ANATOMY and PHYSIOLOGY

Arteries of cecum and vermiform appendix. (Appendix visible at lower right, labeled as "vermiform
process").

Vermiform appendix
In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal)
appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum), from
which it develops embryologically. The cecum is a pouchlike structure of the colon. The
appendix is near the junction of the small intestine and the large intestine.
The term "vermiform" comes from Latin and means "worm-shaped".
Size and location
The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of
the appendix is usually between 7 and 8 mm. The longest appendix ever removed
measured 26 cm in Zagreb, Croatia. 1.The appendix is located in the lower right
quadrant of the abdomen, or more specifically, the right iliac fossa.2Its position within
the abdomen corresponds to a point on the surface known as McBurney's point (see
below). While the base of the appendix is at a fairly constant location, 2 cm below the
ileocaecal valve [2], the location of the tip of the appendix can vary from being
retrocaecal (74% [2]) to being in the pelvis to being extraperitoneal. In rare individuals
with situs inversus, the appendix may be located in the lower left side.
Maintaining gut flora
Although it was long accepted that the immune tissue, called gut associated lymphoid
tissue, surrounding the appendix and elsewhere in the gut carries out a number of
important functions
The digestive tract's immune system is often referred to as gut-associated lymphoid
tissue (GALT) and works to protect the body from invasion. GALT is an example of
mucosa-associated lymphoid tissue.
The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated
lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found
in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung,
salivary glands, eye, and skin.

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The most common diseases of the appendix (in humans) are appendicitis and carcinoid
tumors. Appendix cancer accounts for about 1 in 200 of all gastrointestinal
malignancies. Adenomas also (rarely) present.
Appendicitis (or epityphlitis) is a condition characterized by inflammation of the
appendix. Pain often begins in the center of the abdomen, corresponding to the
appendix's development as part of the embryonic midgut. This pain is typically a dull,
poorly localised, visceral pain.
As the inflammation progresses, the pain begins to localise more clearly to the right
lower quadrant, as the peritoneum becomes inflamed. This peritoneal inflammation, or
peritonitis Diseases
, results in rebound tenderness (pain upon removal of pressure rather than application
of pressure). In particular, it presents at McBurney's point, 1/3 of the way along a line
drawn from the Anterior Superior Iliac Spine to the Umbilicus. Typically, point (skin) pain
is not present until the parietal peritoneum is inflamed as well. Fever and an immune
system response are also characteristic of appendicitis.
Many cases of appendicitis require removal of the inflamed appendix, either by
laparotomy or laparoscopy. Untreated, the appendix may rupture, leading to peritonitis,
followed by shock, and, if still untreated, death.
The surgical removal of the vermiform appendix is called an appendicectomy (or
appendectomy). This procedure is normally performed as an emergency procedure,
when the patient is suffering from acute appendicitis. In the absence of surgical
facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now
recognized that many cases will resolve when treated non-operatively. In some cases
the appendicitis resolves completely; more often, an inflammatory mass forms around
the appendix. This is a relative contraindication to surgery.

A) Importance of the Case Study

The importance case presentation is to help the general public to be aware of the
disease/condition. The study will try to enlighten facts concerning the case itself through
simple information about health condition, its cause and risk factors, and also the
management for patients with appendicitis
B) Objectives

Nurse Centered Objectives

The case finding will try to enlighten the readers especially the nursing students,
what are the causes of appendicitis. It will also give the readers the chance to the
different types management that a patient undergoes as to give them the knowledge on
the measures needed to cure such condition. This also serves as a guide to the
students to know the appropriate interventions to be carried out whenever faced with
the same condition.

Patient Centered Objectives

To be able to help and educate the patient and the relatives about the condition
process and the curative measures that might be used appropriately for the condition of
the patient. It is also intended to educate the relatives what are the causes of the
disease/condition and what are the preventive measures that can be used in order to
prevent such.

Case Study Presented to the Faculty of

College of Nursing

Dee Hwa Liong College Foundation

Sapang Maisac, Duquit, Mabalacat, Pampanga

 In Partial Fulfillment of the Requirements

for the Bachelor of Science in Nursing

Presented by:

Group 7

Anicete, Jomel D.

Bernardo, Arjay D.

Capio, Michelle Jeaned P.

Cuyugan, Arianne Grace T.

Dimalanta, James Gregor G.

Indiongco, Ramonaliza M.

Macaspac, Gerald P.

Morales, Bernard C.

Pamintuan, Scharmen Kaye M.

Pascual, Rowena S.

Tuazon, Karen Joy T.

July 2009

Treatment
The treatment begins by keeping the patient Nil per os (stopping them eating and
drinking), even water, in preparation for surgery. An intravenous drip is used to hydrate
the patient. Antibiotics given intravenously such as cefuroxime and metronidazole may
be administered early to help kill bacteria and thus reduce the spread of infection in the
abdomen and postoperative complications in the abdomen or wound. Equivocal cases
may become more difficult to assess with antibiotic treatment and benefit from serial
examinations. If the stomach is empty (no food in the past six hours) general
anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.
The surgical procedure for the removal of the appendix is called an appendicectomy
(also known as an appendectomy). Often now the operation can be performed via a
laparoscopic approach, or via three small incisions with a camera to visualize the area
of interest in the abdomen. If the findings reveal suppurative appendicitis with
complications such as rupture, abscess, adhesions, etc., conversion to open laparotomy
may be necessary. An open laparotomy incision if required most often centers on the
area of maximum tenderness, McBurney's point, in the right lower quadrant. A
transverse or a gridiron diagonal incision is used most commonly.
In March 2008, an American woman had her appendix removed via her vagina, in a
medical first.[23]
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures, laparoscopic procedures seem to have various advantages over
the open procedure. Wound infections were less likely after laparoscopic
appendicectomy than after open appendicectomy (odds ratio 0.45; CI 0.35 to 0.58), but
the incidence of intraabdominal abscesses was increased (odds ratio 2.48; CI 1.45 to
4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for laparoscopic
procedures. Pain on day 1 after surgery was reduced after laparoscopic procedures by
9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened
by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier
after laparoscopic procedures than after open procedures. While the operation costs of
laparoscopic procedures were significantly higher, the costs outside hospital were
reduced. Young female, obese, and employed patients seem to benefit from the
laparoscopic procedure more than other groups. [24]
There is debate whether emergent appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater
than 6 hours after admission). According to a retrospective case review study [25] no
significant differences in perforation rate among the two groups were noted (P=.397).
Various complications (abscess formation, re-admission) showed no significant
differences (P=0.667, 0.999). According to this study, beginning antibiotic therapy and
delaying appendicectomy from the middle of the night to the next day does not
significantly increase the risk of perforation or other complications. These findings may
fit a theory that acute (typical) appendicitis and suppurative (atypical) appendicitis are
two distinct disease processes. Findings at the time of surgery suggest that perforation
occurs at the onset of symptoms in atypical cases.
Surgery may last from 15 minutes in typical appendicitis in thin patients to several hours
in complicated cases. Hospital lengths of stay usually range from overnight to a matter
of days (rarely weeks in complicated cases.)

Differential diagnosis
In children:
• Gastroenteritis, mesenteric adenitis, Meckel's diverticulitis, intussusception, Henoch-
Schönlein purpura, lobar pneumonia
In adults:
• regional enteritis, renal colic, perforated peptic ulcer, testicular torsion, pancreatitis,
rectus sheath hematoma, and in women: pelvic inflammatory disease, ectopic
 pregnancy, endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz (the passing of
an egg in the ovaries approximately two weeks before an expected menstruation cycle)
In elderly:
• diverticulitis, intestinal obstruction, colonic carcinoma, mesenteric ischemia, leaking
aortic aneurysm.

Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can
occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age,
condition, complications, and other circumstances, including the amount of alcohol
consumption, but usually is between 10 and 28 days. For young children (around 10
years old) the recovery takes three weeks.
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment. The patient may have to undergo a medical
evacuation. Appendectomies have occasionally been performed in emergency
conditions (i.e. outside of a proper hospital), when a timely medical evaluation was
impossible.
Typical acute appendicitis responds quickly to appendectomy and occasionally will
resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial
whether an elective interval appendectomy should be performed to prevent a recurrent
episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis)
is more difficult to diagnose and is more apt to be complicated even when operated
early. In either condition prompt diagnosis and appendectomy yield the best results with
full recovery in two to four weeks usually. Mortality and severe complications are
unusual but do occur, especially if peritonitis persists and is untreated. Another entity
known as appendicular lump is talked about quite often. It happens when appendix is
not removed early during infection and omentum and intestine get adherent to it forming
a palpable lump. During this period operation is risky unless there is pus formation
evident by fever and toxicity or by USG. Medical management treats the condition.
An unusual complication of an appendectomy is "stump appendicitis": inflammation
occurs in the remnant appendiceal stump left after a prior, incomplete appendectomy
Surgery
Typically, appendicitis is treated by removing the appendix. If appendicitis is suspected,
a doctor will often suggest surgery without conducting extensive diagnostic testing.
Prompt surgery decreases the likelihood the appendix will burst.
Surgery to remove the appendix is called appendectomy and can be done two ways.
The older method, called laparotomy, removes the appendix through a single incision in
the lower right area of the abdomen. The newer method, called laparoscopic surgery,
uses several smaller incisions and special surgical tools fed through the incisions to
remove the appendix. Laparoscopic surgery leads to fewer complications, such as
hospital-related infections, and has a shorter recovery time.
Surgery occasionally reveals a normal appendix. In such cases, many surgeons will
remove the healthy appendix to eliminate the future possibility of appendicitis.
Occasionally, surgery reveals a different problem, which may also be corrected during
surgery.
Sometimes an abscess forms around a burst appendix—called an appendiceal
abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep
an infection from spreading. An abscess may be addressed during surgery or, more
commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess
through the abdominal wall. CT is used to help find the abscess. The drainage tube is
left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8
weeks later, when infection and inflammation are under control, surgery is performed to
remove what remains of the burst appendix.
Nonsurgical Treatment
Nonsurgical treatment may be used if surgery is not available, if a person is not well
enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that
appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to
treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in
fiber and easily breaks down in the gastrointestinal tract.