Surgical Pathology of Appendix

Acute and Chronic Appendicitis

Ghidirim Gh., Mishin I., Zastavnitsky Gh., Vozian M.

 The appendicitis presents an inflammation (either acute or chronic)
of the appendix

The first description of the appendix was provided by Berengarius Carpus, Professor
of Surgery at Pavia and Bologna in 1522.
In 1886 Reginald Fitz, an american physician, became the first person to describe the
entity of acute appendicitis.

Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases

per 1000 people per year. There is a slight male preponderance of 3:2 in teenagers and
young adults; in adults, the incidence of appendicitis is approximately 1.4 times
greater in men than in women.
 Anatomy of the appendix

The appendix averages 10 cm in length but can range from 2-20 cm.
The wall of the appendix consists of 2 layers of muscle, an inner circular and outer
longitudinal. The longitudinal layer is a continuation of the taeniae coli.
The appendix is lined by colonic epithelium.
Arterial blood supply
Venous blood supply
 Positions of the Appendix

1. Descending
2. Lateral
4 3. Medial
4. Ascending
5. Retrocecal

2 1
 Congenital agenesis
Number Anomalies Shape anomalies

A B1 Horseshoe-shaped appendix

B2 C
 Ethiology and Pathogenesis

• Microbial factor
Escherichia coli (Gram-negative)
Bacteroides fragilis (Gram-negative bacillus)

• Mechanical factor (obstruction of the appendiceal lumen)

fecal stasis and fecaliths
parasites
or, more rarely, foreign bodies and neoplasms

• Chemical factor
Intestinal contents penetrates in appendiceal lumen (mucosa inflamation)

• Neurogen factor
cortical neuro-reflex disturbances neuro-trofical changes in the appendix
 Inflamation

↑ Intraluminal Pressure

• Lymphoid Swelling
• Decrease Venous Drainage
• Thrombosis
• Bacterial Invasion

Abscess

Gangrene

Perforation (24 to 36 hours)

Peritonitis
 Classification

•Catarrhal (edematous, simple) appendicitis

Inflamation of mucosal and submucosal layers

•Flegmonous appendicitis
Inflamation of all layers

•Gangrenous appendicitis
wall necrosis (& abscesses)
•Perforated appendicitis
 History of disease

• Sudden onset

• Abdominal pain in the right iliac fossa

• Kocher’s sign (35% of cases)

the appearance of pain in the epigastric region or around the stomach at the beginning
of disease with a subsequent shift to the right iliac region

• Nausea

• Single vomiting episode

• Low fever (37.2 to 37.5°C)

• Pulse is slight accelerated

 Points of pain in acute appendicitis

umbilicus
2
Iacubovich triangle
AS AS
3 4

1. McBurney point 3. Lanz point

2. Morris-Kummel point 4.Sonnenberg point
 Symptoms and Signs

Triad of Dieulafoy Hypersensitivity of the skin, tenderness and muscular

contraction at McBurney’s point in acute appendicitis

Blumberg sign
Also referred as rebound tenderness. Deep palpation of the
viscera over the suspected inflamed appendix followed by
sudden release of the pressure causes the severe pain on
the site indicating positive Blumberg's sign and peritonitis
Rovsing's sign
Continuous deep palpation starting from the left iliac
fossa upwards (counterclockwise along the colon) may
cause pain in the right iliac fossa, by pushing bowel
contents towards the ileocaecal valve and thus increasing
pressure around the appendix.
Sitkovskiy (Rosenstein)'s sign
Increased pain in the right iliac region as patient lies on
his/her left side
Bartomier-Michelson's sign
Increased pain on palpation at the right iliac region as
patient lies on his/her left side compared to when patient
was on supine position.
 Symptoms and Signs

Dunphy's sign
Increased pain in the right lower quadrant with coughing

Mandel-Razdolski sign
pain, due to peritoneal irritation upon percussion in the RLQ
The psoas sign (Cope)
right lower-quadrant pain that is produced with either the
passive extension of the patient's right hip (patient lying on
left side, with knee in flexion) or by the patient's active flexion
of the right hip while supine.
 The obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be
demonstrated by flexing and internal rotation of the hip.
 The Alvarado Scoring System
Features Score

• Migratory right lower quadrant pain 1

• Anorexia 1
• Nausea and vomiting 1
• Right lower quadrant tenderness 2
• Right lower quadrant rebound tenderness 1
• Elevated temperature ≥ 37.3°C 1
• Leukocytosis ≥ 10.0X109/L 2
• Neutrophilic shift to left N 75% 1

Total 10

0-3 Discharge with advice to return if no improvement, subject to social circumstances

4-6 Review after 12 h and reassess score, if still 4-6 then treat operatively as below

7-9 Male/child Appendicectomy

Female Laparoscopy then proceed
 Ultrasonography in Acute Appendecitis

Normal appendix:
• Thickened wall >3 mm
• Diameter >6 or 7 mm
• blind-ended, tubular structure
• Blind-ended tubular structure
• maximum wall thickness of 2 mm • Noncompressible
AA • Appendolith
• outer diameter of 6 mm
• Circumferential color flow
• have no peristalsis • Echogenic mesentery
• Free fluid
• and originate from the base of the cecum
• Abscess
 CT scan in Acute Appendecitis

Advantages of CT include:

• more accurate in staging periappendiceal inflammation & abscesses

• more likely to provide alternate diagnosis in patients without appendicitis
• more sensitive for detecting normal appendix
• operator independent
• not limited by pt body habitus
 Acute appendicitis in children
• acute appendicitis uncommon in children younger than 2 or 3 years
• the diagnosis of appendicitis is difficult
• illness develops dramatically rapidly
• violent pain (atypical, unlocalized diffuse periumbilical)
• high grade temperature (39-40°C)
• persistent vomiting
• diarrhea (12%)
• hyperleukocytosis (15.000 – 20.000/mL)
• intoxication (oliguria and anuria)
• physical examination with natural or medicamentous sleep (enema with
chloralhidrate or relanium i.m.)
• appendix situated in pelvic and ascending position
• functional insufficiency of the peritoneum and omentum →gangrene (or perforations)
 Acute appendicitis in elderly
• > 60 yrs – 12% from total number of appendectomies
• clinical signs are less evident (pain is less severe, local tenderness less acute, low
grade temperature)
• the basic symptoms – pain on palpation and alteration of the bowel motility
• elevation in the WBC – moderate or nonexistent
• higher incidence of destructive forms of appendicitis (vascular factor)
• ½ of pts >70 yrs – ruptured appendix at time surgery
• right-sided colon carcinoma?
• Main clinical forms of acute appendicitis in elderly
1. like intestinal obstruction form
2. pseudo-tumorous form
3. acute appendicitis with peritonitis in two times
Subhepatic Appendicitis

CT: Subhepatic location of a normal appendix

 Subhepatic Appendicitis

Liver
GB

Subhepatic appendicitis with faecolith in situ.

Subhepatic appendicitis
 Left-sided acute appendicitis

• excessively moveable cecum

• intestinal malrotation
• the long appendix, which riches the left iliac fossa
 Situs Viscerum Inversus

Cecum
&appendix

X-ray and computed tomography showed situs inversus totalis (SIT) including
dextrocardia, right-sided gastric bubble and reversed spleen and liver.
 Situs Viscerum Inversus

The incidence of SIT reported in the literature varies from 0.001% to 0.01% in the
general population. The incidence of acute appendicitis associated with SIT is reported
to be between 0.016% and 0.024%
Appendicitis during pregnancy

Appendicitis during pregnancy is a

relatively rare condition, though it is thought that
the incidence is similar to that of the non-gravid
population at approximately 1 in 1500
pregnancies.
The majority of appendicitis in
pregnancy occurs during the second trimester
when they are difficult to diagnose both clinically
and by imaging.
The pathologic diagnosis of appendicitis
is confirmed in only 30% to 50% of cases.
Fetal loss rate approaches 40% for perforated
appendicitis.
 Appendicitis during pregnancy

F F
Amyand's hernia (acute appendicitis In inguinal hernia)

Claudius Amyand (1660–1740) is variously

reported as having held the title of “surgeon-
in-ordinary” or “sergeant– surgeon” to King
George II of England.
On 6 December 1735 he performed the first
recorded successful appendectomy.

Incidence - 0.13% - 1%
Amyand's hernia (acute appendicitis In inguinal hernia)

Pathological types of Amyand’s hernia

I - normal appendix
II - acute appendicitis localized in the sac
III - acute appendicitis, peritonitis
IV - acute appendicitis, other abdominal
pathology
DeGarengot hernia

Herniation of the appendix into a

femoral hernia sac was first reported
by DeGarengot in 1731.
 Differential Diagnosis of Acute Appendicitis

Gastrointestinal Gynecologic Pulmonary

Duodenal ulcer (perforation) Ectopic pregnancy Pleuritis
Pancreatitis Endometriosis Pneumonia (basilar)
Cholecystitis Ovarian torsion Pulmonary infarction
Crohn's disease Pelvic inflammatory
Diverticulitis disease Genitourinary
Gastroenteritis Ruptured ovarian cyst Kidney stone
Intestinal obstruction (follicular, corpus Prostatitis
Intussusception luteum) Pyelonephritis
Meckel's diverticulitis Tubo-ovarian abscess Testicular torsion
Mesenteric lymphadenitis Urinary tract infection
Necrotizing enterocolitis Systemic Wilms' tumor
Neoplasm (carcinoid, Diabetic ketoacidosis
carcinoma, lymphoma) Porphyria Other
Omental torsion Sickle cell disease Parasitic infection
Perforated viscus Henoch-Schönlein purpura Psoas abscess
Volvulus Rectus sheath hematoma
Perforated ulcer

• peptic ulcer history

• a severe pain (Dieulafoy sign)
• hypotension or schock
• absence of vomiting
• bradycardia
• absence of fever
• absence of abdomen movement on respiration
• a rigid board-like abdomen
• diffuse tenderness and pain
• Blumberg sign on the whole abdominal wall
• disappearance of liver dullness
 Perforated ulcer

Presence of free air under the diaphragm on abdominal film

CT scan Acute pancreatitis

• alcohol and gallstone!

• high intensive pain in the epigastric area
• shock Hyperleucocytosis
• abdominal distention Elevated amylase levels in blood and urine
• tenderness on the pancreas projection
• tachycardia
• cyanosis
Acute Cholecystitis

• Pain usually beginning after eating fried food,

alcohol
• pain is situated in right upper abdominal quadrant
and radiated to the right subscapular region
• nausea
• multiple vomiting
• fever
• Grekov-Orthner sign
• Murphy sign
• frenicus sign
• tenderness in RUQ
• mass in RUQ
• jaundice
 Ectopic Pregnancy

The vast majority of ectopic pregnancies

implant in the Fallopian tube.
Pregnancies can grow in:
• the fimbrial end (5% of all ectopics)
• the ampullary section (80%)
• the isthmus (12%)
• the cornual and interstitial part of the
tube (2%)

Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last
normal menstrual period, with a range of 5 to 8 weeks.
 Ectopic Pregnancy
EP in progress EP with rupture

uterus

uterus

The classic signs and symptoms : Diagnosis:

• abdominal pain • US and transvaginal ultrasound
• the absence of menstrual periods (amenorrhea) • blood β-human chorionic gonadotropin (β-hCG)
• vaginal bleeding or intermittent bleeding (spotting) • Culdocentesis (fluid is retrieved from the space
separating the vagina and rectum) – blood!
• Laparoscopy
 Ectopic Pregnancy

uterus

uterus

Surgical treatment:

• incise the affected Fallopian and remove only the pregnancy (salpingostomy)
• remove the affected tube with the pregnancy (salpingectomy).
Laparoscopic Treatment of Tubal Pregnancy
 Ovarian Torsion (adnexal torsion)

Ovarian torsion is the twisting of the ovary

due to the influence of another condition or
disease.

This results in extreme lower

abdominal pain.

Approximately 70-75% of cases occur in

women under 30 years old. Approximately
60% of cases of torsion occur on the right
side.

• abnormalities of the fallopian tube such

as extremely longer-than-normal tubes or a
missing mesosalpinx

• ovarian cysts or fibromas, tumor of the

ovary or tubes
 Ovarian Torsion (adnexal torsion)

• Salpingo-oophorectomy
 Case presentation
A 25 year-old female patient was admitted to the ED after 6 hours
after onset, complaining:
Right iliac fossa pain, nausea.
History of the disease: sudden pain onset in the right iliac fossa,
later nausea appeared. Uterine pregnancy 22-23 weeks.
Upon physical examination:
Tongue moist, Abdomen – symmetrically enlarged
(pregnancy), participates in respiration.
Abdominal palpation reveals right lower quadrant
tenderness, RLQ rebound tenderness. Measured fever in
the ED 37.5C
 Case presentation

What is the diagnosis?

How do you confirm it?
 Case presentation
ECG: sinus rhythm, heart rate 100 b.p.m.
Blood test: Hb 126 g/L; Er 4.0X1012/L; WBC 13.4X109/L
USG: Uterine pregnancy 22-23 weeks. Appendix not visible. Free fluid in the RLQ absent.

The Alvarado Scoring System

Features Score Present case

• Migratory right lower quadrant pain 1 -

• Anorexia 1 1
• Nausea and vomiting 1 1
• Right lower quadrant tenderness 2 2
• Right lower quadrant rebound tenderness 1 1
• Elevated temperature ≥ 37.3°C 1 1
• Leukocytosis ≥ 10.0X109/L 2 2
• Neutrophilic shift to left N 75% 1 -

Total 10 8
 Case presentation

What is the diagnosis?

Any additional investigations?
What is the treatment?
Isolated fallopian tube torsion
 Acute Salpingitis

• Abnormal smell and colour of vaginal discharge. The bacteria most associated with salpingitis are
• Pain during ovulation
• Neisseria gonorrhoeae
• Pain during sexual intercourse
• Pain coming and going in periods • Chlamydia trachomatis
• Abdominal pain
• Mycoplasma
• Lower back pain
• Fever (>38°C)
• Nausea
• Vomiting On pelvic examination, motion of the uterus causes pain (Promptov sign)
 Ovarian apoplexy
Ovarian apoplexy is a sudden rupture in
the ovary:

• Ovarian cyst
• Dystrophic and sclerotic changes in
ovarian tissue
• Polycystic ovary syndrome

Clinical symptoms:
Pain syndrome, which occurs primarily in the
mid-cycle or after a minor delay
menstruation Pain is most often localized in
the lower abdomen. Sometimes the pain
may radiate to the rectum, in the lumbar or
the umbilical region.

Hemorrhage in the ovarian tissue and/or intraperitoneal bleeding!

• reduced pressure
• increase heart rate
• syncope
Surgical Treatment (Appendectomy)

Charles McBurney
Surgical Treatment (Appendectomy)
 Surgical Treatment

cecum

appendix

mesoappendix

Intraoperative view
 Appendectomy

• Mesoappendix is ligated
• Ligation of the appendiceal base with absorbable suture
• Purse-string suture is placed on the cecum around the appendiceal base
Appendectomy
Laparoscopic Appendectomy
Laparoscopic Appendectomy
 Meckel’s diverticulum

Meckel’s diverticulum (MD) is the most common congenital abnormality of the gastrointestinal
tract, occurring in 1% to 2% of the population. It is usually asymptomatic and becomes evident
when complicated. MD is usually found within 100 cm of the ileocecal valve (>20cm).
• inflammation
• ischemia and infarction
• gastrointestinal bleeding, obstruction
 Mucocele of the Appendix

Rokitansky’s first report of an appendiceal mucocele in 1842.

Based on data from pathologic specimens, the incidence of AM is approximately 0.07% to 0.3%.

• retention cyst of the appendix (simple mucocele) PMP (!)

• mucosal hyperplasia of the appendix appendectomy
• cystadenoma of the appendix
• cystadenocarcinomas right hemicolectomy
 Vermiform Appendix Torsion

Mishin I, Ghidirim G, Zastavnitsky G, Popa C. Torsion of an appendiceal mucinous cystadenoma.

Report of a case and review of literature. Ann Ital Chir. 2012;83(1):75-8.
 Appendiceal Intussusception

Cecum

Intra-operative view of an Intraoperative finding of a giant

appendico-appendicular intussusception appendiceal mucocele with partial
intussusception into the cecum
I Tip of the appendix invaginates into the proximal lumen
II Distal appendix invaginates into the lumen of the proximal appendix
III Proximal appendix invaginates into the distal appendix
IV Complete intussusception of the appendix within the caecum
Appendiceal Intussusception

Computed tomography (CT) scan shows a 4-cm diameter, hypodense, well-encapsulated,

cystic mass with the presence of wall calcification communicating with the cecum.
 Carcinoid (neuroendocrine) Tumours of the Appendix

Chromogranin A (+++)

Appendiceal carcinoid tumours are found in 0.3 – 0.9% of appendicectomy

• < 1 cm, distal part – appendectomy
• >2 cm and proximal part (↑metastatic spread) - right hemicolectomy
 Periappendiceal Abscess

CT: periappendiceal abscess

• Pain increases
• High grade fever
• Hyperleukocytosis Surgery – drainage of abscess via Pirogov aproach (extraperitoneal)
• Severe pain
• Blumberg positive sign
Pylephlebitis (septic thrombophlebitis of the portal vein)

The venous drainage from the appendiceal area and

terminal ileum flows directly into the portal system.
The organisms most frequently cultured from the blood
were bacteroides (especially Bacteroides fragilis) and E.
coli.
This disease entity occurred in 0.4% of patients with acute
appendicitis before 1950, but it has become very rare due
to major advances in antibiotic therapy and surgical
treatment.
Pylephlebitis is considered a severe condition!
The reported mortality rate of pylephlebitis is 30%-50%,
partly due to a delay in diagnosis from its atypical clinical
findings and a low index of suspicion.
Diagnosis:
• Ultrasound scan with color flow Doppler
• CT scan
 Pylephlebitis (septic thrombophlebitis of the portal vein)

CT scan showing total occlusion of the portal vein with a thrombus

liver abscesses (arrow) extending to the superior mesenteric vein.
• air bubbles or thrombi of the portal venous system
• liver abscesses

The principles of treatment for pylephlebitis:

• to remove the source of infection and eradicate the toxic microorganisms using appropriate
antibiotics
• systemic Ⅳ antibiotics (4 wk), hepatic abscess (at least 6 wk)
• anticoagulation therapy
 Postoperative Complications

• haematoma in the wound

• wound infection
• bleeding may rarely occur from the mesoappendix (appendicular artery)
• faecal fistula (if the method used to secure the appendix stump is insecure)
• incisional hernia through an appendicectomy incision (is also uncommon and usually
occurs after a superficial wound complication)

• Mortality rate due acute appendicitis is 0.1-0.3%

Pelvic Abscess
A pelvic abscess is a collection of pus in the pelvis or
lower abdomen. An abscess usually appears
2-3 weeks after the initial operation.
In males the abscess is located between the bladder
and the rectum.
In females the abscess lies between the uterus and the
posterior fornix of the vagina, and the rectum
posteriorly.
 Pelvic Abscess
Presentation
Systemic features of toxicity: fever, malaise, anorexia, nausea, vomiting.
Local effects, e.g. pain, deep tenderness in one or both lower quadrants, diarrhoea,
mucous discharge per rectum, urinary frequency, dysuria.
Rectal or vaginal examination: may reveal tenderness of the pelvic peritoneum and
bulging of the anterior rectal wall.
Leukocytosis.
CT/MRI scanning may be more effective at identifying the origin of the abscess
Pelvic Abscess

The abscess should be drained

transrectally in men, and transvaginally in
females
• Traditional approach
• Ultrasound-guided aspiration and
drainage
• Percutaneous abscess drainage is
performed using CT or sonographic
guidance
 Subdiaphragmatic absces

A subdiaphragmatic abscess is a localized accumulation

of pus in the abdominal cavity just beneath the diaphragm.

Operative treatment for subdiaphragmatic abscess includes drainage using a needle

and syringe (percutaneous drainage), or one of four different types of open surgical
approaches (transpleural, extrapleural, extraperitoneal, transperitoneal)