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Anatomy: It is a warm shaped tube containing large amount of lymphoid tissue. Length 8-13 cm. It has a complete peritoneal covering called Mesoappendix. he base is attached to the posteriomedial surface of the cecum! about 1 inch below the iliocecal "unction and this coincides with Mc Burneys point N.B. the base is easily identified by following the tenia coli at the point of convergence. he other end is freely moving and usually found in #etrocecal $%& (most common ' give locali(ed inflammation bco( cecum is covered with peritoneum from front and both ) sides) *elvic )1& *ostileal +& ,ubcecal 1.+& *reileal 1& The Blood Supply of the appendi- is by appendicular artery a branch of the posterior cecal artery which is a branch of iliocecal Iliocecal artery posterior cecal artery appendicular artery .enous drainage through appendicular vein to the posterior cecal vein /ppendiclar vein posterior cecal vein Lymphatic drainage through one or two nodes lying in the mesoappendi- into mesenteric nodes superior mesenteric nodes Nerve Supply is derived from sympathetic and parasympathetic (vagus) nerves from the superior mesenteric plexus

 /fferent fiber conducting visceral pain of appendi- enter through the 10th thoracic segment (this e-plains the referred pain at the umbilical level) Acute appendicitis It is the most common surgical emergency! more common in the western countries d't their diet. /ppendicitis is a disease of young adults and children but can occur in elderly patient. *ea1 age of the disease is 1+ years (adolescence). ypes of appendicitis
Causes: 2bstructed Faecolith (the commonest). /ppendicitis Foreign ody. E.g. fruit seeds !in" from inflame adhesion. #ymphoid hyperplasia $ithin the $all. #esion in the cecum e.g. carcinoma. %arm (rare). Coarse (according to presence &acteria)

3on 2bstructed /ppendicitis

causes: Direct infection of lymphoid follicle from appendicular lumen. Hematogenous. E.g. strept (rare)

Present &acteria proliferate in the ' structed appendi( and )n*ade the $all that $as Damaged y pressure necrosis

absent Mucocele: Due to continues +ecretion of mucous from go let cells

Inflammation

&acteria are: E.coli 012 &acteroid. 3seudomonas Inflammation: 4ormal flora of the

4ay resolve. If not treated within 1) hours progressive infection and obstruction which lead to impairment of blood supply gangrene If perforation has occurred the outcome depend on the ability of the omentum to contain the infection A,)f ade-uate omentum there $ill e: .ppendicular mass. .ppendicular abscess B, if the omentum is not ade-uate there $ill e Generalized peritonitis

History Takin
/ge5 can occur at all! but more common in the adolescence age group. ,e-5 same incidence. Symptoms: 1) *ain5 the main symptom. ,ite5 it starts central pain around the umbilicus (visceral pain) and it is a referred pain

because the visceral innervation of the appendi- comes from the10th thoracic spinal segment! the corresponding dermatome encircle the abdomen at the umbilicus. his central pain will shift to the right iliac fossa #I6 after few hours! to )-3 days and then it is Somatic pain (d't irritation of the inflamed appendi- to the sensitive parietal peritoneum). 2nset5 gradual and then becomes sudden. ,everity5 sever. *attern5 7olicy pain obstructed appendi-. 7onstant painnon obst appendi-. 8uration5 usually few hours but it can be )-3 days. *rogression5 increases with time. #elieving5 by bending the leg to the abdomen(fle-ion) or by lying down /ssociation5 with other symptoms5

)) vomiting5 vomiting after the onset of pain because vomiting before pain suggests gastroenteritis. 3) constipation5 ma"ority of cases state that they have been constipated for few days before the attac1 of pain. %) diarrhea5 few of the patients especially when it is pelvic appendicitis (d't irritation to the rectum) +) anore-ia 9) low grade fever5 (3$.) : 3$.$ 7 ) if higher fever thin1 about complicated appendicitis ( by peritonitis and abscess)

in the ;- you have to e-clude other <I symptoms. symptoms of 88-.

!hysical "xamination
<eneral e-amination5 pale (esp. in children) tachycardia ( d't spread of infection) low grade fever tongue5 white and furred with foetor oris ( bad breath) 3ec15 palpate glands and loo1 at the tonsils to e-clude mesenteric adenitis 7hest5 =-amine the lung for right basal pneumonia /bdomen5 inspection5 normal! the abdomen is slowly moving with respiration due to pain. palpation5 right iliac fossa is tender with or without guarding (voluntary contraction of abdominal muscle when palpate) #ebound tenderness 5 >ve in 4c?urney@s point. Si ns: #ovsin $s Si n: *ain in the #ight iliac fossa #I6 d't pressing or palpating the Left iliac fossa LI6. ?ecause either - transmission of air 2r5 - by pressing on the left side you are moving the intestine to touch the inflammewd organ !soas Si n5
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*ain when e-tending the right hip "oint d't spasm of the psoas muscle. ,o! you observe hip fle-ing slightly by patient to decrease the pain. %&turaror internus si n5 *ain with passive internal rotation of the fle-ed #t. high it indicates inflammation overlying the muscle. Blum&er $s si n: *ressing and releasing suddenly in LI6 feels pain in the #I6 A crossed rebound tendernessB Strai ht le raisin si n: >ve with retrocecal appendi-. #ectal "xaminationC enderness ( in the pelvic position! or when there is pus in 8ouglas *ouch). ''x: (according to the location of pain) I ( #I) pain * tenderness A, Intra a&dominal diseases: 4esenteric adenitis5 =specially in children following upper respiratory tract infection D# I. It loo1s li1e appendicitis in their symptoms. Eou must as1 about previous ;- of D# I tonsillitis or enlarged L.3. 4ec1el@s diverticulitis5 2ften indistinguishable from appendicitis! you have to loo1 for 4ec1le@s when you do appendectomy. /cute crohn ileitis5
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II( +entral a&d. +olic

(8iscussed below)

 /ffect young adult F usually there is ;- of recurrent pain. 4ass of inflamed ilieum can be felt. /cute cholecystitis5 ,ometimes pain of inflamed <all bladder descends into #I6. 4urphy@s sigh (>ve in cholecystitis). .omiting F "aundice may be present. *erforated peptic ulcer5 ;-. 2f dyspepsia. ,udden pain on epigastrium shifted to #I6. <as under diaphragm on G-ray. *ancreatitis5 (rare) 8iffuse abd. *ain F sometimes central or #I6 pain. /ssociated with copious vomiting F bac1 pain. B, The urinary tract diseases: #enal colic F acute pyelonephritis5 Eou should as1 about hematuria or loin pain which radiate to the groin region. /s1 if there is any change in (color ' freHuent ' volume) of urine. esticular torsion or undescended testis5 .ery rare. +, -ynecolo ical diseases .females,: /cute salpingitis5 ;- of vaginal discharge! menstrual irregularities and dysmenorrhea or dysuria. ;- of contact with venereal dis. 2n *# or *. e-amination! enlarged fallopian tubes may be palpable. 7onfirm 8- by Laparoscopy =ctopic pregnancy5
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 ;-. 2f missed period. *ain on constant site. ,ever pain. N.B. In female pt you should as1 about5 4id cycle pain5 (esp. in youngs) d't rupture of ovarian follicle o *ain o ?leeding =ctopic pregnancy (missed period) ', +hest: *neumonia and pleurisy5 #t basal pneumonia. /ssociated with tachycardia and cheat pain. 7hest e-amination added sound and friction rub. 7hest G-ray may be helpful.

II- ''x of +entral a&d pain5 In the early stages of appendicitis may suggest5 <astroenteritis5 3ausea! vomiting and diarrhea proceeds the pain. Intestinal obstruction5 Hi h level obstruction characteri(ed by profuse vomiting and little abdominal distension. /o0 level obstruction causes mar1 distention F late onset vomiting. 2n G-ray you will see fluid level. 3oisy bowel sounds.

Investi ation: 1) 7?75 leu1ocytosis esp. neutrophils. )) Drine /nalysis5 to e-clude urinary tract disease *yourea may indicate #t.pyelonephritis. 3) *lain G-ray5 #elated to appendicitis5 4ay show faecolith in #I6. Loss of #t psoas shadow. 2thers to e-clude5 /cute intestinal obstruction. *eptic ulcer perforation. Dretric stone. %) D.,5 o e-clude or verify5 2varian pathology. 2r mesenteric adenitis. 2r carcinoma of the cecum. 2r appendicular mass. +) Laparoscopy5 In doubtful diagnosis. Mana ement: /. 8irect operative management5 If you doubt it is appendicitis or not you can admit the patient for few hours5 If still fever then operate. If it improves don@t operate F he may not have appendicitis. If the patient did not under go appendectomy there will be5 1. ;e may improve give him antibiotics.

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). in some cases there will be adhesions of the omentum and ad"acent viscera to the inflamed appendi- and then there will be formation of /ppendicular mass. Locali(ed abscess. o differentiate between the two! do D.,. F treat both of them by antibiotic if it is5 4ass5 will improve! mass will decrease in si(e! fever will decrease Acan be treated by antibiotics aloneB /bscess5 will not improve(confirm by D.,) Aneed drainage under ultrasonograpgy guidanceB Pramedian incision: N.B: we 8on@t operate and remove the mass b'c there will be )t is a *ertical inflammation around the whole area F you may in"ure the bile or incision lying blood vessels or renal strucrure. parallel to the mid ?. /ppendectomy5 line :ust 1.21,2.1 cm ypes Commonly 2.1 cm of incisions5 elo$ the um ilicus and :ust a o*e the Lanz incision: Grid Iron incision: pu is. Advantage: >rans*erse incision made %hen the D( is certain9 Done $hen the D( is appro(imately 2 cm an incision is made aright dou t and you should elo$ the um ilicus angle to a line :oining the operate. centered in the superior iliac spine to the )t gi*es a good access midcla*icular line. um ilicus. )ts center to the pel*ic organs in >he e(ternal o li-ue eing the line at females. aponeurosis9internal ;c&urney<s point )t can e(tend up$ard o li-ue and trans*erses Has less to deal $ith a muscles are split in the postoperati*e perforated duodenal direction. complication ulcer or other +uperficial intraa dominal >he e(posure is circumfle( artery pathology. etter and e(tension usually need ligation if needed is easier Disadvantage: ?ecently this =i*e limited access to incision ecame so retrocecal appendi(. popular and it is High incidence of performed in most of infection. the patients. High Chance of 11 incisiona hernia ;ay in:ure the ladder.

1 2ou can do /aparoscopic appendectomy +omplications: 7omplications of the operations5 1. ?leeding. ). wound infection5 anaerobic bacteria (flagyl) gram :ve bacteria (gentamycine) gram >ve bacteria (ampicilline) 3. residual abscess5 local. *elvic.(common) *aracolic. %. Intestinal obstruction from adhesions. +. Incisional hernia ( esp. *ara median incision) 9. #t. Inguinal hernia (following the grid iron incision) 7omplications of the appendicitis5 1. locali(ed peritonitis or generali(ed after perforation5 symptoms include5 generali(ed abdominal pain.
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 3ausea and vomiting. ,weating and sometimes rigors. Iith pyre-ia. ). appendicular mass5 pt. present with ;-. 2f %-+ days abd. *ain with locali(ed mass in the #I6. 3o signs of general peritonitis. 7onservative ttt( 80& will resolve) 5 /ntibiotic5 /naerobesflagyl. <-ve gentamycine. < >ve ampicillin. /nalgesia. 2bserve vital signs. he remaining )0& 5 8eterioration. /bscess formation. 3o change. 3. appendicular abscess5 3eed drainage. 4ay give pelvic abscess or portal pyemia through ilio colic vein. N.B: In )0& of the cases the appendi- is found to be normal Eou loo1 for other causes and remove the appendi- as prophyla-is. ''x of a mass in the #I): 1. appendicular mass or abscess. ). carcinoma of the cecum 5 not tender. ?lood in stool. 8eterioration in health over month *t. usually old. ,igns of metastasis e.g. to the liver A enlarged' tenderB 3. 7rohn@s disease5
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%. +. 9. $. 8. J.

8iarrhea. It. loss. /bdominal pain! rectal bleeding. 2ccult blood in stool. Increased =,#. 2varian carcinoma. Iliocecal .?. Iliac L.3 enlargement. Iliac artery aneurysm. psoas abscess. distended gall bladder.

4odified and retyped by5 Iafa /l- uwai"ri

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