“THE STUDY OF CLINICO-PATHOLOGICAL CONDITION OF ACUTE APPENDICITIS”

By Dr. VISHWANATH .P. SHIMPI

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY in

GENERAL SURGERY

Under the Guidance of DR. SANGANNA KOLLUR

DEPARTMENT OF SURGERY M.R. MEDICAL COLLEGE, GULBARGA-585105

SEPTEMBER-2005.

i

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

DECLARATION BY THE CANDIDATE I here by declare that this dissertation/ thesis entitled “THE STUDY

OF CLINICO-PATHOLOGICAL CONDITION OF ACUTE

APPENDICITIS” is a bonafide and genuine research work carried out by

me under the guidance of Dr.SANGANNA KOLLUR, professor,

Department of Surgery.

Date:

Place: GULBARGA Dr. VISHWANATH.P. SHIMPI.

ii

RAJIV GANDHI UNIVERSITY OF HEALTH SICENCES,

KARNATAKA, BANGALORE

CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “ THE STUDY

OF CLINICO-PATHOLOGICAL CONDITION OF ACUTE

APPENDICITIS” is a bonafide research work done by

Dr. VISHWANATH.P. SHIMPI in partial fulfillment of the requirement

for the degree of MASTER OF SURGERY in GENERAL SURGERY.

Date: Place: GULBARGA. Dr. SANGANNA KOLLUR. Research Guide

iii

RAJIV GANDHI UNIVERSITY OF HEALTH

SCIENCES, KARNATAKA, BANGALORE

ENDORSEMENT BY THE HOD, PRINCIPAL HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “THE STUDY OF

CLINICO - PATHOLOGICAL CONDITION OF ACUTE

APPENDICITIS” is a bonafide research work done by

Dr. VISHWANATH. P. SHIMPI under the guidance of Dr. SANGANNA

KOLLUR Professor, Department of Surgery.

Dr. M.S. HARSUR Dr. Mallikarjun B. Prof. & Head of the Dept. Principal

Dept. of Surgery Gulbarga M.R. Medical College, Gulbarga

Date: Date: Place: GULBARGA Place: GULBARGA

iv

COPYRIGHT

DECLARATION BY THE CANDIDATE I here by declare that the Rajiv Gandhi University of Health Science,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation/ thesis in print or electronic format for academic/research

purpose.

Date: Dr. VISHWANATH .P. SHIMPI

Place: GULBARGA

©Rajiv Gandhi University of Health Sciences, Karnataka.

v

ACKNOWLEDGMENTS

I express deep sense of gratitude and respect and thankfulness to my beloved

teacher and guide Dr. SANGANNA KOLLUR, M.S. Professor, Department of Surgery,

M.R. Medical College, for his constant guidance and encouragement throughout My post

graduate career and helping me in the preparation of this dissertation .

I take this opportunity to immensely thank Dr. M.S. HARSUR, professor &

Head of the Department of Surgery. Who has constantly encouraged me in all my

academic endeavours.

I also thank my teachers Dr. R.P. KOTHARI, Dr. V.B. BIRADAR, Dr. S.A.

HALKAI, Dr. R.G. DEVANI, Dr. S.M. PATIL, Dr. R.B. DHADED Faculty of

Department of Surgery for Valuable Suggestions.

I also take this opportunity to thank Dr. MALLIKARJUN BHANDARI. M.D.

Dean M.R. Medical College, Gulbarga. For helping me in enabling to undertake this

study.

I also thank the Faculty members of Department of Pathology, Radiology,

Community Medicine for their Constant help.

I take pleasure in thanking the patients, without whom this dissertation does not

have been possible.

I also thank my co-post graduates, junior post graduates and House surgeons for

their constant help and encouragement.

Last but not the least, I thank my wife, and my children’s, parents, brothers for

their constant encouragement and inspiration despite all the inconveniences.

Date: Place: Gulbarga Dr. VISHWANATH.P. SHIMPI

vi

ABSTRACT

Object: To study clinical and pathological presentation, management and out come of

appendicitis

Methodology: During 2 years study period. We studied 100 cases of acute appendicitis

admitted in Basaveshwara teaching & general Hospital and government general

hospital Gulbarga out of then 97 case are appendicitis and 3 were other causes A

detailed history and through clinical examination was done the diagnosis of Appendicitis

was based upon Alvarado Score, Total W.B.C. count and ultrasonography and

Histopathological examination.

Results: The study group consisted of 100 patients. Majority (62%) of patients were

males and (38%) was Females most, common symptoms were pain in the right iliac

fossa 98%, anorexia in 88%, Nausea 87% and Vomiting 83%, Total leucocyte count >

10.000 in 50%, of patients, and USG findings of localized adynamic illeus in 88%, and

Alvarado Score 7 or> 7 are 90% and Histopathology 89% the overall negative

appendicitis of 16.7% in female and 3.8% in Males.

Conculsion: Thus from above findings, it can be concluded early diagnosis and

appendicectomy is mandatory for better outcome of the patients. The definitive

appendicectomy is the line of management.

Key words: Appendicitis; Alvarado Score; Ultrasonography;

vii

LIST OF CONTENTS

1. Introduction……………………………………………………………….…01

2. Objectives…………………………………………………………………....03

3. Review of Literature………………………………………………………...04

4. Methodology………………………………………………………………...60

5. Results…………………………………………………………………….…63

6. Discussion………………………………………………………………..….77

7. Conclusion…………………………………………………………………...86

8. Summary…………………………………………………………………….87

9. Bibliography…………………………………………………………………88

10. Annexures…………………………………………………………………...95

viii

LIST OF TABLES SI.NO. TABLE PAGE NO.

1. Age and Sex Incidence 63

2. Pain Distribution 65

3. Ultrasonography Reports 69

4. The Condition of the Appendix 73

5. Histopathology Reports 75

6. Age Distribution 77

7. Showing Sex Distribution by Various Authors 78

8. Showing Pain Distribution by Various Authors 78

9. Anorexia as Symptom 79

10. Nausea or vomiting as a symptom 79

11. Presence of Right Illiac tenderness by Various Authors 80

12. Showing signs of Rebound tenderness elicited by Various

Authors

80

13. Fever as a sign by Various Authors 81

14. Leucocyte count by Various Authors 81

15. Visualisation of Normal appendix by USG 82

16. Value of USG in the Diagnosis of Acute Appendicitis 83

17. Alvarado Score 7 or > 7 by Authors 83

18. Histopathological reports by Authors 84

19. Negative Appendicectomy rate by various Authors 85

ix

LIST OF FIGURES

SI.NO. FIGURE PAGE.NO.

1. Surgical Anatomy of the appendix 19

2. Diagram Showing Psoas Test 36

3. Diagram Showing Obturator Test 37

4. Age and Sex distribution 64

5. Showing Pain distribution 66

6. Ultrasonogrophy Findings distributio 70

7. Alvarado score distribution 72

8. Showing conditions of Appendix 74

9. Histopathology distribution 76

x

Introduction

Objectives

Review of Literature

Methodology

Results

Discussion

Conclusion

Summary

Bibliography

Annexures

Photographs

INTRODUCTION

It is a well-known adage that abdomen is a temple of surprises and a magic box

as well. Since the abdomen accommodates innumerable viscera and other anatomical

compliments, diseases of the abdomen constitute a topic full of clinical curiosity. A

meticulous examination of abdomen is one of the most rewarding diagnostic

procedures available to the doctor, especially the surgeon and plans an ideal treatment.

As had been said by Bailey “A correct diagnosis is the hand maiden of successful

operation”. Despite the advancements in the fields of diagnosis the surprises never

cease1.

The appendix a cul-de-sac is crudely referred as “worm of the bowel” in ancient

medical books and also called as abdominal tonsil”.

Acute appendicitis is the most common acute surgical condition of the

abdomen2. Approximately 7 percent of the population will have appendicitis in there

life time3, with the peak incidence occurring between 10 and 30 years4.

Despite technological advances the diagnosis of appendicitis is still based

primarily on the patients history and the physical examination, prompt diagnosis and

surgical referral may reduce the risk of perforation and prevent complications5. The

mortality rate in non-perforated appendicitis is less than 1 percent, but it may be as high

as 5 percent or more in young and elderly patients in whom the diagnosis may often be

delayed thus making perforation more likely2. Preoperative diagnosis of acute

appendicitis is sometimes challenging in young women, children and aged despite all

round improvements in medical field and ultrasonography. Diagnostic scores are

useful easy methods, which help to reach in decision-making. Delay in diagnosis will

1

lead to complication, which increases morbidity where as overzealous diagnosis may

lead to negative appendicectomy rate6.

This study involves to correlate the acute appendicitis between clinically

diagnosed and histopatologically examined specimen and the role of ultrasound in early

diagnosis of acute appendicitis and to exclude negative appendicectomy, in patents

admitted in government general hospital and Basweshwar teaching and general hospital

during the period June 2003 to June 2005.

2

OBJECTIVES

To analyse clinico-pathological condition of acute appendicitis.

To confirm the diagnosis by histopathological examination.

To decrease the negative appendicectomy rate.

To use ultrasound as a guide for diagnosis.

3

REVIEW OF LITERATURE

HISTORICAL REVIEW 7 -12,

It seems appropriate to enlighten one’s mind with historic moments of

medicine, which are fascinating. Credit must be given to those who have contributed

for the benevolence of mankind. Their pioneer works are an inspiration to the new

generations.

Greek votire offerins have been found at coz and onidos, which represented

coils of intestine on which crude effort has been made to represent the appendix.

Tiberius Caesar allowed celsus to dissect on the executed criminals and he must have

felt the presence of appendix. Aryateus of cappedocia in 3rd centaury A.D. is reputed to

have described accurately appendicular abscesses and cured the patient by incision

and drainage of the abscess through the abdominal wall.

1492 Leonardo de Vinci, clearly depicted the organ in his anatomical

drawings. He called it “Orchid” literally ear to denote the auricular appendage

of the caecum.

1521 Berengario D a carpi first described the organ.

1530 Vido vidius first named the worm- like organ as the vermiform appendix

1530 Great scholar Erasmus was the first to record a case of appendicitis

with abscess formation.

1543 Andreas Vesalius illustrated the normal appendix in his ‘De Humani

corporis Fabrica’.

4

1554 Zeanfernel French physician described a case of perforated appendix

after an autopsy on 7 year girl who had suffered from diarrohea and was

given large quince to stop her bowels.

1652 Hiden, a leading German surgeon gave detailed account of diseased

inflamed appendix, after autopsy on a young man who died after several

years of progressive intestinal pain. The appendix was shrunken and

drawn into the small bowel completely filling it, so that no contents

could be forced into the colon, therefore such pain, Appendix was

inflamed and swollen throughout.

1710 Verneys was the first to coin the term appendix vermiformis, the first

description of appendicitis.

1711 Lorenz hester gave the first good description of a case of acute

appendicitis –a postmortem on a executed criminal. morganin (1719)

illustrated beautifully in his Adversaria Anatomica .

1755 Lorenz Hiester, professor at helmstedt recognized that appendix might

be the site of acute primary inflammation.

The first reported appendectomy was by Claudius Amyand surgeon St.George’s

Hospital, London in 1735. It was the first occasion on which the appendix was

successfully removed from the living subject. He removed from a hernial sac an

appendix that has been perforated by pin. By the end of the 18th centaury the appendix

had been described anatomically and that it could be became inflamed and cause

serious, even fatal results. But symptoms were unrecognized and appropriate surgical

treatment was a long way off.

John Parkinson in 1812 recorded a proven case of acute appendicitis. A 5 a

year old boy died 48 hours after the onset of acute abdominal pain and vomiting. At

autopsy an acutely inflamed appendix, which contained a faecolith, was found. He

5

stated that no disease was present in the caecum or proximal appendix but in the

appendiceal tip.

In 1824 French physician Louyer villermay was the first to prove that the

appendix could be the site of inflammation based on study of 2 young men who died

shortly after onset of abdominal pain. Each was found to have a gangrenous appendix

and normal caecum. Melier in 1827 confirmed these findings.

Baron Gullaume Dupuytren and Goldbeck (1830) promoted the theory that

inflammation arouse in the cellular tissue surrounding the caecum-typhilitis and

perityphilitis.

1884 Samuel Fenwick in London exhorted the surgical community to operate

upon a perforated appendix as soon as the diagnosis was always certain.

1886 Fitz, professor of medicine at Harvard who gave a lucid and logical

description of the clinical feature and described in detail the pathological changes of the

disease; he also the first to use the term appendicitis.

1880 lawson tait, apioner of abdominal surgery in great Britain, performed first

planned appedectomy on girl.with an appndeceal abscess. She had recurrent pain in

right iliac fossa . this milestone in history of appendicitis not reported by Tait till 1890.

later John shepherd rediscovered taits important contribution..1887 morton of

philadelphia successfully diagnosed and excised an acutely inflamed appendix within

an abscess cavity.

1889 Charles McBburney described the pathological changes in appendicitiss.

1902 Albert ochsnesr, surgeon from Chicago and sherren at the London hospital

6

recommended a conservative approach to patient with generalized peritonitis following

perforation appendix, to allow the inflammatory process to localize before considering

any operation.

1905 Rockey described a transverse skin incision which elliot had done in1896.

1905 Murphy clearly described the appropriate sequence of symptom of pain

follows by nausea and vomiting with fever a and exaggerated local tenderness the

position occupied by the appendix.

1982 Semm is widely credited with performing the first successful laproscopic

appendicectomy13.

Teicher I et al (1983) described problems related to the confusing diagnosis of

acute appendicitis are evidenced by negative laparatomy rate to assess the feasibility of

this decreasing the diagnostic error in scoring system was made to aid in the diagnosis

of acute appendicitis and concluded that the scoring system could have eliminated over

1/3rd of unnecessary laparotomies14.

Arnbjornsson E (1983) described the role of dietary fiber in the cause of acute

appendicitis was evaluated. By means of food diaries the average daily fiber

consumption was determined in31 patients with acute appendicitis and in 30 control

patients, matched for age and sex. The average daily dietary fiber intake was 17.4g in

the group with appendicitis and 21g in the control group the difference is statistically

significant the result support the hypothesis that diet, in particular a lack of fiber, may

be an important factor in the pathogenesis of acute appendicitis15.

7

Alvarado A et al (1986) described practical scoring system which includes

localized tenderness in right lower quadrant, leucocytosis, migration of pain, shift to the

left, temperature elevation, nausea, vomiting, anorexia, and direct rebound pain the

score helped in interpret ting the confusing picture of acute appendicitis16.

Puyleart JBCM et al (1986) used ultrasonography as a tool to diagnose

appendix. Ultrasonography was performed with 5M Hz or 7.5 MHz transducer using

graded compression technique appendix a was visualized and diameter thickness, free

fluid , ileus , tenderness at mc Burney’s point17.

Abu-yousef MM et al (1989) used high resolution 5- to 7.5-MHz transducers to

compress the bowels displace the interfering gas in the right lower quadrant and

directly visualized the inflamed appendix with a sensitivity that varies from 80 to 95

percent a specificity of 95 to 100 percent and an accuracy of 91 to 95 percent. It is also

possible to differentiate acute appendicitis from the gangrenous and a perforated

appendix. High – resolution sonography is currently the diagnostic method of choice

for appendicitis, particularly in patients with equivocal clinical findings. The technique,

normal and pathological values and limitations of sonography are discussed18.

Addis DG et al (1990) studied the lifetime rate of appendectomy is 21% for men

and 25% for women with approximately 7% of all people undergoing appendicectomy

for acute appendictis3.

Paul man AA et al (1991) described CT finding an inflamed appendix greater

than 6 mm in diameter but the Ct also demonstrates peri appendiceal and inflammatory

changes19.

8

Christian F et al (1992) also showed negative appendicectomy rate by using 5

criteria abdominal pain, vomiting, right lower quadrant tenderness, low-grade fever,

and leucocytosis20.

Korner H et al (1997) studied over a period of 10 years from 1987 to1997,

the over all appendicectomy rate decreased parallel to decrease in incidental

appendiecectomy21.

Gupta H et al (1997) reported that ultrasonography is appropriate in patients in

which the diagnosis is equivocal by history and physical examination. It is especially

well suited in evaluating right lower quadrant or pelvic pain in pediatric and female

patients. A normal appendix (6mm or less in diameter) must be identified to rule out

appendicitis. An inflamed appendix usually measures greater than 6mm in diameter is

non compressible and tender with focal compression. Other right lower quadrant

conditions such as inflammatory bowel disease, caecal diverticulites, meckel’s

diverticulum endometrosis and pelvic inflammatory disease can cause false positive

ultrasonography results22.

Rao PM et al (1997) described the accuracy of CT is due in part to its ability to

identify a normal appendix better than ultrasonography23.

Gallindo Gallego et al (1998) reported ultrasonography combined with clinical

diagnostic scoring increases the diagnostic accuracy in patients with suspected

appendicitis the high specificity of ultrasonography is useful for differential diagnosis

of associated pathology such as mucocele of appendix, mesenteric lymphadenitis, acute

ileitis, crohns disease or gynecological disorders24.

9

Fingerhut A et al (1999) described diagnostic has been advocated as a potential

tool to decide the number of negative appendecectomies performed. However the

morbidity associated with laparoscopic and general anaesthesia is acceptable only if

pathology requiring surgical treatment present, and is amenable to laparoscopic

techniques. The question of leaving a normal appendix in situ is controversial one, 17

to 26% of normal appendix at exploration has a pathologic and histological findings25

Sudhir Kumar Mohanty et al (2000) quoted the modified Alvarado’s score

combined with ultrasound can be used as a cheap inexpensive use way of confirming

acute appendicitis thus reducing negative appendectomy rate26

Geryk B et al (2000) done a retrospective study of the clinical and

histopathological pathological acute appendicitis in children confirms agreement of the

evaluation of the finding on the appendix made by the surgeon and patholo0gist in

72.2% and disagreement in 27.8% the findings is over rated in 11.3% and under rated

in16.5% . agreement is closest in phlegmonous in appendicitis (88.1%) and lowest in

gangrenous appendicitis (54.9%). The most frequently overrated finding is in catarrhal

appendicits(20.7%). The number of missed appendicectomies is from the pathologist

point of view significantly lower(21.8%) than from the surgeons point of view(34.7%)

this indicates obviously that it is not possible an accurate macroscopic assessment of

the progress of appendiceal inflammation. The number of “negative” appendecectomies

is according to surgeon 15.85 percent and according to pathologist 16.8% that is

almost equal.27

Enochsson L et al (2001) quoted laparoscopic appendicectomy may be

beneficial in obese patients in whom it may difficult to gain adequate access through a

10

small right lower quadrant incision. Additionally there may be a decrease risk of

postoperative wound infection after laparoscopic appendecectomy in obese patients28 .

Bhattrarcharjee PK et al (2002) done a study on modified Alvarado score and

concluded high score was found to be a dependable aid both in pre operative diagnosis

of acute appendicitis in the reduction of negative appendectomy.29

George Mathews John et al (2002) done a study on 140 cases of right lower

quadrant pain studied over 2 years period who underwent abdominal and pelvic

ultrasonography. Ultrasonography is a noninvasive procedure, which can be done in

all setups and can be applied to all age groups and in safe on all pregnant women. USG

is found to diagnose inflamed appendix up to specificity of 90 to 99 percent and

sensitivity of 75 to 90%30.

Joseph J Naoum et al (2002) performed a retrospective study on 194

appendicectomy performed, 114 prior to the guide line and 80 after the development of

the guide line the rate of miss diagnosis is decreased from 25 to 6%, the rate of CT use

increased from 32 to 84%, and the perforation rate unchanged. CT evaluation of

patients suspected to have appendicitis has significantly reduced the negative

appendecectomy rate to 3.5 to 8.6%31.

Sivit CJ (2003) done a study about use of cross sectional imaging has proven

useful for the evaluation of suspected acute appendicitis in children. Both graded

compressions sonagraphy and CT have been widely utilized in the imaging assessment

lot the conditions. The principal advantages of sonography are its lower cost lack of

ionizing radiation and ability to assess ovarian pathology that can often mimic acute

appendicitis in female patients. The principal advantages of ct include lesser operator

11

dependency than sonagraphy as reflected by higher diagnostic accuracy, and enhanced

delineation of disease extent in perforated appendicitis32.

De U. De Krishna K (2004) reported a case having right lower quadrant

abdominal pain in a 26-year-old female who underwent appendicectomy 1 year back is

presented. Recurrent appendicitis was noted in appendiceal stump. All though rare

stump appendicitis should be considered in the differential diagnosis of right lower

quadrant abdominal pain33.

Nguyen NT et al (2004) analyzed the outcomes of laparoscopic versus open

appendicectomy, he obtained data from the university health system consortium clinical

data base for all patients who under went appendicectomy for acute and perforated

appendicitis between 1999 and 2003(n=60,236) trends in utilization of laparoscopic

appendicectomy were examined over the 5 year period. Over all 41,085 patients

underwent open appendicectomy and 19,151 patients underwent laparoscopic

appendicectomy. The percentage of appendicectomy performed by a laparoscopy

increased from 20% in 1999 to 43% in 2003. Compared patients who underwent open

appendicectomy, patients who underwent laparoscopic appendicectomy were more

likely female more likely white, has a lower severity of illness, and were less likely to

have perforated appendicitis. Laparoscopic appendicectomy was associated with a

shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30 days readmission

(1.0% vs 1.3%), and a lower rate of overall complication (6.1% vs 9.6%). There was

no significant difference in the observed to expected mortality ratio between

laparoscopic and open appendicectomy(0.5 vs 0.6 respectively). The mean cost per

case of similar between the two groups34.

12

Jones K et al (2004) studied, if there wqs a significant change in the negative

appendicectomy rate with the increased use of CT. 389 appendicectomies were

performed for appendicitis. There was a progressive increase in the use of CT:52% in

2000, 74% in 2001 and 86% in 2002. there was also a decrease in the NA rate over 3

years: 17% in 2000, 9% in 2001 and 2% in 2002. The perforated appendicitis rate

decreased from 25% in 2000 to 9% in 2002. The appropriate utilization as an aid in the

diagnosis of acute appendicitis should decrease the NA rate to 2%35.

Hansen AJ et al (2004) done a study on CT finding alone can accurately predict

the histologic severity of acute appendicitis in patients who have high disease

likelihood. He has taken consecutive sample of 105 patients (50 women and 55 male,

aged 15 to 89 years) undergoing non incidental appendicectomy within 3 days of non

focused abdominal CT. CT scans and histologic features were retrospectively

reinterpreted. CT variables used in the model were fat stranding, appendix diameter,

dependent fluid, appendolithiasis, extra luminal air, and radiologist overall confidence

score. CT findings, when used with regression model can accurately predict the

histologic severity of acute appendicitis in patients initially seen with a high clinical

suspicion36.

Kumar S et al (2004) analyse the treatment of appendicial mass over a 30 year

period, 60 consecutive patients with appendicial mass were randomly allocated to 3

groups: group A-initial conservative treatment followed by interval appendicectomy 6

weeks later; Group B-appendicectomy as soon as appendicial mass resolved using

conservative means: Group C-conservative treatment alone. In patients in group A,

operative time was less, adhesions were encountered less frequently, the incision has to

13

be extended less often and post operative complication were fewer, as comparative to

Group B. patients in Group C had the shortest hospital stay and duration of work-days

lost: only 2 of 20 patients in this group developed recurrent appendicitis during a follow

up period of 24-52(median 33.5) months. Of the 3 treatment modalities compared,

conservative treatment without subsequent appendectomy appears to be the best37.

Blab E et al (2004) studied regarding advancement in the diagnosis of acute

appendicitis in children and adolescents. All diagnostic parameters from the patients

medical history (duration and quality of abdominal pain, stool behavior), the

laboratory(leucocytes, C-reactive protein),The clinic(defence,tenderness on percussion,

nausea, vomiting, dry tongue) and repeated ultrasound investigations(visualization of

the appendix, indirect signs of an inflammatory process in the appendix region) were

documented prospectively and were re-assessed with regard to diagnostic value. As an

additional parameter, prolactin was determined. 1156 patients(593 males/563 females)

with a mean age of 9.51 years(+/-1.2 years) (max.15 years/min.2.3years), referred to

the department with acute abdominal pain, were examined. 233(141 male/92

female;20.1%) of these patients with a mean age of 10.47 years(+/-1.1 year) had

appendicitis. Based on patients medical history laboratory findings, the initial clinical

investigation and the initial ultrasound investigation, 173 patients(74.3% of the later

operated 233 children with appendicitis) were diagnosed with certainity. The diagnosis

of 60 patients (25.7% ) of this group remain uncertain. These patients received a saline

enema and were subjected to a second clinical and sonograhic investigation after 4

hours of parentral fluid substitution. The other 923 patients (79.83%) were discharged

and were followed up as out patients in the following days. Based on this stepwise

procedure, the percentage of correctly diagnosed appendicitis could be increased to

14

97.4%. the measurement of procalcitonin proved to be of no value in the diagnosis of

acute appendicitis. In the children with abdominal pain, high diagnostic can only be

achieved by a carefully combined evaluation of all individual diagnostic parameters

and repeated investigations.38

Old JL et al (2005) done a study on imaging for suspected appendicitis. The

overall diagnostic accuracy achieved by traditional history physical examination, and a

laboratory has been approximately 80%. The ease and accuracy of diagnosis varies by

the patients sex and age, and is more difficult in women of child bearing age, children,

and elderly persons. If the diagnosis of the acute appendicitis is clear from the history

and the physical examination, prompt surgical referral is warranted. In atypical cases,

ultrasonography and CT may help lower the rate of false-negative appendicitis

diagnosis, reduced morbidity from perforation, and lower hospital expenses.

Ultrasonography is safe and readily available, with accuracy rates between 71 and 97%.

All though it is highly sonologist dependent and difficult in patients with a large body

habitus. While there is a controversy regarding the use of contrast media and which CT

technique is the best, the accuracy rate of CT scanning is between 93 and 98%.

Disadvantages of CT include radiation exposer, cost, and possible complications from

contrast media39.

Sakellaris G et al (2005) done a study on acute appendicitis in preschool-age

children during the last 11years, 122 children aged less than 5 years underwent

appendectomy with a preoperative diagnosis of acute appendicitis. At surgery, 29

children presented with acute suppurative appendicitis, 64 children perforated

appendices and 25 children with appendicial abscess. in 3 cases there was no acute intra

abdominal process. In this study the following data were analysed: age, gender,

15

symptoms, duration of symptoms, whether seen by a physician prior to admission and

surgery, physical findings, stage of the disease at operation, histology,postoperative

complications and mortality. The accurate diagnosis in early childhood appendicitis is

still a difficult matter the responsibility of the paediatric surgeon is mainly the clinical

examination with all his clinical skills and facilities and if serious doubt still exist, to

proceed with a laparatomy in order to reach a definite diagnosis40.

16

REGIONAL ANATOMY41-,42

GENERAL CONSIDERATIONS

Abdomen is divided into 9 quadrants by 2 vertical and 2 horizontal lines. The

vertical lines pass through midclavicular line and midinguinal points. The horizontal

lines are transpyloric and transtubercular. Transpyloric line is a horizontal line passing

through the tips of 9th costal cartilage on each side. Transtubercular is a horizontal line

joining the both tubercles of the iliac crests.

Right iliac fossa is the right lateral and the lower most quadrants. The anterior

wall is formed by external oblique, internal oblique, transeverse abdominus muscles

and fascia transversalis. The psoas and quadratus lumborum muscles and thoraco

lumbar fascia form posterior wall and inferiorly it is bounded by the posterior part of

the ileum and iliacus muscle. Lateral wall formed by external oblique internal oblique

transverse abdominis fascia transverrsalis and inferiorly by illiac bone covered by

iliacus muscle.

Appendix 43-49

Vermiform appendix is found only in man, certain anthropoid apes and the

wombat. The appendix lies at the commencement of the large intestine into the right

iliac fossa.

EMBRYOLOGY OF THE APPENDIX

Caecal bud is a diverticulum’s that arises from the post arterial segment of the

midgut loop. The caecum and the appendix are formed by enlargement of this bud.

There proximal part of the bud grows rapidly to form the caecum.

17

Its distal part remains narrow and forms the e appendix.

As the small diverticulum the appendix appears in 6th week of intrauterine life

and is found at the apex of caecum at an early stage. The appendix is pushed medially

by excessive growth of the right wall of the caecum.

Position of the appendix.

The location of the base of the appendix is dependent on the position of the

caecum. The base is attached to the postero medial surface of the caecum2.5cm below

the ileocaecal junction at a site where the 3 taenia coli coalesce. The remaining

portion is free. In relation to anterior abdominal wall lies base is situated 1/3rd or way

up the line joining right anterior superior iliac spine to the umbilicus (McBuney’s

point). In incomplete rotation of the bowel caecum may lie at a higher level beneath the

liver in relation to duodenum and gall bladder in this position signs and symptoms of

acute appendicitis mimic acute cholecystitis. When the caecum is long and mobile the

appendix may lie in the pelvis, in which case the tenderness in acute appendicitis is

found maximally on pelvic examination. Very occasionally caecum and appendix lie in

the left ileac fossa in which cases acute appendicitis mimics acute diverticulitis of

sigmoid colon. The position of the tip of the appendix in relation to the caecum is

variable and has been likened to hands of a clock. The various positions are.

1. 12 O’ clock-retrocaecal position 74%

2. 10 O’ clock-paracaecal position 2%

3. 2 O’ clock-preileal 1% post ileal 5%

4. 5 O’ clock-pelvic 21%

18

5. 6 O’ clock-subcaecal 1.5%

Surgical anatomy of the appendix The appendix can be positioned anywhere on the circumference shown by the arrowed arc.

The appendix varies considerably in length and circumference. The average

length is between 7.5cm and 10cm. Specimens of over 30cms in length have been

recorded. The appendix in males averages 0.5cm longer in length than in females. The

lumen, which should admit a matchstick, is irregular, being encroached upon by the

multiple longitudinal folds of mucous membrane. Appendix has short mesentery of its

own(meso appendix). The mesoappendix that springs from the lower surface of the

mesentery is subject to great variation. Some times as much as the distal 1/3rd of the

appendix is free of mesoappendix. Especially in childhood the mesoappendix is so

transparent that the contained blood vessels can been seen. In many adults it becomes

laden with the fat, which obscures this vessels.

BLOOD SUPPLY

The appendicular artery, a branch of the lower division of the ileocolic artery,

passes behind the terminal ileum to enter the mesoappendix a short distance from the

base of the appendix. It then becomes to lie in the free border of the mesoappendix,but

for a variable distance from the tip, where the mesoappendix is lacking, the artery lie

directly on the muscle wall beneath the peritoneal coat. An accessory appendicular

19

artery a branch of posterior caecal artery may be present but in most people once the

appendicular artery reaches the wall of the appendix proper it becomes an end artery.

Thrombosis of the artery as a result of the appendicitis causes necrosis of the appendix.

The appendicular vein, which follows the appendicular artery along the free border of

the mesoappendix drains into the ileocolic, which is a tributary of inferior mesentic

vein. Inflammatory thrombus may cause suppurating pyelophlebitis in case of

gangrenous appendicitis.

LYMPHATIC VESSELS

Lymphatic vessels traverse the mesoappendix to empty into the iliecaecal lymph

nodes, through a number of mesenteric nodes they drain to superior mesenteric nodes.

NERVE SUPPLY

Derived from sympathetic and parasympathetic nerves from the superior

mesenteric plexus. Afferent nerve fibers concerned with conduction of visceral pain

from appendix are to believe to accompany the sympathetic nerves and enter the spinal

cord at the level of 10th thoracic segments.

MICROSCOPIC APPEARANCE;50-52

Appendix is lined by columnar cells intestinal mucosa of colonic type. Crypts

are present but not many. In the base of crypts lie the special cells-Kulchitzky cells,

which give rise to carcinoid tumours. Appendicitis can be caused by them.

The submucosa contains numerous lymphatic aggregations (follicles). This may

be the cause for appendicitis. The muscular coat consists of 2 complete layers of

smooth muscle-inner muscular and outer longitudinal. The later is formed by the

joining together of taeniacoli at the base of the appendix. The visceral layer of

20

peritoneum envelops the appendix complete except for the narrow line of attachment of

the mesoappendix.

CONGENITAL ANOMALIES46

1. Agenesis- incidence 1 in 100000 persons

2. Duplication- few cases of double appendix are reported.

3. Left sided appendix in situs inversus viscerum where there is complete

transposition of thoracic and abdominal viscera. Occurs in 1, in 35,000 persons.

FUNCTIONS OF HUMAN APPENDIX53-59

1. Embryological

2. physiological

3. Microbiological

4. Biochemical

5. Immuonlogical

1. Embryological

During the 5th fetal week it id the appendix which develops from a bud at the

junction of small and the large bowel and under goes rapid growth into a pouch. in the

6th week there is a transient nubbin surmounting the pouch indicative of being involved

in the rapid development of the pouch. It is only after the 5th fetal month that the

proximal end of this pouch starts growing differentially to give rise to the true caecum

which continues to develop into infancy.

2. Physiological

The goblet cells lining the appendix and adjacent caecum and colon secret a

special type of mucus, which can be, regarded as an antibacterial paint controlling the

21

organisms which develop in the bowel in the region. The paint contains a high

concentration of IgA type immunoglobulins, secretory antibodies produced for mucosal

of surface immunity and part of the bowel-blood barrier.

3. Bacteriological

Through the cells within and over lining the lymphoid follicles and their

production of secretory and humoral antibodies the appendix would be involved in the

control of which essential bacteria come to resiee in the caecum and colon in the

neonatal life. As well it would be involved in the development of systemic tolerence to

certain antigenic agent within the alimentary track whether they are derived from

bacteria, food stuffs or even the body’s own proteolytic enzymes.

4. Biochemical

One in three hundred or so appendicectomy specimens contain a caricinoid

tumor composed of highly specialized type of cell rich in serotonin. The exact function

of such agents in the entire bowel is still being elucidated, but the fact majority of such

tumours within the appendix.

5. Immunological

This the area were the appendix would seem to have its predominant functions

due to its content of lymphoid follicles. Although it was thought the appendisx itself

could be the site for B-lymphocyte induction. The appendix still have a role in this

highly significant function, but not alone and its lymphoid tissue is known for certain to

be involved in the antibodies production. These antibodies of two types

IgA type immunoglobulins for secretory or mucosal surface immunity.

IgM and IgG immnoglobulins for hum moral or blood stream immunity.

22

The above type function have proven the appendix to be part of the

G.A.L.T(Gut associated lymphatic tissue).

23

ETIOLOGY 46,48,49, 60

The riddle of the appendicitis-its actual cause and its meteoric rise from an

insignificant disease to the most common serious intraabdominal inflammatory

affection of western civilised raises has been a matter for much speculation. So far no

satisfactory explanation has been forthcoming. The following etiological factors are

important, but for the most part they are purely contributed.

AGE INCIDENCE: Appendicitis is common in second decade.

SEX: Males are affected more commonly than females.

RACE AND DIET:

Appendicitis is common in the highly civilised European, American and

Australian countries, while it is rare in Asia tics, Africans, and Polynesians.

Rendle short showed that if individuals from the later races migrate to countries

where appendicitis is common, they soon acquire the local susceptibility to the disease.

This is contributed to diet rich in meat and scanty in cellulose.

SOCIAL STATUS:

Acute appendicitis is more common between the upper and middle classes than

those belonging to working class. The use of water closets instead of squatting position

in defecation has been said to increase incidence of appendicitis (Bowers 1939).

FAMILIAL SUSCEPTIBILITY:

This can be accounted for by a hereditary abnormality in position of the organ,

which predisposes to infection. Thus the whole family may have long retrocaecal

appendix with comparatively poor blood supply.

24

OBSTRUCTION TO THE LUMEN OF THE APPENDIX:

When an acutely inflamed appendix has been removed, some form of

obstruction to its lumen can be demonstrated in 80% of cases. Obstructing agents are:

1. IN THE LUMEN—Faecolith and hyperplasia of submucosal lymphoid.They are

laminated composed of inspissated faecal material, calcium, and magnesium phosphate

and carbonates, bacteria and epithelial debris. Rarely a foreign body is incorporated in

the Mass. The presence of faecoliths postulates some form of appendicular stasis,

which may be related to initial swelling of the lymphoid tissue causing partial

obstruction to the lumen of the organ. Radiological demonstration of a stone is an

absolute indication for surgery irrespective of signs and symptoms. Worms – round

worm, threadworm, pinworm and parasites can occlude the lumen. And foreign body

like pin, inspissated barium from previous studies also contribute.

2. IN THE WALL: Stricture.due to fibrosis from earlier inflammation or neoplasm of

which the carcinoid is the commonest cause.

4. Adhesions and kinking outside the wall.

DISTAL OBSTRUCTION OF THE COLON:

Acute appendicitis can result from an obstructing (colon) carcinoma, usally of

the right colon, usually in the elderly cases.

ABUSE OF PURGATIVES:

Ingestion of purgatives especially castor oil by patients with ‘stomach ache’ and

the violent peristaltic action’ which results, favors, and often determines, perforation of

the inflamed appendix. “Purgation means Perforation” is a wise adage.

25

SEASONAL FACTORS:

Particularly in children a possible association between respiratory tract infection

and acute appendicitis exists. Involvement of lymphoid tissue in the tonsils and

appendix may occur simultaneously. A blood borne infection may be present in these

cases.

BACTERIAL FACTORS:

While appendicitis is clearly associated with bacterial proliferation within the

appendix no single organism is responsible, a mixed growth of aerobic and anaerobic

organism are responsible. The most common organisms present are a mixture of

E.coli(85%), entero cocci(30%),nonhaemlytic streptococci, anaerobic streptococci

together with clostrdium welchi(30%) and bacteroides.

VIRAL FACTORS:

An acute viral infection at the time of or just before appendicitis might lead to

lymphoid hyperplasia and subsequent healing might produce scarring, kinking etc,

leading to acute obstruction. Thus it is the effect of viral infection but not the direct

cause. (Jackson & Associate1966)61.

Recently Cytomegalo virus appendicitis has been recognized in patients with

HIV. Tucker and colleagues (1990) reported the 1st case, which had perforated

appendix with periappendicial abscess due to E.coli. Intranuclear inclusions indicative

of CMV infection were found through out the mucosa and submucosa of appendix.

Davidson and colleagues (1991) reported 2 cases.

TUBERCULOSIS OF THE APPENDIX:

26

It has been seldom reported after introduction of antitubercular drugs. Borrow

and Friedman (1952)62 had reviewed 265 cases, but majority were diagnosed at post-

mortem examination of proved cases of tuberculosis. 2 types have been described.

Ulcerative and hyper plastic (koster and kosman1934). Tuberculosis of appendix may

present as mass in right iliac fossa indistinguishable from ilio-caecal tuberculosis.

OTHER RARE CAUSES:

1. Appendicitis complicating regional ileitis (Crohns disease).

2. Carcinoid tumor of the appendix.

3. Primary Adenocarcinoma of the appendix.

These are diagnosed only by histological examination.

27

PATHOLOGY 46,49,63,

The menace of acute appendicitis lies in the frequency with which the peritoneal

cavity is infected from the focus.

1. By perforation.

2. By transmigration of bacteria through the appendicular wall.

During the several hours between onset of acute appendicitis and rupture,

natures walling of process is able to quarantine the inflammation in about 95% of

patients and confine the spill to the periappendiceal area. The greater omentum

attempts to seal off the spread of peritoneal invasion, while violent peristalsis from

ingested purgatives tends to spread it. Obviously if the inflamed appendix lies freely

dangling, the threat of peritonitis is increased and should early perforation occurs,

rapidly diffusing peritonitis is inevitable. An inflammatory mass consisting of matted

intestines and omentum with little or no pus is formed if walling off process is

completed. In some patients however, a progressive suppurative process produces an

expanding collection of pus contained by the walling off process—a periappendicular

abscess.

Two types of appendicitis are known

Non obstructive acute appendicitis:

The inflammation mostly due to bacterial invasion usually commences in the

mucuous membrane, less often in the lymph follicles and can terminate in one of the

following ways.

28

1. Resolution

2. Ulceration

3. Suppuration

4. Fibrosis

5. Gangrene

Once infection reaches the loose sub mucous tissues it progresses rapidly. The

organ becomes turgid, dusky red and hemorrhages occur into the mucous membrane.

The vascular supply of the distal part of the appendix is often in jeopardy because at

this point the artery is intramural and liable to occlusion by inflammation or

thrombosis. This may lead to gangrene of the tip. In some cases, the swelling of the

lymphoid tissue in the appendix may lead to obstruction of the lumen proceeding to

obstructive appendicitis.

Non-obstructive appendicitis may progress sufficiently slowly for protective

barriers to form, and the resulting peritonitis is localized. In many instances the

infection never progress beyond the mucous lining (i.e. catarrhal inflammation) but

although the attack passes off, it is unlikely that a status quo ante is ever regained.

Because the tip suffers most, after resolution of the attack, fibrosis usually occurs there

in and a shrunken tip is classically finding in recurrent appendicitis.

OBSTRUCTIVE ACUTE APPENDICITIS:

When the appendix becomes obstructed the process of events begins with the

accumulation of normal mucus secretion, proceeds to proliferation of the contained

bacteria and the pressure atrophy of the mucosa, which allows bacterial access to the

deeper tissue planes and continues with inflammation of the walls of the appendix with

the vessel thrombosis which because of end artery system leads inevitably to gangrene

29

and then perforation of the necrotic appendix wall. Often within twelve to eighteen

hours the appendix distal to the obstruction becomes gangrenous. Close examination of

gangrenous appendices directly after their removal shows conclusively that they usually

belong to the obstructive group (Wilkie).64

Perforation occurs most often at the site of an impacted faecolith, before

protective adhesions have had time to form. The escaping purulent and gaseous

contents are under higher pressure and early wide spread peritonitis is liable to ensue.

Subphrenic and pelvic abscesses are a common later sequel if the patients survives the

initial peritonitis. An even more lethal form of peritonitis is produced by secondary

rupture of intrabdominal abscess produced by rupture appendicitis. Ascending septic

thrombophlebitis of the portal venous system –pylothrombophlebitis is a very grave but

unfortunately rare complication of gangrenous appendicitis. Septic clots from the

involved mesenteric radicals embolise the liver producing multiple pyogenic abscesses.

When acute inflammation subsides adhesions form and kinking of appendix leads to

obstructive appendicitis. Fibrosis of the wall from previous attacks of the appendicitis

can contribute by narrowing the lumen and promoting faecolith impaction and rarely

appendicitis accompanies ilio-caecal crohn’s disease.

When the obstruction is partial and not complicated by infection “mucocele of

appendix” is formed (Ken 1955).

Less common pathological condition of appendix.

1. Mucocele of appendix

2. Diverticula of appendix

3. Intussusception of the appendix

30

4. Endometriosis of the appendix

5. Primary Crohn’s disease of the appendix

31

CLINICAL FEATURES AND DIAGNLOSIS

AGE INCIDENCE: 65

Rare before the age of two acute appendicitis becomes increasingly common

during childhood and adolescence. The maximum incidence is between the ages 20and

30. There after is gradual decline but no age is exempted. In infancy the lumen of the

appendix is large in relation to intestine and its lumen opens freely into the caecum. In

old age the appendix undergoes involution (Soutler).

CLINICAL FEAUTURES: 46,48,49,66

NON-OBSTRUCTIVE ACUTE APPENDICITIES

There are typically 5 specific features.

ABDOMINAL PAIN, WHICH SHIFTS:

Usually the first symptom is pain around the umbilicus, in the epigastrium or it

may be generalized, this is visceral pain and is therefore somewhat vague, It is due to

distension of the appendix. The pain is constant. After few hours the pain shifts to the

point where the inflamed appendix irritates the parietal peritoneum, which is sensitive.

This pain is somatic or peritoneal, accurately localized and constant. Coughing causes

local pain in acute appendicitis but not in case of a stone in the ureter.

FEVER:

With corresponding increase in pulse rate 80-90 is usual. In severe cases

temperature and pulse rate is even more.

Upset of gastric function: Protective pylorospasm occurs and anorexia, nausea,

infrequent vomiting, a brown furred tongue and a foul breath may manifest this.

Typically the vomiting is of short duration and stops as soon the stomach is empty. In

32

majority of instances the patient is constipated but occasionally diarrhea occurs,

especially in the very young or when the appendix lies in the post ileal or pelvic

position.

LOCALIZED TENDERNESS AT THE SITE OF APPENDIX :

As soon as the pain has shifted, there is localized tenderness either at

McBurney’s point or elsewhere, as determine by the site of the appendix. These

determine the operative approach.

MacBurney (1889) has stated ,the seat of greatest pain determined by the

pressure of one fingered, has been very exactly between an inch and a half to 2 inches

from the anterior superior iliac spine in a straight line drawn from that process to

umbilicus (shepherd1960).67 Now it is generally accepted as a point of junction

between lateral 1/3rd and medial 2/3rd of a line drawn from umbilicus to right anterior

superior iliac spine. These points suppose to correspond to the base of the appendix.

Sir.z.cope 68 (1959) remarks that tenderness over the MacBurney’s point is not always

constant. The pain he says , seems to be actually located in the appendix itself’ and

therefore depends on the position of the appendix and is obtainable when the viscus is

not adhering to any surrounding part. Further the tenderness maybe due to irritation of

the adjacent peritoneum. Gentle percussion can also elicit this point of maximum

tenderness according to Z.cope over the region. It may lie in the flank also.

33

RIGIDITY IN THE RIGHT ILIAC FOSSA:

With the passage of time, accurate localization become more difficult as

muscular rigidity becomes evident in addition to the tenderness. This is due to the

irritation of parietal peritoneum.

OBSTRUCTIVE APPENDICITIES:

The sequence of clinical events occurs much more quickly. The onset is abrupt

and there may be severe generalized abdominal colic from the start. Temperature may

be normal, vomiting is common so that the clinical picture may mimic acute intestinal

obstruction. Once recognised urgent surgical intervention is required because it rapidly

progresses to perforation. In both the types attack can commence at any time, but

frequently it does so in the early hours of the morning, awakening the patient from the

sleep. Pain, anorexia, nausea, vomiting and fever as classical syndrome is not complete

in some cases and in certain cases the only relevant feature is pain or tenderness in the

right iliac fossa (P.H.Smith1965).

SPECIAL FEATURES

1. Cutaneous hyperanaesthesia:

Presence of hyperaaesthesia in sherren’s triangle (this is formed by lines joining

the umbilicus, right anterior superior iliac spine and pubic symphysis) is a good in the

diagnosis of gangrenous appendicitis. This is elicited by simply scratching the

abdominal wall with the finger.

2. Rebound tenderness:

The suspected area is palpated with each expiration. The hand is now

withdrawn suddenly, as a result of this abrupt removal the abdominal musculature

34

springs back into its original position. The patient will immediately cry or at least

wince in pain. This is because the inflamed parietal peritoneum due to underlying

inflamed organ also springs back along with abdominal musculature.

5. Rovsing’s sign:

If the left iliac fossa is pressed pain is appreciated on the right iliac fossa in case

of acute appendicitis. This is due to shifting of the coils or ilium to the right and

pressing on the inflamed appendix.

6. Signs of auscultation:

Activity of intestine may continue normally even in quite advance cases of

acute inflammation, eventually paralytic ileus supervenes and it is indicative of

generalized peritonitis. Sometimes due to obstruction at the terminal ileum, exaggerated

bowel sounds may be heard which confuses the surgeon to arrive at definitive

diagnosis. Finally there is silent abdomen with long history of pain, severe toxemia and

abdominal distension.

35

SPECIAL FEATURES ACCORDING TO THE POSITION.

1.RETROCAECAL:

Rigidity is absent (silent appendix) and even on deep pressure tenderness may

be lacking the reason being that the caecum is distended with gas, which prevents the

pressure exerted by the hand from reaching the inflamed appendix, and gurgling may

even be elicited. Deep tenderness is often present in the loin and rigidity of quadratus

lumborum may be evident.

Psoas spasm due to the inflamed appendix being in contact with that muscle

may be sufficient to cause flexion of the hip joint, to extend the joint causes abdominal

pain. Hyper extension of the hip joint may induce abdominal pain when a degree of

psoas is sufficient to cause flexion of the hip( cope’s psoas test).

2. PELVIC: Early diarrhea results from an inflamed appendix being in contact with

rectum. When appendix lies entirely within the pelvis there is usually complete absence

of abdominal rigidity and often tenderness over the McBurney’s point is lacking as

well. In some instances deep tenderness can be made out just above and to the right of

the symphisis pubis. An inflamed appendix in contact with the bladder may cause

36

frequency of micturation. A child sometimes postpones micturation as this causes pain

(McFadden).

In either event a rectal examination reveals tenderness in the rectovescical

pouch or the pouch of Douglas, especially on the right side. Psoas spasm may also be

present when the appendix is in this position. Alternatively spasm of the obturator

internus is some times demonstrable when the hip is flexed and internally roated. If an

inflamed appendix is in contact with the obturator internus this manoeuvre will cause

pain in the hypogastrium (Zachary cope).

3. POST ILEAL: Although this is rare, it accounts some of the cases of ‘missed

appendix’. Here the inflamed appendix lies behind the terminal ileum. It presents the

greatest difficulty in the diagnosis because the pain may not shift, diarrhea is a feature,

marked retching may occur, and tenderness if any is ill defined , though it may be

present immediately to the right of the umbilicus. As the appendix irritates the lower

ileum, the patient usually passes small stools soon after eating or drinking.

37

4. MALDESCENDED (SUBHEPATIC):

Tenderness in the sub hepatic region is mistaken for acute cholecystitis.

SPECIAL FEATURES ACCORDING TO THE AGE 48,69,70,71

1. ACUTE APPENDICITIES IN INFANTS:

In infants under 36 months of age the incidence of perforation is over

80%(Fields), and the mortality is considerably higher than the general mortality. Indeed

when acute appendicitis occurs during the 1st year of life.

Only 50% of the patients reach their 1st birthday. On of the reason for the rapid

onset of diffuse peritonitis is that the greater omentum is comparatively short and

underdeveloped and is unable to give much assistance in localizing the infection. Even

more important is the difficulty in arriving at an early diagnosis, and particularly in

differentiating the condition from enteritis. acute appendicitis may be associated with

acute respiratory tract infection or exanthema.

2. ACUTE APPENDICITIES IN CHILDREN:

It is rare to find a child with appendicitis who has not vomited and they usually

have complete aversion of food. In addition they do not sleep during the attack and very

often bowel sounds are completely absent in the early stages.

3. ACUTE APPENDICITIS IN THE AGED:

Gangrene and perforation occur much more frequently. Elderly patients with lax

abdominal walls may harbor a gangrenous appendix with little evidence of it and old

people are prone to self medication with laxatives. In addition the picture may stimulate

acute intestinal obstruction and if enemas are given, peritonitis may spread more

38

widely. The immune system becomes weaker in old age. Acute appendicitis therefore

in the older age groups carries a high mortality.

4. ACUTE APPENDICITIS IN THE OBESE:

Obesity can obscure and diminish all local signs of acute appendicitis. It is safer

to operate on such cases through a generous vertical incision rather than miss a

gangrenous appendix.

5. ACUTE APPENDICITIS IN PREGNANCY:

In pregnancy the appendix shifts to the upper abdomen, thus favoring

peritonitis, the nearer the term the greater the danger, even in cases without perforation.

After the 6th month there is a maternal mortality of 20% ten times greater than in the 1st

three months (Parker). As pregnancy advances the pain becomes higher and more

lateral. Microscopic examination of the specimen of urine will help to exclude

pylonephritis, but in doubtful cases it is best to perform early appendicectomy. The

pregnant patient with acute perforated appendicitis aborts of goes into premature labor

in 50% of cases, while in acute non perforated appendicitis this figure is reduced to

30%.

COMPLICATIONS OF APPENDICITIS:

Perforation And Gangrene

When perforation or gangrene occurs within 12-24hrs after the commencement

of the attack, explosive peritonitis is liable to occur. The abdomen becomes rigid,

distended and silent on auscultation. In non-obstructive appendicitis particularly and in

obstructive appendicitis when perforation or gangrene develop after a period of 24

39

hours the defence mechanisms can often contain the peritonitis, especially when the

appendix lies in a relatively secluded portion of the peritoneal cavity e.g. retrocaecal.

THE APPENDICULAR MASS (syn.peri-appendicular phlegmon):

On the 3rd day after the commencement of an attack of acute appendicitis, a

tender mass can frequently be felt in the right iliac fossa beneath some rigidity of the

overlying musculature the other quadrants of the abdomen being free from rigidity or

tenderness. The mass is composed mainly of greater omentum, edematous caecal wall

and edematous portion of small intestine. By 4th or 5th day the mass becomes more

circumscribed. During the ensuing day (5th to 10th day) the swelling either turn into

abscess or resolves.

APPENDIX ABSCESS

It true that is a certain number of masses will contain some pus or that they may

on occasion become frank abscesses but both the terms are not synonymous. The

features include pyrexia, increased leucocytes count. The commonest site of abscess is

in lateral part of right iliac fossa(extension of retrocaecal suppuration) next being

pelvis.

Failure of resolution of appendicular mass or continued spiking Pyrexia usually

indicates that there is pus within the phlegmous appendicular mass.

40

MANAGEMENT

INVESTIGATION:

The diagnosis of acute appendicitis is essentially clinical however a decision to

operate based on clinical suspicion alone can lead to removal of normal appendix in 15-

30% of cases. The premise that is better to remove a normal appendix than to delay

diagnosis does not stand up to close scrutiny, particularly in the elderly. A number of

clinical and laboratory based scoring systems have been changed to assist diagnosis.

1.TOTAL WHITE CELL COUNT:

In 90% of cases of appendicitis WBC count is greater than 10.000cells/cumm.,

with polymorph nuclear predominance. Unfortunately, the WBC is elevated in up to

70% of patients with other causes of right lower quadrant pain. Its role is considered

very high in diagnosis of acute appendicitis. In a detailed study of 493 patients with

acute appendicitis Pieper et,72 al in 1982 noted that only 66.7% had leukocyte count of

11000 or more, and in only 5.5% was it raised to more than 20.000. Doraiswamy73

1979 pointed out that the combination of raised leucocytes count and neutrophilia is

useful in the diagnosis of appendicitis in children. In his study 96% had neutrophilia

and 42% had raised leukocyte count.

2. ERYTHROCYTE SEDIMENTATION RATE (ESR)

Peritonitis following perforation and appendicular abscess give rise to increased

ESR and in other types of appendicitis ESR is normal (Albert Lesser herald and gold

burger, 1935) 74

41

3. URINE EXAMINATION

There may be presence of blood and pus cells in the urine routine examination

due to approximation of inflamed appendix to the ureter.

Graham (1965) quantitative analysed mid stream urine specimens in 71 patients

with a diagnosis of acute appendicitis. Microscopic pyuria was found in 9 patients ( all

females) and 1 had haematuria. 1 male patient had haematuria.

4. PLAIN X- RAY EXAMINATION OF ABDOMEN IN ERECT POSTURE

Some helpful x-ray findings following acute appendicitis are

a) localized air fluid levels in the right iliac fossa.

b) Localized ileus with gas in caecum, ascending colon or terminal ileum. In

retrocaecal appendicitis caecum is distended with gas.

c) Localized soft tissue shadow in the right lower quadrant.

d) Presence of faecolith.

e) Gas in appendix.

f) Obliterated psoas shadow

g) Altered flank right strips (flat line).

h) Free intra peritoneal gas in perforated appendix.

i) Deformity of cecal gas shadow due to adjacent inflammatory mass (this is

difficult to interpret because there may be disturbance of caecal gas from intraluminal

fluid or faeces).

X-ray study is of some help in establishing the diagnosis of this disease

(Brookes D.W and Killen D.A 1965) 75

42

ULTRASONOGRAPHY:

It is a noninvasive procedure and can be done in all set-ups and can be applied

to all age groups and in pregnancy. Ultrasound is found to diagnose inflammatory

appendix it’s specificity of 90-99% and sensitivity of 75-90%.30 With graded

compression method markedly enhances diagnostic accuracy avoiding negative

appendicectomy rate and delay in diagnosis beyond 6 hrs of admission. The inflamed

appendix can be visualized sonographically and the factors like diameter

>6mm(puylaert),17 wall thickness>3mm, complex mass, irregular 1asymmetry, loss of

contour, free fluid, local adynamic ileus, graded tenderness over McBurney’s point are

in favour of appendicitis.

6. CONTRAST ENHANCED CT SCAN:

Is most useful in whom there is diagnostic uncertainty particularly older

patients in whom acute diverticulitis, intestinal obstruction, or neoplasm are likely

differential diagnosis . Selective use of CT scanning may be cost effective by reducing

both the negative appendicectomy rate to 3.5-8.6% and length of hospital stay. 31

DIFFERENTIAL DIAGNOSIS OF ACUTE APPENDICITIS:

1. ABDOMINAL CAUSES

Acute cholecystitis.

Perforated peptic ulcer

Cyclical vomiting

Enterocolitis

Non specific mesenteric lymphadenitis

Intestinal obstruction

Crohn’s disease

43

Carcinoma of caecum

Amoebic colitis

Meckel’s diverticulitis

Acute pancreatitis

Mesenteric vascular occlusion

2. GYNAECOLOGICAL DISORDERS

Salphingits.

Ectopic gestation

Ruptured ovarian follicle

Twisted ovarian cyst

3. RETROPERITONIAL CAUSES

Right uretric colic

Right sided acute pyelonephritis

Torsion of testis

Haematoma in the retroperitonial tissue

4. THORACIC DISEASES

Basal pneumonia and pleurasy

5. OTHER CAUSES:

Henoch-schoenlin purpura

Porphyria

Diabetic abdomen

44

TREATMENT 46,48, 49,76

The treatment to acute appendicitis is immediate appendicectomy without delay.

If the diagnosis is made at an early stage in the attack, and particularly in the absence of

a localized mass, all are agreed that the appendix should be removed urgently.

The acute attack has been likened to a knock at the door saying ‘let me out’

(William Boyd). There is complete agreement that the treatment of early stage of acute

appendicitis in the 1st 2 days of attack, before perforation procedure designed to prevent

peritoneal contamination, prior to perforation of obstructed organ. While there are no

absolute rules, appendicectomy should be avoided in the presence of a mass or

localized abscess or if history is more than 48 hrs long (Bailey and Love). The

treatment after the 2nd day is clothed in controversy. Cases admitted with diffuse

peritonitis are treated with early appendicectomy.

PRE OPERATIVE MANAGEMENT:

1. Nil orally

2. Iv fluids for proper hydration of the patients

3. Antibiotics

In our study commonly used antibiotics were Ciprofloxin, Gentamycin along with Metronidazole.

4. T.P.R/B.P. charting, monitoring, particular attention being given to increase in the pulse rate and temperature.

5. Measuring urine output.

45

SURGICAL MANAGEMENT OF APPENIDICITIS

INDICATIONS FOR APPENDICECTOMY:

ACUTE APPENDICITIS:

In most cases of acute appendicitis, which are seen in the early stages of the

attack, operation should be carried out without delay. A distinction has been drawn

between catarrhal appendicitis in which resolution will frequently occur and obstructive

appendicitis which is likely to progress rapidly to gangrene and perforation. It is usually

impossible, however to determine with any degree of certainty from the clinical

examination which type of appendicitis is present, and the risks, which are involved, do

not justify delay.

An exception may be made in those cases where the attack obviously passing

of, and where, for various reason it may be desirable to postpone operation until a more

convenient time. Such condition arises when appendicitis of mild degree develops

during an acute illness or during the 1st 3 months of pregnancy when appendicectomy is

associated with some risk of miscarriage.

In children and in old people early operation should as a rule to be advised since

there are special dangers of delay. In children the appendix is thin walled and what

appears to be a mild catarrhal inflammation may proceed rapidly to gangrene and

perforation. Both in childhood and old age there is less tendency to localizations and

the risk of general peritonitis are very considerable. Unless, therefore a definite mass is

palpable operation should not be delayed.

46

RECURRENT OR CHRONIC APPENDICITIS:

Once the appendix has become inflamed further attacks at gradually shortening

intervals are to be expected. Appendicectomy during the quiesce3nt stage is attended

by the minimum of risk and discomfort to the patient and it should not be delayed until

a second attack develops, in proportion of cases and frequently in absence of any acute

attack chronic appendicitis may be diagnosed from the existence of a grumbling pain in

the right iliac fossa. in addition there may be general malaise or various digestive

symptoms the so called appendicular dyspepsia(Kerr,1962). Appendicectomy is usually

curative in such cases.

CARCINOMA OF APPENDIX:

In a very small proportion of patients a tumour of the appendix is found (Cohen,

1974). Appendicectomy is satisfactory in the treatment of an adenocarcinoma which is

confined to the mucosa but its diagnosis depends on routine histology of all appendices.

CARCINIOD TUMOUR OF THE APPENDIX.:

The appendix is the most common site for gastrointestinal carcinoid tumour. A

small tumour of the distal appendix is adequately removed by appendicectomy but, if

histological examination shows involment of the base of the appendix right

hemicolectomy is advisable (Anderson, 1985).

TUBERCULOSIS OF THE APPENDIX:

It may present as mass in the right iliac fossa indistinguishable from ilio-

cacecal tubeculosis Anti- tubercular therapy (ATT) is given for the patients.

47

STANDARD TECHNIQUE AND DIFFERENT TECHNIQUES FOR

APPENDICECTOMY

ELECTIVE APPENDICECTOMY:

Removal of appendix between attacks the so called of interval operation will be

described first, since it is usually a simple procedure and a relatively standardized

technique employed.

INCISION:

1. GRIDIRON INCISION:

This muscle splinting muscle incision is commonly used for appendicectomy

the main advantage of this incision is that it does not damage any nerve and being

muscle splitting it heals quickly. Inadvertently the sub costal nerve may be injured

giving rise to inguinal hernias but this is very rare.

The incision an oblique one and perpendicular to the right spino-umbilical line

(which extends from the right anterior superior iliac spine to the umbilicus) through the

Mac Burney’s point that is junction between lateral 3rd and medial 2/3rd of about 3 to 4

inches in length, whose 1/3rd will be above the spino umbilical line and 2/3rd below the

same line. Though this is the classical position of McBurney’s grid iron incision, yet

the surgeon should to try to feel the caecum first before planning the position of the

incision, as sometime the caecum with appendix may lie higher up or even sub hepatic.

the skin, fascia of campher and fascia of scarpa are incised along the line of the

incision. The fibers of the external oblique aponeurosis will be seen running along the

line of the incision. They are simply split. If the incision made higher up or a little3

48

laterally, one will be able to see the fleshy fibers of the muscle. The two margins of the

divided aponeurosis are retracted. The muscle fibers of the internal oblique will be

seen running perpendicular to the line of the incision. These fibers and the muscle

fibers of the transverse abdominis are more or less running in the same direction and

should be split by inserting the tip of the artery forceps and then opening it by the

handle of the scalpel. The fingers are then introduced and the muscle fibers are more

retracted. The fingers are replaced by right angle retractors to expose the transversalis

and the peritoneum. This is picked up by two artery forceps as one layer and incised to

enter the abdomen.

Technique:

The caecum may present as soon as the peritoneum has been opened, or it may

have to be sought for by two fingers introduced into the peritoneal cavity and passed

backwards round the lateral wall. It is easily distinguishable from small bowel by the

presence of taenia coli. The caecum is grasped in a moist pack by the left hand and is

gently withdrawn towards its lower end, when the appendix should follow it in to the

wound. Delivery of the appendix is assisted if necessary by the right index finger,

which is introduced deeply into the lower part of the wound below the caecum. If the

appendix cannot be readily found the operator should trace one of the taenia coli of the

caecum leading to its base. The appendix is then freed by a finger passed along it

towards its tip, any firm adhesions being gently disrupted. If dense adhesions are

present these should be separated or divided under the guidance of the eye, and with the

assistance of a narrowed bladed retractors. Sometimes as the result of previous

inflammation the appendix is sharply kinked and is bound down by adventitious bands

to the right iliac fossa or to the brim of the pelvis. Such bands can be divided with

49

safety and without risk of causing hemorrhage if the knife is kept to the lateral side of

the appendix.

The part of the caecum to which the appendix is attached is retained outside the

wound, while the remainder is returned to the peritoneal cavity. The appendix is raised

up and is held taut by a pair of Babcock’s forceps applied near its tip. The mesoappndix

is clamped with one or more pairs of artery forceps and is divided and ligatured. A

forceps is momentarily applied to the base of the appendix exactly at the point of its

junction with the caecum and a ligature is tied around the crushed area. It assists in the

subsequent control of the stump if the ends of these ligature are kept long are retained

in forceps. A purse string Lambert suture is inserted in the caecal wall around the base

of the appendix. Forceps are then applied to the appendix 5 or 6mm distal to the

ligature, the intervening lumen having been emptied by pressure of the blades. A swab

is placed underneath to absorb any escaping contents and the appendix is divided close

to the forceps the stump is invaginated with slender forceps while the purse string

suture is tightened. The appendix together with the knife, swab and forceps which have

been contaminated by contact with the mucosa are placed in a bowl and are removed

from the field of operation.

Before the abdomen is closed the ligatured mesoappendix is reexamined for

bleeding. The parts within reach are inspected or palpated particular attention being

paid to the lower coils of the ileum and to the ileocaecal lymph glands. In the females

the uterus, right ovary and tubes are palpated by two fingers passed downwards into the

pelvis. the operation is completed by suture of the wounds in layers.

50

RETROGRADE REMOVAL OF APPENDIX:

Frequently the base of the appendix is more accessible than the tip. This is

especially likely to occur when the appendix occupies the retrocaecal position when its

inflamed distal end may be adherent to the posterior wall of the caecum or may even be

buried within the serous port. In such cases the retrograde method of removal may

often simplified the operation. Two pairs of artery forceps are insinuated through the

mesoappendix are applied to the base of the appendix 5-6mm apart. The proximal

forceps is removed and the appendix is ligatured in the groove that has been crushed. It

is then divided close to the distal forceps and the proximal stump is invaginated. The

appendix with its cut end still occluded by the forceps is now freed by careful

dissection and by successive clamping and clipping of its mesentery from base to tip it

is removed.

2. LANZ’S TRANSEVERSE INCISION:

This incision is made at a level of 2-3cm below the umbilicus and is centered on

the midclavicular to midinguinal line. The structures incised in the direction of skin

incision. This incision lies in the direction of skin wrinkles line s and is a better

cosmetic incision the only disadvantage is rectal sheath is opened at the mid end of the

wound.

3. PARAMEDIAN INDISION:

Its chief advantage lies in the strong scar which results the incision is made

parallel to the mid line a distance of 2-3 cm from it. The anterior rectus sheath is

divided in line of incision. Forceps are placed on the medial cut margins, which are

retracted to expose the medial edge of the rectus muscle. The rectus is then displaced

51

laterally to expose the posterior sheath. The posterior sheath is incised together with

the transversals fascia and peritoneum.

Technique:

The caecum may present as soon as the peritoneum has been opened or it may

have to be sought for by two fingers introduced into the peritoneal cavity and passed

backwards round the lateral wall. A finger is inserted into the wound to aid delivery of

the appendix. The caecum is held by a moist pack in the left hand. The appendix is

freed of any firmly adhesions. The appendix is held by a pair of Babcok’s forceps

applied near its tip. The mesentery is clamped with one or more pairs of artery forceps,

and is divided and ligatured. The appendix is crushed near its junction with the ceacum

by a hemostat, which is removed and reapplied just distal to the crushed portion. A

chromic catgut ligature is tied around the suture is inserted into the cacecum 1.2 cm

from the base. It is left un tied until the appendix has been amputated with a scalpel

below the hemostat. The stump is invaginated, while purse string suture is tied, thus,

burying the appendix stump.

4. RUTHERFORD MORISION’S INCISION:

It is useful if the appendix is Para or retrocaecal and fixed. It is essentially an

oblique muscle cutting incision with its lower end over McBurney’s point and

extending obliquely upwards and laterally as necessary.

5. BATTLES’S PARA RECTAL INCISION:

This incision is mostly made on the lower abdomen over the lateral part of the

rectus muscle. The skin and subcutaneous tissue are incised along the line of the

incision the anterior rectus sheaths is also divided in the same line. The rectus muscle is

52

retracted medially to expose the posterior rectus sheath in the upper part of the incision

and fascia transversalis in the lower major part of the incision, where the posterior

rectus sheath is absent below the arcuate line. These nerves should be retracted to get

into the abdomen.

But it may so happen that sacrifice of one or two nerves may be necessary this

will cause some weakness of that segment of the recctus muscle supplied by the nerve.

This incision was previously used for appendicectomy and for unilateral

gynecological operations. But its popularity is on the wane as neither it gives proper

access to the organs concerned nor it can be extended due to the presence of

intercostals nerve.

Closure is carried out in the same manner as that of the paramedian incision.

Shifting Window Technique:

In 1993 Feb-March ASI conference at Hubli a paper was presented on shifting

window technique for appendicectomy.

In this technique periumbilical incision was taken and was shifted to the

McBurney’s point and appendicectomy was performed by the conventional method.

Stumpless Appendicectomy: 77

Stumpless appedicectomy was performed in more than 400 cases between 1982

and 1986. of these only 250 cases would be followed up, of these 205 patients

underwent an elective procedure and the rest 45 an emergency appendicectomy.

In 220 cases a standard McBurney’s incision was made, 20 patients had a

Rutherford Morrison’s incision, were as the rest 10 patients underwent a laparatomy.

53

After inspection and palpation of the caecum, the appendix was identified and delivered

in the wound. The mesoappendix was ligature and a tiny vessel on the mesenteric side

of the caecum was under run. All vascular ligatures were made with 000 linen. An

intestinal clamp was applied over the delivered and emptied caecum about .5cm

proximal to the base of the appendix. A straight artery forceps was then applied over

the base of the appendix flush to the caecum and with a knife the appendix was cut

flush to the artery forceps. Subsequent rent of the caecum was cleaned with wet sponge

and sprit, carefully preventing any spillage and the contamination of the surrounding

structures. The caecal rent was closed in two layers using 0000 or 00000 polyglactin-

910 continuous interlocking sutures. The surrounding fat or omentum, when available

was over swan on the suture line. After through cleaning, the caecum and the intestine

were gently put back.

Laparoscopic Appendicectomy: 78

The most valuable aspect of laparoscopic in the management of suspected

appendicitis is as a diagnostic tool, particularly in women of child-bearing age.

Essential Requirements for Laparoscopic Appendicectomy

Instruments for visualisation:

Light source

Telescope

Video camera system

Beam splitter

Monitor

Video recorder

Video printer

54

Instruments for exposure and manipulation

Insufflator

Puncture instruments

Grasping and dissecting instruments

Occlusion and ligation instruments

Electro surgical unit. Laser equipment is unnecessary

Irrigation and suction instruments

Wound closure instruments

Laparatomy instruments

Preparation of the patient for laparoscopic appendicectomy:

Under the circumstances it is mandatory that the patient be totally prepared

mentally and physically for the procedure. The steps of the laparoscopic procedure are

explained to the patient. It is at all times impressed that patients safety and the necessity

of carrying out a complete and a through procedure may be terminated at any phase and

converted into a open surgery it is made clear that open surgery if require would be

done during the same anesthesia. Specific informed consent must be taken. A fully

informed patients confidence acceptance and cooperation and vital for the smooth

conduct of the procedure.

The preoperative evaluation of the patient is identical to that for open

appendicectomy. As every case is done under general anesthesia the routine evaluation

of the patient for fitness for anesthesia is carried out.

55

The Pneumoperitoneum.

The most important single step in the safe an efficient conduct of any

laparoscopic procedure be it diagnostic or operative is the creation of an adequate

generalized pneumoperitoneum. The pneumoperitoneum is created with help of a

spring-loaded verses needle. A stab inscion is made in the infraumblical region. The

verses needle is held like a dart between the thumb and the index finger, with the little

finger placed on the abdomen wall to act as a guard to prevent too deep or sudden

penetration. The left hand elevates the abdominal wall as high as possible and with the

gentle progressive pressure exerted by dorsiflexing the wrist the tip of the verses needle

is advanced through the various layers of the abdominal wall.

The fact that the needle tip is in the free peritoneal cavity has to establish carefully.

This is done by:

1. Injecting saline

2. Hanging drop test

3. Free movement of the needle tip

4. Once it is established that the needle tip is in the free peritoneal cavity, it is

connected to the electronic pneumoinsufflator and carbon dioxide insufflations is

commenced at a flow rate of one liter per minute. Thee pressure reading on the insufflators at

the tip of the needle and in the intraabdominal cavity are carefully monitor.

5. Percussion of the abdominal wall gives a resonant note and obliteration of

liver dullness.

Next 4 trocars introduced into the peritoneal cavity using suitable incision on

the abdominal wall.

56

Stapling Techniques in Laparoscopic Appendicectomy:

An automatic stapling device, the multifire endo-gia30, is an instrument, which

can be passed through 12mm trocar sleeve, compresses the appendix as well as the

resting stump, occluding its lumen with 3 lines of titanium staples and cutting between

them. Using this stapler, the mean operation time is 35-95 min with no complications or

mortality.

This new stapling device offers a simple and safe method for use in

laparoscopic appendicectomy.

MANAGEMENT OF APPENDIX MASS:46,48:

If an appendix mass is present and the condition of the patient is satisfactory,

the standard treatment is conservative Ochsner-Sherren regimen. This strategy is based

of the premise that the inflammatory process is already localised and that inadvertent

surgery is difficult and may be 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 should clinical deterioration occurs,

that is a rising pulse rate, increasing or spreading abdominal pain or increase in the size

of the mass.

Careful record of the patient’s condition and the extent of mass should be made

and the abdomen regularly re-examined. It is helpful to mark the limits of the mass on

the abdominal wall using a skin pencil. A contrast enhanced CT examination of the

abdomen should be performed and antibiotic therapy instigated. An abscess if present

should be drained radio logically. Temperature and pulse rate should be recorded 4th

hourly and a fluid balance record maintained. Clinical deterioration is evidence of

57

peritonitis is indication for early laparatomy. Clinical improvement is usually evident

within 24-48 hrs. Failure of the mass to resolve should rise suspicion of carcinoma or

Crohns disease. Using this regimen, approximately 90% of cases resolve without

incident. It is advisable to remove the appendix after an interval 6-8 weeks.

POSTOPERATIVE COMPLICATION: 48,79

Post operative complication following appendecectomy are relatively

uncommon and reflects the degree of peritonitis that was present at the time of

operation and intercurrent dieseseases that may predispose to complications.

wound infection

intaabdominal absess

paralytic illeus

respiratory complication

venous thrombosis and embolism

portal pyaemia

faecal fistula

adhesive intestinal obstruction

right inguinal hernia

PROGNOSIS:

Early diagnosis as the general recognisation of the necessity of early operation,

improved anesthesia, improved surgery, improved management of general peritonitis

and newer antibiotics all have added towards better prognosis in these days. Mortality

is negligible in cases which are operated within 48hrs after appearing of symptoms.

Peiper etal,72 (1982) found only 2 deaths in their review of 1018 appendicectomies

58

(0.2%). If appendix is perforated the mortality may be expected to rise. Peltokallio and

Tykka 80 (1981) reported 0.12% in non-perforated and 1.18% in perforated group.

The morbidity and mortality rate for masses is the lowest if treated

conservatively but high if early operation is done (Mcpherson and Kinmonth).81

59

METHODOLOGY

SOURCE OF DATA:

For the study, the patients admitted with Acute Appendicitis in Emergency and

surgical wards in all the units of Government General Hospital and Basaveshwar

Teaching & General Hospital, Gulbarga are included without bias on a serial basis.

This is a randomised study comprising of 100 patients of suspected acute

appendicitis over a period of two years (i.e. from June 2003 to June 2005). The patients

on admission with suspected acute appendicitis are evaluated on the basis of Alvarado

Scoring System.

Inclusion Criteria:

All patients who are coming to surgical OPD at Government General Hospital

and Basaveshwar Teaching & General Hospital, Gulbarga with Complaints of Acute

pain in the right iliac fossa.

Exclusion Criteria:

All patients other than acute Appendicitis are excluded.

A proforma was made for the study of these cases. The cases are subjected to a

detailed clinical examination and essential investigations namely total white cell count

and ultrasonography of abdomen.

60

Alvarado Score:

Symptoms

Migratory RIF pain 1

Anorexia 1

Nausea/ vomiting 1

Signs

RIF tenderness 2

Rebound tenderness 1

Increase in temperature 1

Lab findings

Leucocytosis 2

Shift to the left 1

(Or positive ultrasound finding)

10

USG Criteria of Acute Appendicitis:

• Visualisation of appendix

• Diameter>6mm

• Wall thickness> 3mm

• Complex mass (echo poor, asymmetric)

• Irregular asymmetry

• Loss of contour

• Free fluid

• Local adynamic ileus

• Graded tenderness over Mc Burney’s point.

61

Patients with score of 1-4 are not considered likely to have acute appendicitis;

those with score of 5-6 probably have, those with score of 7-8 possibly have, those with

score of 9-10 are considered to have definitive diagnosis.

Scoring System

1- 4 - Appendicitis unlikely

5- 6 - Appendicitis possible

7- 8 - Appendicitis probable

9- 10 - Appendicitis definitive

Patients with score of 7 and > 7 are subjected to surgery. Operative and

histopathological diagnoses of appendicitis are confirmed.

The cases subjected to emergency surgery are adequately prepared by parenteral

fluids, electrolyte supplementation, administration of broad spectrum antibiotics

intravenously (usually combination of Ciplox 200 mg 12th hourly + Gentamycin 80 mg

12 hourly + Metronidazole 500 mg 8th hourly).

Surgery was done under spinal anesthesia. Grid iron incision was employed in

all cases. Post operatively patients are kept nil orally, till bowel sounds returned,

parenteral fluid, electrolytes, antibiotics and analgesics were continued. Cases are

watched for any post operative complications and treated wherever needed. Post

operatively sutures are removed on 7-9 days and the patients were discharged after

histopathological confirmation.

62

RESULTS

In this series of 100 cases, all the patients who presented with acute symptoms

and diagnosed to have acute appendicitis were included in the study.

Table – 1: Age and Sex Incidence:

Sex Age Group (Years) Male

n=62 Female

n=38 1 –10 2 1

11 –20 26 16

21 –30 28 18

31 –40 6 3

41 –50 -- --

Acute appendicitis is more common in males than females. Boyd discussing

acute appendicitis disease says it is more than twice as common in males as in females

and explains it may be due to fact that young males is more subject to strain and trauma

and that his diet is usually richer in protein than that of the females.

In our series the male to female ratio is 3.1:1.9

In Levis et al series of 1000 cases, the incidence of acute appendicitis was found

to occur most commonly in the age group of 20-30 years in both males and females.

The male to female ratio was 3:2.

In our series, the maximum incidence as found in the age group of 20 to 30

years.

63

Graph-1 Showing Age and Sex Distribution of Cases

2

2628

6

01

1618

3

00

5

10

15

20

25

30

1 –10 11 –20 21 –30 31 –40 41 –50Age Group (Years)

No.

of C

ases

Male Female

64

Clinical Symptoms:

1. Migratory RIF Pain:

In this study 59% of patients presented with pain around umbilicus, which later

shifted to right iliac fossa. Majority of the patients had aching type of pain was noted in

34% of the patients.

Table – 2: Pain Distribution

Site of pain No. of Patients n=100 Percentage

Right iliac fossa 98 98.00

Umbilicus 2 2.00

Lower epigastrium -- --

65

Graph-2 Site of Pain

98

2 0

Right iliac fossa Umbilicus Lower epigastrium

66

1. Anorexia:

Anorexia nearly always accompanies appendicitis. In this series 88% (88) of

patients had anorexia.

2. Nausea or Vomiting:

The second commonest symptom was nausea in 87 patients and vomiting, it

occurred initially with one or two bouts in 83 patients.

Incidence of Vomiting –

Present series………………………………..83%

Schwartz4………………………………………..75%

Vomiting appears after the onset of pain and vomiting is more common among

teenagers and younger age groups.

Physical Signs:

Majority of the patients presents within 24 hours after onset of pain with most

of them presenting between 13-24 hours after the onset of pain.

Right Iliac Fossa Tenderness: On clinical examination of the patient tenderness in

RIF with 100% was the most consistent feature.

Systemic gentle palpation will detect an area of maximum tenderness that

corresponds to the position of the appendix and is usually located in the RIF at or near

Mc Burney’s point.

67

Rebound Tenderness: was present in 44% (44) of the cases. In these cases, there was

presence of local peritoneal involvement or when inflamed appendix was more

interiorly placed.

Increase in Temperature: Low-grade fever was complained by 48% of the cases.

Investigations:

White blood cell count: In our series, the total count of more than 10,000 was present

in 50% of the patients.

In the study of Piper et al 72(1992), they noted that 60% had total count of

11,000 or more and in only 5% it was raised above 20,000.

Ultrasonography: All cases are subjected to ultrasonography and high frequency

probe was used in some cases.

In 88% of the patients, it was seen as localized adynamic ileus.

68

Table –3: USG FINDINGS

USG Findings No of Patients n=100

Percentage

Visualization of appendix 33 33.00

Diameter >6mm 6 6.00

Wall Thickness >3mm 22 22.00

Irregular asymmetry -- --

Loss of contour -- --

Free fluid -- --

Local adynamic ileus 88 88.00

Graded tenderness over McBurney’s

point

88 88.00

Normally study 12 12.00

Management:

Of the 100 cases, 90 are with 7 and more than score. Out of the rest 10 patients,

4 were having 6 score, 3 were having 5 score and 3 were having 4 score.

The three patients with score 4 are treated conservatively and no symptoms

developed further. 7 patients of score 6 and 5 were operated. 1 Male and 2 females

have score of 6. 2 males and 1 female have score of 5, 3 males have score of 4. 3

were confirmed out of 4 male patients the percentage being 75%, 1 was confirmed out

of 3 female patients, the percentage being 33.3%.

69

Graph-3 Ultrasonographic Findings

12

8888

000

22

6

33

0

10

20

30

40

50

60

70

80

90

100

Visualizationof appendix

Diamter>6mm

WallThickness

>3mm

Irregularasymmetry

Loss ofcontour

Free fluid Localadynamic

ileus

Gradedtenderness

overMcBurney’s

point

Normallystudy

USG Findings

No.

of C

ases

70

In 90 patients, 54 were males and 36 were females with a score of 7 and more

than 7. all of them were subjected to surgery with confirmation in 52 out of 54 males –

96.2% and 30 out of 36 females – 83.3%. The negative appendicectomy rate of males is

3.8% and in females 16.7%.

Women with normal appendix who underwent operation were having pelvic

inflammatory disease in 5 patients, and ruptured follicular cyst in 1 patient. One of the

males with normal appendix had Meckels diverticulities while the other had regional

ileitis.

90 patients were given spinal anesthesia and 7 were given general anesthesia.

Incision:

The incision commonly employed was grid-iron incision and was extended

whenever posed with difficulties and better exposure was needed. In one case, the

appendix was normal and a Meckel’s diverticulum was present. Appendicectomy with

excision of Meckel’s diverticulum was done. The position and condition of the

appendix noted intra-operatively.

71

Graph-4 Showing the Alvarado Score

90

4 3 3

7 or > 7 Score of 6 Score of 5 Score of 4

72

Position of Appendix:

Retocaecal………………………………….61

Pelvic………………………………………20

Subcaecal……………………………………8

Paracaecal……………………………….…..5

Preileal and post ileal……………………….3

Table – 4: The condition of The Appendix

Condition No. of Patients n=97

Percentage

Normal 11 11.34

Congested 3 3.09

Inflamed 75 77.31

Gangrenous 2 2.06

Perforated 6 6.18

In Semsi et al series of 100 emergency apendicecetomy, 21% of the patients had

perforated appendix. In Martin Breumen (1970) series perforated appendix constituted

84% of appendicectomy and gangrenous 9.9%.

73

In 94.84% (92) of patients, classical apendicectomy with burying of the

appedicular stump in caecum was done. In 5.16%(5) cases invagination was not

possible because of friable base or caecal congestion and inflammation.

74

Graph-5 Condition of the Appendix

11

3

75

26

0

10

20

30

40

50

60

70

80

normal congested inflamed gangrenous perfortated

Condition of the Appendix

no. o

f Cas

es

75

The post operative complication in our series is wound infection with a percentage of

5% or 5 patients.

The pathological diagnosis of the specimen of the appendix sent for

histopathological study are as follows:

Table –5 : Histopathology Reports

Histopathology No. of Patients

n=97

Percentage

Normal 11 11.34

Acute appendicitis 57 58.76

Acute suppurative appendicitis 27 27.83

Acute gangrenous appendicitis 2 2.07

76

Graph-6 Histopathology

11

57

27

2

NormalAcute appendicitis Acute supurative appendicitisAcute gangrenous appendicitis

77

DISCUSSION

The discussion is based on the observations and analysis of the results in the

study of 100cases with regard to incidence, age, sex, symptoms, signs, investigations

operative findings, and histopathological examinations using Alvarado scoring system.

Clinical Features:

Age incidence

In the present study the common age group found was 20.30 year (46%) and the

median age being 24 years.

Table – 6: Age Distribution

Author Age Group Percentage

Gallendo Gallego et al24 20-30 yr 52.00

Present study 20-30 yr 46.00

SEX INCIDENCE:

It has been established beyond doubt by several authors, that male Sex

predominated over female in the incidence of acute appendicitis.

78

Table – 7: Showing Sex Distribution by Various Authors.

Authors M : F Ratio

Levis et al82 3: 2

P. Ronan ‘O’ connel et al48 3: 2

Addis DG, et al3 1. 3: 1

Blab E et al38 3: 2

Present Study 3. 1: 1.9

Out of 100 Cases, there were 62 Male patients (62%) and 38 Female patients (38%)

Symptoms and Signs.

PAIN:

Pain was a complaint in all the cases in this study. The initial location of pain in

most cases (59%) presented with pain around umbilicus followed by (41%) in the right

lower quadrant and 98% of the patients lately presented with pain in the right iliac

fossa, which adds a diagnostic point of acute Appendicitis.

Table-8: Showing Pain distribution by various Authors.

Authors Pain around

Umbilicus

Pain right lower

quadrant

Pain in the Right

iliac fossa

Gallindo Gallego et al24 49% 32% 96.4%

Schwartz SI4 50% 50% 100%

Present Study 59% 41% 98%

79

ANOREXIA:

Anorexia was present in 88% of patients in present series. Anorexia nearly

always accompanies appendicitis.

Table-9: Anorexia as a symptom.

Authors Percentage

Kallan Met al84 85.00

George Mathews, et al30 92.13

Schwartz SI4 100.00

Present Study 88.00

Nausea or Vomiting:

Nausea was present in 87% of Cases and vomiting in 83% of cases in present

series.

Table-10: Nausea or vomiting as a symptom.

Authors Nausea Vomiting

Owen Td, et al85 84% 78%

George Mathew set al30 92% 70.9%

Schwartz SI4 90% 75%

Present Study 87% 83%

80

Right Illiac fossa tenderness:

Right iliac fossa tenderness was present in all the cases 100% at the time of

presentation, a major contribution for diagnosis of Acute Appendicitis.

Table-11: Presence of Right Illiac tenderness by various Authors.

Authors Percentage

P.K. Bhattacharjee et al29 92.00

Kallan M, et al84 95.00

Galleneto Gallego et al24 94.00

George Mathews et al30 99.1

Present Study 100.00

Rebound Tenderness:

In the present series, in 44% of the cases there was presence of rebound

tenderness, and this is noted when there is local peritoneal involvement and it depends

upon the time of presentation.

Table-12: Showing signs of Rebound tenderness elicited by various Authors.

Authors Percentage

Owen Td et al85 60.00

Gallindo Gallego et al24 56.00

Schwartz SI4 50.00

Present Study 44.00

81

Fever:

Fever was present in 48 cases (48%) in present series in the major of cases fever

was of low grade and continues: the incidence of fever in the Literature and the present

series is compared in the following tables.

Table-13: Fever as Sign by various authors.

Authors Percentage

Kallan M et al85 40.00

Wilcox et al5 50.00

George Mathews et al30 74.03

Present Study 48.00

Leucocyte count: W.B.C. count more than 10.000 cells/ cumm was found in 50% of cases and

only 2% it was raised above 20,000 Cells/ cumm.

Table-14: Leucocyte count by various authors.

Authors Percentage>10.000

Cells./ Cumm.

Percentage > 20,000

Cells/Cumm.

Peiper et al72 60.00 5.00

Galllindo Galling et al24 65.00 3.00

Elangovan’s86 80.00 -

Doraiswamy73 42.00 -

Present Study 50.00 2.00

82

Ultrasonography:

In the present series Visualisation of appendix was only seen in 33% of the

patients. The reasons is due to non availability of high frequency probe.

In a study by Puylaert BCM et all 88.5% of the patients on ultrasound were

reported Visualisation of the appendix in another study by Gallindo Galligo et al 82%

of the patients reported with Visualisation of appendix. In the present series, graded

tenderness over the McBurney’s point by transducer was 88% which is the good

diagnostic feature of acute appendicitis. According to Puylaert BCM et al graded

tenderness over the McBurney’s by transducer was 89% in the present series 88% of

patients are reported as local dynamic illus in ultrasound. The raise of percentage may

be due to other pathologies which also show illus other than appendicitis. In the

present series 12% of the patients were reported as normal study of ultrasound and use

has a role excluding the diagnosis of acute appendicitis.

Table –15: Visualisation of Normal appendix by USG

Authors Percentage

Bhattacharjee PK. et al29 12.5

Puylaert BCM et al17 11.00

Gallindo Gallego et al24 12.00

Present Studies 12.00

83

USG specificity and sensitivity in diagnosis of acute appendicitis:

In the present study USG findings showed 88% sensitivity and 88% specificity

in diagnosing acute appendicitis.

Table-16: Value of USG in the diagnosis of acute appendicitis.

Authors Specificity Sensitivity

George Mathews et al30 90.90% 88.13%

Puylaert JBCM et al17 100% 89%

Gallindo Gallego et al24 82% 89%

Jeffrey et al87 96.2% 89.9%

Ziedan et al88 93.7% 74.2%

Fa et al89 90.6% 66.7%

Abu-you set et al18 95% 85%

Adams et al90 86% 89%

Present Study 88% 88%

Alvorado Score:

In this series 87% are Males and 94.7% were females of score 7 or more than 7.

Table- 17: Alvarado Score 7 or > 7 by Authors.

Authors Percentage

Male Female

Bhattacharjee et al29

84.5 80.00

Sudhir Kumar Mohanty et al26

75.00 88.23

Present Study

87.00 94.7

84

HISTOPATHOLOGY: In the present series 88.65% (86) of the patients are histopathologically

confirmed.

To prove accuracy of scoring, ultrasound sensitivity and specificity histopathological

confirmation is needed.

Table- 18: Histopathological reports by authors

Authors Percentage

Bhatacharjeee et al29

82.7

Sudhir Kumar Mohanty et al26 94.44

George Mathews et al30 84.28

Geryk B et al27

78.2

Present Study

88.65

85

NEGATIVE APPENDICECTOMY RATE: The present study shows negative Appendicectomy rate of 16.7% in females

and 3.8% in male. In females,negative appendicectomy rate is high. This is probably

due to pelvic inflammatory diseases, and ruptured follicular cysts. The conditions are

not properly diagnosed on ultrasound and mimic acute appendicitis.

Table – 19 : Negative Appendicectomy rate by various Authors.

Authors Percentage

Male Female

Sudhir Kumar Mohanty et al26 4.8 6.7

Bhattacharjee et al29 6.9 19.1

Korner H et al21 9.3 22.2

Present Study 3.8 16.7

86

CONCLUSION

The Alvarado scoring system combined with ultrasound can therefore be used

as a cheap and inexpensive way of confirming acute appendicitis thus reducing

negative appendicectomy rate.

History and clinical examination was more diagnostic. Ultrasonography

increases the diagnostic accuracy in patients with suspected acuter appendicitis

to the tune of 90-95%.

Alvarado score with less than 6 leads to more than 25% negative appendicectomy

rate. If the scoring is above 7, the overall accuracy of diagnosis of acute appendicitis

gives up to 90%.

87

SUMMARY

A study of 100 cases who presented with pain in right iliac fossa was conducted

at Government General Hospital and Basaveshwar Teaching & General Hospital,

Gulbarga during the period from June 2003 to June 2005.

Emergency appendicectomy constituted 23.3% of the total abdominal surgeries.

Acute appendicitis is more common in males than females and the highest incidence is

in 2nd & 3rd decade of life.

The patients presented with symptoms of pain in RIF, vomiting or nausea,

anorexia, and sings of RIF tenderness, rebound tenderness, and rise in temperature. The

patients were examined clinically thoroughly by using Alvarado scoring system. The

patients are subjected to investigations like total count and ultrasonography which are

considered in the score.

Ultrasonography has diagnosed 88% of cases as acute appendicitis. 90 of the

total cases which has score 7 and >7 were managed surgically and the remaining 7

patients with score of 6 and 5 were operated and 3 were managed conservatively.

90% of the cases were confirmed intra-operatively and 89% of histopathological

examinations confirmed the diagnosis of acute appendicitis.

Complications like wound infection was seen only in 5% of the patients.

88

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96

PROFORMA

Name of the patient I.P. No.

Age Ward

Sex DOA

Address DOD

Occupation Diagnosis.

PRESENTING COMPLAINTS

1. Pain abdomen

2. Vomiting

3. Fever

4. Diarrhea HISTORY OF PRESENT ILLNESS

1. Pain abdomen

Duration

Site

Shifting of Pain

Mode of onset (gradual and progressive / sudden)

Character (Agonising / colicky / constant burning/ dull aching)

Aggravating factors

Relieving factors

Disturb Sleep

97

2. Nausea / Vomiting

Spontaneous / induced

Projectile / non projectile

Frequency and quantity

Vomitus nature

Relationship with pain

3. Fever duration

Low / moderate / high

Continuous / intermittent /remittent

Chills and rigors

4. Anorexia

5. Loose motions

6. Hematermesis / malena

7. Burning micturition / hematuria / frequency /strangury

8. Loose of weight

9. Bleeding P/R

10. H/O worm infestation

11. H/O cough / breathlessness / chest pain / hemoptysis

PAST HISTORY

1. H/O operation

2. H/O similar complaints previously

3. H/O hypertension / diabetes / kochs

98

PERSONAL HISTORY

1. Diet

2. Smoking

3. Alcohol

4. Bowel habits

5. Micturation

6. Sleep

FAMILY HISTORY

H/O Similar Complaints in family

H/O Koch’s

MENSTRUAL HISTORY

GENERAL PHYSICAL EXAMINATION

1. Nourishment

2. Built

3. Hair distribution

4. Conjunctiva

5. Sclera

6. Tongue Pale / Pink

Moist / dry

Coated / non- coated

7. Cyanosis

8. Nails Pale / Pink

Clubbing

99

Koilonchya

9. Neck Engorged veins

JVP

Thyroid

10. Pedal edema

11. Generalized lymphadenopathy

VITAL DATA

1. Temperature

2. Pulse rate

3. Blood pressure

4. Respiratory rate

LOCAL EXAMINATION - ABDOMEN

INSPECTION

1. Shape Flat/ distension

2. Swelling visible Yes/ No

3. Movement of all quadrant with respiration

4. Engorged vein / Pulsations

5. Visible peristalsis

6. Flanks Full / Empty

7. Umbilicus

8. Hernial Sites

9. Scrotum

100

PALPATION

1. Local rise of temperature

2. RIF Tenderness

Rebound tenderness

3. Guarding / Rigidity Localized / Generalized

4. Pulsations

5. Hepatomegaly

6. Splenomegaly

7. Fluid thrill

PERCUSSION

1. Mass Dull / resonant

2. Shifting dullness

3. Knee elbow position

4. Liver dullness

AUSCULTATION

1. Bowel Sounds

PER RECTAL EXAMINATION

PER VAGINAL EXAMINATION

SYSTEMIC EXAMINATION

1. Respiratory System

2. Cardiovascular System

3. Central nervous System

4. Skeletal system and spine

101

CLINICAL DIAGNOSIS

INVESTIGATIONS:

1. Blood – H b %

TC

DC Polymorphs

Lymphocytes

Eosinophils

ESR Monocytes

2. Urine Albumin

Sugar

Microsocpy

Culture / Sensitivity

3. Blood Sugar

4. Blood urea

5. Serum creatinine

6. Liver function test

7. Barium meal and follow through

8. Stool examination

9. X-Ray Chest

10. Ultrasound abdomen

11. ECG

102

TREATMENT AND FOLLOW UP

1. Operation – early appendicectomy

2. Technique of appendicectomy applied

3. Intra- operative findings

4. Histopathology report

5. Post-operative complications.

103

KEY TO MASTER CHART

L - Leucocytic count > 10000

LI - Localized ileus

IA - Inflammed Appendix

AA - Acute Appendicitis

N - Normal

TA - Thickened Appendix

P - Present

A - Absent

O - Operated

R - Raised Above 1oF

CA - Congested Appendix

VA - Visualisation of Appendix

NA - Normal Appendix

PA - Perforated Appendix

GA - Gangrenous Appendix

NO - Not operated

104