AUFMED

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Dr. Nelson Ayson | September 11, 2015 | SURGERY

THE APPENDIX
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HISTORICAL BACKGROUND
Claudius Amyand (1736) unknowingly did the
first ever appendectomy
He was doing a surgery on an 11-year old
boy who had an inguino-scrotal hernia
with fistula.
Upon operation, he found out that there
was a perforation on the appendix (but
didnt know that it was the appendix) and
pierced it with a needle.
Due to the hernia and perforated
appendix, he developed a fistula.
Typhlitis or perityphlitis term used to
describe
right
lower
quadrant
inflammation in the 19th century
Reginald Fitz coined the term appendicitis
Fergus, in Canada first elective appendectomy
in 1883
Charles McBurney published New York State
Medical Journal describing the indications for early
laparotomy for the treatment of appendicitis; in this
paper he described McBurney point (point of
maximal tenderness)
Later on, he acknowledged McArthur as
the one who first described McBurneys
incision.
Semm

first
successful
laparoscopic
appendectomy in 1982

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ANATOMY

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The THREE TAENIAE COLI converge at the

junction of the cecum with the appendix and can
be a useful landmark to identify the appendix
Taenia libera prominent taenia coli
Normally located retrocecally, on a posteromedial
orientation at the right iliac fossa (where the
sacrum lies)
The appendix can vary in length from <1 cm to >30
cm; most appendices are 6-9 cm long
Luminal capacity of the normal appendix: 0.1 mL
Secretion of as little as 0.5 mL of fluid distal to an
obstruction raises the intraluminal pressure to 60
cm H20
The APPENDICEAL ARTERY, a branch of the
ileocolic artery (which comes from the superior
mesenteric artery), supplies the appendix
Important in surgeons, especially when
doing resection of the intestines
McBurneys Point: point of maximum
tenderness, when one examines with the
fingertips is, in adults, one half to two inches inside
the right anterior spinous process of the ilium on a
line drawn to the umbilicus
Good morning appendix (meaning, voila!
Nakatayo na kaagad!) All you have to do is to
cut/ligate the mesoappendix to the base of the
appendix.
There are cases when > 1cm is adherent to the
cecum, so you leave > 1cm of the appendix
knowing that you are already at the base (kahit
wala pa naman). That is why the critical view is
very important (funneling effect). Because if not,
you might still be leaving a considerable length
and after a few years, patient might be returning to
you complaining of signs and symptoms of
appendicitis.
Drop method double-ligating the base
Sometimes, the obstruction is near the base, so
there is a poor tissue quality and you are in doubt
that the patient will hold the suture. What is done,
aside from ligating it, is that a purse-string suture
is applied and the stump is embedded.

The appendix, ileum, and ascending colon are all

derived from the MIDGUT
The appendix first appears at the EIGHTH WEEK
of gestation as an outpouching of the cecum and
gradually rotates to a more medial location as the
gut rotates and the cecum becomes fixed in the
right lower quadrant
Lymphoid tissues appears at 2 weeks AOG
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

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Page 1 of 10

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PATHOPHYSIOLOGY
Obstruction of the lumen is the dominant etiologic
factor in acute appendicitis
Fecaliths are the most common cause of
appendicieal obstruction
Lymphoid hyperplasia in the younger
population
The proximal obstruction of the appendiceal lumen
(due to bacterial overgrowth) produces a closedloop obstruction, and continuing normal secretion
by the appendiceal mucosa rapidly produces
distention
Distention of the appendix stimulates the nerve
endings of visceral afferent stretch fibers,
producing vague, dull, diffuse pain in the
midabdomen or lower epigstrium 1st symptom
that the patient would experience
Continuous secretion would cause a shift
of the pain to the right side
Peristalsis also is stimulated by the rather sudden
distention, so that some cramping may be
superimposed on the visceral pain early in the
course of appendicitis
As pressure in the organ increases, venous
pressure is exceeded
Capillaries and venules are occluded, but
arteriolar
inflow
continues,
resulting
in
engorgement and vascular congestion
Disruption of the normal blood flow would
lose
the
normal
barrier
against
microorganisms
The inflammatory process soon involves the
serosa of the appendix and in turn parietal
peritoneum in the region, which produces the
characteristics shift in pain to the right lower
quadrant
Extensive distention causes reflex nausea and
vomiting, and the diffuse visceral pain becomes
more severe
Progression of infection and inflammation would
lead to liquefactive necrosis usually to the least
supplied area which is distal to the obstruction and
the antimesenteric border of the appendix
How do we differentiate a phlegmon from a periappendiceal abscess?
Both are complications.
Phlegmon is the matting of the intestines
and fats. The purpose is to form a barrier.
Before the appendix ruptures, the body
tries to suppress generalized peritonitis.
Once there is pus, and an abscess wall is
present, that is what we call a periappendiceal
abscess.
The
only
management is appendectomy.

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SCORING SYSTEMS
Several scoring systems were devised in order to
determine the probability that a patient presenting with
acute or surgical abdomen is a case of appendicitis. The
most commonly used is the ALVARADO SCALE. A better,
but more expensive scoring system used is the AIRS or
Appendicitis Inflammatory Response Score, which uses
CRP evaluation as one of its parameters.
ALVARADO SCORE
Findings
Points
Migratory Right Iliac Fossa Pain
1
Anorexia
1
Nausea or Vomiting
1
Tenderness: Right Iliac Fossa
2
Rebound Tenderness: Right Iliac Fossa
1
Fever 36.3oC
1
Leukocytosis 10x109 cells/L
2
Shift to the Left of Neutrophils
1
INTERPRETATION
<3: Low Likelihood of Appendicitis
4-6: Consider Further Imaging (EQUIVOCAL)
7: High Likelihood of Appendicitis
Highest Points:
tenderness of the right iliac fossa
leukocytosis 10x109 cells/L
APPENDICITIS INFLAMMATORY RESPONSE
SCORE
Findings
Points
Vomiting
1
Pain in the Right Inferior Fossa
1
Rebound Tenderness or Muscular Defense
Light
1
Medium
2
Strong
3
Body Temperature 38.5oC
1
Polymorphonuclear Leukocytes
70% to 84%
1
85%
2
White Blood Cell Count
10.0-14.9 x 109 cells/L
1
15.0 x 109 cells/L
2
C-Reactive Protein Concentration
10-49 g/L
1
50 g/L
2
INTERPRETATION
0-4: Low Probability. Outpatient Follow-Up.
5-8: Indeterminate Group (EQUIVOCAL). Active
Observation or Diagnostic Laparoscopy
9-12: High Probability. Surgical Exploration.
Highest Points:
strong rebound tenderness of the right iliac fossa
or muscular defense

Page 2 of 10

CLINICAL PRACTICE GUIDELINES

Operational Definitions
- Uncomplicated appendicitis includes the
acutely inflamed, phlegmonous, suppurative, or
mildly inflamed appendix with or without peritonitis

atypical history and physical examination and the

surgeon cannot decide whether to discharge or to
operate on the patient
Alvarado score of 4-6
How do you elicit Rovsing's sign?

Complicated
appendicitis

includes
gangrenous appendicitis, perforated appendicitis,
localized purulent collection at operation,
generalized peritonitis, and periappendiceal
abscess

Rovsing's Sign is done by applying either a direct or

rebound pressure on the contralateral side/LLQ. An
indirect tenderness is elicited because there is shifting of
pressure which then affects the parietal peritoneum
causing irritation and pain.

Most of the slides I showed you eventually will have

perforation. Recall the picture I told you to memorize (the
one with the gangrenous appendicitis with localized pus at
the center).

Rebound Tenderness There is inflammation of the

serosal layer of the appendix, thereby, touching the
parietal peritoneum which produces localized pain. The
mechanism for direct tenderness is applied first
(application of pressure on RLQ) then upon sudden
release, there will be a negative pressure inside causing
pain. Trivia: This sign is also known as Blumberg's Sign. It
is usually indicative of peritonitis (and not solely of
appendicitis).

How will you recognize generalized peritonitis? It is very

easy. You cannot even touch any part of the abdomen.
Just by knocking the bed, the patient will recoil. There will
be respiratory splinting.
How do you differentiate voluntary from involuntary muscle
guarding?

Pathophysiology

Relieved with pillow

under feet/back
Relieved with
distraction
Relieved with
analgesia
Area

Voluntary
Voluntary
contraction
of
abdominal
muscles in
response to
pain or
anxiety
Yes

Involuntary
Increased
muscle tone
due to
irritation of
parietal
peritoneum

Yes

No

Yes

No

Bilateral

Unilateral/
bilateral

No

In summary, voluntary muscle guarding is elicited thru

abdominal
palpation
while
involuntary
muscle
guarding/rigid abdomen is not.
Review of the physical examination of the abdomen: IAPP
(Inspection-Auscultation-Percussion-Palpation)
Make sure that you have an assistant/witness when
examining patients of the opposite sex to avoid sexual
harassment law suits.
If the patient is ticklish on palpation, examine using the
patient's hand below yours.
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Equivocal appendicitis a patient with right

lower quadrant abdominal pain who presents with

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Question: Can Meckel's diverticulitis produce direct,

rebound tenderness, and Rovsing's sign?
Answer: Yes.
Both Appendicitis and Meckelss Diverticulum share the
same presentation, history, and physical exam; hence, the
best way to exclude Meckels Diverticulum is intraoperatively although good imaging modalities such as CT Scan
may help in the exclusion. Ultrasound may not be as
reliable as the CT Scan because in this case, it provides a
low specificity and sensitivity.
In the clinics, the presence of peritoneal signs will invalidate the need for exotic lab procedures because the
clinical features of appendicitis are enough to establish and
justify the need for an appendectomy as a reliable management.
PSOAS SIGN
May be elicited in two positions supine and left
lateral decubitus.
If the patient is in left lateral decubitus position, initially
ask the patient to relax and then extend the knee
joint. Observe the presence of pain in the right iliac
fossa. (Pain = Positive Psoas Sign)
If the patient is lying supine, as the patient to relax,
apply resistance on the right thigh, and then ask the
patient to elevate that same thigh with resistance.
Presence of pain indicates a positive Psoas Sign.
There is pain because of the irritation of the psoas
muscle, which borders the peritoneal cavity, in relation
to the anatomy and the underlying pathology of the
inflamed appendix.
This is hence typical of a retrocecal appendicitis.in the
Good Morning type, it (Psoas sign) is rarely elicited
because of the anterior presentation.

Page 3 of 10

The location of the pain is constant and will aid in the

localization of the tip of the appendix.

OBTURATOR SIGN
In a supine position, ask the patient to relax, flex the
knee at 90 degrees the internally rotate the hip to
move the obturator muscle, (tell the patient, ibigay mo
ang paa mo sa akin!). The presence of pain (the tip of
the inflamed appendix in relation to the sheath of the
obturator muscle) will indicate a positive Obturator sign
for a pelvic appendix.
RIGHT PARARECTAL TENDERNESS
In doing your rectal examination, elicit tenderness from
the tip of your gloved finger on the right side of rectal
vault because your appendix is in the right side.
CLINICAL PRACTICE GUIDLINE on ACUTE
APPENDICITIS (Philippine College of Surgeons, 2002)
Committee Evaluation (Level of Evidence and Grade
of Recommendation)
Level of Clinical Evidence (Based on the Assessment
system of the Infectious Disease Society of America)
Level I

Level II

Level III

Evidence from at least one properly designed

randomized controlled trial or meta-analysis
Evidence from at least one well-designed clinical
trial without proper randomization, from cohort
or case-controlled analytic studies (preferably
from one center), from multiple time-series, or
from dramatic results in uncontrolled
experiments
Evidence from opinions of respected authorities
on the basis of clinical experience, descriptive
studies, or reports of expert committees

Categorization of the strength of recommendation

according to the level of agreement of the panel of
experts after votation of the participants
Category A

Category B
Category C

Recommendations that are approved by

consensus (at least 75% of the multi-sectorial
expert panel)
Recommendations that were somewhat
controversial and did not meet consensus
Recommendations that caused real
disagreements among the members of the panel

Executive Summary
1) When should one suspect acute appendicitis?
o Consider the diagnosis of acute appendicitis when a
patient presents with right lower quadrant abdominal pain. [III, A]
All RLQ pain must be suspected for appendicitis, not
absolutely, but primarily. Do your history and physical
examination to further support or exclude the diagnosis of
appendicitis

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2) What clinical findings are most helpful in

diagnosing acute appendicitis?
o Acute appendicitis should be suspected in any
patient (especially male) who presents with a high
intensity of perceived abdominal pain of at least 712 hours duration, with migration to the right
lower quadrant and followed by vomiting.
o Although symptoms alone have a low discrimi-nating
power, the diagnosis of acute appendicitis becomes
more certain when the physical examination findings
include right lower quadrant tenderness,
guarding, rebound tenderness, and other signs
of peritoneal irritation. [I, A]
The pain in appendicitis is gradual and progressive, not
intermittent or on & off. The pain may decrease in intensity
but is not entirely gone. Gastroenteritis may present with
colicky type of pain that is on & off. Observe the patient
carefully and closely. Hold analgesics of any type unless
diagnosis is established. Giving analgesics may mask the
pain of appendicitis and may lead to complications such as
rupture and peritonitis. Give analgesics once diagnosis is
made and need for surgery is established.
3) What diagnostic tests are helpful in the diagnosis of
acute appendicitis?
o Although the diagnosis of acute appendicitis is
primarily based on the clinical findings, the follow-ing
examinations may be helpful:
A. All Cases
a. White blood cell with differential count [I, A]
B. Equivocal Appendicitis in Adults
a. CT Scan
b. Ultrasound
Whenever feasible, CT scan should be preferred over
ultrasonography in the clinically equivocal appendicitis in
adults because of its superior accuracy. [I, A]
C. Equivocal Appendicitis in the Pediatric Age Group
a. Ultrasound (Graded Compression)
b. CT Scan
Although CT Scan and ultrasound have comparable
accuracy in the diagnosis of acute appendicitis in the
pediatric age group, ultrasound is preferred because of
its lack of radiation, cost-effectiveness, and availability
compared to CT Scan
D. Selected Cases
a. Diagnostic Laparoscopy
Despite its statistically significant favorable effects,
diagnostic laparoscopy should be viewed as an invasive
procedure requiring anesthesia and having risks similar to
appendectomy. It should be utilized at this time only in
selected cases. [III, A]

Page 4 of 10

The following are generally not useful in the diagnosis of

acute appendicitis: (1) Plain Abdomi-nal X-ray probably
if you are suspecting a perforated viscus; (2) Barium
Enema may help if there is minimal obstruction, however
in the presence of a perforated viscus WOF chemical
peritonitis; and (3) Scintigraphy very expensive, not
easily accessible. [I, A]
A common practice among surgeons is requesting
urinalysis to rule out UTI on top of history, physical
examination, and other recommended labs. Among
pregnant women, MRI is preferred over CT Scan.
Side note: Proper Urine Collection among female patients
(National Institute of Health: National Library of Medicine)
o Girls and women need to wash the area between the
vagina "lips" (labia). You may be given a special
clean-catch kit that contains sterile wipes.
o Sit on the toilet with your legs spread apart. Use two
fingers to spread open your labia.
o Use the first wipe to clean the inner folds of the labia.
Wipe from the front to the back.
o Use a second wipe to clean over the opening where
urine comes out (urethra), just above the opening of
the vagina.
To collect the urine sample:
o Keeping your labia spread open, urinate a small
amount into the toilet bowl, then stop the flow of
urine.
o Hold the urine cup a few inches from the urethra and
urinate until the cup is about half full.
o You may finish urinating into the toilet bowl.

5) What is the recommended approach to the surgical

management of acute appendicitis?
o Open appendectomy is the recommended primary
approach for the treatment of acute appendicitis in
our
setting.
Therapeutic
laparoscopic
appendectomy is an alternative for selected cases.
It depends on the preference of the patient, the capacity
of the patient, preference of the surgeon, training of the
surgeon and lastly the institution.
6) What is the role of laparoscopic appendectomy in
the management of acute appendicitis in children?
o Laparoscopic appendectomy may be recommended
as an alternative to open appendectomy in the
pediatric age group
Again it depends on the preference of the patient, the
capacity of the patient, preference of the surgeon, training
of the surgeon and lastly the institution.
7) What is the role of antibiotics in the management of
acute appendicitis?
A.
Is
antibiotic
prophylaxis
uncomplicated appendicitis?

The target sign is observed in ultrasound, but this is very

difficult. A graded compression ultra-sound is usually done,
the examiner applies gentle pressure on the area of
interest with an ultrasound probe and either one or two
hands to palpate the RLQ in the same way as doing an
abdominal exam.
The accepted criteria for diagnosis acute appendicitis by
ultrasonography are identification of a noncompressible,
blind-ending tubular structure in the longitudinal axis that
measures >6mm in diameter and lacks peristalsis.

for

In an uncomplicated appendicitis, what type of surgical

wound do you have? Clean contaminated. Therefore, treat
prophylactically for an average of24 hours (48 hours at the
most).Start antibiotics at least an hour prior to cutting.

4) What is the appropriate treatment for appendicitis?

o Appendectomy is the appropriate treatment for acute
appendicitis. [II, A]
There are now breakthroughs in medicine, particularly the
emergence of nonsurgical manage-ment of appendicitis;
however, consider this only if it is an uncomplicated type
that is confirmed by CT scan with presence of fecalith ruled
out. Consider cautiously a nonsurgical approach in the
event of Ascaris lumbroicoides parasitism inhabiting the
appendix (Ultrasound reveals a double lumen, one for the
appendix, the other for the Ascaris).

indicated

YES, antibiotic prophylaxis is effective in the

prevention of surgical site infection for patients who
undergo appendectomy and should be considered
for routine use
Treatment is giving the full course (5-7 days)

B. What antibiotic is/are recommended for prophylaxis

in uncomplicated appendicitis and what is the
appropriate dose & route of administration?
(MEMORIZE)
o
o
o

Cefoxitin 2g IV single dose (adults); 40mg/kg IV

single dose (children)
Alternative agents:
Ampicillin-Sulbactam 1.5-3g IV single dose
(adults); 75mg/kg IV single dose (children)
For patients w/ allergy to beta-lactam antibiotics:
Gentamycin 80-120mg IV single dose +
Clindamycin 600mg IV single dose (adults)
Gentamycin 2.5mg/kg IV single dose +
Clindamycin 7.5-10mg/kg IV single dose
(children)

History and physical examination are still the best

assessment techniques to rule out other pathologies.

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Page 5 of 10

C. What antibiotic is/are recommended for the

treatment of COMPLICATED APPENDICITIS & what is
the appropriate dose, route & duration of
administration? (MEMORIZE)

Adult Patients:
o Ertapenem 1g IV q 24hrs or
o Tazobactam-Piperacillin 2.25g IV q 6hrs or 4.5g IV q
8hrs
o Adults w/ Beta-Lactam Allergy:
Ciprofloxacin 400mg IV q 12hrs +
Metronidazole 500mg IV q 6hrs

Pediatric Patients:
o Ticarcillin-Clavulanic acid 75mg/kg IV q 6hrs
o Alternative: Imipenem-Cilastatin 15-25mg/kg IV q
6hrs
o Pediatric Patients w/ Beta-Lactam Allergy:
Gentamycin 5mg/kg q 24hrs + Clindamycin 7.510mg/kg IV q 6hrs
o
o

For gangrenous appendicitis, the recommended

form of management is to treat in the same manner
as uncomplicated appendicitis (Level I, Category A)
The duration of therapy may vary depending on the
clinicians assessment after the operation. The
therapy may be maintained for 5-7days.
For complicated appendicitis, treatment should be
the full course.(5-7 days)
Sequential therapy: from IV to oral antibiotics may
be considered when gastrointestinal function has
returned (Level I, Category A)
Better if you have an IV preparation with an oral
counterpart.

The absence of fever for 24hrs (temp <38oC), the

ability to tolerate oral intake, & a normal WBC ct w/
3% less band forms are useful parameters for the
discontinuation of antibiotic therapy (Level II,
Category A)

8) Should gram stain, culture & sensitivity be routinely

done?
o Gram stain, culture & sensitivity testing of intraoperative specimens (purulent peritoneal fluid or
tissue) should not be routinely performed except in
high-risk immunocompromised patients (HIV, DM
uncontrolled, pts undergoing chemotherapy, pts
undergoing hemodialysis)

You do not routinely put a drain. When you clean the

area , it is not on the amount of fluid that you get, it
is more on the effluent. Once the fluid is clear then
that is the endpoint of your lavage. Do not stop until
it is clear, no matter how much fluid you get.
If you cannot, that is when you put a drain. The drain
may help but it is double bladed because it is an
open communication with the environment, directly
into the peritoneal cavity. Take good care of the drain
because it is a nidus for further infection.
General peritoneal lavage is not recommended for
localized peritonitis. Intra-peritoneal drains, while
most useful in patients with well-established and
localized abscess cavity, should be selectively
utilized.
Level II, Category A

10) What is the appropriate method of wound closure

in patients with complicated appendicitis?
o The incision may be closed primarily in patients with
complicated appendicitis (PRIMARY wound closure)
o When doc does an appendectomy, even for
uncomplicated cases, he always protects the wound
area with a sterile lap pack (wet sponges) because
in appendicitis there is inflammation at the serosal
layer so once it touches the edge of the wound,
microorganisms can transfer to the wound causing
surgical wound infection postoperatively. This is also
done because you can prevent the drying of the
wound edge. Dry wound edges are prone to
infection.
In a patient who has a very thick subcutaneous tissue,
even in uncomplicated appendicitis, they have a high
chance of surgical site infection. As compared to a patient
who is very lean, even if he has a complicated appendicitis,
most of them do not end up with surgical site infections.
Maybe because the subcutaneous tissue is devoid of blood
vessels unlike muscles and fascia.
11) What is the optimal timing of surgery for patients with
periappendiceal abscess?
A periappendiceal abscess is diagnosed by:
- having a right lower quadrant tenderness
- with a palpable mass
- in a young patient
- confirmed by ultrasound
o

A patient with periappendiceal abscess should

undergo surgery as soon as the diagnosis is made.

Natural Orifice Transluminal Endoscopic Surgery

We already know what microorganisms are present
and what antibiotics are the best for such. Like in
acute appendicitis it is E. coli and if it is ruptures and
if it is Bacteroides fragilis.
9) How should localized peritonitis be managed?
o No necrotic tissue or purulent material should be left
behind as much as possible.

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Advantages:
o Reduction of postop wound pain
o Shorter convalescence
o Avoidance of wound infection & abdominal wall
hernias
o Absence of scars

Page 6 of 10

PICTURE DISCUSSION ON APPENDICITIS

PICTURE 4 (not actual photo)

The actual pictures in this part of the transcription

were from AUFSOM2016 Transclub. Some pictures
were downloaded from the internet and were chosen
as they are most visually-similar pictures available.
PICTURE 1

This is the specimen from above

If you do not clamp the cut portion, the contents
will spill out

PICTURE 5
Serosal engorgement
PICTURE 6

Tip with fibrinous exudates

Involvement of serosal sessels

PICTURE 2

Perforation with fibrinous exudate

PICTURE 7

Markedly dilated, distended appendix

Serosal vessels are very dilated
More prominent symptom: pain > vomiting

PICTURE 3 (not actual picture)

-

Gangrenous appendix with perforation

PICTURE 8 (MEMORIZE THIS PICTURE)

Tinea liberia
Double ligation
Depends on the quality of the tissue
-

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Gangrenous appendix with localized collection of

pus

Page 7 of 10

PICTURE 9

Same manifestations with appendicitis due to its

location
Management is as the same as appendicitis
Segmentally resect the ileum and then perform an
end-to-end anastomosis

PICTURE 13 (not actual picture)

Longganisa-looking appendix

PICTURE 10 (not actual picture)

-

Fecalith

Diagnosis: Volvulus
A very long Meckels diverticulum with a long
fibrous band connected retroperitoneally can
rotate wil lead to gangrene
Management is resection and end-to-end
anastomosis
If diagnosed early, the fibrous band may be
removed and observed for the viability of the
intestine

PICTURE 14 (not actual picture)

PICTURE 11

Pediatric appendicitis

PICTURE 12

Another management is wedge resection

Acquired Diverticulum contains only one layer of
the intestinal wall
True Diverticulum contains all layers of the
intestinal wall

PICTURE 15 (not actual picture)

Outbudding
Diagnosis: Meckels Diverticulum
A true diverticulum
Congenital anomaly that can only be ruled out
intra-operatively

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Diagnosis: Cholecystitis
If this perforates, this condition can mimic an acute
appendicitis
Cholecystitis is one of the differentials for acute
appendicitis
Bile can gravitate into the right iliac fossa leading
to the migration of pain in the right lower quadrant

Page 8 of 10

Upon opening up, check for the fluid in the

peritoneum; if the fluid is bilious, consider a
ruptured cholecystitis or a ruptured ulcer

PICTURE 16 (not actual picture)

Presented also as an acute abdomen

PICTURE 19
Intraoperatively, if the intestines contract when
they are squeezed or stimulated, the intestines are
still viable
PICTURE 20
Diagnosis: Inguinal Hernia
PICTURE 21 (not actual photo)

Diagnosis: Perforated Cecal Mass

Grossly, the perforated mass is red in color
The appendix is normal
This condition also mimics acute appendicitis

PICTURE 17 (not actual picture)

Diagnosis: Twisted Ovarian Mass

VALENTINOS APPENDICITIS
Valentino's syndrome is pain presenting in the right
lower quadrant of the abdomen caused by a duodenal
ulcer with perforation through the retroperitoneum.

Diagnosis: Inguinal Hernia

Presented as an acute abdomen
Upon opening up, the area shows fatty tissue:
omentum that is necrotic
The appendix is normal
Upon history and PE, it was revealed that the
patient has inguinal hernia
The herniated structure was not a part of the small
intestine, rather, a part of the omentum
Management: Resection of the necrotic tissue
In the actual picture, you will be able to visualize
the omentum entering the INTERNAL INGUINAL
RING

It is named after Rudolph Valentino who presented with

right lower quadrant pain which turned out to be perforated
peptic ulcer. He subsequently died from an infection
resulting from surgery attempting to repair the perforation.
The pain is caused by gastric and duodenal fluids that tend
to settle in the right paracolic gutter causing peritonitis and
RLQ pain (Achacoso, et al. 2012).

PICTURE 18 (not actual photo)

Diagnosis: Inguinoscrotal Mass

PI Arellano | Gagui | Galvan | Pamintuan | Timbang

PROPERTY OF AUFSOM BATCH 2017
v3.1 s2015-2016

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PARAMETER

Suspicion of
Acute
Appendicitis
Pertinent Clinical
Findings

Diagnostics and
Laboratory

Treatment
Approach to
Surgical
Management
Laparoscopic
Appendectomy
for children
Antibiotics

COMMITTEE
RECOMMENDATION

Allergy to Beta-Lactam
Antibiotics
Gentamycin 80-120mg IV single
dose + Clindamycin 600mg IV
single dose (ADULT)

LEVEL OF EVIDENCE
AND CATEGORY OF
RECOMMENDATION

EXECUTIVE SUMMARY OF THE CPG ON ACUTE APPENDICITIS

Any patient with RLQ pain

III, A

High Intensity Abdominal Pain

7 to 12 hours duration

Migration to RLQ

Followed by vomiting
Guarding
Rebound Tenderness
Other signs of Peritoneal Irritation
ALL CASES

White Blood Cell with

differential count

I, A

EQUIVOCAL APPENDICITIS
(ADULT)

CT Scan preferred

Ultrasound

I, A

EQUIVOCAL APPENDICITIS
(PEDIA)

Ultrasound preferred

CT Scan

II, A

SELECTED CASES

Diagnostic Laparoscopy

III, A

The following are generally not

useful: Plain Abdominal X-Ray;
Barium Enema; and Scintigraphy
Appendectomy
Open Appendectomy preferred;
Therapeutic laparoscopic
appendectomy as alternative
Alternative to open appendectomy
in children

II, A

ANTIBIOTIC PROPHYLAXIS

Must be considered for

routine use to prevent
surgical site infection

I, A

I, A

Gentamycin 2.5mg/kg IV single

dose + Clindamycin 7.5-10mg/kg IV
single dose(PEDIA)
TREATMENT OF COMPLICATED
APPENDICITIS
(ADULT)

Ertrapenem 1g IV OD

Tazobactam-piperacillin
3.375g IV QID

Tazobactam-piperacillin 4.5g
IV TID

Ciprofloxacin 400mg BID +

Metronidazole 500mg IV QID
if with allergy to Beta Lactam
antibiotics

I, A

I, A
(PEDIA)

Ticarcillin-clavulanic acid
75mg/kg IV QID

Imipenem-Cilastatin 1525mg/kg IV QID as

alternative

Gentamycin 5mg/kg IV OD +
Clindamycin 7.5-10mg/kg IV
QID if with allergy to Beta
Lactam antibiotics

II, A
I, A

I, A

Gram Stain &

Culture
Localized
Peritonitis

Wound Closure
PROPHYLAXIS FOR
UNCOMPLICATED APPENDICITIS

Optimal Timing
of Surgery

Recommended
Cefoxitin 2g IV single dose (ADULT)
Cefoxitin 40mg/kg IV (PEDIA)

I, A

Alternative
Ampicillin-Sulbactam 1.5-3g IV
single dose (ADULT)

I, A

GANGRENOUS APPENDICITIS
Treat as uncomplicated

II, A

DURATION varies on clinician;

maintain for 5-7 days. Shift to oral
therapy with return of GIT function
may be considered

I, A

DISCONTINUE THERAPY if with

absence of fever (T <38C); tolerates
oral intake; normal WBC count with
3% band forms
Not routinely done unless patient is
high-risk
Remove all necrotic tissue or
purulent material. General
Peritoneal Lavage is not
recommended. Intraperitoneal
drains are selectively used.
Incision is closed primarily in
complicated appendicitis
Patients with peri-appendiceal
abscess: STAT

II, A

II, A
II, A

I, A
III, A

Ampicillin-Sulbactam 75mg/kg IV
single dose (PEDIA)
or
Ampicillin-Clavulanate 1.2-2.4g IV
single dose (ADULT)
Ampicillin-Clavulanate 45,g/kg IV
single dose (PEDIA)

PI Arellano | Gagui | Galvan | Pamintuan | Timbang

PROPERTY OF AUFSOM BATCH 2017
v3.1 s2015-2016

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