The document discusses acute appendicitis. It describes the anatomy of the appendix and explains that appendicitis is usually caused by obstruction of the appendix lumen by a fecalith. The clinical features of appendicitis include pain that initially starts around the umbilicus and later localizes to the right lower quadrant, along with nausea, vomiting, fever and tenderness at McBurney's point. Diagnosis is often made through ultrasound or CT scan. Treatment involves surgical removal of the appendix (appendicectomy) through an open or laparoscopic approach.

1. ACUTE APPENDICITIS
Aayusha Bhandari

2. Anatomy
Located at the terminal end of caecum, 2 cm below the
ileocaecal junction.
Length is about 5-10 cm .Diameter of appendix is 3-8 mm and
diameter of lumen is 1-3 mm.
Parts of appendix : base ,body and tip
The mesentery attached to the appendix is known as
mesoappendix which contains appendicular vessels.
Mesoappendix doesn’t extend up to the tip of appendix so in
obstructive type of appendicitis the commonest site of
gangrene is the tip(the least vascular area).

3. • Appendix is supplied by appendicular artery which is a
branch of ileocolic artery. The appendicular artery is an
end artery.
• The base of the apppendix is usually located at the
MacBurney’s point.
• Opening of appendix into the caecum is guarded by valve
of Geralch.
• Most common position of appendix is retrocaecal (78%)
next is pelvic (21%).

4. Different positions of appendix

5. Acute appendicitis
Etiology
Common in young males and whites races
Low fibre diet
Viral infection can cause mucosal oedema and
inflammation which later gets infected by bacteria
30% chances in first degree relatives
Obstruction of lumen by faecoliths(most common),
stricture, foreignbody and roundworm may cause
obstructive appendicitis.
Adhesion and kinking
Distal colonic obstruction
Abuse of purgatives

6. • Organisms are E.coli, enterococci, streptococci,
anaerobic streptococci , Cl.welchii
• Pseudoappendicitis is appendicitis due to acute ileitis due
to yersinia infection.
Pathogenesis
Non obstructive appendicitis: acute inflammation of the
mucus membrane with secondary infection. It may lead to
resolution ,fibrosis ,recurrent appendicitis or eventual
obstructive appendicitis.

7. Obstructive appendicitis :
• luminal obstruction by faecoliths, FB, Carcinoma,lymphoid
hyperplasia ,pinworm
• Mucus and inflammatory fluid collects inside the lumen
and increased intraluminal pressure
• Blockage of lymphatic and venous drainage resulting in
increased oedema of mucosa and wall
• Mucosal ulceration and ischemia, bacterial translocation.
If thrombosis of appendicular artery-ischaemic necrosis –
gangrene of appendix and then perforation at the tip or
base=peritonitis

8. • After perforation-localization at greater omentum and
dilated ileum occurs-with suppuration and
pus=appendicular abscess
• In severe acute appendicitis, localization at G. omentum
and dilated ileum occurs without pus formation =
appendicular mass
• Acute appendicitis with blockage at the opening of lumen-
mucus collects inside the lumen resulting in enlargement
of appendix = Mucocele of appendix

9. Types of appendicitis
1. Acute non-obstructive appendicitis
2. Acute obstructive appendicitis
3. Recurrent appendicitis: repeated attacks of non-
obstructive
4. Subacute appendicitis
5. Stump appendicitis: due to retained stump of appendix
after lap appendicitomy

10. Clinical features

11. • Pain:visceral pain around the umbilicus d/t distension of
appendix later after few hours somatic pain in RIF d/t
irritation of parietal peritoneum d/t inflamed appendix
• Vomiting d/t reflex pylorospasm
• Constipation/diarrhoea
• Fever, tachycardia, fetor oris
• Urinary frequency
 Tenderness and rebound tenderness at McBurney’s point
in RIF
P/R examination tenderness in the right side of rectum
Hyperaesthesia in Sherren’s triangle( ASIS ,umbilicus and
pubic symphisis )

12. Clinical signs in appendicitis
Rovsing’s sign
On pressing the LIF ,pain occurs in the RIF d/t shift of
bowel loops which irritated the parietal peritoneum.
Blumberg’s sign(release sign)
pain upon removal of pressure rather than application of
pressure to the abdomen.
Cope psoas sign(hyperextension) and obturator
sign(internal rotation) of the right hip causing pain in the
RIF d/t irritation of the psoas muscle and obturator
internus muscle respectively.
Baldwing’s test: when legs are lifted off with knee
extended, pain complains pain while pressing over the
flanks.

13. Differential diagnosis
1) Perforated peptic ulcer
2) Ruptured or twisted ovarian cyst
3) Acute cholecystitis
4) Enterocolitis
5) Right ureteric colic
6) Right acute pyelonephritis
7) Crohn’s disease
8) Lobar pneumonia
9) Acute pancreatitis
10) Meckel’s diverticulum
11) Salphingitis
12) Ectopic pregnancy
13) Typhilitis

14. In children
1) Meckel’s diverticulum
2) Acute colitis
3) Intussusception
4) Roundworm colic
5) Lobar pneumonia
6) Acute iliac lymphadenitis
In females
1. Ruptured ectopic gestation
2. Mittelschmerz rupture of ovarian follicle
3. Ovarian cyst torsion
4. Salpingo-oophoritis

15. Investigations
• U/S to rule out stones, cyst, pancreatitis, ectopic
pregnancy and confirm appendicular abscess or mass.
• USG findings: size of appendix >6mm ,hyperechoic
thickened appendix wall >2mm- target sign, appendicolith,
interruption of submucosal continuity, periappendicular
fluid.
• Total leucocyte count is increased.
• Contrast CT scan
• C-reactive protein, MRI
• Plain X-ray: to R/O duodenal ulcer perforation, intestinal
obstruction and ureteric stone

18. Treatment
• Surgery : Appendicectomy
• Approaches
• Grid iron incision at (incision perpendicular to
the McBurney’s point)
• Rutherford Morison incision
• Lanz crease(centering at McBurney’s point)
• Right lower paramedian incision or
• Lower midline incision
• Laparoscopic approach
• Fowler-weir approach
McBurney’s point is the lateral 1/3 and
medial 2/3 of imaginary line joining ASIS
and umbilicus.

20. Open appendectomy
G.A is given.
Mark McBurney’s point and grid-iron incision is given.
Skin is incised. Subcutaneous tissue and superficial
fascia (camper’s and scarpa’s) are cut using cautery.
A nick is given to external oblique aponeurosis.it is
opened in the line of incision and the incised free margins
are lifted up using artery forceps.
Internal oblique and tranversus muscle are split in the line
of fibres.(retracted to reach the peritoneum)
Peritoneum is held at 2 places by mosquito forceps.nick is
given between two forceps.
Peritoneal cavity entered.

21. Caecum is identified by the presence of taenia coli and
ileocaecal junction. Appendix is held by Babcock’s
forceps.
Window is made in the mesoappendix with the help of
curved artery forceps. Mesoappendix and appendicular
artery is ligated using vicryl 2-0
Junction of caecum with appendicular base is identified.
Now the appendix is crushed with straight clamp about 3-
5mm away from the caecum. Reapplied again
Base of the appendix is double ligated using vicryl 2-0.
appendix is cut distal to the suture ligature and removed.
Stump is cleaned with antiseptics and exposed portion is
cauterized.
Internal oblique, T. abdominus and peritoneum closed
with vicryl 1-0. gut preserved. E.O.A is closed vicryl 1-0
continuous

22. Complications after appendicectomy
A. Reactionary haemorrhage d/t slipping of ligature of
appendicular artery
B. Paralytic ileus
C. Residual abscess
D. Pylephlebitis
E. Adhesion, kinking and intestinal obstruction
F. Right inguinal hernia
G. wound sepsis
H. Faecal fistula