1. Investigations

2. The diagnosis of AA is essentially clinical
The diagnosis of AA is essentially clinical. However, a decision to operate based on clinical suspicion alone can lead to the removal of a normal appendix in 15–30 % of cases. A clinical & laboratory-based scoring system: Alvarado score is most widely used to assist diagnosis

3. The Alvarado (MANTRELS) score.
Score * Symptoms: Migratory RIF pain 1 Anorexia 1 Nausea and vomiting 1 * Signs: Tenderness (RIF) 2 Rebound tenderness 1 Elevated temperature 1 * Laboratory: Leukocytosis 2 Shift to left 1 Total: 10

4. - A score of 7 or more: is strongly predictive of AA
- A score of 7 or more: is strongly predictive of AA. - Equivocal score (5–6): US or CT may needed. US is useful in children and thin adults: particularly if gynaecological pathology is suspected, with a diagnostic accuracy in excess of 90 % . Contrast-enhanced CT scan is useful in particularly older patients: in whom acute diverticulitis, intestinal obstruction and neoplasm are possible DD.

5. Preoperative investigations in appendicitis
- Routine: Full blood count, Urinalysis. Selective: Pregnancy test, Urea and electrolytes, Supine abdominal radiograph US of the abdomen/pelvis, Contrast-enhanced abdomen and pelvic CTscan.

6. Treatment

7. The traditional treatment for AA is appendicectomy
The traditional treatment for AA is appendicectomy. but conservative management in those thought not to have obstructive appendicitis: treatment is : - bowel rest & - IV antibiotics, (metranidazole & third-generation cephalosporin). ( successful outcomes in 80–90 %, but there is an approximately 15 % recurrence rate within one year). This approach should be considered in patients with high operative risk (multiple comorbidities).

8. Appendicectomy is emergency (out of hours) operation is essential to prevent the increased morbidity & mortality of peritonitis.
Preoperative preparation:
* IV fluids, to establish adequate urine output
* Appropriate antibiotics should be given.
* Hyperpyrexia in children treated with salicylates.

9. Appendicectomy:

10. I: Conventional appendicectomy. II: Laparoscopic appendicectomy.
Appendicectomy performed under general anaesthetic with the patient supine on the operating table.
2types:
I: Conventional appendicectomy.
II: Laparoscopic appendicectomy.

11. I: Conventional appendicectomy.
Incisions:
1- Gridiron incision: made at right angles to a line joining the anterior superior iliac spine to the umbilicus, its centre along at McBurney's point .
it is possible to convert the gridiron to a Rutherford Morison incision by cutting the internal oblique and transversus muscles in the line of the incision.

12. 1: Gridiron incision for appendicitis, at right angles to a line joining the anterior superior iliac spine and umbilicus, centred on McBurney's point.  

13. 2- Lanz incision (transverse skin crease): is made approximately 2 cm below the umbilicus centred on the midclavicular–midinguinal line . When necessary, the incision may be extended medially, with retraction or division of the rectus abdominis muscle.

14. 2 :Transverse or skin crease (Lanz) incision for appendicitis, 2 cm below the umbilicus, centred on the midclavicular–midinguinal line.

15. 3- lower midline abdominal incision: When the diagnosis is in doubt & it is preferred over a right lower paramedian incision.

17. Removal of the appendix:
- Caecum is identified by the presence of taeniae coli. - Caecum is delivered out. - Base of the mesoappendix is clamped in artery forceps, divided and ligated . - Appendix is crushed near its junction with the caecum in artery forceps. - Ligature is tied around the crushed portion close to the caecum. - Purse-string or ‘Z’ suture may then be inserted into the caecum.

19. II: Laparoscopic appendicectomy:
The most valuable aspect of laparoscopy in the management of suspected appendicitis is as a diagnostic tool, particularly in women of child-bearing age. Patients who undergo laparoscopic appendicectomy have less postoperative pain & discharged from hospital & return to activities of daily living sooner than those have undergone open appendicectomy. There is advantage for laparoscopic over open appendicectomy in obese and early pregnancy.

21. Appendix abscess

22. Failure of resolution of an appendix mass or continued spiking pyrexia usually indicates that there is pus within the phlegmonous appendix mass.
US or CT scan may identify an area suitable for the insertion of a percutaneous drain.
Rarely, this is unsuccessful and laparotomy through a midline incision is indicated.

23. Pelvic abscess

24. Pelvic abscess formation is an occasional complication of appendicitis Can occur irrespective of the position of the appendix within the peritoneal cavity. The most common presentation is a spiking pyrexia several days after appendicitis. Pelvic pressure or discomfort associated with loose stool or tenesmus is common.

25. Rectal examination reveals a boggy mass in the pelvis, anterior to the rectum, at the level of the peritoneal reflection . Pelvic US or CT scan will confirm. Traditionally, treatment is through transrectal drainage under GA or radiologically guided percutaneous drainage.

26. Management of an appendix mass:

27. The standard treatment is the conservative : Ochsner–Sherren regimen
The standard treatment is the conservative : Ochsner–Sherren regimen. is based on: that the inflammatory process is already localised & surgery is difficult & dangerous. It may be impossible to find the appendix and, occasionally, a faecal fistula may form. For these reasons, it is wise to observe a non-operative programme but to be prepared to operate if clinical deterioration occur .

28. Careful recording of the patient's condition and the abdomen regularly re-examined. - mark the the mass on the abd wall by skin pencil. - CT examination of the abdomen should be performed. - start antibiotic therapy. An abscess, if present, should be drained radiologically. Temperature and pulse rate should be recorded 4-hourly and a fluid balance record maintained. Clinical deterioration or evidence of peritonitis is an indication for early laparotomy.

29. Criteria for stopping conservative treatment of an
appendix mass:
- A rising pulse rate.
- Increasing or spreading abdominal pain.
- Increasing size of the mass.

30. Clinical improvement is usually evident within 24–48 hrs Failure of the mass to resolve should raise suspicion of a carcinoma or Crohn's disease. Using this regimen, 90 % of cases resolve.

31. The great majority of patients will not develop recurrence, and it is no longer considered necessary to remove the appendix after an interval of 6–8 weeks. Patients over the age of 40 should have colonoscopy and follow-up imaging to ensure resolution as a small minority (less than 5 %) may have an underlying appendicular or colonic malignancy.

32. Checklist for unwell patient following appendicectomy:
- Examine the wound and abdomen for an abscess.
- Consider a pelvic abscess & perform PR.
- Examine the lungs – pneumonitis or collapse.
- Examine the legs – consider venous thrombosis.
- Examine the conjunctivae for an icteric tinge and the liver for enlargement, and enquire whether the patient has had rigors (pylephlebitis).
- Examine the urine for organisms (pyelonephritis).
- Suspect subphrenic abscess.

33. Postoperative complications following appendicectomy :

34. 1- Wound infection: The most common postoperative complication
1- Wound infection: The most common postoperative complication. Presents with pain and erythema of the wound on the 4th or 5th postoperative day. Treatment is by wound drainage and antibiotics. The organisms responsible are a mixture of Gram-negative bacilli and anaerobic bacteria.

35. 2- Intra-abdominal abscess:
8% following appendectomy develop intra-abdominal abscess.
Spiking fever, malaise and anorexia developing 5–7 days is suggestive of an intraperitoneal collection.
(Interloop, paracolic, pelvic and subphrenic )
US and CT scanning facilitate diagnosis and allow percutaneous drainage.
Laparotomy should be considered in patients suspected of having intra-abdominal sepsis.

36. 3- Ileus: A period of adynamic ileus is to be expected after appendicectomy but Ileus persisting for more than 4 or 5 days, particularly in the presence of a fever, is indicative of continuing intra-abdominal sepsis and should prompt further investigations . 4- Respiratory: postoperative analgesia & physiotherapy reduce the incidence. 5- Venous thrombosis and embolism: are rare after appendicectomy.

37. 6- Portal pyaemia (pylephlebitis):
rare but very serious complication of gangrenous appendicitis associated with high fever, rigors & jaundice.
It is caused by septicaemia in the portal venous system and leads to the development of intrahepatic abscesses (often multiple).
Treatment is with systemic antibiotics and percutaneous drainage of hepatic abscesses.

38. 7- Faecal fistula: Leakage from the appendicular stump occurs rarely, Occasionally, a fistula may result following appendicectomy in Crohn's disease. 8- Adhesive intestinal obstruction: The most common late complication of appendicectomy Occasionally, chronic pain in the RIF is attributed to adhesion formation after appendicectomy. In such cases, laparoscopy is of value in confirming the presence of adhesions and allowing division.

39. Recurrent acute appendicitis
Appendicitis is notoriously recurrent. The attacks vary in intensity and may occur every few months, and the majority of cases ultimately culminate in severe AA. The appendix in these cases shows fibrosis indicative of previous inflammation . Chronic appendicitis, per se, does not exist;

40. Neoplasms of the appendix

41. 1- Carcinoid tumours:
Carcinoid tumours ( argentaffinoma) arise in argentaffin tissue (Kulchitsky cells of the crypts of Lieberkühn).
Carcinoid tumour is found once in every 300–400 appendices subjected to histological examination & is ten times more common than any other neoplasm of the appendix.

42. In many instances, the appendix had been removed because of symptoms of subacute or recurrent appendicitis. The tumour can occur in any part of the appendix, but it is frequently found in the distal third. Unlike carcinoid tumours arising in other parts of the intestinal tract, carcinoid tumour of the appendix rarely gives rise to metastases.

43. Treatment: is appendicectomy but right hemicolectomy is indicated if:
1- Caecal wall is involved.
2- Tumour is 2 cm or more in size.
3- Lymph nodes involvement.

44. 2- Goblet cell carcinoid tumour:
unusual variant, which exhibits a combination of endocrine and glandular differentiation.
3- Primary Adenocarcinoma:
is extremely rare.
4- Mucinous cystadenoma.