Acute appendicitis

• Aetiology of acute appendicitis

  Luminal obstruction

  i. Fecolith

  ii. Neoplasm

  iii. Parasite- threadworm (enterobius vermicularis)

  iv. Foreign body
• Pathogenesis

  Obstruction --> increased intraluminal pressure --> inflammation --> bacterial overgrowth --> ischemia --> gangrene/perforation --> abscess (mass) or peritonitis
• Clinical features

  1 ) Abdominal pain

  Early – Periumbilical due to appendix obstruction (ill defined-visceral pain by sympathetic nerve)

  Late – RIF due to local inflammation of peritoneum (localized- parietal pain by somatic nerve T5-L2)

  2) Nausea and Vomiting

  3) Low grade fever [40°C- complicated peritonitis/abscess]

  4) Anorexia (LOA)
• Physical examination

  1 ) General: septic, fever ± chills/rigor, dehydrated

  2) Abdominal: soft, tender at RIF (at Mc Burney’s point)

  • Rovsing/obturator/psoas +++
  • Rebound & guarding +++ (perforated peritonitis)
• Signs elicited in appendicitis

  1 ) Pointing sign: Asking patient to point where the pain began and where it moved

  2) Rovsing’s sign: Deep palpation if left iliac fossa may cause pain in the right iliac fossa

  3) Obturator sign: Flexion and internal rotation of hip can cause spasm of obturator internus thus elicit pain in the hypogastrium due to inflamed appendix in contact with obturator internus

  4) Psoas sign: Pain relief by lying with right hip flexion due to inflamed appendix can lie on psoas muscle
• Investigation

  1 )FBC- leucocytosis (but not diagnostic)

  2) To rule out other differential

  i. UFEME – UTI and DM

  ii. S.amylase – pancreatitis

  iii. LFT

  iv. UPT – ectopic pregnancy

  3) Imaging

  i. Chest X-Ray – to look for air under diaphragm (perforation) or evidence of calculi

  ii. Abdominal Ultrasound – if suspicious to look for fluid (perforation)
• Complication

  1 ) Appendicitis mass/abscess

  2) Perforation (3 days after onset)

  3) Peritonitis
• Complication - Appendicular abscess


  Definition: Perforation of appendix but collection of pus enclosed within mass of adhesion

  Clinical features: continuous spiking of fever and additional symptoms of abscess (fever + sweating + rigor + increase local pain)

  Examination: oedema + redness of skin

  Treatment

  i. USG/CT guided percutaneous drainage or open drainage

  ii. Discharge

  iii. After 6 weeks do interval appendicectomy
• Complication

  Perforation of appendix
• Consequence

  General peritonitis
• People at risk of perforated appendix

  • Elderly (due to omentum atrophy)
  • Children (due to omentum poorly developed)
  • Immunocompromised
• Clinical features of perforated appendix

  • Rebound and guarding
  • Very high fever (>40°C)
  • Pain aggravated by movement and coughing
  • Generalized board like rigidity
  • Absent bowel sound
• Treatments for perforated appendix


  1. Stabilize patient & operate ASAP

  2. Intense IV broad spectrum antibiotics

  3. IV fluid infusion

  4. Gastric aspiration

  5. Removal appendix

  6. Thorough peritoneal toileting
• McBurney's Point


  Definition: Clinically significant landmark used to locate the base of the appendix.

  Location: At the junction of the lateral one-third and the medial two-thirds of line between umbilicus and ASIS.

  Clinical Significance: Tenderness and pain during appendicitis
• Anatomical correlation McBurney's Point

  The base of the appendix is located approximately 2 cm (0.79 in) beneath the ileocecal valve. The ileocecal valve separates the large intestine from the small intestine.

  By following the teniae coli (longitudinal muscle bands) of the cecum, which converge at McBurney’s point, you can identify the base of the appendix.
• Blood supply of appendix

  Appendicular artery, which is a branch of ileocolic artery. The ileocolic artery itself arises from the superior mesenteric artery.

  Superior mesenteric artery --> Ileocolic artery --> Appendicular artery
• Venous drainage of appendix

  Appendicular vein --> Superior mesenteric vein
• Nerve supply of appendix

  Sympathetic and parasympathetic branches of the autonomic nervous system.

  The ileocolic branch of the superior mesenteric plexus accompanies the ileocolic artery to reach the appendix.

  #: The sympathetic afferent fibers of the appendix arise from T10 of the spinal cord, which explains why early appendicitis pain is felt centrally within the abdomen.
• Principle of management of appendicitis

  1 ) Admit for further management

  2) Keep NBM with IV (dextrose)

  3) Analgesic

  4)Antibiotics (metronidazole + cephalosporin)

  • Prophylatic – for non-perforated appendicitis (single dose)
  • Therapeutic – for perforated or gangrenous appendicitis (for 3-5 days)

  5) Monitor vital signs

  6) Appendicectomy
• Surgical approach for appendicitis

  1 ) Acute or perforated appendicitis --> open Appendicectomy

  2) If unlikely appendicitis but worsening condition --> Exploratory laparoscopy
• Advantages of Laparoscopic appendicectomy

  1 ) Less pain, shorter recovery

  2) Better for obese

  3) Allow inspection of peritoneal contents

  4 ) Lower post-op wound infection rate
• Possible complication of appendicectomy

  1 )Anaesthesia complication- Airway and Breathing (aspiration pneumonia, hoarseness of voice, laryngeal oedema)

  2) Surgical complication

  Early complication

  • Wound infection
  • Haemorrhage

  Late complication

  • Subphrenic and pelvic abscess
  • Faecal fistula
  • Paralytic ileus
  • Intestinal adhesion
• Common causes of appendicitis

  • Obstruction of the Appendix
  • Infection
  • Spicy Diet
  • Junk Foods
  • Enlarged Lymph Nodes
  • Excessive Mucus Production
  • Trauma to the Appendix
• Obstruction of the Appendix

  1. Small ball of stool or hardened mucus blocks the narrow opening of the appendix

  2. Obstruction prevents bacteria from escaping

  3. Bacteria proliferate inside the appendix

  4. Causes inflammation and infection
• Bacteria that can trigger appendicitis

  • E. coli
  • Enterococci
  • Streptococci
  • Clostridium
• Alvarado Score

  Signs:

  • Right Lower Quadrant Tenderness (+2).
  • Elevated Temperature (37.3°C) (+1)
  • Rebound Tenderness (+1).

  Symptoms:

  • Migration of Pain to the Right Lower Quadrant (+1).
  • Anorexia (+1).
  • Nausea or Vomiting (+1).

  Laboratory Values:

  • Leukocytosis (>10,000) (+2).
  • Leukocyte Left Shift (>75% neutrophils) (+1).
• Complication of perforation of appendix

  Complications such as:

  • Peritonitis: A severe inflammation of the intestinal lining within the abdomen.
  • Septicemia: A serious blood infection
• Maintaining Gut Flora


  1. Acts as a haven for beneficial bacteria during diarrheal diseases

  2. Stores and releases helpful microbes to contribute to overall gut health
• Appendix


  • Higher concentration of immune cells (B-cell lymphocytes, T-cell lymphocytes) within its tissues
  • Might play a role in preventing early diseases within the large intestine by bolstering the immune response
• Position of appendix

  Continued growth of caecum during childhood causes rotation of appendix into retrocaecal but intraperitoneal position (74% cases)

  In about 25% cases, rotation of the appendix does not occur resulting in a pelvic (21%), subcecal (1.5%) and paracecal (2%) positions

  In occasional cases, the tip of the appendix becomes extraperitoneal (lying behind the caecum or ascending colon)