2 Semester 1 Major Patho Anato

KURSK STATE MEDICAL UNIVERSITY
Faculty of foreign students (medicine)

Department of Surgery № 2
Acute Appendicitis
Gennady Lukyanchikov
Associate professor of Department of Surgery
№2
Complications of the acute
appendicitis
Part II
Classification of the complications
 Complication of the disease
 Postoperative complications
The Appendix Mass
The Appendix Mass
 Not uncommonly the patient will present
with a history of 4 or 5 days of abdominal
pain and with a localized mass in the right
iliac fossa.
 The mass is conglomerate composed
mainly of the greater omentum,
oedematous caecal wall, and oedematous
portion of the small intestine. In its midst is
an inflamed vermiform appendix.
Clinical Features
 The clinical presentation consist of the
usual findings of acute appendicitis
plus a right lower quadrant mass.
 The patient’s condition is satisfactory.
Pulse is normal.
 Temperature is normal.
 There is no signs of intoxication.
 The abdomen is soft. Bowel sounds are
present and the patient obviously has no
evidence of general peritonitis.
Differential Diagnosis of a Mass
in the right iliac fossa.
 1- Appendix abscess or appendix mass.
 2- Carcinoma of caecum (differentiated from the
above by a longer history, often presence of
diarrhea, positive occult blood with anemia and
finally the barium enema examination).
 3- Crohn's disease (always to be thought of
when there is local mass in a young patient with
diarrhea).
 4- Ilea-caecal tuberculosis (rare in the UK,
common in India).
 5- Psoas abscess, but rare.
Differential Diagnosis of a Mass
in the Right Iiac Fossa.
 6- Pelvic kidney.
 7- A distended gall bladder (which may quite
often extend down as far as the right iliac fossa).
 8- Ovarian carcinoma or tubal mass.
 9- Aneurysm of the common or external iliac
artery.
 10- Retroperitoneal tumor arising in the soft
tissues of lymph nodes of posterior abdominal
wall or from the pelvis.
The Management of an
Appendix Mass(1).
 If an appendix mass is present and condition of
the patient is satisfactory, the standard modern
treatment is conservative.
 The outlines of the mass are marked on the skin.
 A careful watch kept on patient's general
condition, temperature and pulse.
 Temperature and pulse is recorded every 4
hours. Pulse is the indication of intoxication.
 The first feeds should be fluids only and
progression to solid food take place over the
next few days.
The Management of an
Appendix Mass(2).
 Intravenous fluids with fluid balance chart and
daily assay of electrolytes must be instituted.
 Antibiotic therapy: parenteral ampicillin,
gentamycin, and metronidazole are given.
 The outcome of cases suitable for delayed
treatment is that 90% resolve without incident.
 The appendix, however, must be removed later
to avoid further attacks. This should be done
after an interval of 3 months.
 Unless interval appendicectomy is performed
there is considerable risk of a further attack of
acute appendicitis.
Appendix Abscess.
 In the remaining cases the mass obviously

enlarges over the next day or two.
 The temperature fails to subside.
 Failure of resolution of an appendix mass
usually indicates that there is pus within
the mass.
Appendix Abscess.
 The following signs are found:
 Pyrexia.
 Tachycardia.
 The mass obviously enlarged and tender.
 An increased leukocyte count with a
relative increase of polymorphonuclear
cells.
Complication of the abscess
 Perforation into free abdominal cavity
 Perforation into pleural cavity
 Perforation into intestine

Indications for opening an appendicular
abscess:
 When the swelling is not diminishing in size

after conservative treatment.
 When the temperature is swinging above
37.8 on several successive days.
 Failure of resolution of an appendix mass
usually indicates that there is pus within the
mass.
 Ultrasonography will confirm the diagnosis.
Opening an appendicular
abscess.
 The swelling is palpable under anesthetic.
 A retrocaecal appendix abscess should be
opened extraperitoneally. A subcaecal abscess
can be opened in the same manner.
 The incision being placed nearer the anterior
superior iliac spine.
 A pre- or post-ileal abscess can be reached
only through the peritoneal cavity.
Periappendicular abscess
Interval Appendicectomy.
 It is highly important to explain to the

patient that drainage of an appendix
abscess is no safeguard against future
attacks of appendicitis
 The patient should return for
appendicectomy 3 months after the wound
has healed.
Localized Intraabdominal
(intraperitoneal) collections of
pus.
 Following peritonitis, pus may

collect in the subphrenic spaces
or in the pelvis and other places of
peritoneal cavity.
Microflora of abscess
 E.coli (80%),
 Enterococci (30%),
 Nonhemolytic or hemolytic Streptococci ;
 Anaerobic Streptococci together with Cl.welchii

(30%) and bacteroides.
 Proteus
Pelvic Abscess.
 A pelvic abscess may follow any general
peritonitis, but it is particularly common
after acute appendicitis.
 In the male the abscess lies between the
bladder and the rectum; while in the
female it lies between the uterus and
posterior fornix of vagina anteriorly, and
the rectum posteriorly (Douglas pouch).
Clinical Features.
 The most characteristic symptoms of
pelvic abscess are diarrhea and the
passage of mucus in the stools.
 The passage of mucus, occurring for the
first time in a patient who has or is
recovering from peritonitis, is pathognomic
for pelvic abscess.
Investigation of patients with pelvic
abscess
 Rectal examination reviles a bulging of anterior

rectal wall which, when the abscess is ripe,
becomes softly cystic.
 An ultrasound examination.
The Treatment of Pelvic
Abscess
 A pelvic abscess seldom resolves.
 The abscess should be drained deliberately.
 An aspirating needle introduced through the
rectal wall will settle the question.
 In these circumstances drainage of the
abscess is instituted. In neglected cases an
appendix abscess may burst spontaneously
into the general peritoneal cavity, into the
rectum or through the abdominal wall.
The Treatment of Pelvic Abscess
 In women, vaginal drainage through the

posterior fornix is often chosen.
 In other causes, where the abscess is
definitely pointing into the rectum, rectal
drainage is employed.
Subphrenic Abscess.
Anatomy of the subphrenic
region
 The subphrenic region lies between the

diaphragm above and the transverse colon
with mesocolon below and is divided
further by the liver and its ligaments.
Anatomy of the subphrenic
region
 The right and left subphrenic spaces lie
between the diaphragm and the liver and are
separated from each other by the falciform
ligament.
 The right and left subhepatic spaces are
below the liver: the right forming Morison's
pouch and the left being the lesser sac which
communicates with the former through the
foramen of Winslow.
 The right extraperitoneal space lies between
the bare area of the liver and the diaphragm.
Subphrenic Abscess.
Subphrenic Abscess.
Clinical Features of subphrenic
abscess.
Subphrenic infection usually follows

general peritonitis after 10-21 days.
 A swinging temperature which
commences some 10 days after the initial
illness.
Clinical Features of subphrenic
abscess.
 Localizing features are:
pain in the upper abdomen,
pain lower chest or referred to the shoulder
with
localized upper abdominal or chest wall
tenderness.
 There may be signs of fluid or collapse at the
lung base. In late cases a swelling may be
detected over the lower chest wall or upper
abdomen.
Special investigations.
 The WBC count is raised and is in the region of
15000-20000 with a polymorph leucocytosis.
 The important initial investigation is screening of
the chest which reveals an abnormality in nearly all
cases.
 The radiological signs are:
Elevation of the diaphragm, on the affected side.
Diminished or absent mobility of the diaphragm.
Pleural effusion and/or collapse of the lung base.
Gas and fluid level below the diaphragm.
 Accurate localization may be achieved by ultrasound
or CT scan.
The Treatment of Subphrenic
Abscesses
1. If there is clinical or radiological evidence of a
localized abscess, or if resolution fails to occur
on chemotherapy, then drainage may be
carried out under ultrasound control.
2. If this fails, or if the abscess is loculated, then
surgical drainage is performed.
3. Depending on the localization of the abscess,
this is carried out either by a posterior
extraperitoneal approach through the bed of or
below the 12th rib, or an anterior approach via
a subcostal incision.
Surgical approaches
 Transthoracal
 Transabdominal
 Percutaneous under ultrasound control

Interintestinal abscess
Pylephlebitis
Blood supply of the large intestine
Complications After
Appendicectomy.
 1- Early complications
 2- Late complications
Early complications
 Ileus,
 wound sepsis,
 residual abscess (local, pelvic, paracolic,
subphrenic),
 intestinal obstruction from adhesions,
 faecal fistula,
Early complications
 pylephlebitis,
 postoperative thrombosis and embolism,
 pulmonary complications (pulmonary
collapse, or pneumonitis),
 MI,
 thrombosis of portal vein,
 water electrolyte disturbances.
Late complications
 Intestinal obstruction from adhesions,

 Incisional hernia following the grid-iron
incision (especially if a drain is brought
through the wound).
Gangrene of the abdominal wall
after acute appendicitis
Prognosis
 The mortality risk of an individual patient with
acute but not gangrenous appendicitis is less
than 0.1%.
 In gangrenous appendicitis mortality rises to
about 0.6%
 The mortality of perforated appendicitis today is
approximately 5%
 Morbidity from appendicitis continues to be high.
Overall, morbidity currently occurs in 10% of all
patients morbidity

2 Semester 1 Major Patho Anato

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KURSK STATE MEDICAL UNIVERSITY

Faculty of foreign students (medicine)

 Complication of the disease

 In the remaining cases the mass obviously

 Perforation into free abdominal cavity

 Perforation into pleural cavity

 Perforation into intestine

 When the swelling is not diminishing in size

 It is highly important to explain to the

 Following peritonitis, pus may

 Nonhemolytic or hemolytic Streptococci ;

 Anaerobic Streptococci together with Cl.welchii

 Rectal examination reviles a bulging of anterior

 In women, vaginal drainage through the

 The subphrenic region lies between the

Subphrenic infection usually follows

 Percutaneous under ultrasound control

 Intestinal obstruction from adhesions,

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