2. King Faisal University
24.may.2006
King Faisal University
College of Medicine
Surgery I
4th year
Acute Appendicitis
Done by:
Fatima A. Al-Hashim
Iman Al-Mukhtar
Supervised by:
Dr. A. Al-Mulhim
Dr. H. Wadani

3. Objectives Introduction History taking Anatomy Physical examination
Etiology
pathogenesis
Signs & Symptoms
Differential Diagnosis
History taking
Physical examination
Preoperative complication
Investigation
Appendectomy
Postoperative complication

4. Introduction

5. What is appendicitis?? Appendicitis is the inflammation of appendix.
appendicitis is the most common cause of the intra-abdominal infection in developed countries.
& it is the most common emergency surgical operation
appendicitis can occur at any age but is most common below 40 yrs , especially between the ages of 8 & 14 yr &it is very rare below the age of 2.

6. Anatomy

7. Peritoneal covering of the appendix
Site
Rt iliac fossa , attached to the posteromedial aspect of caecum 2cm below the iliocaecal valve.
Size
2-20 cm long (average 10cm) & about 1\2 cm wide
Peritoneal covering of the appendix
It is completely covered with peritoneum & is suspended to the back of the mesentery of terminal ileum by a triangular fold of peritoneum called mesoappendix

8. Branch of ilio-colic artery
Nerve supply
T10 supplies the peritoneal covering of the appendix
referred pain of the appendix is felt at the umbilicus which has the same nerve supply.
Venous drainage
appendicular vein ileocolic vein superior mesenteric vein  portal vein
Arterial supply:
Appendicular artery
Branch of ilio-colic artery
It runs in the free border of the mesoappendix towards the tips.

9. Position
The base of the appendix is fixed , its tip points to one of the following positions
5-post-ileal (1\2 %): the appendix lies behined the terminal part of ileum, in contact with the ileocolic V. it is the most dangerous position because spread of the infection to the vien may lead to portal pyaemia.
1- Retrocecal ( 74% ): behined the caecum ( in the retrocaecal recess)
3-subcaecal (3.5%): the appendix lies below the caecum.
2-pelvic (21%): the appendix hangs over the pelvic brim where it is related to external iliac vessels , ovary & uterine tube.
4-pre-ilial (1%): infront of the terminal part of the ileum

10. Idintification of appendix at operation
Microscopically
the submucosa of the appendix is rich in lymphoid tissue
Idintification of appendix at operation
inside the abdomen the base of the appendix is easly found by identifying the tenia coli of the cecum & following them to the base of the appendix where they coverage to form complete longitudinal muscular coat
conginital abnormalities
)-1-absence of appendix (agenesis
-2-double appendix
-3-appendix lying in the Lt iliac fossa

11. Surface anatomy of the base of appendix ( McBurney's point )
It is a point at the junction of the lateral 1\3 & medial 2\3 of a line extending from the anterior superior iliac spine to the umbilicus (spino-umbilical line)

12. Etiology

13. Infection of appendix by 2 routs
hematogenous
rare
endogenous common
obstructed
non-obstructed appendix
By:
1-faecolith commonest
2-foreign body
3-lymphoid hyperplasia due to viral infection
4-stricture
5-carcinoid tumor
6-chron's disease
7-parasetic infection particularly by oxyuris vermicularis (pin warm)
due to
direct infection of lymphoid follicle from appendicular lumen

14. pathogenesis

15. prolofiration of the gas forming bacteria
bacterial flora located within the lumen of appendix include both aerobic & anaerobic organism typical of those found in the large intestine
obstructed appendix
stasis
prolofiration of the gas forming bacteria
increase intralumenal pressure
acute inflamation of mucosa
acute appendicitis with edema , lymphoid obstruction, & necrotizing ulceration of the mucosa

16. If the diagnosis of appendicitis is not made early the process will continue

17. extension of inflammation across appendicael wall
involvment of serosa by inflammation
visceral peritonitis
obstruction of venous & lymphatic drainage & arterial thrombosis
Gangrene of appendix wall
perforation

18. the outcome of perforation depend on the ability of the omentum to contain the infection
adequate omemtum
apendicular mass or abcess will result
Inadequate
generalized peritonitis

19. Symptoms

20. Periumblical pain  migrate to
Common symptoms:
1-Abdominal pain
Periumblical pain  migrate to
Rt lower quadrent
2-Anorexia
3-Nausea
4-Vomiting
5-low-grade fever

21. Signs

22. 1-Right lower quadrant pain on palpation
(the single most important sign) 2- Low-grade fever (38°C [or 100.4°F])
--absence of fever or high fever can occur 3-Localized tenderness to percussion 4-Guarding 5-Other confirmatory peritoneal signs
(absence of these signs does not exclude appendicitis) • Psoas sign • Obturator sign • Rovsing's sign • Dunphy's sign--increased pain with coughing • Flank tenderness in right lower quadrant

23. Differential Diagnosis

24. Children Elderly -Gastroenterits -Mesenteric adenitis
-Meckel`s diverticulitis
-Intussusception
-Lobar pneumonia
Elderly
-Sigmoid diverticulitis
-Intestinal obstruction
-Colonic carcinoma
-Mesenteric infarction
-Aortic aneurysm

25. Adult male Adult female -Regional enteritis -Ureteric colic
-Perforated ulcer
-Torsion testis
-Pancreatitis
-Rectus sheath hematmoa
Adult female
-Salpingitis
-Pyelonephritis
-Ectopic pregnancy
-Torsion/rupture of
ovarian cyste
-Endometriosis

26. History Taking

27. The components of the surgical history are that of any other history, including;
An introduction
Presenting complaint
History of presenting complaint
Past history ( medical & surgical )
Drugs/allergies
Family history
Social history
Occupational history
Systems enquiry

28. Age & Sex :
Appendicitis does occur at any age but most often affects
young adults or teenagers of either sex.
 Ask about
The site of the pain
Onset
Severity
Pattern
Is it localized in a particular area or not
Radiation
Duration
Progression
Aggregating Factors
Relieving Factors
Associated Symptoms

29. Physical examination

30. General Appearance : Head & Neck :
Patient looks unwell with flushed cheeks
Tongue “ white & furred with foetor oris “
Pale ( especially in children )
Tachycardia
Low grade fever
Head & Neck :
Observe the tonsils & Palpate the lymph nodes

31. Chest : Abdomen : Examine the Lungs Inspection Palpation
Usually normal shape , the abdomen is slowly moves with respiration due to pain
Palpation
The Rt iliac fossa is tender with or without guarding
Rebound Tenderness: +ve in Mcburneys point

32. Signs : I- Rovsing`s sign : II- Psoa`s sign :
Pain in the Rt iliac fossa on palpation or percussion on Lt iliac fossa.
II- Psoa`s sign :
Pain when extending the Rt hip joint due to spasm of the psoa`a muscle .

33. The psoas sign.
Pain on passive extension of the right thigh.
Patient lies on left side.
Examiner extends patient's right thigh while applying counter resistance to the right hip asterisk
Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver

34. III-Obturator`s sign :
Pain with passive internal rotation of the flexed
Rt thigh it indicated inflammation overlying that muscle .

35. V-Straight leg arising sign :
IV-Blumberg`s sign :
Crossed Rebound tenderness in the Rt iliac fossa after pressing and sudden release on Lt iliac fossa .
V-Straight leg arising sign :
+ve in retrocecal appendix

36. Rectal Examination :
Tenderness in pelvic appendix or if there is inflammation or pus in Douglas pouch

37. Preoperative complication

38. Systemic Complications :
Acute toxemia
Septicemia
Portal pyemia

39. Local Complications : Appeddicular Abscess Appedidicular fistula
Rupture  supportive peritonitis
Turns to chronic appendicitis

40. Investigation

41. Complete Blood Count ( CBC ) : Leukocytes Count especially neutrophiles
Urine Analysis
Albuminuria , Hematuria
(25-40% of patient).
Plain X-ray
Ultra Sound
CT scan

42. Appendectomy

43. Conventional Open Operation
Grid-iron incision
Lower midline abdominal incision
Laparoscopic Technique

45. Problems encountered during Appendictomy: A normal appendix is found
The Appendix can not be found
An Appendicular Tumor is found
An Appendix Abscess is found

46. Postoperative complication

47. Wound Infections Postoperative complication Intra-abdominal Abscesses
Venous Thrombus & Embolism
Portal Pyemia ( Pylephlebitis )
Faceal Fistula
Adhesive intestinal obstruction
Right inguinal hernia
Postoperative complication

48. Treatment of postoperative complication
Antibiotic prophylaxis
If perforation has occurred,
IV antibiotics should be continued for 5-10 days.

49. ..Thank You..