1. Surgical pathology of the appendix
Acute appendicitis
Chronic appendicitis
Tumors of the appendix

2. Appendix
Functions – not clear in humans - it may have a significance in immune defense – abundance of lymphoid follicles
- removal of the appendix may be a cause for an increase in colonic cancer incidence - not supported by controlled studies
- endocrine function

3. “Normal” Anatomy

4. Typical position
2.5 cm bellow the ileo-cecal valve (base of appendix) the only fix region – important when trying to find the appendix
Taeniae converge at the base of the appendix
84% free mobile in any possible location
16% fixed retrocecal

5. Acute apendicitis Essentials of diagnosis Abdominal pain
Anorexia, nausea, vomiting
Localized abdominal tenderness
Low grade fever
Leukocytosis

6. General considerations
= acute inflammation of the appendix wall that starts in the mucosa and may extend to adjacent organs
70% of cases present obstruction of the proximal lumen:
Fibrous bands, fecaliths, foreign bodies
Tumors, parasites, lymphoid hyperplasia
External compression
Inflammation starts in the mucosa with ulcerations and secondary bacterial infection

7. Close tube Blood supply affected as disease progresses
Infection in the wall
Increased pressure
Puss formation inside the lumen
Wall destruction: gangrene + perforation
Bacterial peritonitis may be limited by adhesions (plastic peritonitis)

8. Clinical findings
Protean manifestation: may mimic a variety of conditions
Progression of symptoms is essential

9. Clinical findings Onset: vague abdominal discomfort Followed:
Nausea, anorexia, indigestion
Vomiting
Pain, mild, localized in the epigastrum
Pain: localized in RLQ +
Pain or discomfort (moving, walking, coughing)

10. Examination At this moment: Tenderness on coughing, localized in RLQ
Localized tenderness on palpation
Slight muscular rigidity
Rebound tenderness referred to the same area
Rectal and pelvic examination NORMAL
Low fever (<38 degrees)

11. Examination – retrocecal appendicitis
Poorly localized pain (retrocecal position – protected from the abdominal wall)
No discomfort on coughing, walking etc.
Diarrhea
Urinary symptoms (hematuria, urinary frequency)
Pain in the flank – tenderness on one finger examination

12. Examination – pelvic appendicitis
May simulate gastroenteritis
Nausea, vomiting and diarrhea are more prominent (adjacent appendix to pelvic colon)
Negative abdominal examination
IMPORTANT – repeated pelvic (rectal) examination

13. Aberrant positions
Left side appendix – confusion with diverticulitis (malrotation)
RUQ – cecum in abnormal position may mimic cholecystitis or perforated duodenal ulcer
Normal cecum – long appendix – anything is possible

14. Lab workup
High leukocyte count: average /μl, 90% more the with more then 75% neutrophils.
10% have normal formula
Urinalysis typically normal, few leukocytes or eritrocytes. Retrocecal or pelvic – special attention

15. X-Ray findings Plain X-Ray films are usually not contributory
Air-fluid levels or isolated ileus
Fecaliths
Free air in the peritoneum
Signs of peritonitis

16. CT scan

17. Ultrasound scan

18. Appendicitis in pregnancy
Same frequency as in non-pregnant
Difficult diagnosis
High position of the appendix
All usual signs are present
Difficult to interpret leukocytosis
Appendectomy is mandatory and urgent

19. Differential diagnosis

20. Differential diagnosis
Difficult in young and elderly – highest incidence of perforation
High incidence of false positive appendicitis: women PID and other genital conditions

21. Differential diagnosis
Local inflammatory conditions (enterocolitis, urinary infections, urinary stones, pelvic inflammatory disease)
Distant digestive diseases (compliacted duodenal ulcer, billiary stones)
Distant non-digestive diseases (penumonia, myocardial infarction, porphyria, lead poisoning)

22. Complications PERFORATION More severe pain Fever >38
Typically in the first 12 hours
In 50% of patients the appendix is perforated at the time of diagnosis

23. Complications PERITONITIS Localized – microscopic perforation
Increased tenderness, rigidity
Abdominal distension
Ileus
Fever high and toxicity
Douglas pouch very sensible
Generalized – classic presentation

24. Complications APPENDICEAL ABSCESS (appendiceal mass)
Localized peritonitis
Walled off by peritoneum
Symptoms of appendicitis + mass in RLQ
US + CT characteristical

25. Complications APPENDICEAL ABSCESS Differential diagnosis:
Treatment: ATB + diet low in residue
Drainage of abscess +/- appendectomy
Postponed appendectomy 8-12 weeks
Differential diagnosis:
Carcinoma of the cecum
Tumors of the appendix
Genital pathology

26. Complications
Pylephlebitis: suppurative thrombophlebitis of pportal vein
Chills, high fever, jaundice + hepatic abscess formation.
Serious septic problems
CT scan + US: thrombosis and gas in portal system
Treatment: ATB + surgery urgent

27. Treatment

31. CHRONIC APPENDICITIS

32. Chronic abdominal pain
In the RLQ
Possible recurrent attack of acute appendicitis
Other problems
Many do not consider chronic appendicitis a reality

33. Chronic appendicitis
= chronic inflammation in the wall due to multiple acute attacks
Pathology – retractions of appendix and mesoappendix and adhesions
Examination – dispepsia + pain
Workup – to exclude another pathology
Tratament – appendectomy - debatable

34. Tumors of the appendix

35. Classification Benign – fibroma - leyomioma - lypoma
Malignant – carcinoma
Bordeline - carcinoid
- mucocele

36. Benign tumors Very rare
Occasionally may obstruct the lumen and cause acute apendicitis
May arise as a mass in RLQ

37. Carcinoma Rare and never diagnosed preoperatively
Most typical presents as acute appendicitis or RLQ abscess
Prognosis: bad – 10% wide spread MTS at time of diagnosis. Rapid lymph node spread and local spread through peritoneal cavity (ovary)
Treatment: right hemicolectomy + lymph node dissection

38. Carcinoid tumor
The most common location of carcinoid in the digestive tract
Slow growth (<2 cm) and rarely MTS. 3% MTS in lymph nodes
Carcinoid sdr: attacks of vasodilation, diarrhea, abdominal colical pain, tachicardia, hipotension MTS
Examination: RLQ pain + mass

39. Carcinoid Lab workup: Treatment: Urinary 5HIA
US, CT, arteriography, bronchoscopy
Treatment:
Appendectomy
Right hemicolectomy (>2cm, invasion of cecum, invasion mesoappendix, nodes)
MTS – enucleation (<4) +/or chemotherapy

40. Mucocele Not true tumors: Clinical examination:
Chronic distension of the appendix plus continuous mucus secretion.
Flattened epithelial cells
Cystadenoma – columnar epithelium (low grade adenocarcinoma). Do not infiltrate the wall and do not produce MTS
Clinical examination:
RLQ discomfort
Mass
Rupture in peritoneum: pseudomixoma peritonei

41. Mucocele
Treatment: appendectomy

42. MUCINOUS CHIST-ADENOMA - APENDICULAR