Appendix

Anatomy and Histology

The appendix is a narrow, muscular tube with large amount of lymphoid

tissue in its wall, average length between 7.5-10 cm.

It’s attached to the posteromedial

surface of the cecum
approximately 1 inch "2.5cm"
below the ileocecal junction. It has
a complete peritoneal covering
which is attached to the
mesentery of the small intestine
by a short mesentery of its own
called the “mesoappendix”, which
contains the appendicular vessels
and nerves.

Appendix lies in right iliac fossa, its base situated one-third of the way up
the line joining the right anterior superior iliac spine to the umbilicus
(McBurney’s point).

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Blood supply:

 Arteries
Appendicular artery “branch of posterior
cecal artery, which is in turn a branch of the
ileocecal artery, a branch of the superior
mesenteric artery”

 Veins:
posterior cecal vein

Lymphatic drainage:

Drains to lymph nodes in the mesoappendix and eventually into superior

mesenteric lymph node.

Nerve supply:

The appendix is supplied by the sympathetic and vagus nerves from the
superior mesenteric plexus . afferent nerve fibers concerned with
conduction of visceral pain from appendix accompany the sympathetic
nerves and enter the spinal cord at the level of the tenth thoracic segment .

Histology of the appendix:

As the rest of Gastrointestinal tract “mucosa, submucosa, muscularis

propria and serosa” but the most important is the presence of high number
of the lymph follicles in the submucosa.
Crypts are present, but are not numerous. In the base of the crypts lie
argentaffin cells (Kulchitsky cells), which may give rise to carcinoid tumours.

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Position of the tip of Appendix:
During childhood, continued growth of the
caecum commonly rotates the appendix into a
retrocaecal but intraperitoneal position. In
approximately one quarter of cases, rotation
of the appendix does not occur, resulting in a
pelvic, subcaecal or paracaecal position.
Occasionally, the tip of the appendix becomes
extra-peritoneal, lying behind the caecum or
ascending colon.

Appendicitis:

Inflammation of the appendix. Acute appendicitis is the most common

cause of acute abdomen in young adults, and appendectomy is the most
frequently performed urgent abdominal operation.
Epidemiology:

The individual lifetime risk of appendicectomy is 8.6 and 6.7 percent among
males and females, respectively.

Acute appendicitis is relatively

rare in infants, and becomes
increasingly common in
childhood and early adult life,
reaching a peak incidence in the
teens and early 20s.

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The incidence between female and male equal before puberty, at teen-ages
and young adulthood the male to female ratio increase to 3:2 at 25 then
start to decline.

Etiology:

Decreased dietary fiber and increased consumption of refined

carbohydrates may be important, but no unifying hypothesis.

Appendicitis is clearly associated with bacterial proliferation within the

appendix, but no single organism is responsible. A mixed growth of aerobic
and anaerobic organisms is usual. The initiating event causing bacterial
proliferation is controversial. Obstruction of the appendix lumen has been
widely held to be important.
Types of obstruction:

 Faecoliths ”most common, a hard stony mass of feces in the

intestinal tract”
 Fibrotic stricture.
 Tumor (esp carcinoid).
 Parasites (esp Oxyuris vermicularis/pinworm).
 Lymphoid hyperplasia.

Pathophysiology:

Obstruction of the appendix lumen  increase the mucus secretion and

inflammatory exudate  increase in intraluminal pressure leads to
obstruction of lymph drainage  edema and mucosal ulceration develop
with bacterial translocation to the submucosa  If the condition
progresses, further distension of the appendix may cause venous
obstruction and ischaemia of the appendix wall  with ischaemia, bacterial
invasion occurs through the muscularis propria and submucosa, producing
acute appendicitis.

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Complications:

Mortality rate and complications in acute appendicitis are very minimal if

the doctor treats the condition early. The optimum time to treat acute
appendicitis is within (24-48 hrs) from the time that the patient developed
signs and symptoms in.

Perforation of the appendix can lead to:

1. Multiple abscesses inside the peritoneal cavity (This could lead to

septicemia and death).
2. Multiple adhesions inside the abdomen. (The patient will constantly
come complaining of intestinal obstruction then)
3. peritonitis , occurs as a result of:
– Free migration of bacteria through an ischemic wall

– Frank perforation of a gangrenous appendix

– Delayed perforation of an appendix abscess

History: "typical in 50-60%"

 Pain: Pain starts in the peri-umbilical region (poorly localized and
colicky), then after (6-24 hrs) it shifts to the right iliac fossa (more
intense more localized changed in character). Exactly at McBurney's
point (point of maximal tenderness).

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 Why does the pain start at the peri-umbilical region?

Because at first the pain is visceral then it becomes somatic; at first,

the inflammation starts in the mucosa then it will extend to the wall
finally it will reach the serosa, so at the first stage of the
inflammation the patient will feel the pain through the autonomic
nervous system. Since the umbilicus area and the appendix are
innervated by the same segment (T10), the brain wouldn't be able to
tell where exactly the pain is coming from.
After the inflammation has reached the serosa and the parietal
peritoneum (innervated by the somatic nerves) gets irritated, then
the pain will shift to the right iliac fossa where the inflammation
really is.

 LOW grade fever:

After 6 hours, slight pyrexia (37.2-37.7) with a corresponding
increase in pulse rate (80 or 90).

 Anorexia: The pain is also accompanied with Anorexia, so if the

patient's appetite is not affected by the pain then you have to
question your diagnosis.

 Nausea & Vomiting: 1-2 times “these symptoms are very common in
childrens”. Please note that recurrent episodes of vomiting doesn’t
comply with the diagnosis of appendicitis.

“Appendicitis cause HIGH grade fever after 4- days; when the appendix
perforates and cause intra-abdominal abscess or peritonitis. The acute
appendicitis patient does not develop high grade fever on the same day
that he/she first showed symptoms in.”

If the patient comes with Atypical symptoms like: if the pain started at the
Rt. Iliac fossa immediately with no shifting, we should not just prescribe
analgesia and send him/her home (symptomatic treatment). This patient
should be admitted and put under observation and re-evaluate him/her
each 6 hours.

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Examination:

 Pyrexia “low grade”

 Localised tenderness in the right iliac fossa
 Rebound tenderness : When doing the rebound tenderness test, you
must bevery gentle. Also you should not repeat the examination
many times; for that would irritate the patient and sometimes even
perforate the appendix. If the patient didn't have rebound
tenderness at the first time, we can repeat the test again after 6-12
hours.
 Muscle guarding over the point of maximal tenderness

Special sign to elicit in appendicitis:

1. Rovsing’s sign: Deep palpation of the left iliac fossa may cause pain in
the right iliac fossa.

2. Usually, the patient may point to the area of most tenderness when
asked (pointing sign).

3. Psoas sign “retrocecal appendix”: Pain on passive extension of the

right thigh with knee in full extension.

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 4. The obturator sign”pelvic appendix”: Pain on passive internal
rotation of the flexed thigh.

Special cases

– 1. Retrocecal
The presentation might not be fast and straight forward, Rigidity often
absent, and even deep pressure may fail to elicit tenderness (silent
appendix), because the appendix is hiding behind the cecum, , there may
be rigidy of quadratus lumborum, and deep tenderness often present in
loin, so there won't be any clear features on examination for the first time.
But after 2-3 days the presentation will become very prominent. So don't
ignore the patient even if the presentation is not typical or clear because at
the time that the presentation gets clear, it might be too late and the
patient will suffer more than he has to.

2. Pelvic appendicitis: The pelvic cavity is a boney cavity, that’s why

when you examine the abdomen of a patient whose inflamed appendix is
positioned in the pelvis, you will find out that his/her abdomen is soft and
lax with no rigidity and you might miss the diagnosis. “DRE: tenderness in
rectovesical pouch/pouch of Douglas” Mild hematuria and pyuria are

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common, sometimes diarrhea or frequency if it’s with contact with the
rectum or bladder respectively.

3. The Obese: Can obscure and diminish all the local signs

4. Post-ileal Most difficult in diagnosis, Pain may not shift, Diarrhea is a

feature, Marked retching may occur, Tenderness, if any, is ill defined or
immediately to the right of the umbilicus

Diagnosis

The diagnosis of acute appendicitis is essentially clinical

A number of clinical and laboratory-based scoring systems have been

devised to assist diagnosis "the most widely used is the Alvarado score”

- A score of 7 or more is strongly predictive of acute appendicitis.

-In patients with an equivocal score (5–6), abdominal ultra-sound or

contrast-enhanced CTexamination further reduces the rate of negative
appendicectomy.

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Preoperative investigations in appendicitis

■ Routine:
Full blood count "If you found leukocytosis (13000-14000), then this can
support your diagnosis. But if the WBS count was normal, it will not exclude
appendicitis from the differential diagnosis.”

Urinalysis

■ Selective:

Urea and electrolytes

Supine abdominal radiograph

Ultrasound of the abdomen/pelvis

Contrast-enhanced abdomen and pelvic computed tomography scan.

Differential Diagnosis

ANY RT. ILIAC FOSSA PAIN IS DIAGNOSED AS ACUTE APPENDICITIS UNTIL

PROVEN OTHERWISE

 In children: Gastroenteritis, mesenteric adenitis, Meckel's

diverticulitis, intussusception, Henoch-Schönlein purpura, lobar
pneumonia.
 In adults: regional enteritis, renal colic, perforated peptic ulcer,
pancreatitis, rectus sheath hematoma
 in men: testicular torsion
 in women: pelvic inflammatory disease, ectopic pregnancy,
endometriosis, torsion/rupture of ovarian cyst, Mittelschmerz
 In elderly: diverticulitis, intestinal obstruction, colonic carcinoma,
mesenteric ischemia, leaking aortic aneurysm.

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 Treatment

 Urgent appendicectomy;
o Gridiron incision "Mc Burney's incision".
o Lanz incision " A variation of the traditional Mc Burney's incision,
which was made at McBurney's point on the abdomen: The Lanz
incision is made at the same point along the transverse plane and
deemed cosmetically better. It is typically used to perform an
open appendectomy"
o Laparoscopic.

 Short intensive preoperative prep:

- IV fluid - Antibiotics - Hyperpyrexia

Done by : Thair altarbsheh

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