MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE

V.N. Karazin Kharkov National University

Acute appendicitis

Acute appendicitis is an
inflammation of vermiform appendix
caused by festering microflora. It is
the most common acute surgical
disease of the abdomen. It affects 67 % of the population. The mortality
is about 0,2-0,3 % and depends on
complication of acute appendicitis.

Anatomy
a blind muscular tube with

mucosal, submucosal, muscular and

serosal layers
At birth, appendix is short and
broad at its junction with the
caecum, but differential growth of
the caecum typical tubular
structure by about the age of 2
years
During childhood, continued
growth of the caecum commonly
rotates the appendix into a
retrocaecal but intraperitoneal
position
Position of the base of the
appendix is constant, being found
at the confluence of the three
taeniae coli of the caecum, which
fuse to form the outer longitudinal
muscle coat of the appendix.

Anatomy
The

blood supply by the appendicular artery

which arises from the ileocolic artery and the
only blood supply so therefore an end artery
which arises from the superior mesenteric
artery drain by ileocolic vein. The lymphatic
pass to the lymphatic noduls in the
mesoappendix and to the ileocolic lymphatic
noduls along the ileocolic artery than to
superior mesenteric lymphatic noduls.

Various positions of the

appendix:
The position of the appendix is variable
retrocaecal (75%)
pelvic (20%)
front or behind the ileum (5%)
paracolic
subhepatic.

Special Features Based On

Appendix Locations

Etiology and pathogenesis

Most frequent causes of acute appendicitis are festering microbes:
intestinal stick, streptococcus, staphylococcus. Microflora can be
present in the cavity of appendix or range by hematogenic,
lymphogenic ways.
Factors which promote the beginning of appendicitis :
1. Change of reactivity of organism;
2. Constipation and atony of intestine;
3. Excrement stone in its cavity;
4. Thrombosis of vessels of appendix and gangrene of the wall as a
part of inflammatory process;
5. Obstruction (lymph glands, mechanical reason, excrement stone
in its cavity, food residue, ascarid, tumor, etc.
6. Gastrointestial disease;
7. Bacteria invasion.

Classification (by V.I. Kolesnikov)

1. Appendiceal colic.
2. Simple superficial appendicitis.
3. Destructive appendicitis:
) phlegmonous;
) gangrenous;
) perforated.

4. Complicated appendicitis:
) appendicular infiltrate;
) appendicular abscess;
) diffuse purulent peritonitis.

5. Other complications of acute appendicitis

(pylephlebitis, sepsis, retroperitoneal phlegmon, local
abscesses of abdominal cavity).

Acute simple appendicitis

In simple appendicitis the changes are
observed, mainly, in the distal part of
appendix. There is stasis in capillaries and
venules, edema and hemorrhage. Focus of
festering inflammation of mucus membrane
with the defect of the epithelium is seen in 1-2
hours (primary affect of Ashoff). This
characterizes acute superficial appendicitis.

Acute phlegmonous appendicitis

The phlegmon of appendix develops by the end of
the day. The organ increases, it serous layer
becomes dimmed, sanguineous, stratifications of
fibrin appear on its surface, and there is pus in
cavity.

Acute gangrenous appendicitis

In gangrenous appendicitis the appendix is
thickened, its serous thing tunic is covered by
dimmed fibrinogenous, differentiating of the
layer structure through destruction is not
succeeded.

Simple (superficial) and destructive (phlegmonous,

gangrenous) appendicitis which are morphological stages
of acute inflammation that is completed by necrosis.

Diagnostics
1. Anamnesis.
2. Objective examination.
3. General blood and urine analyses.
4. Vaginal examination for women.
5. Rectal examination for men.

Symptoms of simple appendicitis

1. Pain localized in a right iliac area.
In 70 % of patients the pain arises in a
epigastric area it is an epigastric phase of
acute appendicitis. In 2-4 hours it migrates to
the area of appendix (the Kochers sign).
2. Single nausea and vomiting.
3. Fever to 37.5-380C.
4. Retention of stool or single diarrhea.
5. Muscular tension in a right iliac area.

Symptoms of phlegmonous
appendicitis
1. Expressed pain in a right iliac area.
2. Fever to 38-390C.
3. Muscular rigidity in a right iliac area.
4. Peritoneal signs (Blumbergs sign. After
gradual pressing by fingers of anterior
abdominal wall quick taking off the hand
causes the sharp increase of pain.)

Symptoms of gangrenous
appendicitis
1. Expressed pain in a right iliac area.
2. Grave condition of the patient.
3. Signs of local peritonitis.
4. Signs of intoxication

Symptoms of pelvic appendicitis

1. Clinic of irritation of pelvic organs (dysuria,
pulling rectal pain, tenesmi).
2. Absence of muscular tenderness.
3. Painfulness of anterior rectal wall and
posterior vaginal vault.

Symptoms of acute appendicitis

About 100 pain symptomscharacteristic of acute appendicitis are
known, however only some of them have the real practical value.
Blumbergs sign. After gradual pressing by fingers of anterior
abdominal wall quick taking off the hand causes the sharp increase
of pain.
Voskresenkys sign. The increase of pain during quick sliding
movements by the tips of fingers from epigastric to right iliac area.
Bartomiers sign - the increase of pain intensity during the palpation
of right iliac area when the patient lies on the left side.
Rovsing's sign - pain in right lower quadrant during palpation of left
lower quadrant
Rozdolskyys sign. Painfulness in a right iliac area during
percussion.

Clinic of appendicitis in children

In infants acute appendicitis occurs infrequently, but quite
often has atypical character. It results from the peculiarities
of anatomy of appendix, insufficient plastic properties of
the peritoneum, short omentum and high reactivity of
childs organism. The inflammatory process in the
appendix of children rapidly progresses in the first half of
the day, resulting in destruction, even perforation. The
children suffer from vomiting more frequently than an
adult. General condition worsening quickly and the
positive peritoneal symptoms have been shown already
during the first hours of the disease. The temperature
reaction is also considerably expressed. In blood revealed
high leukocytosis. It is necessary to remember, that the
examination of anxious children requires to use a
chloralhydrate enema.

Clinic of appendicitis in elderly

patiens
This group of patients is hospitalized rather late, usually in
2-3 days after the beginning of the disease. Because of the
increased threshold of pain sensitivity, the pain in such
patients is slightly expressed, therefore they almost do not
pay attention to the epigastric phase of appendicitis.
Frequently nausea and vomiting is present, and the
temperature reaction is expressed poorly. Tension of
muscles of abdominal wall is absent or is insignificant due
to old-age relaxation of muscles. But the symptoms of
irritation of peritoneum keep the diagnostic value in this
group of patients. Thus, the sclerosis of vessels of
appendix results in initially-gangrenous forms of
appendicitis in this group.

Clinic of appendicitis during

pregnancy
Enlarged uterus bends the appendix and disturbs its
blood flow resulting in appendicitis. In the first half
of pregnancy the clinic of appendicitis usually
without peculiarities. In the second half of
pregnancy, the enlarged uterus displaces the
caecum together with the appendix upwards, and
overdistension of abdominal wall does not create
adequate tension. It is necessary also to remember,
that pregnant women periodically can have a
moderate pain in the abdomen and changes in the
blood test.

Differential diagnosis
Acute food poisoning
Acute pancreatitis
Acute cholecystitis
Perforative peptic and duodenum ulcer
Right-side renal colic
The apoplexy of ovary
Extra-uterine pregnancy

Differential diagnostics of acute appendicitis

with pancreatitis
Constant pain in the right

iliac region
Muscular tenderness in the
right iliac region
Single vomiting and
diarrhea

violation of diet and use

of alcohol
Vomiting is frequent
and does not bring the
relief to the patients
Pain is more intensive,
and is concentrated in the
upper half of abcupula

Differential diagnostics of acute

appendicitis with perforative peptic ulcer
Pain in the right iliac

Sharp acute diffuse pain

region
Muscular tenderness
in the right iliac region
Single vomiting and
diarrhea

Ulcerative anamnesis
Absence of hepatic

dullness
On X-ray of the
abdomen air above the
liver (air sickle)
Rigidity of anterior
abdominal wall

Differential diagnostics of acute

appendicitis with acute cholecystitis
Constant pain in the

right iliac region

Muscular tenderness
in the right iliac region
Single vomiting and
diarrhea

Acute pain in a right

hypohondrium with irradiation to

the scapula
Muscular tenderness in a right
hypohondrium
Vomiting by bile and nausea
without any relief
Ortner's symptom, phrenic
symptom, Murphys sign
Increased serum bilirubin

Differential diagnostics of acute

appendicitis with gynecologic disorders
Constant pain in the

right iliac region

Muscular tenderness
in the right iliac region
Single vomiting and
diarrhea

Acute pain in a lower part of

the abdomen
Dependence on menstrual
cycle
Vaginal discharge
Blood by punction of
vaginal vault
Bimanual vaginal
investigation

Differential diagnostics of acute

appendicitis with renal colic
Constant pain in the

Periodic acute pain in the

right iliac region

Muscular tenderness
in the right iliac region
Single vomiting and
diarrhea

lumbar region with

irradiation to thigh
Vomiting and nausea
Pasternatskys sign
Fresh erythrocytes in
urine analysis

Treatment
Intravenous
to

fluids

establish adequate urine output

Appropriate
Reduces

antibiotics

the incidence of postoperative wound

infection
When peritonitis is suspected, therapeutic
intravenous antibiotics to cover Gram-negative
bacilli as well as anaerobic cocci should be given
Appendicectomy

Appendicectomy
Conventional Appendicectomy
Laparoscopic Appendicectomy
Postoperative

Complications

Conventional Appendicectomy

McBurneys incision is typical.

Right angles to a line joining the
spina iliaca anterior superior to
the umbilicus. Centred on
McBurneys point

Conventional Appendicectomy
Caecum is identified
Base of mesoappendix is clamped in artery forceps, divided, and

ligated
The freed appendix is crushed near its junction with the caecum in
artery forceps, which is removed and reapplied just distal to the
crushed portion
An absorbable ligature is tied around the crushed portion close to
the caecum
The appendix is amputated between the artery forceps and the
ligature
An absorbable purse-string or Z suture may then be inserted into
the caecum about 1.25 cm from the base
The stump of the appendix is invaginated while the purse-string or
Z suture is tied, thus burying the appendix stump

Laparoscopic appendicectomy

Laparoscopic appendicectomy
The

placement of operating ports may vary according to operator

preference and previous abdominal scars.
The operator stands to the patients left and faces a video monitor placed
at the patients right foot.
A moderate Trendelenburg tilt of the operating table
The appendix is identify & controlled using a laparoscopic tissue-holding
forceps.
By elevating the appendix, the mesoappendix is displayed
A dissecting forceps is used to create a window in the mesoappendix to
allow the appendicular vessels to be coagulated or ligated using a clip
applicator.
The appendix, free of its mesentery, can be ligated at its base with an
absorbable loop ligature,divided, & removed through one of the operating
ports.
It is not usual to invert the stump of the appendix
A single absorbable suture is used to close the linea alba at the umbilicus,
and the small skin incisions may be closed with subcuticular sutures.
Patients who undergo laparoscopic appendicectomy are likely to have
less postoperative pain & to be discharged from hospital and return to
activities of daily living sooner than those who have undergone open
appendicectomy.

Problems Encountered During

Appendicectomy
Problems

Management

A normal appendix is found

Demands careful exclusion of other possible

diagnosis
Remove the appendix to avoid future
diagnostic difficulties

The appendix cannot be found

Caecum should be mobilised, and the taeniae

coli should be traced to their confluence on the
caecum before the diagnosis of absent
appendix is made

An appendicular tumour is found

Small tumours (< 2.0 cm in diameter) can be

removed by appendicectomy
Larger tumours should be treated by a right
hemicolectomy

An appendix abscess is found and Should be treated by local peritoneal toilet,

the appendix cannot be removed
drainage of an abscess and intravenous
easily
antibiotics

Complications
1. Appendicular infiltrate.
2. Appendicular abscess.
3. Diffuse peritonitis.
4. Pilephlebitis

Appendicular infiltrate
Appendiceal infiltrate is the conglomerate of organs and tissue not
densely accrete round the inflamed vermiform appendix. It develops,
certainly, on 3-5th day from the beginning of disease. Acute pain in
the abdomin decreases, the general condition of the patient gets
better. Dense, not mobile, painful, with unclear contours, mass is
palpated in the right iliac area. There are different sizes of infiltrate,
sometimes it occupies all right iliac region. The abdominal wall round
infiltrate during palpation is soft and nontender.
At reverse development of infiltrate (when resorption begins) the
general condition of the patient gets better, activity grows, the
temperature of body and indexes of blood is normalized. Pain in the
right iliac area decreases, infiltrate diminishes in size. In this phase
of infiltrate physiotherapeutic procedure is appointed, warmth on the
iliac area. Two months after resorption of infiltrate appendectomy is
conducted.
Patients with appendiceal infiltrate are managed conservatively.
Taking it into account, bed rest, restricted diet, cold compress on the
area of infiltrate and antibiotic therapy. According to resorption of
infiltrate, within or after two month, elective appendectomy is
performed.

Appendicular infiltrate

If an appendicular infiltrate is present & the condition of the

patient is satisfactory, the standard treatment is the
conservative
Careful recording of the patients condition and the extent of
the mass should be made and the abdomen regularly reexamined.

mark the limits of the mass using a skin pencil.

Temperature and pulse rate should be recorded 4- hourly

and a fluid balance record maintained
A contrast-enhanced CT examination of the abdomen
should be performed and antibiotic therapy instigated.
An abscess, if present, should be drained radiologically.
Clinical deterioration or evidence of peritonitis is an
indication for early laparotomy.
Clinical improvement is usually evident within 2448 hours

Appendicular abscess.
In abscess formation the condition of the patient gets worse, the
symptoms of acute appendicitis become more expressed, the temperature
of body rises, the fever appears. Next to that, pain in the right iliac area
increases. Tender mass is palpable in the right iliac region. Blood test
shows leukocytosis with the acutely expressed shift of leukocyte formula
to the left.
Local abscesses of abdominal cavity, develops mainly in cases of the
atypical location of appendix or due to suppuration. Pelvic abscesses are
seen more frequently, thus a patient is disturbed by pain, dysuria,
diarrhea and tenesmus. The temperature of body rises to 38,0-39,0oC,
and rectal temp is considerably higher. In the blood test leukocytosis,
shift of formula of blood is fixed to the left.
During the rectal examination the weakened sphincter of anus is
weakened. The anterior wall of rectum at first is only painful, and then
its overhanging is observed as dense painful infiltrate.
Treatment of appendiceal abscess must be only operative. Opening and
drainage of the abscess, through retroperitoneal route (incision), is
performed. In this case removal of the appendix is not necessary, because
of denger of bleeding, peritonitis and intestinal fistula.

Pylephlebitis
Pylephlebitis is a complication of both appendicitis and post
appendectomy period. The cause of this pathology is acute retrocecal
appendicitis. Theres thrombophlebitis of veins of appendix, which
passes to the veins of bowel mesentery, and then to the portal vein.
Patients complain of general weakness, pain in right hypochondrium,
high temperature of body, fever and increased sweating. Patients are
adynamic, with slightly icteric of the scleras. During palpation
painfulness is observed in the right half of abcupula often and the
symptoms of irritation of peritoneum are not acutely expressed.
In case of rapidly progress of disease the icterus appears, the liver is
increased, incine hepato-venat insufficiency progresses, and patients
die in 7-10 days after the onset of disease. At gradual subacute
development of pathology the liver and spleen is increased in size,
and after the septic state of organism ascites arises.

Thank you!