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Abdomen Operations

SYNONYM Acute Inflammation of the Appendix

DEFINITION : Appendicitis is infection and inflammation of the Appendix leading to abdominal pain. The Appendix is a narrow finger-shaped blind ended tube, 7 to 10 cm long in adults. It branches off the caecum (the first section of the large intestine, at the junction of the small bowel to the large bowel). It is present in human beings and some monkeys. It has no known function. Acute Appendicitis is the most common abdominal emergency. The disorder is common, especially among adolescents and young adults, between the ages of tenand thirty. It occurs most commonly in developed countries where the typical diet is low in fibreIn some instances the inflammation is the result of a blockage of the lumen of the Appendix. Blockages sometimes occur when a lump of faecal material, loaded with pus-forming bacteria (faecolith) passes from the large intestine to the lumen of the Appendix and becomes lodged thereThe closed end of the Appendix beyond the obstruction then becomes infected with the purulent (pus forming) bacteria. The bacteria proliferate in the lumen and invade the Appendix wall causing a variable degree of tissue necrosis (death of a group of cells). The vascular (arterial) supply to the Appendix is made up of end-arteries. Once these arteries are thrombosed (the formation of an infected clot causing vascular obstruction and stopping the blood supply), gangrene (death of living tissue in considerable mass) is inevitableThis is followed by perforation especially in children. In adolescence and adulthood, perforation will lead either to diffuse general peritonitis (pus inflammation of the membranous lining of the abdominal cavity) or, more fortunately, with a localized Appendix Abscess, but not in CHILDREN. In most cases of Appendicitis, no cause is detected and occursin the non-obstructed AppendixHowever, there is no strict time relationship for this chain of events. For example, the Appendix may perforate in under six hours especially in infants and children, but conversely it is not rare to see an acutely inflamed but not perforated Appendix even after a day or two.The severity of symptoms and signs also depends on the virulence (violent and poisonous effect) of the micro-organisms.                                                                              SYMPTOMS AND SIGNS : Symptoms differ from one person to another. The early symptoms, a few to several hours before the start of the pain in the abdomen, the patient feels unwell and anorexia (loss of appetite) is inevitable especially in children. Constipation is usual. Diarrhoea is not uncommon if the Appendix is situated in the pelvis. The temperature is either normal or the patient runs a low grade pyrexia (mild fever, 37.5° to 38° Centigrade). Usually, the patient feels colicky pain in the upper abdomen or around the umbilicus (naval). Nausea with or without vomiting usually occurs following the onset of painA few hours later, the pain shifts to the right lower abdomen (right iliac fossa).

Typically, the initial pain is moderate and sometimes, the onset is fast BUT NEVER SUDDEN SEVERE PAIN. The pain is aggravated by movement and the patient prefers to lie still with the right knee and hip flexed. In infants and children, the pain may be widespread rather than confined to the right lower portion of the abdomen.

In older people and pregnant women, the pain is usually less severe, and the area is less tender. Tachycardia (rapid pulse) is usual. Initially, the patient looks normal, but a few hours later, they look flushed and may appear toxic (poisoned) and obviously in painCoughing is painful. There is always tenderness in the right lower abdomen which could be severe. If treatment is delayed, the Appendix may perforate, and intestinal contents containing high concentration of noxious bacteria spills into the abdominal cavity, causing diffuse peritonitis. This is a very serious condition and the pain becomes widespread, constant and severe and the patient looks very ill and passes into shock and septicaemia (blood poisoning in which bacteria in large numbers enter and multiply rapidly in the bloodstream) and death if it is left without urgent surgical intervention.

In women, the Ovaries and Fallopian Tubes may become infected, and the resulting blockage of Fallopian Tubes may cause infertility.

DIAGNOSIS : The diagnosis of acute Appendicitis is ESSENTIALLY CLINICAL and they are:

1) The history of the disease.

2) Localized tenderness which is THE CARDINAL SIGN especially in the early stages of acute Appendicitis.

Tests like blood tests, x-rays, ultrasound scanning, and computed tomography (CT-Scan) are useless in the early stages of acute Appendicitis.

Two clinical types of Appendicitis are recognizable.

1) Acute catarrhal which is not obstructive. The symptoms and signs are mild to moderate.

2) Acute obstructive AppendicitisThe symptoms and signs are more acute and stormyThe onset of pain is rapid, but not sudden and tenderness is severe and perforation could happen after a few hours, causing diffuse peritonitisTherefore, treatment is urgent.

TREATMENT IS APPENDICECTOMY (removal of the Appendix) as an emergency, either, by conventional open surgery or endoscopic surgeryThe patient is admitted to hospital and the surgical operation is performed under general endotracheal anaesthesiaIn nearly 15% of operations for Appendicitis, the Appendix is found to be normalHowever, delaying surgery until the cause of the abdominal pain is certain can be fatal especially in children. In acute obstructive type Appendicitis, the Appendix can perforate in less than a few hours after symptoms begin. During the surgical operation, if the Appendix is found to be inflamed, Appendicectomy (removal of Appendix) is performedIf the Appendix is found to be normal, Appendicectomy must still be performedWith an early operation, the chance of death from Appendicitis is extremely low. The patient can usually leave the hospital in two or three days, and convalescence is normally quick and completeFor a ruptured Appendix, the prognosis is more serious. Before antibiotics era (pre-1950), a perforation was often fatalSurgery and antibiotics have lowered the death rate to almost zero although convalescence maybe long.           

THE HISTORY OF APPENDICECTOMY In the eighteenth century, physicians made records of post-mortem examinations, and among these appeared cases which we now recognize as Appendicitis. During autopsy they found abscess formation which had burst and involved the peritoneal cavityThe condition was called Perityphlitiswhich means inflammation around the cecum.

In 1827, a young French physician, Francois Melier recognized that abdominal infections resulted from acute inflammation of the Appendix and if a definite diagnosis could be made, it might even be possible to operate.

Willard Parker of New York diagnosed Appendicitis in its early stages but he was reluctant to operate at this stage, for at that time abdominal surgery was justifiable only as a last resort. However, between 1843 and 1867 he successfully operated and drained Appendicular Abscesses on four patients.

In 1886, Reginald Fitz of Boston named the condition Appendicitis and early operation was the best treatment.

In 1889,Charles McBurney at Roosevelt Hospital advised early operation on Appendicitis and this was accepted by most American surgeons.

Appendicectomy became popular after 1890 by British and American surgeons.

In London, the coronation of King Edward VII had been decided on June 26, 1902. Two days before the coronation, it was announced that the king was suffering from Appendicitis and an emergency surgical operation was requiredThe coronation was postponed and the operation was performed by Sir Frederick Treves and the king was pronounced out of danger within two weeks (Frederick Treves, 1853 – 1923 1st Baronet GCVO CH CB FRCS, a prominent English surgeon of the Victorian and Edwardian eras. An expert anatomist and was renowned for his surgical treatment of Appendicitis).

In the Middle East, the first documented surgical operation of Appendicectomy was carried out in Baghdad, IraqAround 1930King Faisal I of Iraq was complaining of abdominal pain and was diagnosed as suffering from Acute Appendicitis. Successful Appendicectomy under general “mask” anaesthesia was performed in the King’s palace by Mr Abraham FRCS, a Scottish surgeon and the anaesthetist was Dr Harry Sanderson, a Scottish doctor. Dr Sanderson was the founder and the first Dean of The Iraqi Royal Medical College, now Baghdad College of Medicine, founded in 1927.