Appendix

Acute appendicitis, its complications,

Neoplasms

Dr. Mahmoud W. Qandeel

Outlines
• Introduction
• Anatomy and physiology
• Acute appendicitis
• Appendiceal tumors

Dr. Mahmoud W. Qandeel

 All sentences about appendicitis are true except: ( 12 /2017)

A. Posas sign is elicited by extension of the right hip

B. Rovsing sign is elicited by pressing in the left iliac fossa
causing pain in the right iliac fossa
C. Pain is less after laparoscopic compared with open
appendectomy
D. Wound infection is less after laparoscopic compared open
appendectomy
E. In female patients, open approach is preferred over the
laparoscopic appendectomy
Dr. Mahmoud W. Qandeel
 History
• 1889 Mac Burney described location, the clinical features of
appendicitis and the importance of operative intervention and
muscle-splitting incision

Dr. Mahmoud W. Qandeel

 Dimensions

• Averages 9 cm in length but can range from 2 to 20 cm

• The longest appendix ever removed measured 26 cm from a
patient in Zagreb, Croatia.
• The lumen is quite narrow and may be obliterated after mid adult
life.

Dr. Mahmoud W. Qandeel

 Anatomy

The appendix is suspended by a small, Valve of Gerlach

triangular fold of peritoneum, called the
mesoappendix, or appendicular mesentery
Dr. Mahmoud W. Qandeel
• How to identify appendix intraoperatively ?

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Appendicular artery in mesoappendix

Dr. Mahmoud W. Qandeel

 Venous Drainage & Nerve Supply
• Appendicular Vein
• Ileocolic vein Portal Vein
• Superior Mesenteric vein

• Sympathetic Nerves- Derived from T10-L1 ( superior

mesentric Plexus)

• Para Sympathetic Nerves- Vagus

Dr. Mahmoud W. Qandeel

 Positions of Appendix
Position Incidence

Retrocecal 65% Commonest postion

Pelvic 30 % 2nd Commonest position

Pre-ileal 1%

Post- ileal 0.5% Least common site

Paracaecal 2%

Subileal /subcaecal 1.5%

Dr. Mahmoud W. Qandeel

 SURFACE ANATOMY
 Mc.Burney's point, 1/3 of the way along a
line drawn from the Anterior Superior Iliac
Spine to the Umbilicus.

 Base of appendix

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Function
 Secrets IgA, component of the GUT associated lymphoid tissue (GALT)
 As a storage place for the good bacteria needed in the intestinal tract
“acts as a good safe house for bacteria”
(With a disease like dysentery, gut flora can be completely flushed from the
intestine through diarrhea. When this happens, the bacteria living in the
appendix can repopulate the intestinal tract.)

 Inverse association between appendectomy and the development of

ulcerative colitis has been reported, suggesting a protecting effect of
the appendectomy

Dr. Mahmoud W. Qandeel

 Acute Appendicitis:
• The most common cause of acute abdomen that need surgery,
affecting 7% population
• The peak incidence of appendicitis occurs in the second and
third decades of life, with 80% of cases occurring in persons
younger than 45 years with slight male predominance

• Incidence of perforation is 12-20%

Dr. Mahmoud W. Qandeel

 Pathogenesis
• The etiology and pathogenesis of appendicitis are not completely understood.
• Obstruction of the lumen due to fecaliths or hypertrophy of lymphoid tissue
is proposed as the main etiologic factor in acute appendicitis.
• The frequency of obstruction rises with the severity of the inflammatory
process.
• Fecaliths and calculi are found in 40% of cases of simple acute appendicitis, in
65% of cases of gangrenous appendicitis without rupture, and in nearly 90% of
cases of gangrenous appendicitis with rupture.

Dr. Mahmoud W. Qandeel

 Pathogenesis:
Sequence of events in Luminal Obstruction
Proximal occlusion > Closed loop Obst > rapid distention due to:
a. Continuing secretion of the mucosa
b. Rapid multiplication of normal flora

> elevate pressure > capillary/venous occlusion (CONGESTION 1st stage):

S/Sx: (+) visceral afferent pain fibers (vague, dull, diffuse pain in mid-
abdomen or lower epigastrium. Increase peristalsis (crampy pain); N/V
and anorexia

Dr. Mahmoud W. Qandeel

 Inflammatory process involves the serosa of appendix and in turns
parietal peritoneum in the region.

 Infiltration of PMN (SUPPURATIVE 2nd stage)

Damage of the lining epithelium > entrance of bacteria to the wall.

 Impairment of blood supply (inc. pressure than arterial pressure) >

ellipsoidal infarct at antimesenteric border just beyond the point of
obstruction. . (GANGRENOUS 3rd stage) ---> (PERFORATION 4th stage)

❖This process is not inevitable. Some subside spontaneously

Dr. Mahmoud W. Qandeel

• Pain caused by appendicitis is first felt in the region of the
umbilicus. This is visceral pain.

• With increasing inflammation pain is felt in the right iliac fossa.

• This is caused by involvement of the parietal peritoneum of the
region.

Dr. Mahmoud W. Qandeel

 Phlegmonous Mass/Paracaecal abscess

Greater omentum & loops of small bowel become adherent to

the inflamed appendix

Walling off the spread of peritoneal contamination

Phlegmonous Mass / Paracaecal abscess

Dr. Mahmoud W. Qandeel
 Pathogens:
– Anaerobes, aerobes
– Bacteroides fragilis, Escherichia coli, Peptostreptococcus,
Pseudomonas, Bacteroides splanchnicus, Lactobacillus

Dr. Mahmoud W. Qandeel

 Clinical Manifestation:
1. Abdominal pain:
• Classic pain sequence ……….
• Right lower quadrant pain
• Others:
– Left lower quadrant pain (long appendix)
– Flank or back pain (retro-cecal)
– Supra-pubic (pelvic)
– Testicular pain (retro-ileal ----> irritates the spermatic artery and ureter
2. Anorexia nearly always present
3. Vomiting / diarrhea
• Usual sequence : ANOREXIA ---> ABD. PAIN ---> VOMITING
Dr. Mahmoud W. Qandeel
 Signs
Depends on the location of the appendix and presence of rupture
1. Direct and rebound tenderness at Mc Burney’s point.
2. ROVSING sign ---> indicate muscles peritoneal irritation.
3. Involuntary muscle guarding
4. Psoas sign - retrocecal appendix
5. Obturator sign – pelvic
6. Para-rectal tenderness

Dr. Mahmoud W. Qandeel

Mc Burney’s Point -Tenderness

Dr. Mahmoud W. Qandeel

Rovsing’s Sign

Dr. Mahmoud W. Qandeel

Psoas Sign

Dr. Mahmoud W. Qandeel

Obturator Sign

Dr. Mahmoud W. Qandeel

 Laboratory Findings:

1. WBC: leukocytosis
• Simple = 10,000 to 18,000/mm3
• Perforated = >18,000/mm3
2. CRP: sensitive inflammatory marker, takes 12 hours to become elevated.
3. Urinalysis :
 Hematuria and pyuria due to irritation of the ureter and urinary bladder
 No bacteriuria

Dr. Mahmoud W. Qandeel

 Imaging
Graded Compression sonogram (US):
blind-ended, nonperistaltic bowel loop originating from the cecum:
 78–96% sensitivity; 85–98% specificity
 (+) non-compressible appendix, 6mm or > at AP view
 False (-):
a. Appendicitis confined at the tip
b. Retrocecal position
c. Perforated appendix
 False (+):
a. Periappendicitis from surrounding inflammation
b. Dilated fallopian tube
c. Inspissated stool can mimic an appendicitis
d. Obese pt., appendix not compressed

Dr. Mahmoud W. Qandeel

 CT scan
• Inflamed appendix appears dilated (>5 mm), and the wall is thickened.
• There is often evidence of inflammation, which can include periappendiceal
fat stranding, thickened mesoappendix, periappendiceal phlegmon, and free
fluid.
• Fecaliths can be often visualized.
– 92% to 97% sensitivity, 85% to 94% specificity,
– 90% to 98% accuracy
– 75% to 95% positive predictive value, and 95% to 99% negative predictive value.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Laparoscopy

– Diagnostic /therapeutic
– Useful for female to differentiate gynecological pathology

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
 Perforated appendix :

• More in patients > 65 and < 5 yrs age

• Uncommon to occur within 24hrs of onset of abdominal pain
• May lead to peritonitis if failed to walled off the inflammation.

Dr. Mahmoud W. Qandeel

Differential Diagnosis:

• Acute mesenteric lymphaditis

• pelvic inflammatory disease
• Twisted ovarian cyst / ruptured graafian follicle / tubo-ovarian abscess
• Acute gastroenteritis
• Testicular torsion
• Terminal ilietis
• Meckels diverticulitis
• Uretric colic / UTI

Dr. Mahmoud W. Qandeel

 Management:

• Adequate hydration, correct electrolyte imbalance

• Surgery is the mainstay of management ( lap VS open )
• Pre-operative antibiotics:
• Simple AP - one dose preop
• Complicated appendicitis:
• Needs IV antibiotics till the pt is afebrile, tolerating a diet, and has resolution of
leukocytosis.
• Maximum duration for antibiotics is 7-10 days.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
 Appendicitis in the pediatric age
– Difficult to establish diagnosis:
1. Inability of a child to give accurate history
2. Diagnostic delays by both parents & physicians

– Rapid progression to rupture:

• Underdeveloped greater omentum ----> higher morbidity
• < 5y/o had higher rate of perforation as compared to older children

Dr. Mahmoud W. Qandeel

 Appendicitis during Pregnancy
– AP is the most frequent extra-uterine disease. requiring surgical Tx
during pregnancy
– S/Sx:
• Abdominal pain, tenderness
• Rebound tenderness and guarding less due to laxity of abdominal wall
– Abdominal ultrasound
– Dx is difficult due to displacement of the appendix and ??

Dr. Mahmoud W. Qandeel

Appendicitis during Pregnancy

Dr. Mahmoud W. Qandeel

 Appendicitis during Pregnancy
– Risk of surgery:
• Premature labor - 7%
• Appendiceal perforation is significant factor associated w/ fetal and maternal death.
– Fetal mortality
» 3-5% w/ early appendicitis
» 25% perforation

– Suspicion of appendicitis during pregnancy should prompt rapid diagnosis

and surgical intervention

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Tumors of the Appendix
• Appendiceal malignancy is rare
• Discovered during laparotomy or in association w/ acute inflammation of
the appendix

1. CARCINOID: Most common appendix neoplasm

 Firm, yellow, bulbar mass in the appendix
 Located: appendix ---> small bowel ----> rectum
 Carcinoid syndrome is rare in appendiceal carcinoid unless widespread
metastases are present
 Malignant potential related to it’s SIZE ---> > 2cm
 Treatment: < 1cm appendectomy
> 2cm right hemicolectomy

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
Dr. Mahmoud W. Qandeel
 ADENOCARCINOMA:
• Rare
• Histologic type:
• Mucinous adenocarcinoma
• Colonic adenocarcinoma
• Adenocarcinoid
• Manifestation:
• Acute appendicitis (most common )
• RLQ mass
• Treatment: right hemicolectomy

Dr. Mahmoud W. Qandeel

 MUCOCELE:
– Progressive enlargement of the appendix from the intraluminal
accumulation of a mucoid substance
– Histologic type:
a. Retention cyst
b. Mucosal hyperplasia
c. Cystadenomas
d. Cystadenocarcinoma
– Rarely occurs w/ gelatinous ascites (Pseudomyxoma Peritonei) usually
associated w/ malignant ovarian or appendiceal mucinous CA. if
present survival is decreased

Dr. Mahmoud W. Qandeel

 Treatment:
 Benign - appendectomy
 Malignant - right hemicolectomy for cystadenoCA of the
appendix; TAHBSO and appendectomy for ovarian cystadenoCA
 Adjuvant Tx:
 Radiation, intraperitoneal and systemic chemotherapy recommended but it’s
role is unclear

Dr. Mahmoud W. Qandeel

 Lymphoma
• Lymphoma of the appendix is extremely uncommon.
• Other types of appendiceal lymphoma, such as Burkitt’s lymphoma, as well as leukemia,
have also been reported.

• Findings on CT scan of an appendiceal diameter ≥2.5 cm or surrounding soft tissue

thickening should prompt suspicion of an appendiceal lymphoma.

• The management of appendiceal lymphoma confined to the appendix is appendectomy.

• Right hemicolectomy is indicated if tumor extends beyond the appendix onto the cecum
or mesentery

Dr. Mahmoud W. Qandeel

 All sentences about appendicitis are true except: ( 12 /2017)

A. Posas sign is elicited by extension of the right hip

B. Rovsing sign is elicited by pressing in the left iliac fossa
causing pain in the right iliac fossa
C. Pain is less after laparoscopic compared with open
appendectomy
D. Wound infection is less after laparoscopic compared open
appendectomy
E. In female patients, open approach is preferred over the
laparoscopic appendectomy
Dr. Mahmoud W. Qandeel
 All sentences about appendicitis are true except: ( 12 /2017)

A. Posas sign is elicited by extension of the right hip

B. Rovsing sign is elicited by pressing in the left iliac fossa
causing pain in the right iliac fossa
C. Pain is less after laparoscopic compared with open
appendectomy
D. Wound infection is less after laparoscopic compared open
appendectomy
E. In female patients, open approach is preferred over the
laparoscopic appendectomy
Dr. Mahmoud W. Qandeel
 Regarding simple appendicitis , all are true except ? ( 7/ 2017)

A. Periumbilical pain is visceral in nature and occurs early .

B. Right iliac fossa pain is somatic in nature and occurs later .
C. Positive rebound tenderness means peritoneal irritation
D. CT scan is the preferred imaging test for appendicitis in
females and children .
E. Meckel diverticulum may mimic the clinical picture of
appendicitis .

Dr. Mahmoud W. Qandeel

 Regarding simple appendicitis , all are true except ? ( 7/ 2017)

A. Periumbilical pain is visceral in nature and occurs early .

B. Right iliac fossa pain is somatic in nature and occurs later .
C. Positive rebound tenderness means peritoneal irritation
D. CT scan is the preferred imaging test for appendicitis in
females and children .
E. Meckel diverticulum may mimic the clinical picture of
appendicitis .

Dr. Mahmoud W. Qandeel

 All sentences about appendicitis are true except ? ( 7 /2017)

A. Mcburney point corresponds to the location of the tip of

appendix .
B. Psoas sign is elicited by extension of the right hip .
C. Laparoscopy is one of the diagnostic methods .
D. Rovsing sign is elicited by pressing in the left iliac fossa
causing pain in the right iliac fossa
E. Alvardo score is not routinely calculated for the diagnosis of
appendicitis .
Dr. Mahmoud W. Qandeel
 All sentences about appendicitis are true except ? ( 7 /2017)

A. Mcburney point corresponds to the location of the tip of

appendix .
B. Psoas sign is elicited by extension of the right hip .
C. Laparoscopy is one of the diagnostic methods .
D. Rovsing sign is elicited by pressing in the left iliac fossa
causing pain in the right iliac fossa
E. Alvardo score is not routinely calculated for the diagnosis of
appendicitis .
Dr. Mahmoud W. Qandeel
Acute appendicitis is most commonly associated with which of
the following signs ? ( 1/ 2017)

A. Temperature above 40 Celsius .

B. Frequent loose stools .
C. Anorexia , abdominal pain , RLQ tenderness .
D. WBC count > 20.000 per cu ml .
E. None of above .

Dr. Mahmoud W. Qandeel

Acute appendicitis is most commonly associated with which of
the following signs ? ( 1/ 2017)

A. Temperature above 40 Celsius .

B. Frequent loose stools .
C. Anorexia , abdominal pain , RLQ tenderness .
D. WBC count > 20.000 per cu ml .
E. None of above .

Dr. Mahmoud W. Qandeel

 Which of the following is the most common neoplasm of the
appendix : ( 10/ 2016)

A. Mucinous adenocarcinoma
B. Carcinoid tumor
C. Malignant mucocele
D. Lymphoma
E. Lymphosarcoma

Dr. Mahmoud W. Qandeel

 Which of the following is the most common neoplasm of the
appendix : ( 10/ 2016)

A. Mucinous adenocarcinoma
B. Carcinoid tumor
C. Malignant mucocele
D. Lymphoma
E. Lymphosarcoma

Dr. Mahmoud W. Qandeel

 Which of the following is the most reliable in confirming the
diagnosis of acute appendicitis : (10 /2016)

A. Classic history of initial periumbilical pain shifting to the

right lower quadrant
B. Rebound tenderness
C. Localized tenderness at Mcburneys point
D. Psaos sign presence
E. Rovsing sign presence
Dr. Mahmoud W. Qandeel
 Which of the following is the most reliable in confirming the
diagnosis of acute appendicitis : (10 /2016)

A. Classic history of initial periumbilical pain shifting to the

right lower quadrant
B. Rebound tenderness
C. Localized tenderness at Mcburneys point
D. Psaos sign presence
E. Rovsing sign presence
Dr. Mahmoud W. Qandeel
 The appendiceal artery is a branch of ? ( 7 /2016)

A. Right colic artery .

B. Middle colic artery .
C. Left colic artery .
D. Ileocolic artery .
E. Hypogastric artery .

Dr. Mahmoud W. Qandeel

 The appendiceal artery is a branch of ? ( 7 /2016)

A. Right colic artery .

B. Middle colic artery .
C. Left colic artery .
D. Ileocolic artery .
E. Hypogastric artery .

Dr. Mahmoud W. Qandeel

The most common presentation for Appendicea adenocarcinoma is ?
( 7 /2016)

A. Acute appendicitis .
B. Ascites .
C. Chronic anemia .
D. Palpable abdominal mass .
E. Incidental finding .

Dr. Mahmoud W. Qandeel

The most common presentation for Appendiceal adenocarcinoma is ?
( 7 /2016)

A. Acute appendicitis .
B. Ascites .
C. Chronic anemia .
D. Palpable abdominal mass .
E. Incidental finding .

Dr. Mahmoud W. Qandeel