Types of appendicitis:

A. Pathological types: 

1. Obstructive type.
2. Non Obstructive type.

B. Clinical types:

1. Acute appendicitis.
2. Recurrent appendicitis.

C. Other types:

1. Catarrhal.
2. Suppurative.
3. Gangrenous.

Symptoms of acute appendicitis : 

• Periumbilical colic (pain).
• Pain shifts to right iliac fossa.
• Anorexia
• Nausea & vomiting.

signs of acute appendicitis : 

• Pyrexia
• Localized tenderness in the right ilise fossa (Mc Burney’s point tenderness).
• Muscle guarding
• Rebound tenderness.

Other signs

Pointing sign: The patient is asked to point to where the pain began and where it moved.

Rovsing’s sign :  Deep palpation of the left iliac fossa may cause pain in the right iliac fossa

Psoas sign: Positive in retrocaecal appendix. (An inflamed appendix lies on the psoas muscle and the patient, often a young adult, will lie with the right hip flexed for pain relief). Pain in extension of hip joint.

Obturator test:  Positive in pelvic appendix. (Spasm of the obturator internus is sometimes demonstrable when the hip is flexed & internally rotated. If an inflamed appendix is in contact with the obturator internus, this maneuver will cause pain in the hypogastrium).

Investigations of Appendicitis:

Still now in most of the cases it is diagnosed clinically.

Routine:

1) . Full blood count (FBC):

• Neutrophilic leukocytosis.
• Raised ESR.

2) Urine analysis

Selected cases : 

1. Pregnancy test.
2. Urea & electrolytes.
3. Supine abdominal radiograph.
4. USG of the abdomen /pelvis. It is done in case of female where there is confusion of origi pain either from appendix or adnexa.
5. Contrast-enhanced CT scan of the abdomen.

Treatment of Appendicitis :

Non-operative management: Conservative management-

• Bowel rest by nothing by mouth.
• IV fluids.
• IV antibiotics- 3rd generation cephalosporin + metronidazole.
• More recently entrapenam has been used.

Operative management:

Emergency appendicectomy : 

• Conventional appendicectomy.
• Retrograde appendicectomy.
• Laparoscopic appendicectomy.

For more curiosity of Appendicitis : 

Steps/pathogenesis of acute appendicitis: Obstruction of the lumen of the appendix due to any cause →Secretion & accumulation of mucus within the lumen→ Intraluminal pressure is increased Obstruction of the draining veins Venous congestion and ischaemia→ Bacterial invasion Additional inflammatory oedema and exudates → More injury→ Acute appendicitis.

Risk factors for perforation of the appendix:

1. Extremes of age.
2. Immunosuppression.
3. Diabetes mellitus.
4. Faecolith obstruction of the appendix lumen.
5. Free lying pelvic appendix.
6. Previous abdominal surgery.

Atypical presentation of acute appendicitis :  

1. Suprapubic discomfort.
2. Tenesmus.
3. Acute lower abdominal pain.
4. Poorly localized abdominal pain.
5. Normal temperature with vomiting.
6. Early diarrhoea (in pelvic appendix).
7. Marked retching (in postileal appendix)

The conservative treatment & monitoring of acute appendicitis.

Conservative treatment of acute appendicitis: Please write from above discussion.

Monitoring of the patient:

• Pulse & blood pressure.
• Temperature
• Urine output.

Fates of acute appendicitis : 

Resolution spontaneously or by drug.

Relapse & recurrent appendicitis.

Complication of acute appendicitis:

1. Appendicular lump formation (made up of the appendix, caccum, greater omentum & coils of intestine).
2. Appendicular abscess
3. Perforation of the appendix.
4. Gangrene of the appendix.
5. Peritonitis-Generalized or localized.
6. Septicaemia & systemic sepsis syndrome.
7. Portal pyemia
8. Intestinal obstruction due to obstructive ileus,    inflammatory adhesion, formation between appendix & omentum or between appendix & small bowel.
9. Liver abscess.
10. Pelvic abscess, subphrenic abscess

Appendix Surgical anatomy :

• Synonym:  abdominal tonsil as it plays algnificant role in immune system of the body.
• It is a blind muscular tube with mucosal, submucosal, muscular and serosal layers. It is a part of large intestine. It averages about 7.5 to 10 cm in length and its irregular lumen is about 0.2 cm in diameter.
• Locations :  Bass of appendix: Attached to posteromedial surface of caecum about 2.5 cm below the ileocecal junction

Body and tip of appendix (position of appendix: 

1. Retrocaecal / Retrozolic
2. Pelvic (21%).
3. Paracaecal (26)
4. Subcaecal (1.5%)
5.  Preileal (1%) 6)
6. Postileal (0.5%)

Peritoneal covering: Vermiform appendix has a complete peritoneal covering which is attached to the lower layer of mesentery of small intestine to form a short mesentery of its own, the mesoappendix.

Variations: Distal 1/ 3rd of appendix may be bare of mesoappendix.

Arterial supply:

1. Appendicular artery (an and artery), a branch of lower division of ileocolic artery.
2. An accessory appendicular artery may be present.

 Mode of arterial sunph: The appendicular artery passes behind the terminal ileum to enter the mesoappendix a short distance from the base of the appendix then comes to lie in the free border of the mesoeppendix but for a variable distance from the tip where mesoappendix is lacking→ the artery lies directly on the muscle wall beneath the peritoneal coas – once the appendicular artery reaches the wall of the appendix proper it becomes an end artery

Venous drainage: Appendicular vein joins posterior caecal vein.

Lymphatic drainage: Four to six or more lymphatics traverse the mesoappendix to empty into ileo-caecal lymph nodes.