The appendix is a midgut organ and is first identified at 8 weeks of gestation as a small outpouching of the cecum. evidence suggests that the appendix may serve as a reservoir of “good” intestinal bacteria and may aid in recolonization and maintenance of the normal colonic flora.The theory is that the microbiome of the appendix has a protective function and that the loss of this eliminates an element of beneficial immunologic redundancy.
In addition, a recently published epidemiological study found a significant link between appendectomy prior to age twenty and the development of prostate cancer. Also patient who have undergone appendectomy get protection from ulcerative colitis.
The ileocolic artery, one of the major named branches of the superior mesenteric artery, gives rise to the appendiceal artery which is end artery , which courses through the meso-
appendix and supplies appendix.
The appendix is of variable size (5–35 cm in length) but averages 8 to 9 cm in length in adults. Its base can be reliably identified by defining the area of convergence of the taeniae at the tip of the cecum and then elevating the appendiceal base to define the course and position of the tip of the appendix, which is variable in location. The appendiceal tip may be found in a variety of locations, with the most common being retrocecal but intraperitoneal.
Appendix also has been reported as duplication , triplication and even absent appendix. Presentation of appendicitis can be acute , chronic , recurrent, stump ,perforation , lump , associated with maliganancy.
Appendicitis is caused by luminal obstruction. The appendix is vulnerable to this phenomenon because of its small luminal diameter in relation to its length. The causes of the luminal obstruction are many and varied. These most commonly include fecal stasis and fecoliths but may
also include lymphoid hyperplasia, neoplasms, fruit and vegetable material, ingested barium, and parasites such as ascaris or pinworm
infestation. Common isolates include Escherichia coli, Bacteroides fragilis, enterococci, Pseudomonas aeruginosa, Klebsiella pneumoniae.
Appendicitis must be considered in every patient (who has not had an appendectomy) who presents with acute abdominal pain.
Patients presenting with acute appendicitis typically complain of vague abdominal pain that is most commonly periumbilical in origin and reflects the stimulation of visceral afferent pathways through the progressive distention of the appendix. Anorexia is often present, as is nausea with or without associated vomiting. Either diarrhea or constipation may be present as well. As the
condition progresses and the appendiceal tip becomes inflamed, resulting in peritoneal irritation, the pain localizes to its classic location in the right lower quadrant. This phenomenon remains a reliable symptom of appendicitis. Patients with appendicitis typically appear ill. They frequently lie still because of the presence of localized peritonitis, which makes any movement painful. Tachycardia and mild dehydration are often present to varying degrees. Fever is frequently present, ranging from low-grade temperature elevations (<38.5°C) to more impressive elevations of body temperature, depending on the status of the disease process and the severity of the patient’s inflammatory response. Absence of fever does not exclude appendicitis.This pain fever vomiting traid is called as Murphys traid. Atypical presentation may also occur and symptoms vary according to position of appendix.
Laboratory studies should be interpreted with caution in cases of suspected appendicitis and should be used to support the clinical picture rather than definitively to prove or to exclude
the diagnosis. Tests used are cbc with TLC, DLC ,CRP, IL6 ,urine analysis and procalcitonin.
Various abdominal signs like pointing sign , rovsing sign, obturator sign , cope psoas sign may used to locate and diagnose acute appendicitis.
Ultimately, no symptom or sign has been demonstrated to be uniquely predictive of appendicitis .For this reason, a number of clinical scoring systems have been developed to serve as predictive models for appendicitis. These have included the Alvarado score (which remains the most well known), the pediatric appendicitis score, and the appendicitis inflammatory response score, and the adult appendicitis score. Of these, the alvarado score (MANTRELS), which includes eight clinical and laboratory variables used to assign a numerical score, remains the most widely used.
Variety of imaging studies also used sometimes to evaluate diagnosis like plain radiographs ,USG abdomen , CECT abdomen .CT scanning is the most common imaging study used to diagnose appendicitis and is highly effective and accurate.
The gold standard and least controversial treatment of acute uncomplicated appendicitis remain prompt appendectomy. The patient should undergo fluid resuscitation as indicated, and the intravenous administration of broad-spectrum antibiotics directed against gram-negative and anaerobic organisms should be initiated immediately.
Complicated appendicitis and those not responding to conservative management should undergo open or laparoscopic appendectomy . Patient presenting with appendicular lump should initially be conserved with ocshner sherren regime and followed by interval appendicectomy after 6 weeks and if any deterioration observed during conservative management then exploration should be undertaken.
Maliganancies are also found in Appendix which are listed here
Epithelial tumors
Adenoma
LAMN
HAMN
Mucinous adenocarcinoma
Colonic-type adenocarcinoma
Goblet cell carcinoma
NETS
Classic
Tubular
Other
Lymphoma
Metastases
Mesenchymal tumors (GIST, desmoid, leiomyo
ma, leiomyosarcoma)
Noncarcinoid NETs (ganglioneuroma, pheo
chromocytoma, paraganglioma)
Sarcomas (HIV-associated Kaposi sarcoma,
desmoplastic small round cell tumor)
Neuroectodermal and nerve sheath tumors
(schwannoma, neurofibroma).
Most of malignacies are detected after appendectomy and managed according to size, location, base and mesoappendix involvement.
Early and accurate diagnosis of appendicitis can decrease patient morbidity and hospital costs by reducing the delay in diagnosis of appendicitis and its associated complications, as well as by avoiding inpatient observation prior to surgery in patients who present with atypical symptoms. Furthermore, both CT and ultrasound may rapidly provide alternative diagnoses which can be treated on an outpatient basis.
