also an excellent technique for
identifying other inflammatory processes
masquerading as appendicitis

33. Appendicial Rupture
•Immediate appendectomy has long been the
recommended treatment for acute
appendicitis because of the presumed risk of
progression to rupture
•rate of perforated appendicitis  25.8%
•Children <5 years of age and patients >65
years of age have the highest rates of
perforation (45 and 51%, respectively)

34. Appendicial Rupture
•Appendiceal rupture occurs most frequently
distal to the point of luminal obstruction
•Fever with a temperature of >39°C (102°F) and a
white blood cell count of >18,000 cells/mm
3
•In the majority of cases, rupture is contained and
patients display localized rebound tenderness
•Generalized peritonitis will be present if the
walling-off process is ineffective in containing the
rupture.

35. Appendicial Rupture
•Phlegmon- matted loops of bowel adherent to
the adjacent inflamed appendix, or a
periappendiceal abscess
•Phlegmons and small abscesses can be treated
conservatively with IV antibiotics
–well-localized abscesses can be managed with
percutaneous drainage
–complex abscesses should be considered for
surgical drainage

36. Differential Diagnosis
•The differential diagnosis of acute appendicitis depends
on 4 major factors: the anatomic location of the inflamed
appendix; the stage of the process (i.e., simple or
ruptured); the patient's age; and the patient's sex
1.Acute Mesenteric Adenitis
2.Gynecologic disorders
3.Acute gastrointeritis
4.Other intestinal disorders

37. Treatment
•Open appendectomy
•Laparoscopic
appendectomy
•Natural orifice
transluminal
endoscopic surgery
•Interval appendectomy

38. Treatment

39. Thank you!