Acute appendicitis

Appendicitis is an inflammation of vermiform Appendix. which  is blind intestinal diverticulum, about 2-20 cm in length (average 9cm), which is arises from posteromedial aspect of caecum where three tenia coli are collect.

Position of appendix 

• Retrocaecal 65%
• pelvic  31%
• subcaecal 2%
• pre-ileal 1%
• post-ileal 0.4%

Blood supply of appendix

Arterial supply by appendicular artery, which is branch of ileocolic artery(ileocolic artery is branch of Right colic ,which arises from superior mesenteric  artery).

Appendicular Vein drain blood from Appendix. The Appendicular Vein drain into ileocolic vein, which ultimately  drain into Right colic vein and superior mesenteric  vein respectively.

Lymph drainage of appendix

The lymphatics drain into one or two intermediate nodes lying in the mesoappendix that eventually drain into the superior mesenteric lymph nodes.

Nerve supply to appendix

Sympathetic and parasympathetic nerve.

• Sympathetic nerve fibers originate in lower thoracic part of spinal cord.
• parasympathetic nerve fibers from  the Vagus nerve

Histology

The mucosa is  appendix is similar to the colon. That is columnar type with crypts containing numerous mucus- secreting glands. Large amount of lymphoid tissue is present in lamina propria, which is distinguishing feature of appendix.

Function  of Appendix

In herbivores, the appendix are highly developed that helps in the digestion of cellulose by bacteria. In humans, the appendix is generally recognized to be vestigial organ, but the presence of excessive amount of lymphocytes suggests that the organ may play important role in defense mechanisms against bacterial infections. 

Etiology and pathogenesis

Most common causes of acute appendicitis are festering microbes: streptococcus, staphylococcus. Microflora can be present in the cavity of appendix by the way of hematogenous  and  lymphatic.

Aggravating factor for  beginning of appendicitis include:

• Change of reactivity of organism
• Constipation and atony of intestine
• Excrement stone in its cavity
• Thrombosis of vessels of appendix 
• Gastrointestinal disease 
• Bacteria invasion

• Obstruction due to:

      1) Anatomy: wormed shaped appendix, twisting or bends of appendix.

         2) Narrow appendix

  3) Excessive lymph node

  4) Mechanical reason

  5) Excrement stone in its cavity

  6) Food residue

  7) Ascaris (Roundworm) 

  8) Tumor

Types of pathology

• Acute simple Appendicitis
• Acute purulent Appendicitis
• Gangrenous and perforated
• Appendicular abscess
• Appendicular infiltration

Clinical Features

• Most cases asymptomatic
• Suddenly pain in epigastric area later pain is localized in right iliac area (Pain does not irradiate). Pain is shift from epigastric area to right iliac area (area of appendix) after 2-4 hours of onset that is called Kocher’s symptom.

During abdomen palpation, Local tenderness is present at McBurney’s point - the junction between 1/3 from anterior superior iliac spine and 2/3 from umbilicus.

• Nausea, Vomiting
• Low grade fever
• Variable urinary symptoms include frequency & dysuria - because of an inflamed appendix close to the right
  ureter or bladder 

Sign

• Psoas sign - pain on active elevation of legs

• Obturator sign - pain on internal and external rotation of of the hip.

• Blumberg’s sign - pain felt upon sudden release of steadily applied pressure in right iliac area.

• Rovsing’s sign - Increased pain in the right lower quadrant when pressure applied on left sigmoid bowel.

• Bartomier’s sign - Pain is increase during palpation in right iliac area when patient is in left lateral position.

• Sitkovskiy’s sign - Patient is in left lateral position, feel pain in right iliac area due to displacement of caecum to the left.

• Obrazcov’s sign - Put your one hand in patient back and placed another hand in right iliac area, and when patient  elevate right leg, in appendicitis pain is present.

• Voskresensky’s sign - By a left hand the shirt of patient is drawn downward and fixed on pubis. By the taps of 2-4 fingers of right hand epigastric area is pressed and during exhalation of patient feel pain.

Diagnosis

• Anamnesis
• Clinical Examination
• Blood test - It does not give specific information of acute appendicitis but which would specify presence of inflammation(leucocytosis, shift to left).
• Urine analysis
• Vaginal examination in women to find out  the gynecological  problems(e.g. ruptured ovarian cyst, pelvic inflammatory disease).
• Rectal examination
• X-ray
• Ultrasound
• CT scan

Differential diagnosis

• Acute pancreatitis
• Acute food poisoning
• Acute cholecystitis
• Peptic ulcer and duodenal ulcer  perforation
• Right side renal colic
• Extrauterine pregnancy

Management 

Non-operative management

• Nil per oral
• Bed rest 
• Cold compression on the area of inflammation
• Parenteral fluids for maintain hydration
• Antibiotic therapy that reduce wound infection
• Symptomatic treatment

Operative management

• Appendicectomy - when the mass is explored
• If abscess is found - only drain pus

Appendicectomy can be done by two method:

• Open (make small incision)
• Laparoscopic 

Complication

• Perforation
• Abscess
• Peritonitis (rupture spreads infection throughout the abdomen)