THE APPENDIX

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The
APPENDIX
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• Surgical Anatomy
• Function of the Appendix
• Acute Appendicitis
• Problem areas in Diagnosis
• Tumors of the Appendix

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Surgical
ANATOMY
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• ? Appendix is a blind intestinal diverticulum
  (6-10 cm) in length arises from the postero
  medial aspect of the caecum inferior to the
  ileocaecal junction origin where it arises from
  the site at which the three taeniae coli
  collect. The appendix has short ? Mesentery
  (The Meso- appendix).
• ? The position of the appendix is variable can
  lie , retrocaecal (75), pelvic (20) front or
  behind the ileum 5 and paracolic.
  

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• ? The blood supply by the appendicular artery
  which arises from the ileocolic artery and the
  only blood supply so therefore an end artery
  which arises from the superior mesenteric artery
  drain by ileocolic vein.
• ? The lymphatic pass to the LN in the
  mesoappendix and to the ileocolic LN along the
  ileocolic artery than to SM LN.

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• ? Nerve supply of the appendix derives from
  sympathetic and parasympathetic. The
  sympathetic nerve fibres originate in the lower
  thoracic part of the spinal cord and the
  parasympathetic nerve fibres from the vagus
  nerve.

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Function
of the
APPENDIX
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• The development of the lymphoid tissues in
  it, wall during childhood suggest may have
  immunological function by secretion of
  Immunoglobulins.
• The function of the appendix in adolescence
  and adult is regress as lymphoid tissues regress
  in elderly. The appendix lumen obliterated by
  fibrosis.

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Incidence

• Acute appendicitis is the most common acute
  surgical emergency of the abdomen.
• The disease occurs at all ages but most
  frequently below age 40 years specially, between
  the ages 8-14. It is very rare below the age of
  two.
• The sex ratio is 11 prior to puberty adult MF,
  21. However the incidence is decreased for last
  10 years. This may be due to better diagnosis,
  changing in dietary habit, better nutrition, high
  vit intake and antibiotics.

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Aetiology and Pathogenesis

• The combination of obstruction and infection
  required to produce acute appendicitis.
• The common causes of obstructive appendicitis
  include
• Swelling of the lymphoid tissues of the
  appendix
• Adhesions
• F.B
• Worms Contd

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• Tumor of the appendix or caecum
• Once obstruction has occurred it follows by
  distension with secretion and compression of the
  veins draining the appendix. Then follow
  arterial stasis than infarction of the mucosa and
  invasion of the wall by bacteria, finally to
  reach the peritoneal cavity.

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Diagnosis of the Acute Appendicitis

• History

Clinical Examination
Investigations
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Clinical features

• generalized (visceral pain) 1-12 h0
• (a) Pain localized (somatic pain)
• (b) Anorexia, nausea and vomiting (1-3 times)

Other Presentations
According to localization of the appendix.
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Signs of Acute Appendicitis

• Abdominal examination reveals the following
  signs
• a- Localized rebound (tenderness)
• b- Rigidity
• c- Rovsings sign
• d- Anterior tenderness on rectal examination
• e- Fever between 37.3 38.50c
• f- Psoas sign

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Investigations

• Moderate leukocytosis 10000 to 18000 /mm3
• Urine analysis - normal
• Radiology the diagnosis of acute appendicitis
  based on history and clinical finding x-rays used
  for D/D or complications of appendicitis (plain
  abdomen and chest x-ray)

1.
2.
3.
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Problem Areas in Diagnosis

• Appendicitis in infancy.
• Appendicitis during pregnancy.
• Appendicitis in the elderly
• Appendicitis developing in hospital

1.
2.
3.
4.
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Complications of
ACUTE APPENDICITIS

• Pre-operative complications
• Post-operative complications

A.
B.
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PRE-OPERATIVE COMPLICATIONS

• Perforation
• Appendicular abscess
• Portal pyaemia
• Peritonitis

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POST-OPERATIVE COMPLICATIONS
(local)

• Bleeding
• Urinary retention
• Wound infection
• Intra peritoneal abscess
• Post app. fistula
• Intestinal obstruction

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Treatment of
ACUTE APPENDICITIS
1.

• Appendicectomy
• Conservative TR (Ochsner Sherren)
• Is indicated when a palpable mass is present in
  RIF, but contra indicative the following
  condition.
• ? Children below 10 years of age
• ? Elderly patients
• ? Diabetic patients
• ? Doubtful diagnosis

2.
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DIFFERENTIAL DIAGNOSIS

• The diagnosis of acute appendicitis is
  essentially clinical and rest on the finding of
  pain, tenderness and guarding in RIF.
• Gastroenteritis
• Intestinal obstruction
• Acute mesentric adentitis
• Uretric colic
• Intussusception
• crohns disease

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• Ileococal TB
• Acute Salpingitis (PID)
• Rupture ectopic pregnancy
• Twisted ovarian cyst
• perforated peptic ulcer
• acute pancreatitis
• Meckels diverticulum
• Henoch-Schonlein purpua

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Problems during
APPENDICECTOMY

• Normal appendix or (Lilly white) appendix
• Lumps in the appendix
• Mucocele of the appendix
• Acute terminal ileitis
• Meckels diverticulum

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CHRONIC APPENDICITIS
(The grumbling appendix)

• Recurrent about of RIF pain occur and are
  labelled as grumbling appendix due to recurring
  about of low grade appendicitis. These patients
  may have several admission for abdominal pain and
  this is justifiable to remove the appendix when
  other investigations prove negative.

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TUMORS OF THE APPENDIX

• Neoplasms of the appendix are very uncommon and
  are usually diagnosed at operation or autopsy.
• (1) Adenocarcinoma
• (2) Carcinoid Tumor