1. Dr A. Badrek-Amoudi FRCS
The Appendix
Dr A. Badrek-Amoudi FRCS
ABA-The Appendix- 4th year Lectures

2. ABA-The Appendix- 4th year Lectures
How do you diagnose appendicitis.
What are the classical and atypical features of appendicitis
Are investigations always needed and what is their role
How do you prepare your patient prior to surgery
What are the surgical approaches
How do you care for your patient after surgery
A 15 year old girl presents with a right lower abdominal pain.
A 6 year old boy with a history of sore throat presents with lower abdominal pain
A 45 year old man presents with a sudden onset of epigastric pain localised to RIF
ABA-The Appendix- 4th year Lectures

3. The Appendix Introduction
1889 Mac Burney described location, the clinical features of appendicitis and the importance of operative intervention and muscle-splitting incision.
ABA-The Appendix- 4th year Lectures

4. The Appendix Surgical Anatomy
Surface anatomy
Development: diverticulum of ceacum appearing in the 8th week of life
Positions: constant base, tip varies (retroceacal, pelvic, subcaecal, preileal, pericolic)
Blood supply
Location during surgery
Surrounding anatomical structures
Part of the gut lymphoid tissue.
ABA-The Appendix- 4th year Lectures

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9. The Appendix Acute Appendicitis Epidemiology
Most common surgical emergency.
Slightly more common in men.
Incidence are falling from 100 to 50 in ( ).
1 in 6 of the population will have an appendectomy.
In Saudi Arabia incidence are comparable to western figures
? More common in European societies (Diet).
? Relation to class status.
Age > 2 yrs, (associated with lymphoid development).
Up to 16% of appendicectomies are normal 75% are in women
ABA-The Appendix- 4th year Lectures

10. The Appendix Acute Appendicitis Pathology I
Luminal obstruction.
Lymphoid hyperplasia 60%
Faecolith 35%.
Inspissated barium.
Fruit seeds }<4%
Worms. < 1%
Extra-luminal obstruction eg Ca Cecum
Raised intra-luminal pressure
Mucus accumulation
Multiplication of bacteria.
( E.Coli, Bacteroids, peptostreptococcus, Psuedomonas)
Venous and lymphoid congestion and.
ABA-The Appendix- 4th year Lectures

11. The Appendix Acute Appendicitis Pathology II
Impaired arterial flow, thrombosis and gangrene.
Perforation may occur through devitalized tissue.
Histological terms used:
Catarrhal appendicitis
Suppurative ;;;
Necrotic ;;;
Gangrenous ;;;
Perforated ;;;
Appendicular mass
The risk of perforation is not inevitable.
ABA-The Appendix- 4th year Lectures

12. The Appendix - Acute Appendicitis Clinical Features I
Full History Duration, severity, onset, System review. and examination: General, throat, chest…..etc
Only 55% have classical features.
Atypical 45%
History hours
Abdominal pain:
(diffuse and periumbilical, localizing to the RIF)
Anorexia (almost always).
Vomiting (75%).
Low grade fever.
If >38 suspect perforation
Tenderness, guarding and rebound: Be gentle
Rovsing’s, psoas, obturator signs: unreliable and late
ABA-The Appendix- 4th year Lectures

13. The Appendix - Acute Appendicitis Clinical Features II
Tender Appendicular mass
Atypical:
(loin, high RUQ, deep pelvic)
Diarrhea ( not always gastroenteritis)
Urinary frequency
The Extremes of Age:
Children < 5 rapid progression
Pain in the elderly is less intense
ABA-The Appendix- 4th year Lectures

14. The Appendix - Acute Appendicitis Investigations
White cell count: high sensitivity 96%, low specificity
Urine analysis
Plain Xray, nonspecific
Ultrasound highly sensitive (80-90%), excludes other pathologies.
Computer Tomography: More superior to USS in diagnostic accuracy.
Barium enema: Good accuracy, but technically difficult and false positives are common.
Laparoscopy
Active observation
Computer aided diagnosis.
Peritoneal lavage
ABA-The Appendix- 4th year Lectures

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17. The Appendix - Acute Appendicitis The Very Young
Diagnosis may be more difficult to establish, WBC is likely to be normal
(12% are normal).
Children are more likely to progress to perforated appendix
(? Under-developed Greater Omentum).
ABA-The Appendix- 4th year Lectures

18. The Appendix - Acute Appendicitis The Very Old
Greater morbidity and mortality
Less typical presentation
Cancer may be a possibility as an underlying cause.
Perforation of 50% and mortality of 20% has been reported
ABA-The Appendix- 4th year Lectures

19. The Appendix - Acute Appendicitis The Pregnant
Implications: Clinical Findings, Lab Ix, Surgery
1: 2000 pregnancies.
More common in the first two trimesters
The appendix is pushed superiorly and laterally
WBC > 15
Premature Labor 10-15% with surgery
Perforated appendix leads to fetal death in 20%
Rapid diagnosis and treatment is advised.
ABA-The Appendix- 4th year Lectures

20. The Appendix - Acute Appendicitis In AIDS Patients
Be aware of CMV or Kaposi sarcoma as the underlying cause
WBC may not rise
ABA-The Appendix- 4th year Lectures

21. The Appendix - Acute Appendicitis The Management
Preop:
IVI,
analgesia,
IV antibiotics
Conventional appendicectomy
Types of incisions
Laparoscopic appendicectomy:
(questions regarding pain, hospital stay, operation time, to daily activity, wound infection)
ABA-The Appendix- 4th year Lectures

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23. The Appendix - Acute Appendicitis Post-Operative
Check the vitals
Check the abdominal signs and bowel movement
Check the wound
Advise on mobilization
In OPD:
Check wound
Check the Histology
ABA-The Appendix- 4th year Lectures

24. The Appendix - Acute Appendicitis Prognosis
Mortality: from 0.2% to 1%
Complications increase with perforation
Morbidity:
Wound abscess,
Wound infection (less with MacBurney’s incision),
Wound dehiscence
Intra-abdominal abscess,
Faecal fistula,
Intestinal obstruction,
Adhesive band,
inguinal hernia.
Fertility
ABA-The Appendix- 4th year Lectures

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26. The Appendix - Acute Appendicitis Problems
Mass palpable pre-operatively
Appendix is normal at operation
Tumor is found in appendix
Prophylactic appendicectomy
ABA-The Appendix- 4th year Lectures

27. The Appendix – Chronic Appendicular Conditions Chronic Appendicitis
A loose term referring to a multitude of conditions associated with RIF pain and in which pathology of the appendix has been found.
ABA-The Appendix- 4th year Lectures

28. The Appendix – Chronic Appendicular Conditions Appendicular Mass
Results from either:
Localized by edematous, adherent omentum and loops of small bowel
Appendicular abscess
Incidence is 10%
Higher in children
Management controversy:
Interval vs Immediate appendicectomy
ABA-The Appendix- 4th year Lectures

29. The Appendix – Chronic Appendicular Conditions Tumors of The Appendix
Carcinoid:
Arise from Kluchitsky cells
Mean age 20-40
Yellow bulbar mass
In F>M
In third decade of life
Usually lies near the tip
In the absence of LN spread with <2 cm in diameter appendicectomy is sufficient. Otherwise a R hemicolectomy is necessary.
Adenocarcinoma and Lymphoma.
ABA-The Appendix- 4th year Lectures

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