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Because of the variation in position, the appendix is said to be the only organ in the body without anatomy.
However, the anatomy of vermiform appendix has been discussed in detail here.
ETIOLOGY
1. White race > Dark race; Young males; Middle class and rich
2. Diet rich in meat and lacking cellulose
3. Long retrocecal appendix (due to diminished blood supply)
4. Luminal obstruction: fecolith, ball of worms (oxyuriasis vermicularis), lymphoid hyperplasia, foreign
objects, stricture (tumor)
5. Non-obstructive: Bacterial (E.coli, Enterococci, Proteus, Pseudomonas, Klebsiella, anaerobes) and Viral
infection
TYPES
1. Mucosal: Mildest
2. Phlegmonous: Slow onset and relatively slow progression
3. Necrotic: Acute bacterial infection with ischemic necrosis → Perforation
PATHOGENESIS
CLINICAL FEATURES
A. Symptoms:
1. Murphy’s triad (Pain → Vomiting → Fever):
a. Shifting pain: Severe colicky periumbilical visceral pain (common T10 innervation for both appendix and
umbilicus – referred pain) which later migrates to right iliac fossa (somatic pain due to inflammation of
parietal peritoneum)
Somatic phase of pain is based on anatomy of appendix:
Long tip: Left lower quadrant (LLQ) pain
Retrocecal/Retrocolic: Right Flank or back
Pelvic: Suprapubic pain
Retroileal: Testicular pain (from irritation of spermatic artery and ureter)
Pregnancy: Right upper quadrant (RUQ) pain (if appendix is shifted)
b. Vomiting (1-3 times/day): Vomiting occurs after pain in contrast to gastroenteritis which is opposite to
appendicitis.
c. Fever
2. Others:
Diarrhea (May be mistaken for gastroenteritis)
Pyuria / Hematuria (May be mistaken for UTI)
Facial flushing
B. Signs:
Mnemonic: ABC OPqRST
Symptoms (MAN):
Migrating RIF pain (1)
Anorexia (1)
Nausea and vomiting (1)
Signs (TRE):
Tenderness RIF (2)
Rebound tenderness (1)
Elevated temperature (1)
Laboratory (LS):
Leukocytosis (2)
Shift to left i.e Neutrophilia (1)
Anaylsis of score:
< 5 : not sure
5-6: compatible
6-9: probable
>9: confirmed
TZANAKIS SCORING SYSTEM
1. Right lower abdominal tenderness : 4 points
2. Rebound tenderness : 3 points
3. Presence of white blood cells greater than 12,000 in the blood : 2 points
4. Presence of positive ultrasound scan findings of appendicitis : 6 points
A total score of 15 is the maximum that can be scored. Where a patient scores 8 or more points, there is greater
than 96 percent chance that appendicitis exists.
A. Laboratory:
1. Total WBC count: Leukocytosis 10,000 to 18,000/cu.mm (If >18,000/cu.mm, consider perforation with or
without abscess)
2. Urinananalysis: Several WBCs and RBCs may be found in appendicitis secondary to bladder irritation from
inflamed appendix.
3. Elevated CRP (C-reactive protein)
B. Diagnostic Imaging:
1. Abdominal X-ray (may reveal fecolith): to rule out perforation
2. Abdominal USG (+ve if >6mm noncompressible appendix): to rule out gynecological pathology
3. Laproscopy: to rule out ovarian pathology in females
4. Abdominal CT scan
CT scan is costly and one need to keep the economic status of patient in mind before sending this
investigation.
COMPLICATIONS
1. Rupture (Perforation) → Generalized peritonitis
Increased risk in infants (thin omentum without much fat) and elderly (atherosclerosis of appendicular artery
which is an end-artery)
2. Appendicular mass: cecum, terminal ileum and appendix sealed by greater omentum
3. Appendicular abscess
4. Others: Adhesions, Portal pyaemia, Abdominal actinomycosis
TREATMENT
1. Definitive treatment: Appendicectomy or Appendectomy (Open or Laproscopic)
Video for Indications and Operative procedure for Open Appendectomy
2. Appendicular mass: Appendicectomy is contraindicated as it may lead to fecal fistula. Hence, we opt a
conservative treatment (Oscher and Sherren’s regime – ABCDEF).
1. Aspiration (with Ryle’s tube)
2. Bowel care (purgatives shouldn’t be use due to risk of perforation)
3. Charts (Temperature, Pulse, Respiration, Mass size)
4. Drugs (Antibiotics to cover all gram positive, gram negative and anaerobe organisms)
5. Exploratory laparotomy (Only in suspicion of abscess)
6. Fluid I.V (To correct dehydration)
The patient is kept in close observation and within 3-4 days if: