КФУ им. В.И.

Вернадского
Медицинская академия имени С.И. Георгиевского
Кафедра Хирургии №1
доцент Косенко Александр Викторович

Acute Appendicitis
ACUTE APPENDICITIS
 Acute appendicitis is an inflammation of a
vermiform appendix caused by purulent
microflora.
Approximately 7 percent of the population will have appendicitis in
their lifetime with the peak incidence occurring between the ages of
10 and 30 years. Despite technologic advances, the diagnosis of
appendicitis is still based primarily on the patient's history and the
physical examination. The mortality rate in nonperforated
appendicitis is less than 1 %, but it may be as high as 5 % or more
in young and elderly patients, in whom diagnosis may often be
delayed, thus making perforation more likely. Prompt diagnosis and
surgical referral may reduce the risk of perforation and prevent
complications.
 Etiology and pathogenesis
Obstruction of the narrow appendiceal lumen initiates the
clinical illness of acute appendicitis. Obstruction has
multiple causes, including lymphoid hyperplasia (related to
viral illnesses, including upper respiratory infection,
mononucleosis, gastroenteritis), fecaliths, parasites, foreign
bodies, Crohn's disease, primary or metastatic cancer and
carcinoid syndrome. Lymphoid hyperplasia is more
common in children and young adults, accounting for the
increased incidence of appendicitis in these age groups.
 Classification
(by V.I. Kolesnikov)
1. Appendiceal colic.
2. Simple superficial appendicitis.
3. Destructive appendicitis:
а) phlegmonous;
б) gangrenous;
в) perforated.
4. Complicated appendicitis:
а) appendicular infiltrate;
б) appendicular abscess;
в) diffuse purulent peritonitis.
5. Other complications of acute appendicitis (pylephlebitis,
sepsis, retroperitoneal phlegmon, local abscesses of abdominal
cavity).
 Symptoms of simple appendicitis
1. Pain localized in a right iliac area.
In 70 % of patients the pain arises in a epigastric area – it is an epigastric
phase of acute appendicitis. In 2-4 hours it migrates to the area of
appendix (the Kocher’s sign).
2. Single nausea and vomiting.
3. Fever to 37.5-380C.
4. Retention of stool or single diarrhea.
5. Muscular tension in a right iliac area.
Rovsing's sign - pain in right lower quadrant during palpation of left
lower quadrant
Sitkovsky’s sign - increase of pain in a right iliac area when the patient
lies on the left side
Bartomier’s sign - the increase of pain intensity during the palpation of
right iliac area when the patient lies on the left side.
Dunphy's sign-increased pain with coughing
 Symptoms of phlegmonous appendicitis
1. Expressed pain in a right iliac area.
2. Fever to 38-390C.
3. Muscular rigidity in a right iliac area.
4. Peritoneal signs
Blumberg’s sign. After gradual pressing by fingers of anterior
abdominal wall quick taking off the hand causes the sharp
increase of pain.
Voskresenky’s sign. The increase of pain during quick sliding
movements by the tips of fingers from epigastric to right iliac
area.
Rozdolsky’s sign. Painfulness in a right iliac area during
percussion.
 Symptoms of gangrenous appendicitis

1. Pain in a right iliac area.

2. Grave condition of the patient.
3. Signs of local peritonitis.
4. Signs of intoxication
 Symptoms of retrocaecal appendicitis
1. Non-expressive abdominal clinic.
2. Expressed pain in a right lumbar area.
3. Pain and muscular rigidity in a right iliac area during
palpation.
Yaure-Rozanov sign - Painfullness during palpation of Petit
triangle
Gabay’s sign - Blumberg’s sign in Petit triangle
Pasternatsky’s sign - tapping of lumbar region cause the pain
Psoas sign - pain on extension of right thigh
 Symptoms of retrocaecal retroperitoneal
appendicitis

1. Clinic of retroperitoneal phlegmon.

2. The signs of retrocaecal appendicitis.
3. Flank tenderness in right lower quadrant.
 Symptoms of pelvic appendicitis
1. Clinic of irritation of
pelvic organs (dysuria,
pulling rectal pain, tenesmi).
2. Absence of muscular
tenderness.
3. Painfullness of anterior
rectal wall and posterior
vaginal vault.
 Symptoms of left-side appendicitis

All the appendicular signs locate on the left iliac region

 Clinic of appendicitis in children
In infants acute appendicitis occurs infrequently, but quite
often has atypical character. It results from the peculiarities
of anatomy of appendix, insufficient plastic properties of the
peritoneum, short omentum and high reactivity of child’s
organism. The inflammatory process in the appendix of
children rapidly progresses in the first half of the day,
resulting in destruction, even perforation. The children more
frequently than an adult suffer from vomiting. General
condition worsening quickly and the positive peritoneal
symptoms have been shown already during the first hours of
the disease. The temperature reaction is also considerably
expressed. In blood revealed high leukocytosis. It is
necessary to remember, that the examination of anxious
children requires to use a chloralhydrate enema.
 Clinic of appendicitis in elderly patients
This group of patients is hospitalized rather late, usually in
2-3 days after the beginning of the disease. Because of the
increased threshold of pain sensitivity, the pain in such
patients is slightly expressed, therefore they almost do not
pay attention to the epigastric phase of appendicitis.
Frequently nausea and vomiting is present, and the
temperature reaction is expressed poorly. Tension of muscles
of abdominal wall is absent or is insignificant due to old-age
relaxation of muscles. But the symptoms of irritation of
peritoneum keep the diagnostic value in this group of
patients. Thus, the sclerosis of vessels of appendix results in
initially-gangrenous forms of appendicitis in this group.
 Clinic of appendicitis during pregnancy
Enlarged uterus bends the appendix and disturbs its blood
flow resulting in appendicitis. In the first half of pregnancy
the clinic of appendicitis usually without peculiarities. In the
second half of pregnancy, the enlarged uterus displaces the
caecum together with the appendix upwards, and
overdistension of abdominal wall does not create adequate
tension. It is necessary also to remember, that pregnant
women periodically can have a moderate pain in the
abdomen and changes in the blood test. Nevertheless, psoas-
sign and the Bartomier’s sign has a diagnostic value.
 Complications

1. Appendicular infiltrate.
2. Appendicular abscess.
3. Diffuse peritonitis.
4. Pilephlebitis
 Diagnostics
1. Anamnesis.
2. Objective examination.
3. General blood and urine analyses.
4. Vaginal examination for women.
5. Rectal examination for men.
 Differential diagnostics
Systemic Genitourinary
• Diabetic ketoacidosis • Kidney stone
• Henoch-Schonlein • Pyelonephritis
purpura • Wilms' tumor
Pulmonary Other
• Pleuritis • Parasitic infection
• Pneumonia (basilar) • Psoas abscess
• Pulmonary infarction • Rectus sheath hematoma
 Differential diagnostics
Gastrointestinal Gynecologic
•Cholecystitis •Ectopic pregnancy
•Crohn's disease •Endometriosis
•Duodenal ulcer •Ovarian torsion
•Gastroenteritis •Pelvic inflammatory
•Intestinal obstruction disease
•Meckel's diverticulitis •Ruptured ovarian cyst
•Mesenteric lymphadenitis •Tubo-ovarian abscess
•Necrotizing enterocolitis
•Neoplasm (carcinoid,
carcinoma, lymphoma)
 Differential diagnostics of acute
appendicitis with perforative peptic ulcer
• Pain in the right iliac • Sharp acute diffuse pain
region • Ulcerative anamnesis
• Muscular tenderness • Absence of hepatic
in the right iliac region dullness
• Single vomiting and • On X-ray of the
diarrhea abdomen air above the
liver (air sickle)
• Rigidity of anterior
abdominal wall
 Differential diagnostics of acute
appendicitis with intestinal obstruction
• Constant pain in the right • Periodic acute diffuse pain
iliac region • Constant vomiting and
• Muscular tenderness in nausea without any relief
the right iliac region • Retention of stool and gases
• Single vomiting and • Abdominal distension
diarrhea • On X-ray of the abdomen
Kloiber's cups (air-fluid
levels)
• Splashing sound, increased
peristalsis
 Differential diagnostics of acute
appendicitis with acute cholecystitis
• Constant pain in the • Acute pain in a right
right iliac region hypohondrium with irradiation
to the scapula
• Muscular tenderness
• Muscular tenderness in a right
in the right iliac region
hypohondrium
• Single vomiting and • Vomiting by bile and nausea
diarrhea without any relief
• Ortner's symptom, phrenic
symptom, Murphy’s sign
• Increased serum bilirubin
 Differential diagnostics of acute
appendicitis with gynecologic disorders
• Constant pain in the • Acute pain in a lower part
right iliac region of the abdomen
• Muscular tenderness • Dependence on menstrual
in the right iliac region cycle
• Single vomiting and • Vaginal discharge
diarrhea • Blood by punction of
vaginal vault
• Bimanual vaginal
investigation
 Differential diagnostics of acute
appendicitis with renal colic
• Constant pain in the • Periodic acute pain in the
right iliac region lumbar region with
• Muscular tenderness irradiation to thigh
in the right iliac region • Vomiting and nausea
• Single vomiting and • Pasternatsky’s sign
diarrhea • Fresh erythrocytes in
urine analysis
Steps of operation in appendicitis
Steps of operation in appendicitis
Steps of operation in appendicitis
Steps of operation in appendicitis
Steps of operation in retrocaecal
appendicitis
Steps of operation in retrocaecal
retroperitoneal appendicitis
Thank you