KABWE CENTRAL HOSPITAL

SURGERY
“APPENDICITIS”

BANDA WISDOM CHILUFYA

What is the blood supply of the appendix?

• The appendicular artery – branch of ileocolic artery

a branch of superior mesenteric artery

• What is the surface landmark of the appendix?

Mc Burney’s pt ( jxn of lateral 1/3 and medial 2/3 of
a line from ASIS to umbilicus. Base of appendix
importance- gridiron or Mc Burney’s) incision
Where may the appendix be found?

• Positions of the free end appendix of the appendix

are variable
1. retrocaecal – 70 %
2. Pelvic - 20 %
3. pre-ileal
4. post - ileal
5. Subcaecal (6 o'clock)
6. Subhepatic or rt paracolic gutter –rest < 5 %
What are the causes of Rt iliac fossa pain ?

• Appendicitis
• UTI
• Renal colic
• Terminal ileitis 20 Crohn’s dizz
• Mechel's diverticulum
• Ectopic pregnancy
• Ovarian cyst
• Salpingitis
• PID
Appendicitis

• Refers to the inflammation of the appendix

etiology

• Not clear

• There is some evidence that eating green

vegetables and tomatoes is protective

• In elderly pts use of NSAIDs ↑ risk

PATHOPHYSIOLOGY

• Appendicitis is caused by obstruction of the

appendicular lumen from a variety of causes.
Independent of the aetiology, 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 cells
and the formation of pus and subsequent higher
intraluminal pressure.
• If appendicular obstruction persists, intraluminal
pressure rises ultimately above that of the
appendicular veins, leading to venous outflow
obstruction. As a consequence, appendicular wall
ischemia begins, resulting in a loss of epithelial
integrity and allowing bacterial invasion of the
appendicular 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, appendicular abscess or peritonitis may
occur, leading to sepsis. This is illustrated in the
figure below.
symptoms

• Abdominal pain: Most common symptom

• Nausea: 61-92% of patients
• Anorexia: 74-78% of patients
• Vomiting: Nearly always follows the onset of pain;
vomiting that precedes pain suggests intestinal
obstruction
• Diarrhea or constipation: As many as 18% of
patients
• Features of the abdominal pain are as follows:
• Typically begins as periumbilical or epigastric pain,
then migrates to the RLQ
• Patients usually lie down, flex their hips, and draw
their knees up to reduce movements and to avoid
worsening their pain
signs

• Pointing sign

• Tenderness and rebound tenderness (blumbergs

sign) max at Mc Burney’s point
• Guarding and rigidity – Rt iliac fossa

• Rovsing sing- palpation Lt iliac fossa produces pain

in Rt iliac region (Exp- diplacement of colonic gas
and small bowel coils impinging upon inflammed
appendix)
• Psoas test – irritation of Psoas major muscle when
hip is extended – retrocaecal appendix

• Obturator test
seen in pelvic appendicitis due to irritation of
obturator muscle. Flexion and medial rotation of hip
produces pain
• Baldwing’s sign; pain on lifting both legs and
pressing on the right frank
• Hyperaesthesia in ‘Sherren’s triangle’. This triangle
is formed by anterior superior iliac spine, umbilicus,
• pubic symphysis.
• Features of generalised peritonitis

• DRE

• VE r/o Gyn pathology

SCORING SYSTEM

Avolrado Scoring System

Features Score
Symptoms
Migrating RIF pain 1
Anorexia 1
Nausea/Vomiting 1
Signs
Tenderness RIF 2
Rebound tenderness 1
Elevated temperature 1
Labaratory
Leucocytosis 2
Shift to left 1
Total 10

Score <5 – Not sure

5-6 – Compatible
6-9 - Probable
>9 - Confirmed
Complications of acute appendicitis

• Relapse and recurrent appendicitis

• Appendicular mass
• Appendicular abscess
• Perforation - has got 20% mortality
• Peritonitis
• Portal pyaemia
Peritonitis. In the study done by Mugala et al, showed that raptured
appendix is the third commonest cause of peritonitis in children in
Chingola-Zambia (Mugala DD, et al, 2016)
Ix

1. FBC, Dc (Total WBC count) Amolst always above

10,000 cell/mm3 (95% of pts)

>20,000/mm3 suggest complicated appendicitis and

gangrene or perforation

2. Urine examination –R/O UTI

3. CRP –elevated within first 12 hours of acute
inflammation
4. Plain Abd x-ray erect incl CxR –R/o perforation
May show diluted small bowel loops in RIF
5. Abd u/s - R/o gyn problems
6. CECT –Contrast Enhanced CT Scan is the
investigation of choice (sensitivity 90%, specificity
90%)
Helps to R/o ca of caceum duodenal perforation
e.t.c
 TREATMENT
• MANAGEMENT OF APPENDICITIS
• Appendicitis is an emergency and the management is
surgical removal of the inflamed appendix before it becomes
complicated. Below is the management of appendicitis
depending on the presentation.
•
• ACUTE APPENDICITIS
• For acute appendicitis that has not undergone complication
upon making the diagnosis is the surgical intervention in
which the appendix is surgically removed. The process is
called appendicectomy. In which an incision is made at the
Mcburney’s point called Macburney’s incision to access the
base of the appendix.
MANAGEMENT OF APPENDICULAR MASS

• Appendicular mass is the localisation of infection

occurring 3 to 5 days after an attack of acute
appendicitis. It involves the omentum, ceacum,
small bowel surrounding the inflamed appendix to
localise infections in the right iliac fossa

• The management of appendicular mass is different

from acute appendicitis. In the sense that its
managed conservatively because the bowels are
friable and any surgical disturbance may create
faecal fistula. An appendicular mass is confirmed
by ultrasound.
CLINICAL FEATURES

• The mass is tender, smooth, firm, well localised, not

moving with respiration, not mobile, all borders well
made out (well localized) and resonant on
percussion.
• Patient may have fever and features of toxicity.
Treatment

• Conservative using Ochsner-Sherren Regimen

• Due to the fact that nature has already localised the

infection, if now disturbed will cause faecal fistula
OCHSNER-SHERREN REGIMEN OF
APPENDICULAR MASS
• Temp, BP, Pulse chart.
• Marking the mass to identify the
progression/regression.
• Antibiotics (Ampicillin, metronidazole, gentamycin,
or other drugs given depending on severity and
requirement).
• IV fluids.
• Analgesics.
• Initial nasogastric aspiration
• Patient usually shows respond by 48 to 72 hours
and mass reduces in size, temperature and pulse
becomes normal. Appetite is regained. 90% of
patients respond to conservative therapy. Patient is
discharged and advised to come for interval
appendectomy after 6 weeks.
 Andrew James Symington 1825

“The health profession is a

noble and pleasant one,
though laborious and often full
of anxiety.”