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ACUTEACUTEAPPENDICITISAPPENDICITISANACUTEINFLAMMATIONOFAPPENDIXANACUTEINFLAMMATIONOFAPPENDIX720141101HISTORICALBACKGROUND20141102THEREISEVIDENCEINTHELITERATURETHATALCHEMISTSANDPHYSICIANSINTHE1500SRECOGNIZEDTHEEXISTENCEOFACLINICALENTITYASSOCIATEDWITHSEVEREINFLAMMATIONOFTHECECALREGION,KNOWNAS“PERITYPHLITIS”PERITYPHLITIS20141103ALTHOUGHTHEFIRSTSUCCESSFULAPPENDECTOMYWASREPORTEDIN1736,ITWASNOTUNTIL1886THATREGINALDFITZHELPEDESTABLISHEDTHEROLEOFSURGICALREMOVALOFTHEINFLAMEDAPPENDIXASCURATIVETHERAPYFORTHISDISEASE,WHICHWASONCETHOUGHTTOBEFATAL20141104IN1889,CHARLESMCBURNEYPRESENTEDHISCLASSICREPORTONTHEIMPORTANCEOFEARLYOPERATIVEINTERVENTIONFORACUTEAPPENDICITISFIVEYEARSLATER,HEDEVISEDTHEMUSCLESPLITTINGINCISIONWHICHTODAYBEARSHISNAME20141105INCIDENCE20141106REMAINSONEOFTHEMOSTCOMMONACUTESURGICALDISEASESROUGHLYPARALLELSTHATOFLYMPHOIDDEVELOPMENT,WITHTHEPEAKINCIDENCEINEARLYADULTHOOD100/100,0001975TO52/100,000199120141107APPROXIMATELY7OFINDIVIDUALSINWESTERNCOUNTRIESDEVELOPAPPENDICITISATSOMETIMEDURINGTHEIRLIVES,ANDABOUT200,000APPENDECTOMIESFORACUTEAPPENDICITISAREPERFORMEDANNUALLYINTHEUSATHERATEOFNORMALAPPENDECTOMYAVERAGES1668FEMALE20141108ANATOMYANDFUNCTION20141109THEAPPENDIX,LIKEAEARTHWORM,ISASTRUCTURECONNECTEDTOTHECECUM,ITSAVERAGELENGTHIS510CMANDITIS0507CMINDIAMETERANIMMUNOLOGICORGANWHICHACTIVELYPARTICIPATESINTHESECRETIONOFIGA201411010AFTERTHEAGE60,VIRTUALLYNOLYMPHOIDTISSUEREMAINSWITHINTHEAPPENDIXANINTEGRALCOMPONENTOFTHEGUTASSOCIATEDLYMPHOIDTISSUE,ITSFUNCTIONISNOTESSENTIAL201411011APPENDIXISATTHEBASEOFCECUM,THEMEETINGOFTHREECOLICBANDSAPPENDIXISATTHEBASEOFCECUM,THEMEETINGOFTHREECOLICBANDSANTERIORBANDILEUMILEOCECALVALVECECUMAPPENDIX201411012UMBILICUSRIGHTANTERIORSUPERIORILIACSPINEITSPROJECTIONONBODYSURFACEISMCBURNEYSPOINT,WHICHISAPOINTONETHIRDOFTHEDISTANCEBETWEENTHERIGHTANTERIORSUPERIORILIACSPINEANDTHEUMBILICUS201411013THEAPPENDIXISLOCATEDINRIGHTILIACTHEAPPENDIXISLOCATEDINRIGHTILIACFOSSARIGHTLOWERQUADRANTFOSSARIGHTLOWERQUADRANTNEIGHBORINGORGANSARENEIGHBORINGORGANSAREOVARYFEMALEOVARYFEMALERIGHTURETERRIGHTURETERCECUMCECUMASCENDINGCOLONASCENDINGCOLONTHEENDOFTHEILEUMTHEENDOFTHEILEUM201411014ANATOMICPOSITIONANATOMICPOSITION1、PREILEAL1、PREILEAL1133662、PELVIC2、PELVIC3、RETROCECAL3、RETROCECAL4、SUBCECAL4、SUBCECAL555、LATERALCECAL5、LATERALCECAL6、RETROILEAL6、RETROILEAL2244201411015THEAPPENDIXRUNSINTOASEROSALSHEETOFTHEPERITONEUMCALLEDTHEMESOAPPENDIXTHEMESOAPPENDIXCARRIESTHEAPPENDICULARARTERY,WHICHISATERMINALARTERYOFTHEILEOCOLICARTERY,WHICHLIESINITSFREEBORDERANDITHASANAPPPENDICULARVEIN,WHICHRETURNSBLOODTOTHEPORTALVEIN201411016ETIOLOGYANDPATHOGENESISETIOLOGYANDPATHOGENESIS201411017OBSTRUCTIONOFTHELUMENTHEDOMINANTCAUSALFACTORFECALITHSHYPERTROPHYOFLYMPOIDTISSUEINSPISSATEDBARIUMFROMPREVIOUSXRAYSTUDIESVEGETABLEANDFRUITSEEDSINTESTINALWORMS,PARTICULARLYASCARIDS201411018FECALITHFECALITHSARETHEUSUALCAUSEOFAPPENDICEALOBSTRUCTIONANDAREFOUNDINABOUT40OFCAUSESOFSIMPLEACUTEAPPENDICITIS,ABOUT65OFGANGREOUSAPPENDICITISWITHOUTRUPTURE,AND90OFCAUSESOFGANGREOUSAPPENDICITISWITHRUPTURE201411019HYPERPLASIAOFLIMPHOIDFOLLICLES201411020APPENDICEALMALIGNANCIESARERARE,OCCURRINGIN05OFALLAPPENDECTOMIESTHETUMORSAREUSUALLYDISCOVEREDATTIMEOFLAPAROTOMYEITHERASANINCIDENTALFINDINGORINASSOCIATIONWITHACUTEINFLAMMATIONOFTHEAPPENDIX201411021STAGESOFAPPENDICITIS201411022THEPROBABLESEQUENCEOFEVENTSFOLLOWINGOCCLUSIONOFTHELUMENISASFOLLOWSACLOSEDLOOPOBSTRUCTIONISPRODUCEDBYTHEPROXIMALBLOCK,ANDCONTINUINGNORMALSECRETIONOFTHEAPPENDICEALMUCOSARAPIDLYPRODUCESDISTENSIONTHELUMINALCAPACITYOFTHENORMALAPPENDIXISONLYABOUT01MLTHEREISNOREALLUMENSECRETIONOFASLITTLEAS05MLDISTALTOABLOCKRAISESTHEINTRALUMINALPRESSURETOABOUT60CMHO2201411023THEHUMANBEINGISONEOFTHEFEWANIMALSWITHANAPPENDIXCAPABLEOFSECRETINGATPRESSURESHIGHENOUGHTOLEADTOGANGRENEANDPERFORATIONDISTENTIONPERISTALSISISALSOSTIMULATEDSTIMULATESNERVEENDINGSOFBYTHERATHERSUDDENVISCERALAFFERENTPAINFIBERS,DISTENTION,SOTHATSOMEPRODUCINGVAGUE,DULL,CRAMPINGMAYBYDIFFUSEPAINTHEMIDSUPERIMPOSEDONTHEABDOMENORLOWERVISCERALPAINEARLYINTHEEPIGASTRIUMCOURSEOFAPPENDICITIS201411024CONTINUESDISTENTIONNOTONLYFROMCONTINUEDMUCOSALSECRETION,BUTALSOFROMRAPIDMULTIPLICATIONOFTHERESIDENTBACTERIAOFTHEAPPENDIXASPRESSUREINTHEORGANINCREASES,VENOUSPRESSUREISEXCEEDEDCAPILLARIESANDVENULESAREOCCLUDED,BUTARTERIOLARINFLOWCONTINUES,RESULTINGINENGORGEMENTANDVASCULARCONGESTION201411025CLINICALLYDISTENSIONOFTHISMAGNITUDEUSUALLYCAUSESREFLEXNAUSEAANDVOMITING,ANDTHEDIFFUSEVISCERALPAINBECOMESMORESEVERETHEINFLAMMATORYPROCESSSOONINVOLVESTHESEROSAOFTHEAPPENDIXANDINTURNPARIETALPERITONEUMINTHEREGION,PRODUCINGTHECHARACTERISTICSHIFTPAINTOTHERIGHTLOWERQUADRANT201411026THEMUCOSAOFTHEGASTROINTESTINALTRACT,INCLUDINGTHEAPPENDIX,ISVERYSUSCEPTIBLETOIMPAIRMENTOFBLOODSUPPLYTHUSITSINTEGRITYISCOMPROMISEDEARLYINTHEPROCESS,ALLOWINGBACTERIALINVASIONOFTHEDEEPERCOATSASPROGRESSIVEDISTENSIONENCROACHESONTHEARTERIOLARPRESSURE,THEAREAWITHTHEPOORESTBLOODSUPPLYSUFFERSMOSTELLIPSOIDALINFARCTSDEVELOPINTHEANTIMESENTERICBORDER201411027ASDISTENSION,BACTERIALINVASION,COMPROMISEOFVASCULARSUPPLY,ANDINFARCTIONPROGRESS,PERFORATIONOCCURS,USUALLYTHROUGHONEOFTHEINFARCTEDAREASONTHEANTIMESENTERICBORDER201411028THISSEQUENCEISNOTINEVITABLESOMEEPISODEOFACUTEAPPENDICITISAPPARENTLYSUBSIDESPONTANEOUSLYMANYPATIENTSWHOAREFOUNDATOPERATIONTOHAVEACUTEAPPENDICITISGIVEAHISTORYOFPREVIOUSSIMILARBUTLESSSEVEREATTACKSOFRIGHTLOWERQUADRANTPAIN201411029BACTERIOLOGYAVARIETYOFANAEROBES,AEROBES,ORFACULTATIVEBACTERIAHAVEBEENCULTUREDFROMPERITONEALFLUID,ABSCESSCONTENTS,ANDAPPENDICEALTISSUEINPATIENTSWITHGANGRENOUSOFPERFORATEDAPPENDICITISANAVERAGEOF10DIFFERENTORGANISMSWERERECOVEREDPERSPECIMEN201411030AQUANTITATIVEBACTERIOLOGICSTUDYOFTHEAPPENDIXWALLOFCHILDRENSHOWEDNOSIGNIFICANTDIFFERENCESBETWEENTHEFLORAOFNORMALSNDOFACUTELYINFLAMEDAPPENDICESBACTEROIDES,ECOLI,ANDSTREPTOCOCCIWERETHEMOSTCOMMONORGANISMSISOLATEDCYTOMEGALOVIRUSASSOCIATEDAPPENDICITISHASBEENREPORTEDINAPATIENTWITHAIDS201411031CLINICALMANIFESTATIONSYMPTOMSABDOMINALPAINANOREXIAVOMITING201411032ABDOMINALPAINISTHEPRIMESYMPTOMOFABDOMINALPAINISTHEPRIMESYMPTOMOFACUTEAPPENDICITISACUTEAPPENDICITISCLASSICALLYTHEPAINISINITIALLYDIFFUSELYCENTEREDINCLASSICALLYTHEPAINISINITIALLYDIFFUSELYCENTEREDINTHELOWEREPIGASTRIUMORUMBILICALAREA,ISMODERATELYTHELOWEREPIGASTRIUMORUMBILICALAREA,ISMODERATELYSEVERE,ANDISSTEADY,SOMETIMESWITHINTERMITTENTSEVERE,ANDISSTEADY,SOMETIMESWITHINTERMITTENTCRAMPINGSUPERIMPOSEDAFTERAPERIODVARYINGFROM1CRAMPINGSUPERIMPOSEDAFTERAPERIODVARYINGFROM1TO12H,BUTUSUALLYWITHIN4TO6H,THEPAINLOCALIZESINTO12H,BUTUSUALLYWITHIN4TO6H,THEPAINLOCALIZESINTHERIGHTLOWERQUADRANTTHERIGHTLOWERQUADRANT201411033THISCLASSICPAINSEQUENCE,THOUGHUSUAL,ISNOTINVARIABLEINSOMEPATIENTS,THEPAINOFAPPENDICITISBEGINSINTHERIGHTLOWERQUADRANTANDREMAINSTHERE201411034VARIATIONSINTHEANATOMICLOCATIONOFTHEAPPENDIXACCOUNTFORMANYOFTHEVARIATIONSINTHEPRINCIPALLOCUSOFTHESOMATICPHASEOFTHEPAINFOREXAMPLE,ALONGAPPENDIXWITHTHEINFLAMEDTIPINTHELEFTLOWERQUADRANTCAUSESPAININTHATAREA201411035ARECTROCECALAPPENDIXMAYCAUSEPRINCIPALLYFLANKORBACKPAINAPELVICAPPENDIXPRINCIPALLYSUPRAPUBICPAINARETROILEALAPPENDIXMAYCAUSESTESTICULARPAIN,PRESUMABLYFROMIRRITATIONOFTHESPERMATICARTERYANDURETER201411036THESEQUENCEOFSYMPTOMAPPEARANCETHESEQUENCEOFSYMPTOMAPPEARANCEHASGREATDIFFERENTIALDIAGNOSTICSIGNIFICANCEINHASGREATDIFFERENTIALDIAGNOSTICSIGNIFICANCEINOVER95OFPATIENTSWITHACUTEAPPENDICITIS,OVER95OFPATIENTSWITHACUTEAPPENDICITIS,ANOREXIAISTHEFIRSTSYMPTOM,FOLLOWEDBYANOREXIAISTHEFIRSTSYMPTOM,FOLLOWEDBYABDOMINALPAIN,WHICHISFOLLOWEDINTURNBYABDOMINALPAIN,WHICHISFOLLOWEDINTURNBYVOMITINGIFVOMITINGOCC