APPENDICITIS

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• APPENDICITIS

DR KULWANT SINGH
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Contents
Dr Kulwant Singh
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Incidence

• Commonest abdominal surgical emergency.
• One person in six develops appendicitis at
  some time.
• It is relatively uncommon in developing rural
  communities.

Dr Kulwant Singh
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Appendicitis
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Surgical Anatomy

• The appendix is attached at the point of
  convergence of the three taeniae coli of the
  caecum on its posteromedial wall
• - The meso-appendix is a peritoneal fold
  containing fat appendicular artery
• - Commonly behind the caecum (Retrocaecal)
• - On psoas muscle at or below pelvic brim
  (Pelvic)
• - Rarely Pre-ileal Post-ileal Paracaecal
• - Length less than 1 to greater than 30cm (most
  are 6-9 cm in length)
• - After age of 60 no lymphoid tissue remains

Dr Kulwant Singh
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Surgical Anatomy
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POSITIONS OF APPENDIX
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CAUSES
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APPENDICITIS
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APPENDICITIS
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APPENDICITIS
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APPENDICITIS
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APPENDICITIS
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APPENDICITIS
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APPENDICITIS
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Acute appendicitis
- Organisms enter the wall lodge in sub mucosa
, proliferate , wall becomes red turgid - Rate
of acceleration of inflammation increase in
presence of obstruction to lumen of appendix
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Acute appendicitis with mass
Obstruction infection lead to distension with
pus hence increase intraluminal pressure lead to
venous occlusion , oedema , arterial occlusion ,
gangrene and perforation follows , rapidly
localised by defence mechanism (greater omentum
coils of bowel ) . Appendix mass is formed , can
undergo suppuration to produce an appendix abscess
Dr Kulwant Singh
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Acute appendicitis with peritonitis
- Free perforation following obstruction
infection allows infected material to disperse
widely in peritoneal cavity lead to intense
peritoneal reaction with outpouring of fluid -
Serosal surfaces of bowel become injected flaked
with clotted lymph
Dr Kulwant Singh
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Clinical Features
Abdominal pain periumblical at first , then to
right iliac fossa within a few hours it becomes
persistent . Onset is usually sudden , may arise
in right iliac fossa and remains there
Anorexia nearly always accompanies appendicitis
Vomiting occurs in about 75 of patients
(most vomit once or twice )
Retrocaecal appendix may cause flank or back
pain Pelvic appendix may cause suprapubic pain
Dr Kulwant Singh
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Clinical Features
Most patients give history of constipation before
onset of pain , diarrhea in some particularly
children
Fever Low grade Around 100 degee F Oc.
Haematuria
Murphys Triad Pain Vomiting Fever
Dr Kulwant Singh
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Clinical Features
Stage of shock pale , sweating anxious -
Elevated pulse rate - Low blood pressure -
Temperature is subnormal - Respiration is rapid
shallow - Tenderness in the RIF
Stage of perritoneal reaction Severe local
tenderness in the RIF - Rebound tenderness -
Board like rigidity - Marked rectal
tenderness RIF
Stage of flank peritonitis Abdominal distension
Absent bowel sounds Faecal vomitus
Dehydration
Appendicitis with peritonitis three stages
Dr Kulwant Singh
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CLINICAL FEATURES
LOCAL SIGNS
Tenderness of a localised persistent nature is
the most important abdominal finding , situated
at RIF , classically at McBurneys point (
junction of middle outer third of a line from
umbilicus to anterior superior iliac spine
Rigidity over RIF Rebound tenderness (best
elicited by percussion)
Tenderness on right side during rectal
examination (may be only sign with pelvic
appendicitis )
Dr Kulwant Singh
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CLINICAL FEATURES
ROVSINGS SIGN
Continuous deep palpation starting from the left
iliac fossa upwards (anti clockwise along the
colon) may cause pain in the right iliac fossa,
by pushing bowel contents towards the ileocaecal
valve and thus increasing pressure around the
appendix. This is the Rovsings sign.
Dr Kulwant Singh
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CLINICAL FEATURES
PSOAS SIGN
Psoas sign is right lower-quadrant pain that is
produced with the patient extending the hip due
to inflammation of the peritoneum overlying the
psoas muscles and inflammation of the psoas
muscles themselves. Straightening out the leg
causes the pain because it stretches the muscles,
and flexing the hip into the "fetal position"
relieves the pain.
caecum
CAECUM
Iliacus muscle
Iliacus muscle
inflamed appenix
Inflamed appendx
Psoas muscle
Psoas muscle
Dr Kulwant Singh
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CLINICAL FEATURES
OBTURATORS SIGN
Iliac tuberosity
Caecum
Inflamed appendix
Obturator internus
Ischial tubersosity
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CLINICAL FEATURES
BLOOMBERGS SIGN
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CLINICAL FEATURES
Dr Kulwant Singh
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Clinical Features
POINTING SIGN
Dr Kulwant Singh
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Alvarado Score
Above 8-9 Sure Below 5 negative 5-8
investigate
Dr Kulwant Singh
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Differential Diagnosis
Dr Kulwant Singh
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Differential Diagnosis
CHILD
ADULT
FEMALE
OLD
Dr Kulwant Singh
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Homoeopathic Medicines
Iris Tenax
Bryonia
Lycopod
Bell
Dr Kulwant Singh
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Homoeopathic Medicines
Echin.
Merc Cor
Merc Sol
Ars. Alb
Dr Kulwant Singh
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QUICK REPERTORISATION
BOERICKE APPENDICITIS TOTAL MEDICINES 30
Dr Kulwant Singh
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QUICK REPERTORISATION
KENT APPENDICITIS TOTAL MEDICINES 22
Dr Kulwant Singh
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QUICK REPERTORISATION
PHATAK APPENDICITIS TOTAL MEDICINES 20
Dr Kulwant Singh
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QUICK REPERTORISATION
CLARKE APPENDICITIS TOTAL MEDICINES 19
Dr Kulwant Singh
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Thank You