A 27-year-old woman presented

with three-day history of

generalized mild abdominal pain

The pain initially was diffuse, intermittent,

colicky and unaffected by food or movement
Onset of N&V and watery diarrhea since this
morning
More than 6 times of stool per day that were
non-foul-smelling and non bloody
 She denied dysuria, back pain or abnormal
vaginal bleeding
She was sexually active only with her
husband, denied any history of STDs and
previous surgery. Other than that, her past
medical history was unremarkable
 Temperature 38
celcius
PR 112/min
BP 120/80
RR 20/min
Palpation : generalized
mild tenderness with
some voluntary
guarding at supra-
pubic area
No signs of peritonitis
Rectal examination
was unremarkable
 WBC 15,000/mm3,
85% of PMN
Urinalysis
revealed a white
blood cell count
of 5-10 cells, RBC
3-5cells, but no
bacteria
Urine pregnancy
test was negative.
What is the
connection?
Differential Diagnosis ?
Acute gastroenteritis Question : How to link
dyspepsia symptoms with
UTI, pyelonephritis supra-pubic pain and white
blood cells in urine ?
Appendicitis ?
Most common
Can you link
the symptoms
up now?
 Anatomy
Location of appendix : Right Iliac Region
Classical location : Distal 1/3 of
McBurneys Line (line connecting ASIS
and umbilicus)
Positions of appendix can vary
 Relation to
peritoneum
Cecum and appendix are intraperitoneal
organs (except in some, retrocecal
appendix can be retroperitoneal Am J Surg 1981)
Mesoappendix is connected to mesentery
of small intestine
Variations in the degree of fusion of the cecum to the
peritoneum.
A, The cecum is unattached and quite free to move about
B, The cecum is held by a narrow mesenteric fold,
permitting moderate mobility
C, Cecum with a retrocecal appendix is bound down to
the iliac peritoneum over an extensive area
Mesoappendix
 Vascular Supplies
Appendicular artery (terminal branch)
from ileocolic artery (SMA)
Appendicular vein going to superior
mesenteric vein and portal circulation
 Structure
Blind ended tubular structure
What happens when you have a tubular
structure with a blind end?
Everyone likes a balloon
But what if the balloon
is filled up with too
much air ?
Normal appendix Inflamed appendix

Obstructed

Perforated appendix
 Lymphoid
Faecolith
hyperplasia
obstructs
after viral
the lumen
infection
Faecolith / lymphoid Swelling eventually
hyperplasia after causes VOO and arterial
viral infection ischemia, gangrene and
obstructs the lumen perforation

Continual mucus Stagnation

secretion and bacterial
stagnation leads to (+) infection and
intraluminal pressure inflammation
Based on 3 stages
Visceral pain stage
Somatic pain stage
Complication stage
Visceral vs somatic pain
Nerve supplies of parietal vs visceral
peritoneum
Neural pathway of abdominal pain
Splanchnic nerve
- Carries fibers from autonomic nervous
system
Spinal nerve (cerebrospinal nerve)
- Innervates the muscles and skin of
abdomen
Bilateral innervation

1 2
 Visceral organs (and their peritoneum)
receives bilateral innervation from
autonomic system via the fibers from
prevertebral ganglia
The fibers are C-fibers (unmyelinated
fibers)
 Visceral pain is often in the midline
related to embryologic origin of the organ
in the midline
They receive bilateral splanchnic
innervation; as they grow, they move
laterally taking the nerves with them
Visceral pain (visceral peritoneum)
C-fibers are sensitive to tearing and
stretching but not for proprioception
C-fibers have slow transmission, hence the
pain is dull
C-fibers distribution is not dense; hence
the pain is poorly localized
 Muscles and skin (and parietal
peritoneum) receive unilateral
innervation from spinal nerves
The fibers are myelinated fibers
Anterior abdominal peritoneum : T6-12
Pelvic peritoneum : Obturator nerve
Somatic pain (parietal peritoneum)
Myelinated fibers are sensitive to both
tearing,stretching and proprioception
High transmission speed, hence pain is
intense
Pain localizes to the corresponding
dermatome
Somatic pain (parietal peritoneum)
Hyperesthesia over the overlying skin due
to common innervation
Referred pain
A type of visceral pain
Due to innervation of a different sites
originating from the same spinal segment
Visceral pain stage
Visceral peritoneum is irritated
Dull, vague pain around
periumbilical/lower epigastric area
Other symptoms : hyper-peristalsis
 Diarrhea BEFORE vomiting suggests
appendicitis, the reverse suggests AGE
Fever in appendicitis is not acute; its
slowly progressive as the inflammation
worsens
 A non perforated appendix will only
causes mild fever (<38 celcius),
Peritonitis will cause high grade fever,
(Perforation normally happens > 24
hours after the initial inflammation)
Hamburgers sign
Reluctance to eat the food one likes
before
Mechanism of symptoms :
Afferent autonomic fibers from appendix
T10 (explains why the pain is
periumbilical initially)
Sympathetic stimulation leads to N&V and
anorexia
Somatic pain stage
Appendix becomes swollen enough to
irritate parietal peritoneum
Localized right lower quadrant pain
Migrating pain is classical for
appendicitis
Somatic pain stage
Cutaneous hyperesthesia at RLQ
The pain may cause guarding or
stimulate a local reflexes causing rigidity
Pain in RLQ when
going through speed
bumps could be
suggestive of
appendix
BMJ 2012
Periumbilical pain
- Vague and

appendicitis symptoms
poorly localized
- Hyper-peristalsis
(flatus, diarrhea)

Progression of
Nausea, vomiting,
anorexia
Mild fever

RLQ pain
- Intense and can be
pinpointed
Complication stage
Perforation leads to generalized
peritonitis
Rebound tenderness, rigidity
Complication stage
Onset of perforation : severe pain
After a while, patient feels better but
flight/fight response still continues ; patient
often stays still with thoracic breathing to
avoid pain
Finally, if untreated, sepsis and shock can
happen
Specific signs
Rovsings sign : painful while palpating
left lower quadrant due to referred pain
from swollen appendix
Obturator sign
Psoas sign
Obturator sign
With the knee flexed, internally rotate
the hip
An inflamed appendix will come into
contact with obturator muscle and causes
pain
Psoas sign
Passively extend the leg
The psoas muscle will irritate the
inflamed appendix, causing pain
With 7 different anatomical orientations, do you
expect classical symptoms happen in ALL cases?
 Be Skeptical !!
Always
What are the
consider
other
appendicitis
different
in patient
diagnosis of
presenting
right lower
with
quadrant
abdominal
pain ? Give
pain if
me at least 5
appendix is
still present
 Adenitis (Yersinia,
Campylobacter)
Birth (Meckels
diverticulum)
Crohns disease, Cancer
Diverticulitis
Ectopic pregnancy
Typhlitis
Infectious colitis,
Intussusception
PUD perforation
(Valentinos sign)
 Differential Diagnosis by
Populations
Children-adolescent
Mesenteric adenitis, Meckels diverticulum, Intussusception
Young-middle aged adults (<50)
Crohns disease, Diverticulitis
Females : Gynecological causes (Ectopic pregnancy,
Ovarian torsion, Ovarian cyst, PID), Mittelschmertz
(ovulation pain/midcycle pain)
Post-transplantation
Infectious colitis, Typhlitis
Elders (>50)
Perforated cecal cancer, Diverticuliti
Divide the appendix position generally
into
Ileal (above iliac crest)
Pelvic (below iliac crest)
Ileal position of appendix
Normally will produce classical clinical
picture
Paracecal appendix localized mass on
right flank can be palpated due to lack of
overlying muscles
 A medially directed (pre/post/sub-ileal)
appendix may rub against the
descending right ureter UTI like
symptoms & pyuria (like in this case)
 Retrocecal appendix is the most common
position adopted by the appendix
However, its presentation is not the MOST
classical
Classical RLQ pain can be absent as
retrocecal appendix is overlaid by
abdominal muscles
 Positive psoas sign; some patients may
flex the thigh to avoid the pain upon
extension of psoas muscle
Retrocecal appendix can be
retroperitoneal, and therefore causes a
myriad of presentations
An axial CT image in the
upper pelvis shows edema
of the cecal wall which,
along with barium in the
cecum (C), contributes to
the "arrowhead sign" of
appendicitis. A dilated fluid
filled appendix (large
arrow) is seen with adjacent
stranding of retroperitoneal
fat (arrowheads). The
appendix follows a
retrocecal course (small
arrows).
What are retroperitoneal organs?
SAD PUCKER Ureter
Suprarenal gland Colon (ascending
Aorta/IVC and descending)
Duodenum (2nd and Kidney
3rd portion) Esophagus
Pancreas Rectum
Danger zone due
to proximity to
appendix
 Retrocecal and retroperitoneal appendicitis
can lead to abscesses in retroperitoneal
organs (perinephric, psoas abscess)
Lateral cutaneous nerve of thigh crosses the
psoas muscle from behind once the pus
gets through the psoas fascia and the muscle,
it can reach the nerve pain in lateral thigh
Pelvic position of appendix
Located in non-demonstrative part of
peritoneum
Somatic pain maybe absent
Even the classical RLQ pain can be
absent
Tenderness is only present in rectal
examination (so do a PR !!)
Demonstrative vs non demonstrative part
of peritoneum
Non demonstrative part is the
peritoneum that lies posteriorly and in
pelvic part (retrocecal/pelvic appendix)
Not demonstrative as the overlying
organs/muscles prevent them to
demonstrate its symptoms
Demonstrative

Non-demonstrative
 Demonstrative

Non-demonstrative
 A perforated pelvic appendicitis may not
have rebound tenderness as it is in
contact with non-demonstrative
peritoneum
Gravid uterus in pregnancy may push
the peritoneum away from the anterior
abdominal wall, causing no
rigidity/rebound tenderness
 Retrocecal appendix : suspect by psoas
sign; patient adopting a typical posture
Pelvic appendix : pus will accumulate in
pelvis, extreme tenderness on PR
Pregnancy : see later explanation
Doing A Good Physical Examination Will Save Your Ass
in Appendicitis !!
 Always consider ectopic
pregnancy (should be main
differential diagnosis, get a urine
pregnancy test)

However, appendicitis in pregnancy is a

headache too.
 Classically taught that appendicitis in
pregnancy produces RUQ pain due to
effect from the gravid uterus

Turns out common is still common

RLQ pain is the most commonly present
in pregnancy with appendicitis
 As stated, peritonitis due to perforated
appendix in pregnancy may produce
less rigidity/rebound tenderness
However, a perforated appendicitis is
NOT good for both mother and baby !!
MANTRELS
Migrating pain
Anorexia
Nausea and vomiting
Tenderness in RLQ
Rebound tenderness
Elevated temperature
Leucocytosis
Left Shift
Note that :
Original Alvarado
score did not state that
a score < 5 (1-4) could
rule out appendicitis
So the original scoring
system should NOT be
used to rule out
appendicitis
 Chart from the
original
Alvarados article
They investigated a
total of 227 patients
with confirmed
appendicitis
A score of > 5
predicts well , but a
score of < 5 misses
8 patients !!
Hence, the
usefulness of
Alvarado score as a
rule out score is put
to the test (modified
Alvarado score)

Annals of Emergency Medicine 1986

Modified
Alvarado score

< 4 : discharge
5-6 : admit
7-8 : surgery
 The Alvarado score is a useful diagnostic
rule out score at a cut point of 5 for all
patient groups. The score is well calibrated
in men, inconsistent in children and over-
predicts the probability of appendicitis in
women across all strata of risk (BMC Medicine 2011)
 Performing a good history taking and
physical examination is still better than
any other scoring systems
Clinical judgement > Alvarados score
 Imaging is the main modality
FBC : Leucocytosis with left shift
Mild metabolic alkalosis due to vomiting
 Presence of
faecolith
Sentinel loop
Scoliosis due to
RLQ pain

AXR is not reliable

as faecolith is
found only in
<10% of the cases
What can
you see?
 Low radiation exposure
Good choice in pregnant women,
children or patients with low likehood
Sens : 86%, spec : 81%
 Diameter of appendix > 6mm (most
sensitive and specific)
Non compressible appendix (2nd most)
Intraluminal fluid
Round
appendix
despite
compression

Diameter >
6mm
 Sens of 99%; spec of 95%
The BEST modality to diagnose CT scan
One drawback is the radiation dose (3000-5000
mrad) radiation dose to cause fetal anomalies is 5000 mrad
Appendicial findings:
Diameter > 6mm
Wall thickness > 3mm
Faecolith

Peri-appendicial findings
Fat stranding
Fluid
Abscess

Focal cecal wall dilatation

(sentinel loop)
Faecolith with multiple ileal
loops dilatation

Faecolith prevalence is too low to consider the

faecolith the most common cause of non-perforated
appendicitis. Faecoliths are more prevalent in
paediatric appendicitis than in adult appendicitis.
(Ann R Coll Surg Engl. 2013)
Fat stranding : abnormal fat
attenuation
Not filling with
contrast
Arrow Head Sign due thickened
wall
Appendix abscess
Management is divided
into
Perforated vs non
perforated
Complications
Non-perforated appendicitis
Prompt lap appendectomy with
empiric antibiotics for not more
than 24 hours

Perforated appendicitis
Prompt lap appendectomy with
empiric antibiotics until
afebrile and normal WBC
Abscess
CT-guided drainage and IV
antibiotics (with NPO,IVF)
Interval appendectomy after 6
weeks is not always required,
but if not done there is 20%
risk of recurrent appendicitis
(so many would prefer to do it
in elective settings)
Incidental appendectomy
Laparatomy reveals no
appendicitis, but appendix is
removed to avoid diagnostic
confusion in the future
 There have been studies showing the use
of antibiotics in management of non-
complicated appendicitis w/o
appendectomy
But the data is not robust enough to
recommend ONLY antibiotics use
Empirical antibiotics should cover
anaerobes and Gram negative organisms
 In non perforated appendicitis, post-op
antibiotics may not be beneficial
(recommendation to stop it after surgery)
In perforated appendicitis, post-op
antibiotics > 5 days does not lower the
incidence of IAIs but cessation when
fever + leucocytosis is present is
associated with IAI development
Surg Infect (Larchmt) 2013
 As a rule, early intervention is key when
appendicitis is suspected
Fetal demise increases from 5% in
simple to 28% in perforated appendicitis

Laparoscopic appendectomy is safe and

effective during pregnancy and is
associated with good maternal and fetal
outcome World J Surg. 2009
 Pre-operation Post-operation

Wound infection
Paralytic ileus
Adhesion
Perforation Faecal fistula
Peritonitis
Stump appendicitis
Appendicular
mass, abscess Right sided hernia
 Can range from
abscess to phlegmon
Management :
conservative using
Oschner-Sherren
regimen
- NPO, IVF, IV
antibiotics
- Interval
appendectomy
 Acute colonic
dilatation, without any
mechanical
obstruction
Normally will resolve
with conservative
supportive
management
 Causes SBO (A of the mnemonic ABC)
Intestinal adhesion is the most common
post-op cause of SBO
 Enterocuteneous fistula
from the leakage from
the appendicial stump
Most commonly occur in
periappendicitis
involving the base of
appendix and the
cecum
 Residual appendiceal tissue left at the
time of appendectomy may predispose
to the rare development of stump
appendicitis
Contributing factors :
- Severely inflamed appendix
misidentification of cecal-appendiceal
junction
- Stump > 3mm
 Incisional hernia
Inguinal hernia (weakness to inguinal
muscles due to damage to
iliohypogastric nerve in appendectomy)
Iliohypogastric nerve
Innervates internal
oblique and transverse
abdominis muscle,
especially their lower
part which forms
conjoint tendon (falx
inguinalis

An incision in
McBurneys line can
potentially damage the
nerve and weakens the
conjoint tendon
Anatomy of inguinal canal
Posterior wall : fascia
transversalis, conjoint
tendon
Weakness in conjoint
tendon can lead to
protrusion of the
abdominal organs into
the inguinal canal
A form of direct
inguinal canal (lateral
to inferior epigastric
artery)
Complication Management
Wound infection Topical and systemic antibiotics

Postoperative ileus Correct any underlying electrolyte abnormalities

Most postoperative ileus will recover with
supportive treatment
For severe symptoms, nasogastric can be used

Adhesion Laparoscopic adhesiolysis

Faecal fistula Regular dressing, most will close by itself

If remains open > 1 month, surgical excision of
the tract and segmental resection of involved
bowel with end-end anastomosis

Stump appendicitis Resection of the appendicial stump

Right sided hernia Herniorraphy/hernioplasty

1) Types of appendectomy incision
McBurneys : angled down following EOM
Lanzs : modified McBurneys incision
Rocky-Davis : transverse incision
 Lanz incision is more
transverse and lies closer to
ASIS
The direction of incision
tends to make ilioinguinal
and iliohypogastric nerve
more susceptible
However its a more
cosmetic pleasing incision

ASIS
2) Abdominal layers during McBurney incision
Skin, s/q tissues, scarpa fascia, external oblique,
internal oblique, transverse abdominis, fascia
transversalis, preperitoneal fat, peritoneum
3) Lap appendectomy
steps
Identify the
appendix
Staple the
mesoappendix (or
coagulate if there
are vessels on
mesentery)
Transect the
appendix, remove it
Irrigate and
aspirate till clear
4) Do not get peritoneal cultures if appendicitis not
perforated (post-op IAI incidence is low)
The practice of culturing samples taken from a ruptured appendix is redundant,
because the antibiotic that has already been initiated is effective in most of the
patients and the decision to modify the therapeutic regimen is dominated by
clinical considerations Eur J Surg, 2001
5) Follow the taenia down where they converge
on appendix
6) Sweep your fingers LATERAL to MEDIAL along
the LATERAL peritoneum in finding appendix so
that you wont tear the mesoappendix and open
into retroperitoneal cavity
6) If appendix is retrocecal and retroperitoneal,
divide the lateral peritoneal attachment of
cecum
7) Use electrocautery on exposed mucosa on
the stump so that the mucosal cells are killed; If
not they will continue to secrete mucus forming
a mucocele
8) The removed appendix should be biopsied.
Adenocarcinoma of appendix can present as
appendicitis if positive should be treated
with right hemi-colectomy