1. APPENDICITIS
DR KULWANT SINGH

2. Contents 1 Definition 2 Pathophysiology 3 Clinical Features 4
Diagnosis 4
Differential Diagnosis 5
Treatment 6
Dr Kulwant Singh

3. Commonest abdominal surgical emergency.
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

4. INFLAMMATION OF APPENDIX IS APPENDICITIS
Generally Caused by an obstruction: Faecalith. Lymphoid obstruction, Infection.
Dr Kulwant Singh

5. 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

6. Surgical Anatomy Predisposing factors : 1- Obstructive agents
2- Infective agents
Obstructive agents
Foreign bodies :
animal (e.g. thread worms ,round worms) ,
vegetables (e.g. seeds , date stones)
mineral (faecalith = common cause)
submucous lymphoid tissue hyperplasia leads to obstruction
Dr Kulwant Singh

7. POSITIONS OF APPENDIX
Dr Kulwant Singh

8. CAUSES Infective agents :
Primary infection leading to lymphoid hyperplasia
Secondary infection caused by pressure of an obstructed agent leads to epithelial erosion and bacteria gain access to the wall
Both aerobic & anaerobic organisms are involved including ( coliforms , enterococci , bacteroids & other intestinal commensals )
Dr Kulwant Singh

9. APPENDICITIS PATHOPHYSIOLOGY
Acute appendicitis is thought to begin with obstruction of the lumen
Obstruction can result from food matter, adhesions, or lymphoid hyperplasia
Mucosal secretions continue to increase intra luminal pressure
Dr Kulwant Singh

10. APPENDICITIS PATHOPHYSIOLOGY
Eventually the pressure exceeds capillary perfusion pressure and venous and lymphatic drainage are obstructed.
With vascular compromise, epithelial mucosa breaks down and bacterial invasion by bowel flora occurs.
Dr Kulwant Singh

11. APPENDICITIS
PATHOPHYSIOLOGY
Increased pressure also leads to arterial stasis and tissue infarction
End result is perforation and spillage of infected appendiceal contents into the peritoneum
Dr Kulwant Singh

12. APPENDICITIS
PATHOPHYSIOLOGY
As inflammation continues, serosa and adjacent structures become inflamed
This triggers somatic pain fibers, innervating the peritoneal structures.
causing pain in the
RLQ
Dr Kulwant Singh

13. APPENDICITIS
PATHOPHYSIOLOGY
The change in stimulation form visceral to somatic pain fibers explains the classic migration of pain in the peri-umbilical area to the RLQ seen with acute appendicitis.
Dr Kulwant Singh

14. APPENDICITIS PATHOPHYSIOLOGY
Exceptions exist in the classic presentation due to anatomic variability of the appendix
Appendix can be retrocecal causing the pain to localize to the right flank
In pregnancy, the appendix ca be shifted and patients can present with RUQ pain
Dr Kulwant Singh

15. APPENDCITIS WITH PERITONITIS
APPENDICITIS
TYPE
ACUTE
APPENDCITIS
APPENDCITIS WITH MASS
APPENDCITIS WITH PERITONITIS
Dr Kulwant Singh

16. 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
Dr Kulwant Singh

17. 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

18. 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

19. Clinical Features 1 3 2
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

20. Clinical Features 5 4 6
Most patients give history of constipation before onset of pain , diarrhea in some particularly children
Fever
Low grade
Around 100 degee F
Oc. Haematuria
Murphy’s Triad
Pain
Vomiting
Fever
Dr Kulwant Singh

21. Clinical Features 1 3 2 Appendicitis with peritonitis : three stages
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

22. CLINICAL FEATURES LOCAL SIGNS
Tenderness of a localised & persistent nature is the most important abdominal finding , situated at RIF , classically at McBurney’s 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

23. CLINICAL FEATURES ROVSING’S 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 Rovsing’s sign.
Dr Kulwant Singh

24. CLINICAL FEATURES PSOA’S 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

25. CLINICAL FEATURES OBTURATOR’S SIGN
Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur..
Dr Kulwant Singh
Iliac tuberosity
Caecum
Inflamed appendix
Obturator internus
Ischial tubersosity

26. CLINICAL FEATURES BLOOMBERG’S SIGN
Also referred as rebound tenderness. Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes severe pain on the site indicating positive Blumberg's sign and peritonitis.
Dr Kulwant Singh

27. CLINICAL FEATURES MCBURNEY’S SIGN
To elicit Mcburney’s sign patient should be in supine position with his knees slightly flexed and his abdominal muscles relaxed. Palpate deeply and slowly in the right lower quadrant over McBurney’s point located about 2” from the Rt. Ant. Sup. Iliac Spine. On a line between the spine and umbilicus (1/3rd outer side). Point pain and tenderness is a positive sign and indicates appendicitis.
Dr Kulwant Singh

28. Clinical Features SIGNS B A C F D E UNWELL LOOK COATED TONGUE
FOUL BREATH
COUGH TENDERNESS
TACHYCARDIA
POINTING SIGN
Dr Kulwant Singh

29. Rt Iliac Fossa Tender (2)
Alvarado Score
Above 8-9: Sure
Below 5: negative
5-8: investigate
Anorexia
Nausea and Vomiting
Fever
Leucocytosis (2)
Shift to left
Rebound Tenderness
Rt Iliac Fossa Tender (2)
Rt Iliac Fossa Pain
Dr Kulwant Singh

30. Differential Diagnosis
Ca Caecum
Perforated P.U.
Empyema GB
Renal Mass
Ovarian cyst
Fibroid uterus
Crohn’s disease
Ureteric calculus
Ileo caecal TB
Liver and GB inflamm.
Eterocolitis
Pancreatitis
Rt Lobar Pneumonia
Ectopic gestation
Worm Ball
Oophoritis
Dr Kulwant Singh

31. Differential Diagnosis
Gastroenteritis, Mesenteric adenitis, Meckel’s diverticulum, Intussception
Regional enteritis, Ureteric Colic, Perforated P.U., Torsion of Testis, Pancreatitis
Pelvic Inflammatory Diseases, Pyelonephritis, Ectopic Pregnancy, Ovarian Cyst, Endometriosis, uterine fibroids.
Diverticulitis, intestinal obstruction, carcinoma colon etc.
CHILD
ADULT
FEMALE
OLD
Dr Kulwant Singh

32. Homoeopathic Medicines
Specific. Severe Pain Rt Groin. > warmth, Dryness of mouth and eyes
Pain RIF, >rest <motion, Constipation, Dryness of m.m., Thirst ++. Vomiting.
Pain RIF, Dyspepsia, Constipation, <4-8 PM, sedentary habit, intellectual person, lack of exercise,
Acute stage, severe pain, violent, unbearable, sudden onset. Vomiting. High Fever
Iris Tenax
Bryonia
Lycopod
Bell
Dr Kulwant Singh

33. Homoeopathic Medicines
Chronic, suppurative and inflammation persists, pain with fever
Violent and Active. Caecal region painful. Tenesmus. Hot urine passed drop wise.
Pain RIF, dysenteric stool, bruised sensation, tender lump in RIF, perspiration ++
Sepsis, Chills, Restlessness, Prostration, Diarrhoea, Fever, Fear of Death
Echin.
Merc Cor
Merc Sol
Ars. Alb
Dr Kulwant Singh

34. BOERICKE APPENDICITIS TOTAL MEDICINES: 30
QUICK REPERTORISATION
BOERICKE
APPENDICITIS
TOTAL MEDICINES: 30
Dr Kulwant Singh

35. KENT APPENDICITIS TOTAL MEDICINES: 22
QUICK REPERTORISATION
KENT
APPENDICITIS
TOTAL MEDICINES: 22
Dr Kulwant Singh

36. PHATAK APPENDICITIS TOTAL MEDICINES: 20
QUICK REPERTORISATION
PHATAK
APPENDICITIS
TOTAL MEDICINES: 20
Dr Kulwant Singh

37. CLARKE APPENDICITIS TOTAL MEDICINES: 19
QUICK REPERTORISATION
CLARKE
APPENDICITIS
TOTAL MEDICINES: 19
Dr Kulwant Singh

38. Thank You