Saleh M.

Al Salamah

Surgical Anatomy Function of the Appendix Acute Appendicitis Problem areas in Diagnosis Tumors of the Appendix

Saleh M. Al Salamah

Saleh M. Al Salamah

Appendix is a blind intestinal diverticulum (6-10 cm) in length arises from the postero medial aspect of the caecum inferior to the ileocaecal junction origin where it arises from the site at which the three taeniae coli collect. The appendix has short Mesentery (The Mesoappendix).
The position of the appendix is variable can lie , retrocaecal (75%), pelvic (20%) front or behind the ileum 5% and paracolic.
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Saleh M. Al Salamah

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 LN in the mesoappendix and to the ileocolic LN along the ileocolic artery than to SM LN.

Saleh M. Al Salamah

Nerve supply of the appendix derives from sympathetic and parasympathetic. The sympathetic nerve fibres originate in the lower thoracic part of the spinal cord and the parasympathetic nerve fibres from the vagus nerve.

Saleh M. Al Salamah

Saleh M. Al Salamah

Saleh M. Al Salamah

Saleh M. Al Salamah

The development of the lymphoid tissues in it, wall during childhood suggest may have immunological function by secretion of Immunoglobulins.

The function of the appendix in adolescence and adult is regress as lymphoid tissues regress in elderly. The appendix lumen obliterated by fibrosis.
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Saleh M. Al Salamah

Incidence
Acute appendicitis is the most common acute surgical emergency of the abdomen. The disease occurs at all ages but most frequently below age 40 years specially, between the ages 8-14. It is very rare below the age of two. The sex ratio is 1:1 prior to puberty adult M:F, 2:1. However the incidence is decreased for last 10 years. This may be due to better diagnosis, changing in dietary habit, better nutrition, high vit intake and antibiotics.
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The combination of obstruction and infection required to produce acute appendicitis. The common causes of obstructive appendicitis include:
Swelling of the lymphoid tissues of the appendix
Adhesions F.B Worms
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Tumor of the appendix or caecum Once obstruction has occurred it follows by distension with secretion and compression of the veins draining the appendix. Then follow arterial stasis than infarction of the mucosa and invasion of the wall by bacteria, finally to reach the peritoneal cavity.

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Diagnosis of the Acute Appendicitis

History Clinical Examination

Investigations

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Clinical features
(a) Pain

generalized (visceral pain) 1-12 h0 localized (somatic pain)

(b) Anorexia, nausea and vomiting (1-3 times)

Other Presentations:

According to localization of the appendix.

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Signs of Acute Appendicitis

Abdominal examination reveals the following signs:

a- Localized rebound (tenderness)

b- Rigidity c- Rovsings sign d- Anterior tenderness on examination e- Fever between 37.3 38.50c f- Psoas sign
Saleh M. Al Salamah

rectal

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Investigations
Moderate leukocytosis 10000 to 18000 /mm3 Urine analysis - normal Radiology: the diagnosis of acute appendicitis based on history and clinical finding x-rays used for D/D or complications of appendicitis (plain abdomen and chest x-ray)
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Problem Areas in Diagnosis

Appendicitis in infancy.
Appendicitis during pregnancy. Appendicitis in the elderly Appendicitis developing in hospital

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Complications of
ACUTE APPENDICITIS
Pre-operative complications Post-operative complications

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PRE-OPERATIVE COMPLICATIONS
Perforation
Appendicular abscess

Portal pyaemia
Peritonitis

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POST-OPERATIVE COMPLICATIONS

(local)
Bleeding
Urinary retention

Wound infection
Intra peritoneal abscess Post app. fistula Intestinal obstruction
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Treatment of
ACUTE APPENDICITIS
Appendicectomy Conservative TR (Ochsner Sherren) Is indicated when a palpable mass is present in RIF, but contra indicative the following condition.

Saleh M. Al Salamah

Children below 10 years of age Elderly patients Diabetic patients Doubtful diagnosis
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DIFFERENTIAL DIAGNOSIS
The diagnosis of acute appendicitis is essentially clinical and rest on the finding of pain, tenderness and guarding in RIF. Gastroenteritis

Intestinal obstruction
Acute mesentric adentitis Uretric colic Intussusception
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crohns disease

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Ileococal TB Acute Salpingitis (PID)

Rupture ectopic pregnancy

Twisted ovarian cyst

perforated peptic ulcer

acute pancreatitis Meckels diverticulum Henoch-Schonlein purpua
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Problems during APPENDICECTOMY

Normal appendix or (Lilly white) appendix

Lumps in the appendix

Mucocele of the appendix

Acute terminal ileitis

Meckels diverticulum
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CHRONIC APPENDICITIS
(The grumbling appendix)
Recurrent about of RIF pain occur and are labelled as grumbling appendix due to recurring about of low grade appendicitis. These patients may have several admission for abdominal pain and this is justifiable to remove the appendix when other investigations prove negative.

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TUMORS OF THE APPENDIX

Neoplasms of the appendix are very uncommon and are usually diagnosed at operation or autopsy.

(1)
(2)

Adenocarcinoma
Carcinoid Tumor

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