Gynaecological causes that are frequently mistaken for appendicitis :

¶ Pelvic inflammatory disease

Here you will find a history of dysmenorrhea, offensive vaginal discharge and burning micturition, cervical tenderness will help, its always a good idea to consult a gynaecologist when in doubt.

¶ Torsion/Hemorrhage of ovarian cyst

This is challenging as it presents very closely as appendicitis, but the pain start in the same place and remain in the same place, its helpful to do pelvic ultrasound.

¶ Ectopic pregnancy

Can be excluded by pelvic ultrasound and pregnancy test, a history of missed menstrual cycle is helpful.

¶ Endometriosis.

¶Mittelschmerz pain

-This one is due to rupture of a follicular cyst, pain classically happen midcycle.

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Q:Why appendicitis in infants is much dangerous than older patients?

A: Because the condition itself is rare and the patient is unable to give history, these reasons will cause delayed diagnosis and the condition can progress to perforation, furthurmore the greater omentum in infants is so small and underdeveloped, this makes the omentum unable to provide good help in localising the infection, thus the condition will more likely end up with life threatening diffuse peritonitis.

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Diarrhea in appendicitis

-This may occur in two situations

1- Pelvic appendix, here the inflamed appendix is in contact with the rectum, irritation of which cause diarrhea.

2- Post ileal appendix, this is rare, here the inflamed appendix is in contact with the terminal ileum, producing diarrhea and marked retching.

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Special features of pelvic appendix

◼️ Early diarrhea = irritation of the rectum

◼️ Increased frequency of micturition = Irritation of the urinary bladder.

◼️ Tenderness on rectal examination espscially on the right side in the rectovesical pouch.

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Special clinical features of retrocaecal position of the inflamed appendix

•Tenderness in Rt iliac fossa may be abscent ( this is because the appendix is located behind the caecum that may prevent the pressure elicited by the hand to reach the inflamed structure).

•Rigidity at Rt iliac fossa may be abscent, again because the caecum protect the anterior peritoneum from being irritated by the inflamed appendix, instead Rigidity may be found at the quadratus lumborum.

•Psoas spasm
Here the inflamed appendix is behind the caecum and in contact with this muscle, spasm of which causes flexsion of the hip joint, at this point when you hyperextend the hip joint pain in abdomen may be felt.

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Basis of obturator sign:

Here it is shown that the inflamed appendix lie on top of this muscle, when you maneuver the hip by flexsion and internal rotation you will place stress on the muscle and cause pain.

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SIGNS OF APPENDICITIS

◼️ Pyrexia

-Which is low grade and usually occur after 6 hours. May be absent in 20% of early cases.

◼️ Muscle guarding

-Start gentle superficial palpation from the left iliac fossa, work your way in anticlockwise fashion until you reach the right iliac fossa, guarding will be felt over the area of maximum tenderness classically the McBurney's point.

◼️ Rebound tenderness

-This can be shown by gentle percussion over the area of maximum tenderness.

◼️ Pointing sign

-Ask the patient to point where the pain has began and where it has shifted, the patient typically point around the umbilicus and then move to the right iliac fossa, this demonstrates the classic visceral-somatic pain sequence, which is present only in about half of all proven cases.

◼️ Rovsing's sign

-Deep palpation of left iliac fossa causes pain in the right iliac fossa, this may arise from the fact that bowel is displaced toward the right side when you push on the left side irritating the inflamed area, and may arise from the fact that when you push in the left iliac fossa this will displace the gas in the colon toward the right side, either ways it is useful to support the diagnosis.

◼️ Psoas sign

-Sometimes when the inflamed appendix lie over the psoas muscle, you will find the patient flexing the right hip in attempt to Relief the pain, such position is known as psoas sign.

◼️ Obturator sign



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Notes of worth

-A family history is useful because one third of children with appendicitis show a similar family history in first degree relatives.

-In first 6 hours, there is rarely any change in temperature and heart rate, after that time, usually there is slight pyrexia (37.2-37.7C) and slight increase in heart rate to about 80-90 bpm.

-In children a temperature of greater than 38.5 C tend to suggest another diagnosis such as acute mesentric adenitis.

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CLASSIC SYMOTOMS OF ACUTE APPENDICITIS

¶ PERIUMBILICAL COLIC

-At first the pain is poorly localised and classically felt around the umbilicus, it has a colicky nature similar to that of small bowel obstruction but has less intensity, the underlying pathophysiology is stimulation of the visceral nerves of visceral peritoneum, which is casted to the midline.

¶ PAIN SHIFT TO RIGHT ILIAC FOSSA

-Here, when the inflammatory process extend through the appendix wall, and reach the parietal peritoneum, the latter will be irritated and since it is heavily enriched with somatic nerves, patients typically describe that the pain has moved to the right iliac fossa, became more intense, and changed in nature from colicky to constant.

¶ ANOREXIA

-A very useful and constant clinical feature especially in children.

¶ NAUSEA

-Which can be accompained by one or two episodes of vomitting that follow the onset of abdominal pain due reflex pylorus spasm (as described by john murphy a professor of surgery chicago USA).

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IMPORTANT NOTE

Ischemic necrosis of the appendix is a result of venous occlusion secondary to excessive distension of the inflamed appendix.

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Sequence of appendicitis

Occlusion of lumen (Inflammation may precede occlusion in many cases possibly due to viral infection) ➡️ Accumulation of mucous and inflammatory exudate within the lumen ➡️ aid in bacteria proliferation and increase lumen pressure ➡️ Distension ➡️ Occlusion of venous drainage ➡️ ischaemia of appendix wall ➡️ translocation of bacteria throughout the wall ➡️ bacteria may enter the peritoneal cavity ➡️ furthur ischaemia can cause gangrene of appendix ➡️ Perforation ➡️ life threatening peritonitis.

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Faecolith

This is a a mix of faecal matter, calcium phosphate, bacteria and epithelial debris, the incidental finding of which is a relative indication of prophylactic appendicectomy.

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Aetiologic implications of acute appendicitis:

¶ No single unifying hypothesis can explain the cause.
¶ No single organism was found to be responsible.
¶ Bacterial proliferation usually is a mixture of aerobic and anaerobic bacteria.
¶ Low fibre diet is found to be important, just like with diverticulitis the incidence of appendicitis is higher in those with low fibre and high refined carbohydrate diet.
¶ Proliferation of submucous lymphoid tissue was found to be important as it narrows the lumen.
¶ Obstruction of the lumen is found in majority of cases and held as an important factor.
¶ Luminal obstruction may be due to a faecolith (see image below), Stricture of appendix (usually as a consequence of previous appendicitis resolved without surgery), Parasite (especially pinworm), or tumors (like caecum adenocarcinoma or carcinoid).

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Important note

The incidence of acute appendicitis is EQUAL among males and females BEFORE puberty, in teens and young adults the male to female ratio is 3:2 at age 25 years, this increased incidence of appendicitis among males declines thereafter

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Note

The appendicular artery usually is an end artery, meaning that thrombosis of this artery will cause necrosis of the appendix i.e Gangrenous appendicitis, sometimes this does not occur as few indivisuals have an accessory appendicular artery which provide an alternative blood supply.

The lymphatic drainage of appendix goes to the ileocaecal lymph nodes.

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Important surgical anatomy of the appendix :

1) The base of the appendix is always present at the confluence of the three taeniae coli, this helps the surgeon to locate the appendix whenever elusive.

2) The mesoappendix arise from the lower surface of the mesentry or sometimes the terminal ileum, it can be so transperant that it shows the vessels within,
especially in children, but in adults it can be laden with fat and obsecures these vessels.

3) The appendicular artery is a branch of the lower division of the ileocolic artery, it pass behind the terminal ileum to enter the mesoappendix at short distance away from the base.

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Note

The appendix is an intraperitoneal structure, but occasionally the tip of the appendix becomes extraperitoneal lying behind the caecum or ascending colon.

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Note
The appendix in infants has a wider mouth and also shorter when compared to older age groups, this makes it less liable to occlusion and Inflammation.

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The vermiform appendix is a muscular tube and has all the layers common to the rest of the intestine namely mucosa, submucosa, muscularis propria and serosa, note the narrow lumen, combined with the blind end, indeed is liable to occlusion and becoming inflamed

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What are the other benign tumors of the parotid gland?

•Warthin’s tumors (papillary cyst adenoma, lymphomatosum)
•Oxyphylic adenoma (Oncocytoma).



-What is the origin of Warthin’s tumor?
-The tumor probably arises from parotid tissue included in the lymph nodes which are usually present within the parotid sheath.
-Micro scopically it is lined by columnar epithelial cells supported by lymphoid stroma.

•What are the features of  Warthin’s tumor?
Clinical features of Warthin’s tumor:
•2nd most common benign tumor
•It is soft and sometimes fluctuant(cystic)
•Seen usually in males
•Seen after 40 years •May be bilateral (10%bilateral).
•This tumor has nomalignant potential.

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