CHAPTER I

INTRODUCTION

The appendix is a narrow tubular pouch attached to the intestines. When the appendix is blocked, it becomes

inflamed and results in a condition termed appendicitis. If the blockage continues, the inflamed tissue becomes

infected with bacteria and begins to die from a lack of blood supply, which finally results in the rupture of the

appendix (perforated or ruptured appendix).

The American Journal of Epidemiology study found that appendicitis was a common condition affecting

approximately 6.7% to 8.6% of the population. IN the U.S. 250,000 cases of appendicitis are reported annually.

Individuals of any age may be affected, with the highest incidence occurring in the teens and twenties; however,

rare cases of neonatal and prenatal appendicitis have been reported. Increased vigilance in recognizing and

treating potential cases of appendicitis is critical in the very young and elderly, as this population has a higher

rate of complications. Appendicitis is the most common pediatric condition requiring emergency abdominal

surgery. (1)

1

CHAPTER II

REVIEW

ANATOMY

APPENDIX VERMIFORM

Also called as vermix, vermiform appendix is a narrow vermin (worm shaped) tube arising from the

posteromedial aspect of the cecum (a large blind sac forming the commencement of the large intestine) about 1

inch below the iliocecal valve. Small lumen of appendix opens into the cecum and the orifice is guarded by a

fold of mucous membrane known as ‘valve of Gerlach’. The 3 taenia coli (taenia libera, taenia mesocoli and

taenia omental) of the ascending colon and caecum converge on the base of the appendix.

Although the appendix serves no digestive function, it is thought to be a vestigial remnant of an organ that was

functional in human ancestors. (2)

Picture 1

The length varies from 2 to 20 cm with an average of 9 cm with diameter of about 5mm. It is longer in children

compared to adults. In the fetus it is a direct outpouching of the caecum, but differential overgrowth of the

lateral caecal wall results in its medial displacement.

The appendix is suspended by a small traignular fold of peritoneum, called the mesoappendix

Picture 22

Location of Appendix:

Right lower quadrant of abdomen and more specifically right iliac fossa.

McBurney’s point lying at the junction of lateral one-third and the medial two-thirds of the line joining

the umbilicus to the right anterior superior iliac spine roughly corresponds to the position of the base of

the appendix.

McBurney’s point is the site of maximum tenderness in appendicits.

Variations in Appendix position:

Although the base of the appendix is fixed, the tip can point in any direction. Hence, the position of the

appendix is extremely variable. The appendix is the only organ in the body which is said to have no

anatomy. When compared to the hour hand of a clock, the positions would be:

1. 12 o clock: Retrocolic or retrocecal (behind the cecum or colon)

2. 2 o clock: Splenic (upwards and to the left – Preileal and Postileal)

3. 3 o clock: Promonteric (horizontally to the left pointing the sacral promontory)

4. 4 o clock: Pelvic (descend into the pelvis)

5. 6 o clock: Subcecal (below the cecum pointing towards inguinal canal)

6. 11 o clcok: Paracolic (upwards and to the right)

Most common position of appendix (75% of cases): Retrocecal

Second most common position of appendix (20% of cases): Subcecal

If the appendix is very long, it may actually extend behind the ascending colon and abut against the right kidney

or the duodenum; in these cases its distal portion lies extraperitoneally.

Picture 3

Arterial Supply:

1. Appendicular artery: The mesoappendix, containing the appendicular branch of the ileocolic artery

(branch of superior mesenteric artery), descends behind the ileum.

2. Accessory appendicular artery: An accessory appendicular artery can branch from the posterior cecal

artery which is also a branch of ileocolic artery.

3

Picture 4

Venous drainage:

Appendicular vein –> Ileocolic vein –> Superior mesenteric vein –> Portal vein

Lymphatic drainage:

There is abundant lymphoid tissue in its walls.

From the body and apex of the appendix 8-15 vessels ascend in the mesoappendix and are 4ccasionally

interrupted by one or more nodes –> unite to form 3 or 4 larger vessels –> inferior and superior ileocolic

nodes

A few of them pass indirectly through the appendicular nodes situated in the mesoappendix.

Nerve supply:

1. Sympathetic nerves: T9 and T10 spinal segments through the celiac plexus

2. Parasympathetic nerves: Vagus

Histology: Inside to outside

Picture 5

1. Mucosa:

No villi

4

Epithelium invaginates to form crypts of Liberkuhn but the crypts do not occur as frequently as in the

colon

Muscularis mucosae is ill defined

2. Submucosa:

Large accumulations of lymphoid tissue in the lamina propria and submucosa. Hence appendix is also

called abdominal tonsil.

There is often fatty tissue in the submucosa

.

3. Muscularis externa:

Thinner than in the remainder of the large intestine

Comprises 2 layers: Inner circular muscle layer and Outer longitudinal muscle layer

Outer longitudinal smooth muscle layer does not aggregate into taenia coli

4. Serosa and peritoneum

5

CHAPTER III

APPENDICITIS

Definition

Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to

its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous

overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. In fact,

despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is

one of the more common causes of acute abdominal pain. (3)

Epidemiology

Appendicitis is one of the more common surgical emergencies, and it is one of the most common causes of

abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million

patient-days of admission. The incidence of acute appendicitis has been declining steadily since the late 1940s,

and the current annual incidence is 10 cases per 100,000 population. Appendicitis occurs in 7% of the US

population, with an incidence of 1.1 cases per 1000 people per year. Some familial predisposition exists.

In Asian and African countries, the incidence of acute appendicitis is probably lower because of the dietary

habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in cultures with a

higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of feces, decrease bowel transit

time, and discourage formation of fecaliths, which predispose individuals to obstructions of the appendiceal

lumen.

In the last few years, a decrease in frequency of appendicitis in Western countries has been reported,

which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is believed

to be related to poor fiber intake in such countries.

There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of

appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy

is approximately equal in both sexes.

The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in

the geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10 years. Lymphoid

hyperplasia is observed more often among infants and adults and is responsible for the increased incidence of

appendicitis in these age groups. Younger children have a higher rate of perforation, with reported rates of 50-

85%. The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have

been reported. Clinicians must maintain a high index of suspicion in all age groups.

Etiology

Appendicitis is caused by obstruction of the appendiceal lumen. The most common causes of luminal

obstruction include lymphoid hyperplasia secondary to inflammatory bowel disease (IBD) or infections (more

6

common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients),

parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms.

Fecaliths form when calcium salts and fecal debris become layered around a nidus of inspissated fecal

material located within the appendix. Lymphoid hyperplasia is associated with various inflammatory and

infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and

mononucleosis.

Obstruction of the appendiceal lumen has less commonly been associated with bacteria (Yersinia

species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species), parasites

(eg, Schistosomes species, pinworms, Strongyloides stercoralis), foreign material (eg, shotgun pellet,

intrauterine device, tongue stud, activated charcoal), tuberculosis, and tumors. (3)(5)(7)

Type of Appendicitis

1. Acute

Acute appendicitis is considered to be the most common cause of abdominal pain and distress in

children and teenagers worldwide. Acute appendicitis develops very fast and is much simpler to detect,

in most cases it requires immediate surgery.

Acute appendicitis refers to complete obstruction of the vermiform appendix. Bacterial infections are

also a cause of acute appendicitis. The appendix is a tubular extension of the large intestine and its

function is thought to be related with the process of digestion. When the appendix is blocked by calculus

and faeces or it is squeezed by the lymph nodes (due to bacterial infection, the lymph nodes usually

become swollen and press against the appendix), it swells and usually doesn't receive enough blood.

Bacteria grow inside the appendix, eventually causing its death. In acute appendicitis, the inflammation

of the appendix is serious and can lead to complications (perforation, gangrene, sepsis). Acute

appendicitis is a surgical emergency and most patients with this form of illness already have

complications before entering the operation room.

2. Chronic

Chronic appendicitis usually refers to a milder form of the illness and almost unperceivable symptoms

this may include inflammation of the vermiform appendix with recurring attacks of right-sided

abdominal pain over an extended period of time.

Chronic appendicitis is quite rare, develops slower, has less pronounced symptoms and it is much more

difficult to diagnose. Some people with chronic appendicitis may only experience a generalized state of

fatigue and illness.Treatment doesn't necessarily involve surgery, as in the case of acute appendicitis. If

it is discovered in time, chronic appendicitis can often be cured with antibiotics. However, chronic

appendicitis has a recidivating character and therefore ongoing treatment is required.

Symptoms of chronic appendicitis may vary on an individual basis for each patient. Only your doctor

can provide adequate diagnosis of symptoms and whether they are indeed symptoms of Chronic

appendicitis. (4)

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Pathophysiology

Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes.

Independent of the etiology, obstruction is believed to cause an increase in pressure within the lumen. Such an

increase is related to continuous secretion of fluids and mucus from the mucosa and the stagnation of this

material. At the same time, intestinal bacteria within the appendix multiply, leading to the recruitment of white

blood cells and the formation of pus and subsequent higher intraluminal pressure.

If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal

veins, leading to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in

a loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall.

Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and

veins, leading to perforation and gangrene of the appendix. As this process continues, a periappendicular

abscess or peritonitis may occur. (3)(5)

Picture 6

Sign and Symptom

Symptoms include pain in the abdomen, loss of appetite, nausea, vomiting, constipation or diarrhea,

inability to pass gas, low-grade fever, and abdominal swelling. Not everyone has all of these symptoms, and it

can be especially hard to diagnose the condition in very young children. (5)

A more detailed list of symptoms follows:

Pain in the abdomen. It often starts first around the belly button, then moving to the lower right area.

loss of appetite

nausea

vomiting

constipation or diarrhea

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inability to pass gas

low-grade fever and chills

abdominal swelling

elevated white blood cell count

The pain in the abdomen may be vague and mild at first, but it usually gets worse over time. The pain can

also get worse with moving, taking deep breaths, coughing, or sneezing. People may have a sensation called

"downward urge," also known as "tenesmus," or the feeling that a bowel movement will relieve their

discomfort. It is extremely important that people with these symptoms do not take laxatives, enemas to relieve

constipation, or highly potent pain medications in this situation, as these can mask other symptoms that the

doctor should know about and even cause the appendix to rupture. Anyone with these symptoms needs to see a

qualified physician immediately.

In cases of untreated appendicitis, the appendix can rupture, spilling pus and infective material into the

abdomen and causing a serious condition called peritonitis. Peritonitis is an inflammation of the peritoneum

which is a thin membrane that lines the abdominal wall and covers most of the organs of the body. Peritonitis

resulting from a ruptured appendix may occur 36-72 hours after the onset of appendicitis. Symptoms of

peritonitis include fever, severe abdominal pain, and tenderness that is worsened by movement and pressure on

the abdomen. The abdomen may also become stiff and board-like. Other symptoms can include weakness, pale

skin, and shock. The death rate from peritonitis is approximately 20%.

Diagnosis

Appendic i t i s remains a c l in ica l d iagnos i s . The th ree s igns and symptoms tha t a re

mos t predictive of acute appendicitis are pain in the right lower quadrant, abdominal rigidity, and migration of

pain from the periumbilical region to the right lower quadrant. A reliable historical feature is the characteristic

sequence of symptoms, which is periumbilical abdominal pain followed by anorexia, nausea, fever, and right lower

quadrant pain. The diagnosis of appendicitis should be reconsidered inpatients in whom nausea and emesis are the first signs of

illness. (5)(7)

The most valuable physical examination finding is localized tenderness.

1. McBurney's point islocated two inches from the anterior superior iliac spine on a line drawn from this process

through the umbilicus. However, the site of maximal tenderness may be some distance away from

McBurney'spoint. Rebound tenderness, which suggests peritoneal inflammation, is also referred to the right

lower quadrant. Local hyperesthesia of the skin and muscular rigidity may be present. Several signs of muscle

inflammation may also be present.

9

Picture 7

2. The psoas sign is elicited by asking the patient to raise a straightened right leg against resistance by

the examiner; alternatively, the patient lies on the left side and the examiner gently hyperextends the

straightened right leg to stretch the psoas major muscle.

Picture 8

3. The obturator sign is sought by passive internal rotation of the right leg with the patient supine and

the right hip and knee flexed.

Picture 9

4. Pain in the right lower quadrant with palpation in the left lower quadrant (Rovsing's sign) is associated with a

pelvic appendix and also indicates the site of peritoneal irritation.

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Laboratory Test

Elevated white blood cell counts are common in acute appendicitis, with the average leukocyte count ranging from

10,000 to 18,000 cells/mm3. Significant peripheral lymphocytopenia is also common. Although

leukocytosis is common, 30% of patients with acute appendicitis have a normal white blood cell count. Small

numbers of erythrocytes and leukocytes are found in the urine in about half of patients with appendicitis.

However, urinary erythrocyte counts exceeding 30 cells per high-power field or leukocyte counts

exceeding 20 cells per high-power field suggest a urinary tract disorder. Pelvic cultures may be useful in

sexually active, menstruating women. Pregnancy test to exclude pregnancy.

Imaging Test

Diagnostic imaging should be performed in patients suspected of having appendicitis in whom the

diagnosis is unclear.

1. CT scan

The best radiologic test is a computed tomography (CT) scan. An abdominal CT scan for acute appendicitis has a

sensitivity of 95% and a specificity of 90%. Air in the appendix or a contrast-filled lumen in a normal-appearing

appendix virtually excludes the diagnosis. However, anonvisualized appendix does not rule out

appendicitis. A benefit of a complete abdominal CT scan is that it permits visualization of the entire

abdomen, and an alternative diagnosis is found in up to 15%of patients. Alternative diagnoses

include, but are not limited to, colitis, diverticulitis, small-bowelobstruction, inflammatory bowel

disease, adnexal cysts, acute cholecystitis, and acute pancreatitis.A limitation of abdominal CT scanning is that it takes

up to two hours to perform the test after apatient receives the standard oral preparation. In addition, a normal

appendix is visualized in only75% of patients. An appendiceal CT scan can be performed with rectal

contrast alone and thin cutsthrough the right iliac fossa. Because oral contrast is not given, the scan can

be performed within 15minutes, and exposes the patient to only one-third the radiation of standard abdominal CT.

Results of an appendiceal CT scan are 93% to 98% accurate in confirming or ruling out appendicitis. The routineuse

of appendiceal CT in emergency department patients improves patient care both by

avertingunnecessary appendectomies and by expediting delivery of the necessary medical or

surgicaltreatment. Computed tomography scans may be less accurate in diagnosing appendicitis in

younger children compared with adults. A relative lack of body fat makes it difficult to identify fat streaking

andvisually separate an inflamed appendix from surrounding tissue or bowel.

2. Plain Radiograph

Abdomina l rad iography has a low sens i t iv i ty and spec i f ic i ty for the d iagnos i s o f

acu te appendicitis. Plain radiographs are abnormal in about 55% of patients with early acute

appendicitis and are usually not helpful for establishing the diagnosis. Multiple nonspecific

abnormalities may beseen, including a right lower quadrant appendicolith, localized right lower quadrant

ileus, loss of the psoas shadow, deformity of the cecal outline, and right lower quadrant soft tissue

densities. Plainradiographs are not useful for establishing the diagnosis of acute appendicitis and have no role in the

diagnostic workup, unless an alternative diagnosis is being considered that might show up on plain film.

3. Ultrasonography

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Ultrasonography is used to diagnose acute appendicitis, especially in children and pregnant women. It

can be very useful for defining pelvic pathology in women. Limitations of ultrasonographyare that it is

operator-dependent and may be non diagnostic in those with a large body habitus or a large amount of

bowel gas. Although appendicitis may be ruled out if the appearance of the appendixis normal on ultrasonography,

a normal appendix is seen in less than 5% of patients. Failure to seethe appendix, whether it is diseased

or normal, limits the usefulness of this imaging modality for the diagnosis of acute appendicitis. The

overall sensitivity of ultrasonography varies between 75% and90%; specificity ranges from 86% to 100%.

4. Laparoscopy

Laparoscopy is the only diagnostic procedure other than formal laparotomy that allows direct

visualization of the appendix. The entire appendix must be seen before the operator can conclude it is normal ( f ree

of d i sease) . Feas ib i l i ty o f l aparoscopy in obese pa t ien ts and those wi th prev ious

abdominal operations depends greatly on the surgeon's experience with the procedure. Diagnostic

laparoscopy is most useful for female patients, since a gynecologic cause of symptoms is identified in approximately

10% to 20% of women with suspicion of appendicitis. However, laparoscopy is an invasive

procedure with approximately a 5% complication rate, usually associated with the use of general

anesthesia.

Differential Diagnosis (6)

Surgical Urological Gynecological Medical

Intestinal Obstruction Right ureteric colic Ectopic pregnancy Gastroenteritis

Intussusception Right pyelonephritis Ruptured ovarian follicle Diabetic ketoacidosis

Acute Cholecystitis Urinary tract infection Torted ovarian cyst Terminal ileitis

Perforated Peptic Ulcer Salpingitis/pelvic

inflammatory disease

Preherpetic pain on the

right 10th and 11th dorsal

nerves

Mesentric Adenitis

Meckel’s Diverticulitis

Pancreatitis

Treatment (5)(6)

Appendectomy is the only acceptable treatment for acute appendicitis. Although appendicitis

occasionally resolves without surgery, a policy of nonoperative treatment is hazardous because delay risks

perforation. Patients who present within 24 to 72 hours after symptom onset can usually be treated with

immediate appendectomy.

In contrast, patients who present with a longer duration of symptoms and have findings localized to the

right lower quadrant are presumed to have appendiceal abscesses and should be treated initially with antibiotics,

intravenous fluids, and bowel rest. Immediate surgery in these patients is associated with increased morbidity,

often requires extensive dissection, and has the additional risks of spreading a localized infection throughout the

peritoneal cavity and injuring adjacent structures. Percutaneous CT-guided drainage of the abscess, with

12

appropriate antibiotic coverage, allows the majority of abscesses to resolve. Most patients have a follow-up CT

scan when their drain output is minimal and no longer purulent. Antibiotics are continued for 14 days or for one

week after documented resolution of the abscess. Elective appendectomy is performed six to ten weeks later to

prevent recurrent appendicitis, which occurs in up to 20% of patients. Older patients should also have a

colonoscopy or barium enema to rule out cecal pathology.

Appendectomy can be performed through a traditional open procedure or laparoscopically. The

operative approach depends on the confidence in the diagnosis, history of prior surgery, and the patient's age,

gender, and body habitus. For example, a conventional appendectomy is recommended for a thin, adolescent

man with a classic presentation for acute appendicitis. On the other hand, for an obese, premenopausal female

with equivocal symptoms, a laparoscopic approach is recommended. Laparoscopy is preferred when the

diagnosis of appendicitis is in doubt, especially in premenopausal females and in the obese. A number of

published studies have compared open versus laparoscopic surgery for appendicitis. The weight of the evidence

suggests that in adults, although operative costs are higher with laparoscopy, overall costs to society are lower

because pain is reduced and patients can return to work sooner.

The procedure begins with a diagnostic laparoscopy and continues with appendectomy if appropriate.

The success rates are high, and complications are infrequent. Compared with open appendectomy, laparoscopic

appendectomy requires less postoperative analgesia, a shorter hospital stay, and a shorter period of disability.

Surgical wound infections are also less frequent. Laparoscopy may offer an advantage to patients in whom the

diagnosis is uncertain since it permits inspection of other abdominal organs. This benefit is greater for women,

who have higher negative appendectomy rates, and in whom laparoscopy often reveals other pathology.

Evidence supports the use of systemic antibiotics to prevent wound infection in appendicitis. In patients

with acute nonperforated appendicitis, antibiotic coverage for surgical wound prophylaxis is adequate and

postoperative antibiotics are unnecessary. In those with perforated appendicitis, the antibiotic regimen should

cover enteric gram-negative rods and anaerobes. A second- or third-generation cephalosporin or a

fluoroquinolone plus metronidazole is adequate for most patients. Antibiotics should be continued for seven to

ten days.

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INTRAOPERATIVE SEQUENCE (5)

APPENDECTOMY

The excision of the appendix usually performed to remove an acutely inflamed organ.

Many surgeons perform an appendectomy as a prophylactic procedure when operating in the abdomen

for other reasons. This procedure is then referred to as an incidental appendectomy.

Position

Supine, with arms extended on armboards

Incision Site

McBurney (muscle splitting) incision.

Packs/ Drapes

Laparotomy pack

Four folded towels

Instrumentation

Major Lap tray or minor tray

Internal stapling device

Supplies/ Equipment

Basin set

Blades

Needle counter

Penrose drain

Culture tubes

Solutions

Sutures

Internal stapling instruments

Medication

14

Procedure

1. An incision is made in the right lower abdomen, either transversely oblique

(McBurney) or vertically (for a primary appendectomy).

2. The surgeon’s assistant retracts the wound edges with a Richardson or similar

retractor.

3. The appendix is identifies and its vascular supply ligated.

4. The surgeon grasps the appendix with a Babcock clamp, and delivers it into

the wound site.

5. The tip of the appendix may then be grasped with a Kelly clamp to hold it up,

and a moist Lap sponge is placed around the base of the appendix (stump) to

prevent contamination of bowel contents, in case any spill out occurs during

the procedure.

6. The surgeon isolates the appendix from its attachments to the bowel

(mesoappendix) using a Metzenbaum scissors.

7. Taking small bits of tissue along the appendix, the mesoappendix is double-

clamped, and ligated with free ties.

8. The base of the appendix is grasped with a straight Kelly clamp, and the

appendix is removed.

9. The stump may be inverted into the cecum, using a purse-string suture on a

fine needle, cauterize with chemicals, or simply left alone after ligation.

10. Another technique is to devascularize the appendix and invert the entire

appendix into the cecum.

11. The appendix, knife, needle holder, and any clamps or scissors that have come

in contact with the appendix are delivered in a basin in the circulating nurse.

12. The wound is irrigated with warm saline, and is closed in layers, except when

an abscess has occurred, as with acute appendicitis.

13. A drain may be placed into the abscess cavity, exiting through the incision or a

stab wound.

14. An alternative technique may be use the internal stapling device, by placing

the stapling instrument around the tissue at the appendiocecum junction.

15. By using the technique, the possibility of contamination from spillage is

greatly reduced.

Perioperative Nursing Consideration

1. Instruments used for amputation of the appendix are to be isolated in a basin.

2. If ruptured, the case must be considered contaminated, and the surgeon may

elect to use antibiotic irrigation prior to closure of the abdomen with an

insertion of a drain.

3. There may be no skin closure of the wound if the appendix has rupture.

Complication

Complications of appendicitis include wound infection, perforation,

peritonitis, abscess formation, urinary tract disorders, and pylephlebitis. The overall

perforation frequency is 10% to 30%. Perforation within 12 hours of pain onset is

unusual, but the risk of this complication rises significantly after 48 hours. Sixty-five

percent of patients with perforated appendicitis have been symptomatic longer than 48

hours. Perforation rates are highest in children and the elderly, due to delays in

presentation and diagnosis. Perforation occurs in 90% of children younger than two

years of age and in 35% of all children. In the elderly, a combination of delayed and

atypical presentations, confounding medical conditions, and a decreased index of

suspicion contribute to higher rates of perforation. Between 40% and 75% of patients

older than 60 years of age have a perforated appendix by the time of the operation.

Perforation is recognized preoperatively in 70% of patients. Suggestive

clinical features include symptom duration of more than 36 hours, fever higher than

38.58 C, toxic appearance, diffuse abdominal tenderness, abdominal mass, and

marked leukocytosis. Appendiceal perforation leads to multiple complications,

including peritonitis, abscess formation, wound infection, urinary retention, and small

bowel obstruction. Other intra-abdominal abscesses may develop after perforation,

most commonly in the pelvis.

Pylephlebitis is septic thrombophlebitis of the portal venous system. This rare

complication of appendiceal perforation is characterized by high fever, rigors,

jaundice, and abnormal liver function tests. (5)(6)

Wound infection

The rate of postoperative wound infection is determined by the intraoperative wound

contamination. Rates of infection vary from <5% in simple appendicitis to 20% in

cases with perforationand gangrene. The use perioperative antibiotics has been shown

to decrease the rates of postoperative wound infections.

Intra-abdominal abscess

Intra-abdominal or pelvic abscess may form in the postoperative period after gross

contamination of the peritoneal cavity. The patients present with a swinging pyrexia,

and the diagnosis can be confirmed by ultrasonography or CT scan. Abscesses can be

treated radiogically with a pigtail drain, although open or per rectal drainage may be

needed for pelvic abscess. The use of perioperative antibiotics has been shown to

decrease the incidence of abscess.

SPECIAL CONCIDERATION

Pregnancy

The most common non-obstetric emergency needing surgery in pregnancy is

appendicitis with an incident of 0.15 to 2.10 per 1000 pregnancies. A reduction in the

incidence of appendicitis during pregnancy particularly during third semester.

Displacement of the appendix by the gravid uterus means that presentation is often

atypical or may be mistaken for the onset of labour. Nausea and vomiting are often

present with associated tenderness located anywhere on the right side of the abdomen.

Appendix Mass

In patients with a delayed presentation, a tender mass with overlying muscle rigidity

may be felt in the right iliac fossa. The presence of a mass may be confirmed on USG

or CT scan, underlying neoplasia must be excluded, especially in an elderly people.

The initial treatment in a patient who is otherwise with initiation of appropriate

resuscitation and intravenous broad spectrum antibiotics. In most cases the mass will

decrease in size over in subsequent days as the inflammation resolves. Although

patients need observation to detect early sign of progress of inflammatory process.

Appendix Abscess

Patients with an appendix abscess have a tender mass with a swinging pyrexia,

tachocardia and leukocytosis. The abscess is most often located in the lateral aspect of

the right iliac fossa but may be pelvic; a rectal examination is useful to identify a

pelvic collection. Abscess can be showed by USG and CT scan and a percutaneous

radiological drainage may be done.

Chronic (recurrent) Appendicitis

Recently, with the advent of neurogastroenterology, the concept of neuroimmune

appendicitis has evolved. After a previous minor bout of intestinal inflammation,

subtle alterations in enteric neurotransmitters are seen, which may result in altered

visceral perception from the gut; this process has been implicated in a wide range of

gastrointestinal conditions. Further work is needed to determine if the clinical entity

of “neuro- immune appendicitis” truly exists, but it remains an interesting area.

Inflammatory bowel disease

A histor y of appendicectomy is associated with delayed onset of disease and a less

severe disease phenotype in patients with ulcerative colitis. The influence of

appendicectomy in Crohn’s disease is not as clear; some evidence suggests a delayed

onset of disease in patients after appendicectomy,although contradictory evidence also

exists to suggest an increased risk of developing the condition depending on the

patient’s age, sex, and diagnosis at the time of operation.

Prognosis

Acute appendicitis is the most common reason for emergency abdominal

surgery. Appendectomy carries a complication rate of 4-15%, as well as associated

costs and the discomfort of hospitalization and surgery. Therefore, the goal of the

surgeon is to make an accurate diagnosis as early as possible. Delayed diagnosis and

treatment account for much of the mortality and morbidity associated with

appendicitis.

The overall mortality rate of 0.2-0.8% is attributable to complications of the disease

rather than to surgical intervention. The mortality rate in children ranges from 0.1% to

1%; in patients older than 70 years, the rate rises above 20%, primarily because of

diagnostic and therapeutic delay.

Appendiceal perforation is associated with increased morbidity and mortality

compared with nonperforating appendicitis. The mortality risk of acute but not

gangrenous appendicitis is less than 0.1%, but the risk rises to 0.6% in gangrenous

appendicitis. The rate of perforation varies from 16% to 40%, with a higher frequency

occurring in younger age groups (40-57%) and in patients older than 50 years (55-

70%), in whom misdiagnosis and delayed diagnosis are common. Complications

occur in 1-5% of patients with appendicitis, and postoperative wound infections

account for almost one third of the associated morbidity. (3)(7)

CHAPTER IV

SUMMARY

Appendicitis is an inflammation of the appendix that occurs most often in

people between the ages of 10 and 30. It is considered a medical emergency, and

treatment often involves surgery to remove the appendix. If treatment is delayed, the

appendix can burst, causing infection and even death. Possible symptoms of an

inflamed appendix include abdominal pain, fever, and constipation. When there is a

blockage inside the appendix, a person may develop appendicitis. Causes of the

appendix blockage can include feces, bacterial or viral infection in the digestive tract,

traumatic injury, or genetics. If the blockage is not treated quickly, the appendix could

rupture. Common appendicitis signs and symptoms include pain in the lower-right

abdomen, loss of appetite, and vomiting. However, people who have appendicitis may

not have all of the usual symptoms. In addition, symptoms may be different or hard to

diagnose in children, the elderly, and pregnant women. Those who experience

possible symptoms should see their doctor for proper diagnosis and treatment. A

physical exam, a medical history, and appendicitis tests, such as x-rays or a CT scan

are all part of the process when making an appendicitis diagnosis. In some cases, a

laparoscopy may be necessary to confirm the condition. This procedure avoids

radiation, but requires general anesthesia. Once a diagnosis of appendicitis is

confirmed, the necessary treatment is usually surgery. In some cases, if the diagnosis

is uncertain, the doctor may prescribe antibiotics as treatment if he or she is unsure

whether the symptoms are being caused by appendicitis or something else, such as an

infection. Many people want to know how to prevent appendicitis. Although there is

no way to prevent appendicitis, people who are able to recognize appendicitis

symptoms may be able to prevent more serious appendicitis symptoms from

occurring.

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