APPENDICITIS

Lazaro, Gennielene
Llopis, Aple
Loluquisen, Rogelio

Anatomy of
Appendix

Average Length:
Adult varies from <1cm to >30 cm,
average 6-9 cm.
Outside diameter: 3-8 mm
Luminal diameter:1-3 mm.
Luminal Capacity: 0.1ml
> Tip-located anywhere in the right lower
quadrant of the abdomen or pelvis.
> Base-located by following the
longitudinally oriented taenia coli to their
confluence at the cecum.

Blood Supply:
Arterial - from the appendicular branch of the ileocolic
artery. It originates posterior to the terminal ileum, entering
the mesoappendix close to the base of the appendix. A
small arterial branch arises at this point that runs to the
cecal artery.
Lymphatics - flows into lymph nodes that lie along the
ileocolic artery.
Innervation-derived from sympathetic elements contributed
by the superior mesenteric plexus (T10L1), afferents from
parasympathetic elements brought in via the vagus nerve.

Histological features :
Muscularis layer - not well defined; deficient in some
locations.
Submucosa and mucosa (+) lymphoid aggregates, (+)
or (-) germinal center; Lymph vessels are prominent.
Mucosa same like large intestine, except for the
density of the lymphoid follicles.
Crypts of Lieberkuhn - irregular sized and shape.
Neuroendocrine complexes (ganglion cells, Schwann
cells, neural fibers, and neurosecretory cells) positioned
just below the crypts.
Serotonin - prominent secretory product; mediating pain
arising from the noninflamed appendix.
These complexes may be the source of carcinoid
tumors, for which the appendix is known to be the most
common site of origin.

Function: may play a role in immune

surveillance. The mucosa of the
appendix, like any mucosal layer, is
capable of secreting fluid, mucin, and
proteolytic enzymes.

Diseases of Vermiform
Appendix
1. Acute Appendicitis
. Etiology: low fiber diet (contribute to changes
in motility, flora, or luminal conditions that
predispose to development of fecaliths)
. Pathogenesis: OBSTRUCTION
(+) fecalith
(-) fecalith: hyperplasia of lymphoid tissue in the
mucosa and submucosa
Neoplasm (carcinoma/carcinoid tumor) or foreign
body ~2%

Acute Appendicitis
Bacterial
bacterial
invasion
into
the mucosa
and
Luminal
pressure
exceeds
pressure
within
the
increases
Secretion
Rise
outflow
Capillary
Mucosal
in overgrowth;
luminal
of
ischemia,
pressure
in
of
blood
pressure
mucus
pressure
and
is
inflammation,
and
exceeded
lymph
within
fluidisthe
obstructed
and
ulceration

Local Changes within the

Appendix

ROLE
OF appendix:
NORMAL
COLONIC
FLORA
Inflamed
60% aspirates
(+) anaerobes

 Natural Hx and Complications

24-36h average time from onset of
symptoms to perforation
Complications are observed in the very
young and very old patients.

Complication

Management

Spreading peritonitis

Antibiotics, appendectomy

Abscess
Abdominal
Retroperitioneal

Antibiotics, appendectomy
Percutaneous drainage reserved for poor surgical risk
patients; interval appendectomy in 6 weeks
recommended

Intestinal Obstruction

Antibiotics, Appendectomy

Bacteremia/systemic

Antibiotics, appendectomy, or
sepsis percutaneous drainage of appendiceal abscess
until acute episode resolves

Fistula
Abdominal Wall
Antibiotics until acute episode
resolved, then bladder interval
appendectomy and closure of
Fistula
Liver Abscess

Pyelophlebitis

Broad-spectrum antibiotics;
percutaneous drainage of liver
and appendiceal abscess;
interval appendectomy
Broad-spectrum antibiotics; systemic
anticoagulation; percutaneous
drainage of liver and appendiceal
abscesses; interval appendectomy

Clinical Presentation
Signs

Three Diagnostic Maneuvers

Rovsings

Laboratory Findings
WBC Count

Imaging Studies

Differential Diagnosis

Inflammatory Bowel Disease

Meckels Diverticulum
Ectopic Pregnancy
Endometriosis
Gastroenteritis
Pelvic Inflammatory Disease
Renal Calculi
UTI (both female and male)

Treatment and Mgt

Preoperative: restore fluid balance, esp in the very
young and in aged patients. Patient should be well
hydrated, manifested by good urine output. NGT is
passed for decompression of stomach to minimize
vomiting during induction of anesthesia.
Antipyretics and external cooling may be needed since
hyperpyrexia may complicate anesthesia.
Perforated AP: IV fluid resuscitation and prompt
appendectomy; all pus is drained with postoperative
antibiotics continued for 3-7 days.
Nonperforated AP: prompt appendectomy, 24 hours of
antibiotics, discharge home usually on POD #1

 Types of Appendectomy
Open vs Laparascopic

 Postoperative Care
Fluid balance maintained by IV administration
of LRS.
Patient is permitted to sit up for eating on the
day of operation and may get out of bed on
first postoperative day.
Sips of water may be given as soon as nausea
subsides. Diet is gradually increased.
(+) evidence of peritoneal sepsis: frequent
doses of Antibiotics. Constant gastric suction
until all evidence of peritonitis and abd
distention has subsided. Accurate estimate of
fluid intake and output must be made.

Possible Complications

Abscess
Wound infection
Perforation
Bowel obstruction

Prognosis

Overall Mortality: 0.2-0.8%

Mortality in children: 0.1-1%
>17 y/o: > or = 20%
Mortality of uncomplicated AP:
<0.1%
Mortality of Complicated AP: >0.6%
Attributable to complications

Special Considerations
Advanced Age

Pregnancy

Pregnancy

Pregnancy

Thank you