Appendix Signs, Symptoms and Causes

Appendix

Appendix Introduction

Acute appendicitis is the most common emergency encountered by the general surgeons. Men have a slightly increased incidence of acute appendicitis compared to women. Incidence is 11 per 10,000 persons/year.

Appendicectomy is a simple surgery, no doubt, but sometimes it can be very difficult and disappointing— sometimes one may not be able to find the appendix.

Read And Learn More: Gastrointestinal Surgery Notes

Hence, appendicectomy should not be taken lightly. The choice of surgery today is laparoscopic appendicectomy—one advantage being one can look into all quadrants of the abdomen—not to miss other causes such as perforated duodenal ulcer (see later Valentino appendix), etc. and very helpful to detect subhepatic appendicitis.

Historical Events Related to Appendix:

• Claudius Amyand (1736) – Removed inflamed appendix from hernia sac
• Reginald Fitz (1886) – Coined the term Appendicitis
• Charles McBurney (1889) – Described McBurney point
• Kurt Semm-  Did first laparoscopic appendicectomy
• Santiaggo Horgan and –  Transvaginal removal of the Mark A Talamini appendix a procedure called
• NOTES – Natural Orifice Transluminal Endoscopic Surgery.

Appendix Development And Anomalies

Embryologically, the appendix and caecum develop as outpouchings of the caudal limb of the midgut loop in the sixth week of human development. By the fifth month, the appendix elongates into its vermiform shape, hence called the vermiform appendix. At birth, the appendix is located at the tip of the caecum but due to unequal elongation of the lateral wall of the caecum, the adult appendix typically originates from the posteromedial wall of the caecum, caudal to the ileocaecal valve. A few anomalies are given below.

1. Duplication: Duplication of the appendix is one anomaly which is further divided as follows:
   • Type 1: Single caecum—partial duplication
   • Type 2: Single caecum and 2 separate appendices
   • Type 3: Double caecum with each one having one appendix .
2. Situs inversus: In this condition, appendix is found on the left side. Adds confusion to the diagnosis of acute appendicitis.
3. Subhepatic appendix: It happens in malrotation of the gut. Patients with subhepatic appendicitis may complain of pain in the right lower quadrant. A McBurney incision is usually given only to find no appendix in that location. Laparoscopy has the advantage of looking into all quadrants of the abdomen.
4. Congenital absence of the appendix is rare

Surgical Anatomy Of The Appendix

1. It is 8–10 cm long, may vary from 3 to 30 cm in length.
2. It is situated 2 cm posteromedial to ileocaecal junction, at the point of convergence of the three taeniae coli.
3. It is the primary cause of lower abdominal pain on the right side.

Positions of the Appendix

1. Retrocaecal in about 70 % of patients (12 o’clock)
2.  Pelvic in 20% of cases (4 o’clock)
3. Preileal and postileal (2 o’clock)
4.  Subcaecal (6 o’clock)
5. Paracaecal
6. The subhepatic appendix is associated with subhepatic caecum. It occurs due to malrotation of the gut.

Layers of the Appendix

• The mesoappendix is the continuation of the mesentery of the ileum above. It comes down carrying blood vessels in the mesoappendix.
• The appendix has a serosa and a mucosa lined by columnar epithelium (similar to intestinal mucosa) between which are the circular and longitudinal muscle fibres.
• Submucosa has rich lymphoid follicles (lamina propria). The lymphatic tissue decreases as age advances. Hence, the incidence of appendicitis is less after the age of 30 years.
• Appendicular orifice is occasionally guarded by an indistinct semilunar fold of mucous membrane, known as valve of Gerlach.

Blood Supply of the Appendix

• The appendicular artery is a branch of ileocolic artery.
• The accessory appendicular artery of Seshachalam (a branch of posterior caecal artery) is a branch of ileocolic artery, which runs in the mesoappendix. Veins follow the artery and end in the superior mesenteric vein, thus draining into portal vein.
• This is the reason for development of pylephlebitis in cases of suppurative appendicitis.
• Pylephlebitis means thrombophlebitis of portal veins or its branches.

Locating the Appendix

• Trace the taenia coli or trace ileal loops at laparotomy. Taenia coli point to the base of the appendix. However, surface marking of the appendix is done as follows:
• Draw a line from the anterior superior iliac spine to the umbilicus. The junction of lateral 1/3rd and medial 2/ 3rds of this line indicates the location of the appendix.
• This is the point of maximum tenderness in appendicitis.
• This is called McBurney’s point.

Surgical Anatomy and Significance

1. The area of the maximum tenderness in acute appendicitis is called McBurney’s point—corresponds to the site of the appendix in the vast majority of the cases. This is the site selected for incision in open method.
2.  Appendicular artery must be ligated in an open or laparoscopic method—to free mesoappendix.
3.  Severe inflammation of the appendix can spread to portal vein via ileocolic vein and can result in portal pyaemia, a very dangerous condition.
4. Malrotation of the gut—the appendix may be in the subhepatic region—to be kept in mind in cases wherein the appendix is not found in the right iliac fossa.

Lymphatics

The lymphatic channels which are 4 to 6 in number drain into ileocolic nodes, ileocaecal nodes and appendicular
nodes in the mesoappendix.

Appendix Acute Appendicitis

It is one of the most common surgical emergencies encountered by general surgeons. Sometimes acute appendicitis can be dangerous.

Acute Appendicitis Definitions

1. Acute appendicitis: Sudden appearance of signs and symptoms of appendicitis
2. Recurrent appendicitis: Recurrent attacks of acute appendicitis—incidence is 15 to 25%.
3. Grumbling appendicitis: Low-grade recurrent bouts of colics, vomiting with frequent admission, self-limiting cases.
4. Simple appendicitis: If the duration of symptoms is less than 48 hours or imaging does not show any abscess or phlegmon.
5. Complicated appendicitis: Acute appendicitis with perforation or large abscess/phlegmon.
6. Pseudoappendicitis: Acute ileitis mimics appendicitis following Yersinia infection. It can also be due to Crohn’s disease.
7. Stump appendicitis: It is the inflammation and infection of residual appendicular stump (postoperative cases). To avoid stump appendicitis, one should not leave an appendicular stump longer than 3 mm.
   • Everybody should be aware of this condition.
   • Symptoms are similar to acute appendicitis.
   • More in laparoscopic appendicectomies because of lack of a three-dimensional perspective and absence of tactile feedback.
   • This can happen, if the exact junction of appendixwith caecum is not clearly identified.
   • CECT is the best investigation.
   • Rare cause of recurrent appendicitis after appendicectomy is duplicated appendicitis.
   • It may require stump appendicectomy.
8. Prevention: It is important to ligate and divide at the base of the appendix to avoid this complication (more so in laparoscopic appendicectomy).

Why Appendicitis is Dangerous?

• The appendix is a cul-de-sac (closed at one end) and can be easily blocked.
• The appendicular artery is an end-artery (gangrene can occur fast).
• Inflammatory oedema causes easy and early thrombosis of appendicular artery.
• The appendix has thin muscular coat. Hence, perforates easily.
• The lumen of the appendix is very narrow—1–3 mm in diameter.
• Closed loop obstruction: Intraluminal pressure builds up as the appendicular mucosa secretes fluid resulting in mucosal ischaemia. Slowly bacterial overgrowth and translocation occurs.

Acute Appendicitis Aetiology

1. Racial and dietary factors:

• It is more common in White race than in coloured persons. Young males are affected more often.
• It may be related to Westernization of food—a diet rich in meat precipitates appendicitis and a diet rich in fibre (cellulose) protects the person from appendicitis.

2. Familial susceptibility: It is related to having a long retrocaecal appendix in which case the blood supply is diminished to the distal portion and may precipitate appendicitis.

3. Socioeconomic status: Appendicitis is common in middle class and rich people. The exact reasons are not known.

4. Obstructive theory: Obstruction to the lumen of the
appendix due to faecoliths, worms, ova and cysts. Obstruction can also be due to lymphoid hyperplasia or neoplasm. Entamoeba causes obstructive appendicitis. It is seen only in one-third of cases

5. Non-obstructive theory: It is due to bacteria such as E. coli, enterococci, Proteus, Pseudomonas, Klebsiella and anaerobes which produce diffuse inflammation of the appendix and cause appendicitis. This seems to be more common cause than obstruction.

Acute Appendicitis Pathogenesis

Acute Appendicitis Pathology

1.  In Non-Obstructive Cases (Catarrhal Appendicitis):

• The process of inflammation is slow and gradual.
• A mild attack may completely resolve or mucosal and submucosal oedema can occur.
•  Ulceration of the appendix results in slow bacterial invasion of lymphoid tissue.
• Gangrene and perforation are rare.

2. In Obstructive Cases:

Symptoms are abrupt, vomiting is more, pain is more and tenderness is more.

It is a more dangerous variety.

• Appendix looks inflamed, with congested blood vessels. The tip especially looks more inflamed. As the inflammation is more severe, the outer aspect looks dull and purulent exudates may be seen. Areas of blackening or green colour indicate gangrene or necrosis with perforation. In acute inflammation, neutrophils are dominant and in cases of gangrenous appendicitis, vascular thrombosis is a feature.
• The important pathological events can be summarized as follows—due to obstruction, the contents get infected fast and the tension increases. The appendix becomes a closed loop, which results in septic thrombosis of vessels. Gangrene of appendix, perforation, and peritonitis, followed by a local abscess can occur.
• In children, greater omentum is very thin. Hence, it cannot localize the infection. In adults, omentum is like a fatty apron which localizes the infection.
• In aged patients, because of atherosclerosis, gangrene occurs very fast resulting in peritonitis. Obstruction is caused by faecoliths, worms and bands which cause tenting. Obstructed appendicitis is one of the examples for closed loop obstruction. Other causes are volvulus, and carcinoma hepatic flexure with competent ileocaecal valve.

Nonobstructive Theory in Acute Appendicitis

• This is seen in two-thirds of the cases. Hence, it is more common than obstructive theory.
• Bacterial or viral infection is the cause.
• It causes mucosal ulceration.
• This is followed by bacterial invasion.
• The decrease in the incidence of enteric fever in the
• Western world has decreased incidence of acute appendicitis—a support for infective theory.
• In many cases of appendicitis, the appendix is notdilated (against obstructive theory)
• Common bacteria encountered in acute appendicitis are Bacteroides fragilis, Escherichia coli, Clostridium perfringens, Streptococcus faecalis, Pseudomonas aeruginosa, etc.

Acute Appendicitis Clinical Features

• The peak incidence is in the second and third decades.
• Very uncommon before the age of two.

Symptoms:

• Pain is severe, colicky type, initially felt in the umbilical region and it is due to distension of appendix. This is a visceral pain. After a few hours, the pain localizes to the right iliac fossa. It is a somatic pain which is due to inflammation of parietal peritoneum. This type of pain is called shifting pain of acute appendicitis or migratory pain—most reliable symptom of acute appendicitis.
• Normal appendix is mobile. So, the site of maximum pain and tenderness can vary.
• Vomiting occurs once or twice due to reflex pylorospasm. It contains stomach contents. However, it is never frequent such as in intestinal obstruction.
• Appendicitis is unlikely in patients with normal appetite. Usually, patients have anorexia.
• Fever: Fever is of low grade (around 100°F) and indicates bacterial inflammation.
• Pain first, followed by vomiting and then by fever is called
• Murphy’s1 triad of symptoms of acute appendicitis (Murphy’s syndrome).
• Haematuria: Haematuria is uncommon and it is due to inflammation of retrocaecal appendix which irritates the ureter in the retroperitoneum.
• Constipation: Constipation is the usual feature, except in pre- and post-ileal appendicitis, where they produce diarrhea due to irritation of ileum.

Signs:

• Cough tenderness (Dunphy’s sig):  Indicates inflammation of parietal peritoneum. This is an important physical sign which differentiates acute appendicitis from right-sided ureteric colic.

• Tenderness and rebound tenderness: Are present at McBurney’s point. Rebound tenderness is called of peritonitis.
• Blumberg sign: It is due to inflammation of the parietal peritoneum. This physical sign can be elicited in all cases of peritonitis.
• Guarding and rigidity: Are present in the right iliac fossa in complicated appendicitis. However, guarding and rigidity of back muscles (erector spinae) indicates retrocaecal appendicitis.
• Rovsing sign: Palpation of left iliac region of abdomen produces pain in the right iliac region. It is because of displacement of colonic gas and small bowel coils impinging upon the inflamed appendix.
•  Hyperaesthesia: Hyperaesthesia in the Sherren’s triangle Sherren’s triangle is formed by anterior superior iliac spine, umbilicus and pubic symphysis. It is due to irritation of lower abdominal nerves.
• Cope’s psoas test: Seen in retrocausal appendicitis. There will be irritation of the psoas major which produces flexion at the hip. If any attempt is made to extend the hip, it produces pain.
• Cope’s obturator test: Seen in pelvic appendicitis due to irritation of the obturator muscle. Flexion and medial rotation produce pain.
•  Features of generalised peritonitis:  Are seen only when there is a rupture. Gangrene and perforation is more common in elderly patients because of atherosclerosis. In infants, the omentum is very thin without much of fat. Hence, diffuse peritonitis occurs very fast.

• Rectal examination: There is tenderness in the right rectal wall—differential tenderness.

•  Per vaginal examination: The presence of ovarian mass, tenderness on the movement of the cervix, and adnexal tenderness may suggest obstetric pathology.

Signs and symptoms vary depending on the location

Variations in Acute Appendicitis:

• Retrocaecal: Silent (no rigidity in the right iliac fossa).
• Pelvic: Causes diarrhoea.
• Postileal: Causes diarrhoea—called missed appendix.
• Subhepatic: Manifests as pain in the right iliac fossa, very difficult to remove from gridiron incision.
• In pregnancy: The location of the pain is shifted higher up and laterally.

Acute Appendicitis Investigations

1. Total WBC count:

• WBC is almost always increased above 10,000 cells/mm3, in most of the patients (95%).
• A very high white blood cell count (>20,000/mm3) suggests complicated appendicitis with gangrene or perforation.

2. Urine examination:

• Urine examination is mainly to rule out urinary tract infection, haematuria and sometimes pyuria.
• In suspected patients, pregnancy tests can also be done.

3. C-reactive protein:

• C-reactive protein is elevated in any inflammatory condition such as appendicitis.
• Elevated in the first 12 hours of any acute inflammation and is very nonspecific.
• However, if total counts and CRP levels are not elevated, the probability of acute appendicitis is almost nil.

4. Plain X-ray abdomen erect:

• X-ray is taken to rule out other causes of acute abdomen such as perforation of hollow viscous (Free gas under the diaphragm) and intestinal obstruction (multiple air-fluid levels).
• In appendicitis, one or two dilated small bowel loops may be seen in right lower region due to ileus. If a radio-opaque stone in the direction of ureter is found, it suggests ureteric colic.
• The presence of faecolith is highly suggestive of acute appendicitis in plain X-ray.

5. Abdominal:

• Abdominal ultrasound to rule out other causes including gynaecological causes. Ultrasound can demonstrate a non-compressible, a peristaltic tubular organ with a thick wall.
• It can be used to elicit probe tenderness (sensitivity of 85%, specificity of 90%).

Acute Appendicitis Advantages:

• It is a simple bedside investigation.
• Economical
• This can confirm acute appendicitis in about 50% of the patients.
• Appendicolith, pericaecal fluid collection or inflammation can be diagnosed—indirect features of acute appendicitis.
• More sensitive and specific in children—thin abdominal wall.

Acute Appendicitis Disadvantages:

• It is operator-dependent
• It is not a choice in fatty obese patient
• Gas within the dilated intestine may obscure the
  appendix

6. CECT: Contrast-enhanced CT scan is the investigation of choice (sensitivity of 90 to 100%, specificity of 90%), especially when diagnosis is not established or in atypical cases. All the findings mentioned in the ultrasound can also be defined by CT scan.

Typical CT findings:

• The appendix is more than 7 mm in diameter
• Thick inflamed wall
• Mural enhancement (target sign)
•  Periappendicular fluid or air

CT Advantages:

• More objective.
• Sensitivity and specificity is almost 95%.
• Helps to rule out carcinoma caecum, duodenal perforation, acute pancreatitis, etc.
• Can detect anomalies as in subhepatic appendicitis.

CT Disadvantages:

• Pregnant woman—it is contraindicated.
• In children—better to avoid it for the fear of radiation exposure and risk of cancer developing at a later date.
• Expensive, long time for the contrast to reach the site.
• Low fat, sensitivity is less.
• Allergy to contrast and contrast nephropathy (dehydration, high creatinine, diabetics precipitating factors).
• The importance of a CT scan is highlighted in the clinical notes given later.

7. MRI: Ideal in pregnant women.

• A 65-year-old lady was examined for features of acute appendicitis of 8 hours duration. On examination, she had McBurney tenderness but a vague mass was palpable. It is unusual for an appendicular mass to appear within 8 hours following appendicitis.
• Ovarian pathology was considered, and gynaecological opinion was requested. It was normal. CT scan was done. It revealed mucocoele of the appendix (8 cm size).
• She underwent lower midline laparotomy and it was removed. CT scan gave a correct diagnosis, and it guided the treatment policy.

Appendix Scoring System

To avoid negative appendicectomies, many scoring systems have been developed considering signs, symptoms and investigations. Most commonly used

Alvarado’s scoring system is given in below:

• Score less than 5: Not sure
• Score 5–6: Compatible
• Score 6–9: Probable
• Score more than 9: Confirmed

Alvarado Scoring System:

Even though Alvarado’s scoring is highly suggestive of appendicitis, it is only a simple and cost-effective scoring system. This can be applied when sophisticated investigations such as ultrasonography and CT scan are not available.

Surgical wisdom:

• Symptoms, signs (tenderness in McBurney point) and rebound tenderness with increased total counts, often do not need any sophisticated imaging tests.
• However, ultrasound being an extended surgical arm, it should be done.

Appendix Differential Diagnosis Of Acute Appendicitis

Innumerable conditions may mimic some signs of appendicitis. A few important conditions have been considered here.

In Children

• Enterocolitis: Enterocolitis is common in children. It presents with severe diarrhoea with blood and mucus in the stools.
• Meckel’s diverticulitis: Meckel’s diverticulitis can present with abdominal pain, vomiting, fever—signs and symptoms are similar to acute appendicitis (difficult to differentiate clinically).
• Worm ball: Worm ball is common in children in the developing countries. However, features of intestinal obstruction will be present.
• Acute iliac/mesenteric lymphadenitis: Non-shifting pain and rebound tenderness are absent. It is viral in origin and self-limiting. Neck nodes will give clue to the diagnosis.

In Young Adults

• Right-sided ureteric colic: Haematuria, severe pain from loin to groin, absence of cough tenderness help in excluding acute appendicitis.
• Amoebic typhlitis: Amoebic typhlitis is associated with diarrhoea, blood in the stools and tenderness in left iliac fossa (Manson Barr’s amoebic point of tenderness).
• Torsion of undescended testis: Absence of testis in the scrotum clinches the diagnosis.
• Meckel’s diverticulitis
• Yersinia ileitis: Acute, self-limiting inflammation of the ileum caused by Yersinia pseudotuberculosisIn Middle Age.

In Middle Age

1. Acute pancreatitis: Inflammatory exudate collects and gravitates in the right iliac fossa resulting in pain, guarding and rigidity in the right iliac fossa. History of alcohol intake, severe backache and tenderness in the epigastrium help in diagnosing acute pancreatitis.
2. Perforated duodena: Perforated duodenal l ulcer can present with pain in the right side of the abdomen due to similar causes mentioned above.
3. Acute cholecystitis: Acute cholecystitis can also present with features of acute appendicitis. However, it is common in elderly females.
4. Pain: Pain in the right iliac fossa and tenderness is due to dilated intestinal loop peristalsis as in ileocaecal tuberculosis or carcinoma caecum. Presence of an irregular and hard mass suggests carcinoma caecum.

In Females

1. Ruptured ectopic gestation: Missed periods, features of haemorrhagic shock (pallor), and extreme tenderness on movement of cervix during per vaginal examination clinch the diagnosis.
2. Pelvic inflammatory diseases:
   • These are group of inflammatory conditions affecting young women.
   • Tubo-ovarian sepsis, salpingitis and endometriosis are grouped under this.
   • Bilateral pelvic pain, high degree fever, and absence of anorexia are some of the features.
   • Tenderness is present in both iliac fossae on deep palpation—no cough tenderness.
   • Vaginal discharge helps in the diagnosis.
   • Culture for Chlamydia trachomatis and Neisseria gonorrhoeae must be obtained.
3. Midmenstrual (mittelschmerz):  Rupture of ovarian follicle occurs about 14th to 16th day and can produce
   abdominal pain.
4. Torsion of ovarian cyst: Torsion of ovarian cyst produces very severe abdominal pain with a mass.

Appendix Clinical Notes:

A 30-year-old lady was diagnosed with acute appendicitis with classical features—pain, fever, vomiting and tenderness in the McBurney’s point. A gynaecological examination revealed pelvic infection. An infected copper T was removed which was the cause of abdominal pain.

A 22-year-old man underwent appendicectomy for right-sided abdominal pain. At laparotomy, appendix was normal. However, it was removed. He continued to have abdominal pain. An ultrasound of the abdomen revealed torsion of the undescended testis. Nobody had examined his external genitalia!

A 36-year-old male who had previous history of abdominal pain underwent appendicectomy for tenderness and rebound tenderness in the right iliac fossa. Operative surgery notes said that the appendix was slightly inflamed and seropurulent fluid was present in the right iliac fossa. After 2–3 days, greenish fluid (bile) started draining out through the tube. The condition of the patient deteriorated and on reexploration this time, by midline incision revealed perforated chronic duodenal ulcer!!

Systemic Diseases

1. Pleurisy and pneumonia: Both these conditions can have radiating pain and can have guarding.
2. Porphyria: Violent intestinal colic occurs due to spasm. It is precipitated by barbiturates. Urine is orange-coloured and when it is exposed to sunlight, the colour changes to amber.
3. Pott’s spine causes compression of nerve roots— radicular pain.
4. Preherpetic pain of the 10th and 11th dorsal nerves is located over the same area. Marked hyperesthesia is present.
5.  Purpura and bleeding disorders.
6. Polyserositis syndromes: Dengue fever, leptospirosis, etc. can have peritoneal irritation and can secrete fluid in the peritoneal cavity. Ultrasound may even reveal probe tenderness. Doing an appendicectomy can be dangerous in these patients. It may worsen pre-existing conditions including pneumonia, and may result in ARDS.

A Few Special Situations: One should be careful and be firm in decision-making of appendicectomy in these cases.

1. Children and Acute Appendicitis

• Appendicitis is rare under 2 years of age because lymphatic tissue is not yet developed by that time.
• Signs are not very well located.
• Greater omentum is very thin. Perforation peritonitis is common.
• Hence, early surgery is recommended.
• Open or laparoscopic method is followed.
• Remember to rule out acute mesenteric lymphadenitis (viral), Yersinia ileitis and Meckel’s diverticulitis.

2. Pregnancy and Acute Appendicitis:

• Most common cause of abdominal pain and nonobstetric emergency in pregnancy is acute appendicitis.
• Incidence may be 1 to 1.5/1000 pregnancies.
• Symptoms of nausea and vomiting are confused for morning sickness.
• Migration of pain need not be present. Leukocytosis is seen in pregnancy cases—it is a normal occurrence.
• Tenderness is shifted because the appendix is displayed superiorly and laterally.
• Ultrasound is the investigation of choice. When in doubt MRI is a useful investigation.
• Treatment is by laparotomy and appendicectomy.
• Fetal loss is 3% but with perforation, it is 30%.
• The maternal mortality rate in perforated appendicitis is 4%

3. Acquired Immunodeficiency Syndrome (AIDS) and Appendicitis:

• Incidence of acute appendicitis is more common in
• AIDS patients: 4-fold than non-AIDS patients
• Pain is more chronic than acute
• Diarrhoea is more common
• Leukocytosis is not common
• Delay in the presentation may be present especially patients with low CD count
• Interestingly, outcomes or results are surprisingly good after surgery

Appendix Complications Of Acute Appendicitis

1. Appendicular mass:

• Following an attack of acute appendicitis, infection is sealed off by greater omentum, caecum, terminal ileum, etc. which results in a tender, soft to firm mass in the right iliac fossa.
• Presence of a mass is a contraindication for appendicectomy because it is very difficult to remove appendix from such a mass.
• An attempt to remove it may result in a faecal fistula.

Appendicular mass is treated by Ochsner and Sherren regime:

• Aspiration with Ryle’s tube to give rest to the gut, only if vomiting is present.
• Bowel care—purgatives should not be used (may cause perforation).
• Charts—temperature, pulse, respiration, diameter of the mass. Swinging temperature, and increase in size of mass indicates an appendicular abscess.
• Drugs to cover all the organisms—gram-positive, gram-negative and anaerobic organisms.
• Exploratory laparotomy should not be done. However, when the condition of the patient is not improving, there is a suspicion of an abscess and when doubtful of the diagnosis, exploration is indicated (see the clinical notes).
• Fluids: The patient is kept nil orally for one or two days. During this time, intravenous fluids are given to correct dehydration.
• After 3–4 days, the abdomen becomes soft, tenderness decreases and once stools are passed, Ryle’s tube is removed. Clear oral fluids followed by soft diet is given.
• By one week, the patient is back to normal. After 6–8 weeks, the patient is advised elective appendicectomy.
• Interval appendicectomy is not done nowadays until and unless patient has recurrent symptoms of appendicitis or there is a faecolith.
• A 60-year-old lady was diagnosed with appendicular mass and was undergoing conservative management. On the fourth day, she developed features of early septic shock.
• As the patient was not improving, a laparotomy was done. It was a case of volvulus of the caecum.

2. Perforated appendicitis

• Incidence is about 8–10%.
• More common in children and elderly patients.
• Delay in seeking medical treatment is the main factor. Other factors which precipitate perforation are diabetes mellitus, AIDS, faecolith. The pain usually localizes to the right lower quadrant, if the perforation has been walled off by surrounding intra-abdominal structures including the omentum
• Perforated appendicitis can also give rise to generalised peritonitis and septic shock
• Rigors and chills with fever of 102°F (38.9°C) or above.
• As a complication of perforation peritonitis, portal pyaemia (pylephlebitis) can develop, it can be very dangerous.
• Emergency laparotomy, appendicectomy, drainage of pus, peritoneal lavage, and antibiotics are main principles.
• It causes generalised peritonitis with 10–20% mortality rate. Mortality depends upon various factors including age, performance status and delay is presentation to the hospital. Mortality is due to uncontrolled sepsis and multiorgan failure.

Perforated appendicitis: Principles of surgery

• Careful handling of appendix, gentle separation of bowel loops.
• Crushing of base is not required. Appendicectomy is done in the usual manner.
• Drainage of abscess cavity/pus. Always drain the peritoneal cavity.
• Wound is closed but skin is not closed (prevents wound infection). Continue antibiotics for 4 to 7 days. Enteral nutrition (oral) to be started once paralytic ileus settles down.

3. Appendicular abscess :

If the infection is not controlled properly following an attack of appendicitis, an abscess can occur in relation to the appendix.

They are

1. Retrocaecal
2. Postileal and preileal
3. Pelvic
4. Subcaecal abscesses.

Clinically,it presents with high-grade fever with chills and rigors and a tender boggy swelling in the right iliac fossa or in the right lumbar region. Pelvic abscess presents with diarrhoea.

Diagnosis is by late presentation to the hospital (3–4 days) and high-grade fever with chills and rigors

Appendicular Abscess:

• Ultrasound/CT scan is done to assess the size and location of abscess.
• Abscess greater than 4–6 cm in size needs to be drained by guided percutaneous aspiration or drainage through rectum or vagina.
• Ongoing inflammation may force a surgeon to do appendicectomy (open/laparoscopic) at the same admission.
• Those who improve require appendicectomy after 6 weeks

1. Retrocaecal abscess: Retrocaecal abscess is drained by an extraperitoneal approach. An incision of 5 to 6 cm is made in the right iliac fossa and all muscles are divided. However,peritoneum is not opened. It is swept medially and pus is drained outside. Appendicectomy is done at a later date . Most of abscesses of this type are drained by ultrasound-guided pigtail catheter insertion.

2. Preileal and postileal: Preileal and postileal abscesses also can be drained by a pigtail catheter.

3. Pelvic abscess: Pelvic abscess is drained via the rectum.

4.  Subcaecal: May require extraperitoneal drainage

4. A few cases can have spreading necrotizing fasciitis of the lateral abdominal wall including inguinal region and scrotum. They require a more aggressive approach of treatment with antibiotics, debridement, appendicectomy, drainage of pus, etc.

Treatment of Acute Appendicitis

Preoperative Resuscitation:

• Once diagnosis of acute appendicitis is suspected, the patient is admitted to the hospital. IV fluids—isotonic saline or Ringer lactate is given.
• Electrolytes are corrected especially in late cases of acute appendicitis/perforation peritonitis, etc.
• Ryle’s tube is not necessary in simple appendicitis but is definitely required in complicated cases (peritonitis).
• Fluroquinolones second-generation cephalosporins along with metronidazole is given. Informed consent is taken.
• Laparoscopic emergency appendicectomy:
  • Emergency appendicectomy is offered when patient comes within 24 to 48 hours of abdominal pain. It is very important to rule out or detect a mass, especially if a decision is made to operate around 2nd or 3rd day.
  • If a mass is palpable, it is better not to operate at that time (please refer to operative surgery, appendicectomy). A few important steps are given here.
• The appendix is identified by tracing Taenia coli which converges onto the base of the appendix. Mesoappendix is divided in between ligatures. A pursestring suture is applied all around the appendix in the caecum. The appendix is divided in between ligatures, the stump is invaginated and the pursestring is tightened. The abdomen is closed in layers.

Laparoscopic appendicectomy:

• Laparoscopic appendicectomy has become more popular nowadays because of less postoperative pain, and speedy recovery.
• Benefit is maximum in obese, women and elderly patients. (see Chapter in Operative Surgery).

The algorithm of treatment of appendicitis is given in below

Problems Encountered during Appendicectomy

1. The incision is small:

• Location is higher up—one can extend the incision to about 2–3 cm in cases of slightly higher placed appendix.
• However, if it is sub-hepatic, never hesitate to close the incision and give a midline incision and do appendicectomy.
• An attempt to remove the appendix with McBurney incision, with traction and limited exposure may result in injury to ileum or colon and may result in faecal fistula.

2. Normal appendix is found:

• Look for Meckel’s diverticulitis, intestinal obstruction, stricture, etc.
• If bile is found, it means perforated duodenal ulcer— most common (Valentino).
• Close the incision and do laparotomy. If mesenteric nodes are enlarged, do lymph node biopsy.

3. Sometimes you will find some other pathologies:

Wisdom/Mistakes /Surprise for Surgeon:

1. Creeping fat: Crohn’s disease
2. Ileum: Meckel’s diverticulum
3. Mesentery: Lymph nodes
4. Peritoneum: Tubercles
5. Ovaries: Tubo-ovarian mass
6. Sigmoid colon: Diverticulitis (redundant colon)
7. Bile: Perforation of duodenal ulcer

4. Gangrenous appendix involving base:

• Problem one can face here is that the purse-string can be applied but invagination of the stump is not possible. Risk of faecal fistula is also present.
• Appendicectomy, wash and a drain is kept.

5. Difficult to isolate the appendix which is gangrenous but pus is present: Limited ileocecectomy can be done.

6. The appendix cannot be found: First, mobilise the caecum and look for subcaecal or retrocaecal sites. Look also into preileal or postileal sites. Then mobilise the ascending colon also. Agenesis of the appendix is very rare.

7. Surprise findings of carcinoma caecum: If suspicion of a carcinoma is high, hemicolectomy should be done. Otherwise, take a biopsy—do appendicectomy

Incidental Appendicectomy

It means removal of the normal appendix at laparotomy for another condition.

Examples: When you do Laparotomy and ileal resection for stricture and anastomosis. (Can we do appendicectomy?)

Ovarian cyst: Torsion (right) ovary is removed. (Can we add appendicectomy?)

Since benefits of appendicitis/appendicectomy are more in young patients, if the patient is under 30 years, it may be justifiable to do incidental appendicectomy provided it can be removed through the same incision, without much difficulty. The patient should be stable to tolerate the procedure.

Contraindications for Incidental Appendicectomy:

• Crohn’s of caecum
• Radiation treatment of caecum
• Immunosuppression
• Vascular grafted patient (aortoiliac, etc.)
• Chances of infection are high in this group of patients.
• The result will be faecal fistula—difficult to treat

Post – Appendicectomy Fistula

It can occur after appendicectomy especially when gangrene of the appendix extends to the base of the caecum.

• It can also occur, if purse-string suture is not properly applied, or injury to the terminal ileum or caecum, etc.
• Tuberculosis is one of the important causes of faecal fistula in Indian patients to be kept in mind. Actinomycosis is a rare cause of faecal fistula following appendicectomy, discharge of faeculent contents or faecal matter after appendicectomy suggests faecal fistula ).
• Usually, discharge stops after a few days provided there is no distal obstruction.
• Cases which do not respond to conservative treatment: Fistula with long tracks, complex fistula, and some diseases such as tuberculosis are managed by resection of the diseased portion of the caecum or ascending colon.

Faecal Fistula—can Occur:

• After drainage of appendicular abscess
• After appendicectomy—if purse-string sutures are not properly applied
• If the caecum is also involved by inflammation
• If the cause of appendicitis is carcinoma
• If chronic diseases develop or are present—tuberculosis,
• Crohn’s disease or actinomycosis
• If appendicitis is associated with carcinoma caecum

Clinical Note:

• A 23-year-old girl presented to the hospital with a faecal fistula following an appendicectomy of 6 months duration. It was a low-output fistula. She had a colostomy bag applied to 4 × 2 cm oval opening at the incision site in the right iliac fossa.
• CT fistulogram showed two irregular contrast-filled tracts connected to caecum, ascending colon and retroperitoneum.
• Exploratory laparotomy and limited right colectomy were done. Tubercles were noted in the peritoneum. A biopsy was taken.
• The final histopathology report was tuberculosis.
• She was put on ATT for 6 months. She recovered well.

Neoplasm Of The Appendix

1. Neuroendocrine Tumour:

• It is the most common neoplasm of the appendix , less aggressive, majority are benign and cured with simple appendicectomy.
• Goblet cell carcinoid tumour— it is more aggressive, requires right hemicolectomy. If the tumour is more than 2 cm, has more than 2 mitosis per high power field and lymphovascular invasion, it is adenocarcinoma of the appendix.

2. Carcinoma:

• It is very rare.
• Often it is colonic type. Other type is mucinous adenocarcinoma.
• Can present as acute appendicitis due to obstruction caused by the tumour
• Mucinous variety has better prognosis.
• Colonic variety should be treated by right hemicolectomy.

3. Cystic Neoplasm of the Appendix:

• Rare occurrence.
• Simple cyst (non-neoplastic mucocele) and mucinous cystadenoma (like pancreatic).
• Can attain large size.
• Diagnosis is by ultrasound/CT scan.
• Appendicectomy is the treatment of choice.
• It can rupture into the peritoneal cavity resulting in pseudomyxoma peritonei.

Mucocoele Of The Appendix

Mucocoele Definition: It means accumulation of mucus within the lumen of the appendix.

Mucocoele Causes:

• It can be a simple retention cyst due to blockage by foreign body or mucosal hyperplasia.
• It can also be due to a mucinous adenocarcinoma.

Mucocoele Pathology

• The majority of epithelial tumours of the appendix are mucin rich, thus results in gross distension.
• Mucocoeles resulting from non-neoplastic occlusion
• (simple retention cysts) rarely exceed 2 cm in diameter.
• Mucinous neoplasms of the appendix are by far the most common cause of mucocoeles.
• Mucocoeles larger than 2 cm are more likely to represent benign neoplasms.

Mucocoele Diagnosis

• It is impossible to differentiate clinically mucocoele of the appendix and acute appendicitis when they present with abdominal pain. If a mass is palpable, it can be confused with appendicular mass.
• CT scan is the investigation of choice. The anatomic relationship between the elongated cystic mass and the caecum is usually more clear at CT scan than at ultrasound.

Mucocoele Complications 

• Gross enlargement and can present as mass abdomen.
• Rupture will result in pseudomyxoma peritone
• Secondary infection: Can result in ‘empyema’ of the appendix.

Treatment: Appendicectomy.

Miscellaneous Valentino Appendix

• Rudolf Valentino was an Italian actor acting in
• Hollywood was operated for right iliac fossa pain with features of peritonitis in the early 20th century.
• Following a few days of surgery, he died of sepsis. The actual disease was perforated duodenal ulcer. This is a typical case scenario that holds true even today.
• The contents from the upper abdomen after perforation or pancreatitis, gravitate down along right paracolic gutter. The symptoms and signs mimic appendicitis.
• CT scan is the investigation needed to rule out other causes.

Appendix Post-Appendicectomy Sepsis (A Case Report)

• A 32-year-old man presented to casualty with septic shock after 5 days after appendicectomy. It was a difficult appendicectomy. The gangrene of the appendix was almost involving the base. On examination, he was having paralytic ileus and jaundice.
• The abdomen was distended—guarding was present, more in the right iliac fossa. He was admitted to the hospital.

Post-Appendicectomy Sepsis Investigations

• Total counts were 20,000 cells/cu mm: Indicating sepsis
• Urea: 51 mg%, creatinine 1.1 mg%—dehydration, pre-renal failure [K⁺]– 3.2 mmol/l, [Na⁺]– 129 mmol/l
• Total Bilirubin: 19 mg%, Direct bilirubin: 16.6 mg%
• AST: 189 IU/l, ALT: 100 IU/l, ALP: 167 IU/l
• Plain X-ray chest revealed free gas under the diaphragm.
• Remarks: It showed he was in sepsis—counts were elevated, urea was high—renal failure set in slowly, increased bilirubin levels—sepsis with cholestasis.
• CT scan: Done after hydration—showed pneumoperitoneum and liver cyst (incidental) and free fluid in the peritoneal cavity

Conclusion: He was in sepsis. The probable reason was that the appendicular base (stump) had given way.

Post-Appendicectomy Sepsis Exploratory Laparotomy

• Faecal peritonitis
• One litre of frank purulent pus in the peritoneal cavity.
• Gangrene of lateral wall of caecum with sloughing of caecal wall.
• Appendix not seen—post-appendicectomy
• Ileum normal
• Cystic lesion on the anterior surface of right lobe of the liver
• The rest of the viscera was normal.

Post-Appendicectomy Sepsis Procedure

• Limited resection of the ileocaecal segment and endtoend ileo-ascending colon single layer anastomosis
• Peritoneal lavage
• Drains in the pelvis and subhepatic space
• Skin not closed (wound infection is very common)

Post-Appendicectomy Sepsis Postoperative

• 6th Postoperative Day:
  • Patient had greenish discharge from the right DT.
  • Anastomotic leak and enterocutaneous fistula was suspected.
  • The patient was passing flatus.
  • RS: Basal crepitations
  • Managed conservatively
  • TPN was given for 5 days.
  • Discharge subsided by 5 days.
• 8th Postoperative Day:
  • Breathlessness
  • Fever
  • Hypoxia: SpO₂: 85%
  • Chest X-ray—pneumonia
  • Intubated, ventilated for 5 days, appropriate antibiotics
  • By 20th day, he was discharged from the hospitalleak had stopped.

This case report has been given here for the following message:

• Acute appendicitis can be dangerous.
• Leak should be suspected if a patient who underwent appendicectomy does not improve in the postoperative period.
• High total count, increased bilirubin, and oliguria suggest sepsis.
• CT scan is the best investigation in such cases. When in doubt re explore. The danger lies in delay, not in surgery.

Interesting ‘Most Common’

1. The most common surgical emergency encountered by a general surgeon is acute appendicitis.
2. The most common emergency surgery is appendicectomy.
3. The most common non-obstetric surgical disease of the abdomen during pregnancy is acute appendicitis
4. The most significant symptom of acute appendicitis is migratory pain.
5. The most significant sign of acute appendicitis is rebound tenderness in McBurney’s point
6. The most prominent scoring system to diagnose acute appendicitis is the Alvarado score.
7. The most common anaerobic bacteria in acute appendicitis is
8. Bacteroides fragilis and aerobic bacteria is Escherichia coli.
9. The most common complication after appendicectomy is wound infection.
10. Most common age group for acute appendicitis is below 40 years.
11. The most common neoplasm of the appendix is carcinoid tumour.

Appendix Multiple Questions And Answers

Question 1. The most common position of the appendix is:

1. Subhepatic
2. Subcaecal
3. Retrocausal
4. Pelvic

Answer: 1. Subhepatic

Question 2. The incidence of appendicitis is less after 30 years because:

• The appendix undergoes involution
• The lymphatic tissue in the appendix decreases
• Most people would have had their appendices removed
• The vascularity reduces

Answer:  2. The lymphatic tissue in the appendix decreases

Question 3. The name Seshachalam is associated with which of the following arteries?

1. Accessory appendicular artery
2. Appendicular artery
3. Ileocolic artery
4. Posterior caecal artery

Answer: 1. Accessory appendicular artery

Question 4. The appendicular orifice is occasionally guarded by an indistinct semilunar fold of mucous membrane called:

1. Valve of Gerlach
2. Valve of Heister
3. Valve of Kerckring
4. Valve of Houston

Answer: 1. Valve of Gerlach

Question 5. The most common scoring system used for appendicitis is ___________ scoring system.

1. Child-Pugh
2. Furtado
3. Murray
4. Alvarado

Answer: 4. Alvarado

Question 6. Palpation of left iliac region of the abdomen produces pain in the right iliac region in appendicitis because of

1. Sympathetic reaction
2. Displacement of colonic gas and small bowel coils
3. Sigmoid colon is also affected
4. Ileocolic reflex

Answer: 2. Displacement of colonic gas and small bowel coils

Question 7. Cope’s psoas test is positive in

1. Retrocaecal appendicitis
2. Pelvic appendicitis
3. Preileal appendicitis
4. Subcaecal appendicitis

Answer: 1. Retrocaecal appendicitis

Question 8. Rebound tenderness in acute appendicitis is called

1. McBurney’s sign
2. Blumberg’s sign
3. Rovsing’s sign
4. Sherren’s sign

Answer: 2. Blumberg’s sign

Question 9. The most common cause of non-obstetric emergency with abdominal pain in pregnancy is due to

1. Acute appendicitis
2. Acute cholecystitis
3. Acute gastritis
4. Acute hepatitis

Answer: 1. Acute appendicitis

Question 10. Contraindications for incidental appendicectomy include all of the following except

• Crohn’s of caecum
• Radiation treatment of the rectum
• Immunocompetent individuals
• Previous vascular reconstruction in the abdomen

Answer:  3. Immunocompetent individuals

Question 11. The following statement is TRUE about appendicular abscess

• Abscess greater than 4–6 cm in size needs to be drained by laparotomy
• Appendicectomy must be done along with laparotomy for appendicular abscess
• Can present with diarrhoea
• Conservative management is advised till the inflammation settles down.

Answer: 3. Can present with diarrhoea

Question 12. Most common aerobic bacterium involved in acute appendicitis is

1. Salmonella typhi
2. Streptococcus
3. Escherichia coli
4. Clostridium perfringens

Answer: 3. Escherichia coli

Question 13. The following statement is about occurrence of faecal fistula following appendicectomy

• Faecal fistula can occur if the cause of appendicitis is carcinoma caecum
• Faecal fistula can occur if chronic diseases such as tuberculosis is present
• Faecal fistula can occur if purse string sutures are not applied properly
• It is always due to actinomycosis

Answer: 4. It is always due to actinomycosis

Question 14. The most reliable symptom of acute appendicitis is

1. Fever
2. Migratory pain
3. Right iliac fossa pain
4. Vomiting

Answer:  2. Migratory pain

Question 15. Appendicular perforation is common because of the following reasons except

1. The appendix is a cul-de-sac
2. It has a blood supply with profuse collaterals
3. It has a narrow lumen
4. The muscle coat of appendix is thin

Answer:  2. It has blood supply with profuse collaterals

Question 16. Appendicular mucosa contains the following except(predominantly)

1. Columnar epithelium
2. Neuroendocrine cells
3. Goblet cells
4. Paneth cells

Answer:  4. Paneth cells

Question 17. About Paneth cells following are true except

1. They are found mainly in colon
2. Found just below the crypts of Lieberkühn
3. Have antibacterial property
4. They produce lysozymes

Answer:  1. They are found mainly in the colon

Question 18. Following precautions have to be taken to treat appendicitis in a pregnant lady in the 2nd trimester except

1. Initial evaluation should be by ultrasound imaging
2. MRI is the most ideal imaging
3. Gadolinium contrast should be used
4. Open (Hasson) technique is used in laparoscopic appendicectomy

Answer: 3. Gadolinium contrast should be used