Appendix (Introduction)

• Appendix – a vestigial organ, is a blind ended muscular tube of variable length (average 7 to 10 cm) and variable circumference (1 to 5 mm).
• It is a part of caecum where three taeniae coli merges.
• Its mesoappendix is variable having the appendicular artery (a branch of ileocolic artery) at its margin.
• Lymph drainage is to ileocolic lymph nodes.
• Usually the base of appendix is at constant position (Mc Burney’s point) while its body is at variable positions (retrocaecal, pelvic, paracaecal, subcaecal, pre & postileal) so add in the difficulty of its diagnosis , as is true for abnormal position of caecum e.g. situs inversus viscerum.

Clinical diagnosis of appendicitis

• It is a more clinical diagnosis than laboratory investigations.
• Common history is poorly localised colicky abdominal pain at peri-umbilical region, associated with anorexia, nausea, occasionally vomit than this pain shift to right iliac fossa as somatic pain.
• On examination local abdominal tenderness, rebound tenderness, may or may not muscle guarding are important signs associated with low grade pyrexia and tachycardia.
• Pointing sign, Rovsing’s sign, psoas sign, obturator sign may help in diagnosis of appendix at different location.
• The clinical features of appendicitis varies according to the position of appendix as in retrocaecal , pelvic and at ileum etc and due to mal position of caecum (subhepatic) as well.
• Clinical features also varies in obese, in pregnancy and at different ages as in infants, adult and elderly.

Differential diagnosis of appendicitis These condition must be consider.

• In children
  gastroenteritis, tonsil tummy,  mesenteric adenitis, meckel’s diverticulitis, intussusception, lobar pneumonia etc,
• In adult
  Right ureteric colic, regional enteritis, perforated peptic ulcer, pancreatitis, torsion of testis, regional ileitis  etc.
• In adult female
  Pelvic inflammatory disease,, ectopic pregnancy (ruptured  or un ruptured), torsion or rupture of ovarian cyst, midcyclic bleeding, endometriosis, pyelonephritis,  acute cholicystitis etc.
• In elderly
  Intestinal obstruction, colonic carcinoma, diverticulitis, mesenteric infarction etc.
• Rare differential diagnosis are:-
  Preherpatic pain of right 10th and 11th dorsal nerves, abdominal crises of diabetes mellitus, typhlitis , spinal conditions e.g., tuberculosis, metastatic carcinoma,  multiple myeloma, osteoarthritic spine, osteoporotic vertebral collapse etc.

Investigations in appendicitis

• Routine
  -Blood complete picture
  -Urinalysis
  -Urea
  -Sugar
  -Ultrasonography
• Selective
  -X ray plain abdomen in standing including diaphragm
  -Contrast-enhanced CT scan of abdomen and pelvis
  -Electrolytes
  -Pregnancy test