STUDY OF THE ANATOMICAL POSITION OF THE APPENDIX IN NORMAL POPULATION AND IN INFLAMED CASES

by

Dr Thyagaraj. J

Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore

In partial fulfillment of the requirements for the degree of

Master of Surgery in

General Surgery

Under the guidance of Professor & H.O.D Dr T.K. Lakshmikanth

Department of Surgery Bangalore Medical College

Bangalore

2005

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “STUDY OF ANATOMICAL

POSITION OF THE APPENDIX IN NORMAL POPULATION AND IN

INFLAMED CASES" is a bonafide and genuine research work carried out by me under

the guidance of Dr T.K. Lakshmikanth, M.S., Professor and Head of the Department

of surgery, Bangalore Medical College, Bangalore.

Signature of the CandidateName Dr. Thyagaraj. J

Date: Place: Bangalore

II

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “STUDY OF ANATOMICAL

POSITION OF THE APPENDIX IN NORMAL POPULATION AND IN

INFLAMED CASES" is a bonafide research work done by Dr. Thyagaraj. J in partial

fulfillment of the requirement for the degree of Master in Surgery

Date : Place: Bangalore. Signature of the Guide

Dr. T.K. Lakshmikanth M.S., Professor & Head of The Department of Surgery Bangalore Medical College Bangalore.

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION

This is to certify that the dissertation entitled “STUDY OF ANATOMICAL

POSITION OF THE APPENDIX IN NORMAL POPULATION AND IN

INFLAMED CASES" is a bonafide research work done by Dr. Thyagaraj. J under the

guidance of Dr T.K. Lakshmikanth, M.S., Professor and Head of the Department of

surgery, Bangalore Medical College, Bangalore.

Seal & Signature of the HOD Name: Dr T.K. Lakshmikanth

Seal & Signature of the Principal Name Date: Place: Bangalore

Date : Place: Date : Place: Bangalore.

III

COPYRIGHT

Declaration by the Candidate I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation / thesis in print or

electronic format for academic / research purpose.

Date : Place: Bangalore.

Signature of the Candidate Name: Dr. Thyagaraj. J

IV

ACKNOWLEDGMENT

The writing of dissertation brings a trying time. During this period, one

enters a seemingly endless tunnel of references, discussions, corrections and statistical

data. It would be very easy to give in to despair but for the support of god, my teachers

and colleagues.

I wish to express my profound gratitude to my guide, Dr. T.K.

LAKSHMIKANTH, Professor and Head of the Department of Surgery, BMC. Bangalore.

His vast experience, patients-first attitude and enduring patience with my inexperience,

saw me through to the completion of this dissertation work. With wholehearted gratitude,

I wish to acknowledge my unrepayable debt to him.

I also wish to thank Dr. Shivaswamy, with a deep sense of gratitude for his

support and able guidance.

I am grateful to Dr. Sheshasayi, Assistant Professor Department of general

surgery for his sustaining support, encouragement and able guidance

I am grateful to Dr. Suresh Chandu and Dr. Jayaraj Ravikar, for their

constant support and encouragement at every stage.

I wish to express my profound gratitude to Dr. Beemappa Havanur.

Incharge Head of the Department of forensic medicine for his generous support and

guidance during every stage of this work

My hearty thanks to Mrs. Padmaja, Statistician Department of community

medicine Bangalore Medical College, Bangalore, For simplifying the intricacies of this

dissertation’s statistical work.

V

My sincere thanks to all the post graduate colleagues in the Department of

General Surgery and Forensic Medicine for their wholehearted support and help

I am grateful to my ´PATIENTS` for their co-operation in the present

study. I am also grateful for the ´cadavers` used in the present study without which this

dissertation would not have been possible.

In the end, with all humility, I thank God, Almighty for his grace in seeing

through to the completion of my dissertation work.

Date:

Place: Bangalore Signature of the Candidate Name Dr. Thyagaraj

VI

LIST OF ABBREVIATIONS USED

(in alphabetical order)

VII

ABSTRACT

Background & Objectives The most common position of the appendix is a subject

of controversy also the relation of the position of appendix and clinical picture and course

of the appendix is a subject of controversy. The objective is to study the various positions

of the appendix in normal population, and the position of the appendix in inflamed cases,

and the relation of the position to the clinical presentation and management of

appendicitis.

Methods All patients undergoing appendectomy in Bowring and Lady Curzon

hospitals and Victoria hospital May 2003 to August 2005 were included in the clinical

group. In normal population group, all cadavers undergoing autopsy from June 2003 to

July 2005, at Bowring and Lady Curzon hospitals mortuary were included.

Results There were a total of 150 cases, 50 in clinical group, and 100 in autopsy group.

The commonest position of the appendix is Retro-caecal (32.6%), Followed by Post-ileal

(26.6%), Pelvic (21.3%), Para-caecal (8%), Sub-caecal (5.3%) and Pre-ileal (4%). There

was no statistically significant difference in the position of the appendix in the clinical

and autopsy group. Certain positions like fixed retro-caecal, pelvic and post-ileal

presented more often atypically. Only 3 of 29 (10.3%) cases with typical presentation had

complications whereas 11 of the 21 cases (52.4%) with atypical presentation had

complications.

VIII

Interpretation & Conclusion There is no increased predisposition for any of the

position of the appendix to get inflamed. Complications were more common in cases

fixed retro-caecal, post-ileal and pelvic appendix. The patients with the above positions

presented more often atypically than typically and with subtle signs and symptoms

leading to delayed diagnosis and increased complications.

Keywords: Vermiform appendix; Anatomical position of Vermiform appendix; Appendicitis; Retrocaecal appendicitis; Pelvic appendicitis.

IX

TABLE OF CONTENTS 1. Introduction Page No. 1 2. Objectives Page No. 4 3. Review of Literature Page No. 5 4. Methodology Page No. 54 5. Results Page No. 60 6. Discussion Page No. 72 7. Conclusion Page No. 82 8. Summary Page No. 86 9. Bibliography Page No. 88 10. Annexures Page No. 98

X

LIST OF TABLES

Sl.No NAME PAGE No. 1 Position of the appendix according to various authors 8 2 Alavarado Score 35 3 Teicher scoring system 36 4 Age &Sex distribution of cases 64 5 Incidence of various positions of appendix in our study 65 6 Length of the appendix in our study 65 7 Relationship between fixity of appendix & clinical presentation 66 8 Statistical comparison of the position of appendix in clinical and

autopsy group 70

9 Statistical comparison of position of position of the appendix with clinical presentation and complications

71

10 Comparision of various positions of appendix according to different authors

76

11 Comparison of position of appendix at autopsy according to various authors

77

12 Comparison of position of appendix at surgery according to various authors

77

13 Comparision of average length of appendix according to various authors

78

XI

LIST OF FIGURES

Sl No NAME PAGE No. 1 Position of the appendix in relation to caecum and ileum 11 2 Position of the appendix in relation to various types of caecum 11 3 Age and Sex distribution of cases 67 4 Various positions in clinical and autopsy group 67 5 Distribution of cases according to various age group 68 6 Typical presentation of appendicitis 69 7 Atypical presentation of appendicitis 69 8 Sub hepatic caecum with para-caecal appendix 79 9 Sub-caecal position of appendix 79 10 Retro-caecal position of appendix 80 11 Post-ileal position of the appendix 80 12 Paracaecal position of the appendix 81 13 Pelvic position of the appendix 81

XII

INTRODUCTION

Appendicitis is a common sometimes confusing, and treacherous cause of

acute abdomen at all ages. The appendix is regarded as a vestigial organ, useless to man,

with no known important function, but can be a real nuisance at times, when it may

become the seat of infection. The diagnosis of appendicitis can be difficult, occasionally

taxing the skills of the most experienced clinician. The delays in the diagnosis arise from

errors either from the patient or physicians.

Anatomy is rightly called the father of surgery; this is made more evident

in case of appendix as the variations in the positions of the appendix will lead to varied

clinical presentation.

The most common position of the appendix is variously described by

many authors Wakeley et- al as retrocaecal (65.3%) (1), Collins et-al as pelvic (78.5%) (2)

and Pickens G et-al as postileal (3). Guidry SP et al have concluded that anatomic

variations of the location of appendix are often responsible for delays in the diagnosis of

appendicitis (4). Poole GV has stated that the paucity of symptoms and signs, in patients

with hidden appendix, is responsible for the delayed diagnosis of appendicitis before

perforation (5).

1

With the advent of laparoscopic appendectomy, there is a controversy as

to which is the better approach, as most of the appendices can be removed with a small

incision by the open approach. Karl A Zucker et-al have opined that the laparoscopic

appendectomy would be preferred approach in case of retrocaecal appendix, as the

incision required in open approach is longer with its associated morbidity, which can be

reduced by laparoscopic approach, also other abdominal viscera can be evaluated (tubes

& ovaries) as diagnosis of appendix is by excluding other pelvic pathology. Left sided

appendicitis may be confusing and is better evaluated by laparoscopy (6).

Varshney et-al have concluded that the retrocaecal position of the

appendix is less prone to infection (7), whereas Collins et-al have described higher

incidence of perforation and serious complications in acute appendicitis (8), other studies

one prospective (9) and two retrospective studies have established that the retrocaecal

position of the appendix does not alter the clinical course of acute appendicitis (10,11).

Appendicitis in different positions may mimic various other diseases, like

in Retro-colic =colitis, Post-ileal = Ureteric colic, Pelvic = enteric ileal perforation,

Pelvic inflammatory disease, Torsion of ovarian cyst, Ruptured tubal gestation, Sub-

hepatic = Hepatitis, Biliary colic.

From the above information it is evident that there are lots of

controversies regarding the various positions of appendix and also clinical presentation of

appendicitis, in relation to different positions. Hence there is a need for the study of the

2

various positions of appendix in the normal population and in patients with appendicitis

and also the clinical picture and complication in the various positions.

Our study is performed in clinical cases representing the inflamed

appendix group and the autopsy group, which represents the normal appendix group, in

the inflamed group the relation between the various positions of the appendix, and the

clinical presentation and complications is studied.

3

OBJECTIVES OF THE STUDY

To study the various positions of the appendix in normal population, as determined,

by the position in cadavers (100 cases) and the position of the appendix in inflamed

cases, as determined by the position of the appendix at laparotomy in clinical cases,

and the relation of the position to the clinical presentation and management of

appendicitis.

REVIEW OF LITERATURE

ANATOMY (12, 13, 14, 15)

4

Anatomy is the father of surgery Development (12) : - During the early stages of development, the midgut is attached to

the dorsal wall of the body by means of a short dorsal mesenterium. Because the

midgut grows considerably faster than does the rest of the embryonal body, it experiences

various regular movements & rotations, which can be divided into three phases.

Phase I: - (Physiologic umbilical hernia) During 6th week of gestation, the midgut

undergoes considerable elongation, resulting in a hairpin bend loop. As the embryonal

cavity does not have enough room to accommodate the intestinal loops, the loop extends

to the extra embryonic coelom. Around the axis of the superior mesenteric artery the

intestinal loop rotates 90 degrees anticlockwise.

Phase II: - (closure of physiological umbilical hernia) During 10th week of gestation the

intestinal loops relocate into the embryonal cavity, with an additional 180 degrees

counter clockwise rotation. The bud like complex of the caecum is now located on the

right side of the upper abdominal cavity directly below the liver. With the elongation of

the transeverse colon the caecum is pushed in a caudal direction (descensus) & caecum

finally lies in the right iliac fossa.

Phase III: -At about 12th week of gestation the mesenterium of the ascending &

descending colon is pushed against the dorsal body wall and fuses completely with the

parietal peritoneum

Development of the appendix (12) : - At about 6th week of gestation a small diverticulum

appears on the caudal limb of the midgut loop and this later differentiates into caecum

5

and appendix. According to Borman the increasing accumulation of meconium with in

the colon is the cause of the increase in diameter of this section of the intestine, because

of a mucosal fold the distal part cannot be filled completely with meconium so the

growth is not stimulated there and the vermiform appendix borders against the caecum as

a thin structure. Post-partum the caecum exhibits increased growth laterally resulting in

the dislocation of the vermiform appendix in the medial direction

Normal variations in the peritoneal fixation of appendix (12)

1 - Intra-peritoneal

2 - Intra-peritoneal retro-caecal with in paracaecal fossa

3 - Extra-peritoneal retro-caecal, para-caecal fossa present

4 - Extra-peritoneal retro-caecal, para-caecal fossa absent

5 - Extra-peritoneal retro-caecal, lying anterior to the right kidney & associated with sub-hepatic caecum.

Anatomy of the appendix (12,13,14)

Vermiform appendix is a narrow worm shaped part of the intestine, which arises from the

postero-medial part of the caecum 2cm or less below the ileo-colic junction, all taenia

start at the base of the appendix. The canal of the appendix is small and open into the

caecum by an orifice lying below & a little beyond the ileo-caecal opening, the orifice is

guarded by a mucosal fold (Gerlach valve) lumen may be partly or wholly obliterated in

the later part of the life. The length of the appendix varies from 2 – 35 cms the average

being 9 cms. It is longer in children than the adult life; its position may vary.

6

Sir Frederich Treaves has described the following positions of the appendix, making the

vermiform appendix as pointer and caecum as the dial of the clock as follows (14,16).

Para-colic or Para-caecal or 11 O’ clock position - Appendix is directed upwards &

to the right and lies on the right side of the caecum. In this position it may lie either

behind the peritoneum or may partially project into the peritoneal cavity & may lie in

front of the right kidney.

Retro-caecal or Retro-colic or12 O’ clock position - Appendix lies either behind the

caecum or the ascending colon and may be intraperitoneal or lie behind the peritoneum.

Splenic or 2 O’ clock position - Appendix is directed towards the spleen and may pass

either in front of the ileum (Pre-ileal) or behind the terminal part of the ileum (Post-ileal)

Promonteric or 3 O’ clock position - Appendix is directed transversely inwards

towards the sacral promontory.

Pelvic or 4 O’ clock position - Appendix hangs over the brim of the pelvis and projects

into the pelvic cavity

Midinguinal or 6 O’ clock position: – Appendix passes downward towards the middle

of the inguinal ligament (Sub-caecal position).

In 1901 Holmes reported, a case in which the proximal portion of the appendix

was situated extra-peritoneally and its distal portion was free (17). In 1904, Briggs cited a

case of girl aged 20 years in whom tip of the appendix was both retro-caecal and extra

peritoneal (17). In 1905 Kelly and Hurdon described a case of buried retro-caecal

appendix operated upon by Follis (17). Kelly cited a case operated on by Finney in 1898

7

in which a retro-caecal appendix was not only retro peritoneal but also lay with the tip

buried in the substance of the psoas muscle (17).

Different observers have found different positional variations, out of which the largest

study conducted was by Wakeley (1933: 10,000 cases). According to his series, the

most common position of the appendix is, retro-caecal (62%) (1).

Position of the appendix according to various authors

Percentage occurrence of various positions of appendix.

Author

No. Of Specimens

Retro- caecal

Pelvic Post- ileal

Pre- ileal

Sub- caecal

Para-caecal

Wakeley, 1933

10,000 62% 31% 0.4% 1% 2% -

Shah &Shah, 1942

591 51.4% 16.6% 15.6% 11.7% 4.7% -

Solanke TF. 1970

125 38.4% 31.2% 12% 4% 11.2% 2.4%

Varshney S. 1996

600 19% 53% 1% 2% 7% 18%

Golalipour MJ. 2003

117 32.4% 33.3% 2.6% 18.8% 12.8% -

TABLE No - 1

In 1933 Wakeley reported that the position of the appendix at any given time

depends largely on the caecum and the caecum in turn is subjected to wide fluctuation of

contour & some change in the position as a result of tonus, peristaltic activity and

contents. When the caecum is distended the appendix has a dependent position and when

it is contracted, the appendix is sharply turned upwards into a retrocaecal position (1).

In 1938, Marbury found the following facts (17).

8

1. The relative position of the appendix in the body, and its relation to the

peritoneum is governed by embryological factors. In th 4th month the caecum

leaves its position on the left side of abdomen; ascends with its mesenteric

attachment rotates to right iliac fossa, however the ascent and rotation may

cease at any point and hence appendix may be found anywhere along the

course followed by the caecum.

2. If the meso appendix is short, the appendix will be situated either in the

retrocaecal or retrocolic positon.

3. Appendix may be attached to the posterior parietal peritoneum at any time

during the descent of the colon, if descent is arrested early, tip of the appendix

may be found in the region of the gallbladder, if not the appendix may attain

retrocaecal position or may even be free in the peritoneal cavity.

Variations from the typical origin of the appendix from the caecum and the various forms

of the caecum as described by Treaves (16).

Type I - Foetal type: (2%) The caecum is conical in shape & appendix arises from the

apex.

Type II - Quadrilateral: (3%) Appendix arises from between the two bulging sacculi Type III - Usual / Adult type: (90%) appendix arises dorso-medial aspect of the

caecum

Type IV - (4%) In this appendix originates at the ileo-caecal angle

In 1936 Nicholson has shown that deformities of the appendix are, responsible for

the ill health and poor development of children, and are predisposing causes of the

disease. He also stated that the predisposition to acute appendicitis is familial (18,19).

9

Maisel in 1960 studied, 100 fetuses & 300 adult specimens and concluded that

pelvic position was the most frequent both in fetuses and in adults as against 31.01%

reported by Wakeley(20). He further made a distinction, mobile and fixed appendix.

According to his observations 72% of foetal & 62.5% of adult specimens were freely

mobile in the pelvic and preileal positions. Mobile appendices were found in both the age

groups in retrocaecal and retrocolic position (1.4% of infants & 26.7% of adults).

Unfixed appendices were associated with mobile caecum. The fixed retro-caecal & retro-

colic appendices were either extra-peritoneal (90%), adherent to the; posterior abdominal

wall or attached to the posterior surface of the caecum or ascending colon. Fixed splenic

appendices were either attached to the left layer of the mesentery of the termial ileum or

located within the root of the mesentery. All foetal or majority of the adult specimens

were freely mobile (20).

FIG - 1 Positions the appendix(in relation to the cecum and ileum, with frequencies of occurrence (%). C – caecum, Tc –taenia coli)

10

Redrawn from Wakeley, C.P.G. The position of the vermiform appendix as ascertained by an analysis of 10,000 cases. J. Anat. Physiol.67: 277-283, 1933.

Type I Type II Type III Type IV

FIG – 2 Position of appendix in relation to various types of caecum

Note variations on the position of the appendix (a) and its relationship to the tenia coli (tc). Arterial Supply (14,15): - The main appendicular artery, which is a branch of the lower

division of the ileo-colic artery, enters the mesoappendix a short distance from the base

of the appendix with a branch of the posterior caecal artery. The main appendicular artery

approaches the tip of the organ, at first near to, and then in the edge of the mesoapendix.

The terminal part of the artery lies on the wall of the appendix hence may be thrombosed

in appendicitis, resulting in distal gangrene & necrosis. In about 50% of the cases an

accessory artery of Dr. Sheshachalam a branch of posterior caecal artery is present &

needs separate ligation during appendectomy.

11

Venous drainage, Lymphatic drainage& Nerve Supply (13,14): - The veins correspond

to the arteries and drain to the ileo-colic and then to the superior mesenteric vein. Lymph

vessels pass to the lymph nodes in the mesentery of the appendix and those along the

ileo-colic artery. Nerves are derived from the vagus (parasympathetic nerves) and from

the superior mesenteric ganglia and celiac ganglia (sympathetic nerves). The nerves are

distributed in plexus around the ramification of the superior mesenteric artery.

Peritoneal folds and recesses around caecum and appendix (13)

The recesses may lodge the appendix or an abscess

a) Superior ileo-caecal recess. b) Inferior ileo-caecal recess. c) Retro-caecal recess.

Congenital Abnormalities Agenesis (21): - In 1 in 1,00,000 persons, the appendix may be absent. Collins collected

57 cases of true agenesis of the appendix

Duplication (12,22): - A few cases of double appendix have been reported. In some cases

one of the twin appendices, have been found to be inflamed and the other uninvolved

In between 1906-1936, many authors have cited examples of double appendix of

different types and in many cases reported that the anomaly is associated with a defect in

the anterior abdominal wall, agenesis of urinary bladder, double uterus, etc, suggesting

that anomalies almost always are multiple rather than single due to the defective

germplasm.

Waugh (22) describes three types of double appendix.

12

Type I: - Appendix with two separate Lumina & a common muscular wall. Type II: - Two completely separate appendix originating from caecum. Type III: - A normal shaped & normal positioned appendix combined with a hypo-

plastic one with possible atypical origin.

Left sided appendix (12): - This is seen in situs inversus viscerum and in some

cases on nonrotation of the gut. The appendix lies in the left iliac fossa. B.Block,

Maurice & Michael, have described 55 cases of left sided appendix, during 1931-1938.

These were associated with partial or complete transposition of the viscera.

High caecum (12): - Failure of the caecum to descend results in the appendix being

situated in the right hypochondrium (sub-hepatic position).

Functions of the appendix (23): The human vermiform appendix is usually referred to as

vestigial organ with no known functions. This implies a more fully developed organ at an

earlier stage of the individual’s development or in the earlier stages of the evolution

process of the species. There is evidence that this is the case on the contrary. Currently

available evidence suggests that the appendix is a highly specialized part of the

alimentary tract.

The appendix Participates in the secretory immune system of the gut. Secretory

immunoglobins produced by the Gut-associated lymphoid tissue (G A L T) function as a

very effective barrier that protects the milieu interior against the hostile milieu exterior.

13

Though the appendix is an integral part of the G A L T, Mediated Secretory globulin

immune mechanism, it is not indispensable. Removal of the appendix produces no

detectable defect in the functioning of the immunoglobin system. Thus the human

appendix is a useful, though not indispensable immunologic organ.

HISTORICAL ASPECTS (24, 25, 26) Those who cannot remember the past are condemned to repeat it

- santayana. The existence of the appendix was known even when the pyramids were being built

because certain Coptic jars containing bowel, inscribed with references to the WORM

OF THE BOWEL, and the hermetic books of Thoth and Books of the Dead, contain

statements which probably refer to the appendix (24).

Berengas Da Corpi (1954) gave the first full account of the appendix and

appendicular perforation (24). Andreas Vesalius (1534) Professor of anatomy at Ponda,

has given a detailed description of the normal appendix in his treatise on Defabrica

14

alumini Corporis (24). Morgagni, in his Adversaria Anatomica, has devoted some

portion of his work to the appendix, to describe its size, size, and its relations to other

structures (25). Verhgen (1710) coined the word Appendix. Liberkuhn, in 1739,

published a classic paper on the appendix in which he described, for the first time, crypts

in the mucosa, which bear his name (24). In 1735, on December 6th, Claudius amyad

performed the first appendectomy (26). In 1755, Heister recognized that the appendix

might be the site of acute primary inflammation (24). In 1842, Wyes Killer gave a

presentation entitled Observations in the inflammatory conditions of caecal appendix (24).

In 1886, Fitz Professor of medicine at Harvard published his classic monograph on

25 patients with perforating diseases of the Vermiform appendix, with special reference

to early diagnosis and treatment. He gave a lucid & logical description of the clinical

features & described, in detail, the pathologic changes in the disease. He was the first to

use the term appendicitis. He also suggested that, appendectomy would be essential for

cure (24).

Mc Burney in New York, in 1899 gave a lucid description, of the clinical features of

acute appendicitis and pioneered the removal of the acutely inflamed appendix before

perforation occurred and also devised the muscle – splitting incision (grid iron), named

after him (25). The teaching of Murphy at Chicago further popularized the early

intervention (24).

In 1901 Homes described, a case in which the proximal portion of the appendix was

situated extra-peritoneally. In 1904, Briggs cited a case of girl aged 20 years in whom tip

of the appendix was both retrocaecal and extra peritoneal. In 1905 Kelly and Hurdon

15

described a case of buried retrocaecal appendix operated upon by Follis. Kelly cited a

case operated on by Finney in 1898 in which a retro-caecal appendix was not only retro-

peritoneal but also lay with the tip buried in the substance of the psoas muscle. In 1915,

Strauss, found 22 extra-peritoneal appendices in 1651 autopsies. In 1910, Albert

Oschner, in chicgao, and James Sherren in London, advocated conservative line of

management in late cases. In 1928, Small, reported 7 cases of retroperitoneal appendices

operated upon by him over a period of 25 years. In 1932 Donald C Collins reviewing

literature on the length and position of appendix from 1861 to 1929 has cited the longest

appendix which measures 33 cms reported by Graver (1890) and the shortest 0.5 cms

reported by Huntington (1903) (2).

INCIDENCE OF APPENDICITIS Acute appendicitis is the most common cause of acute surgical abdomen and

appendectomy is the commonest emergency operation being performed. The lifetime

rate of appendectomy is 12% for men and 25% for women, with approximately 7% of

all people undergoing appendectomy for acute appendicitis (30,31). Over a 10-year

period from 1987 – 1997, the overall rate of appendectomy rate decreased parallel to

the decrease in incidental appendectomy (32).

Age Incidence (28): - While all ages are susceptible, the second and third decades are

the most frequently affected, while it is relatively less common at the extremes of age.

16

Sex incidence (28): - There is no particular predilection for either sex in acute

appendicitis till puberty. Among teenagers and young adults, the male to female ratio

is 3: 2. After the age of 25, the excess of male incidence decreases gradually until the

sex ratio is equal

Geo-graphic distribution (26): Appendicitis is most frezuently observed in North

America, British Isles, Australia, New Zealand, and among white South Africans. It is

rare in most of Asia, Central Africa, and among Eskimos. When people from these

areas migrate to the Weatern world or change to a Western diet, appendicitis becomes

prevalent, suggesting that the distribution of disease is determined environmentally

rather than genetically.

CLASSIFICATION OF APPENDICITIS (23,33)

1. Acute appendicitis

2. Recurrent appendicitis

-Recurrent acute appendicitis

-Recurrent sub-acute appendicitis

3. Chronic Appendicitis

Classification of Acute Appendicitis (33)

Depending on the gross and microscopic picture of the inflamed appendix:

17

1. Acute focal appendicitis: The appendix is grossly normal, but the microscopic

sections studied show scattered foci of inflammatory infiltrate with in the wall:

mucosal ulcers may be present.

2. Acute suppurative appendicitis: The appendix is grossly inflamed, oedematous

and injected, with peritoneal exudates. Microscopic sections show diffuse

inflammation.

3. Acute gangrenous appendicitis: Vascular thrombosis is present in addition to

signs of inflammation but with no gross perforation.

4. Acute Appendicitis with perforation: There is severe inflammation of the

appendix, with the disruption of the wall and exit of appendiceal contents into the

peritoneal cavity

5. Acute appendicitis with Peri-appendiceal abscess: This is secondary to

perforation with an attempt at localization of the inflammatory process by the

adjacent structures

Chronic appendicitis (34):

Divergence of opinion exists regarding the entity of chronic appendicitis, as a

cause of recurrent pain in the right iliac fossa. This always requires investigation to

exclude inflammatory bowel disease and gynecological disorders in females.

Relief of pain follows appendectomy in a proportion of these patients. The

appendix is usually long, fibrotic and contains faecolith. Histological examination shows

chronic inflammation.

18

ETIOLOGY AND PATHOGENESIS

ETIOLOGY: The following etiological factors are important but for the most part they

are purely contributory.

Race & Diet (26): Appendicitis is particularly common in highly civilized, European,

American and Australian countries, while it is less common in Asians, Africans and

Polynesians. It is possible that the rise of appendicitis amongst the highly civilized races

is due to departure from a simple diet, rich in cellulose, to one relatively rich in meat.

Familial susceptibility (18): This is unusual, but generally well-accepted fact, could be

accounted for by, an inherited malformation or mal-position of organs, which predisposes

to infection and similar diet consumption amongst the family members.

Bacterial factors (34): Any specific bacteria or protozoa do not cause acute appendicitis.

Culture from inflamed appendices showed normal bowel flora, Suggesting secondary

invasion of the damaged tissue from the lumen of the bowel. Though appendicitis has

been reported with salmonella and shigella enterocololitis, is probably due to obstruction

by hyper-plastic lymphatic follicles in the appendix

OBSTRUCTION: Wilkie (1914), Wangensteen et al (1937 and 1940) and Peiper et al

(1983) have documented appendicitis following obstruction of the appendix in

experimental animals. Wangensteen et al showed that combined obstruction and bacterial

19

invasion resulted in acute appendicitis whereas obstruction of a bacteria free lumen

resulted in mucocoele.

The obstruction may be

1. In the lumen: Faecoliths, parasites, (Pin worms, Ascaris, taenia) foreign bodies

(rare cause) – vegetables & fruit seeds, inspissated barium, pins, lead shot, bones,

eggshells, glass, teeth, nails, dice, the bulb of thermometer or others.

2. In the wall: lymphatic hyperplasia, stricture, tumors, carcinoid, appendix,

appendicular metastases, especially from breast carcinoma.

3. Outside the wall: Adhesions and kinks, congenital and post-inflammatory

strangulation in a hernial sac, carcinoma of the caecum and ascending colon.

i. FAECOLITH: Faecal material is commonly present in normal and inflamed

appendix. Faecolith is ovoid about 1-2 cm in length. Unlike ordinary faeces, a true

faecolith shows a well- ordered lamination on section.

Composition: Inspissated faecal material, calcium and magnesium phosphates and

carbonates, bacteria and epithelial debris and rarely, a foreign body may be incorporated.

Significance: In 10% of the cases of appendicitis, a faecolith was demonstrated by plain

radiograph of the abdomen. Radiological demonstration of a stone is an absolute

indication for appendectomy, irrespective of the signs or symptoms.

20

ii. LYMPHATIC HYPERPLASIA: The amount of lymphatic tissue in the appendix

parallels the incidence of acute appendicitis, the peak for both occurring in the early

teens. Hyper-plastic follicles may partially obstruct the lumen, setting the stage for the

development of appendicitis. Hyperplasia of the lymphoid tissue may be a response to

acute respiratory or other diseases producing a generalized reaction of the lymphoid

tissue. The lymphatic follicles of the appendix also respond to infection in the gut

iii. PARASITES (25): Pinworms and Ascaris are the commonest parasites reported to

cause obstruction of the appendix.

PATHOGENESIS (33)

The primary pathogenic event in acute appendicitis was thought to be intra-luminal

obstruction

ROLE OF LUMINAL OBSTRUCTION:

The events that follow obstruction of the appendix depend upon interaction amongst

four factors, - the contents in the lumen, the degree of obstruction, the continued

secretion by the appendiceal mucosa and the inelastic character of the appendiceal serosa.

The sequence of events following the occlusion of lumen is probably as follows. –

A closed loop obstruction is produced by the proximal block and continuing normal

secretion of the appendiceal mucosa, very rapidly, resulting in distension. The luminal

capacity of normal appendix is only about 0.1 to 0.2 ml. As little as 0.5 ml, distal to a

block, raises the intraluminal pressure to about 60 cm of water.

21

The human being is one of the few animals with an appendix capable of

secreting at pressures high enough to lead to gangrene and perforation. Progressive

mucous accumulation raises the intra luminal pressure; virulent bacteria convert the

accumulating mucus to pus. Continued secretion, combined with relative inelasticity of

the serosa, leads to further rise in the pressure within the lumen; obstruction of the

Lymphatic drainage ensues, leading to oedema of the appendix; diapedisis of the bacteria

begins and mucosal ulcers appear. This is the stage of acute focal appendicitis.

The bacterial invasion spreads through the walls of the appendix. This stage is called

acute suppurative appendicitis. The inflamed serosa of the appendix comes in contact

with the parietal peritoneum, as a result of which somatic pain arises. This is perceived as

classic shift and localization of pain in the right lower quadrant.

These pathologic processes continue, resulting in venous thrombosis and then to

compromise the arterial blood supply. The area of the appendix with the poorest blood

supply undergoes gangrene, with the appearance of ellipsoidal infarcts. The development

of gangrenous appendicitis is the first stage of complicated appendicitis. Morbidity

increases, as these infarcts functionally act as perforations. They permit the escape of

bacteria from the lumen of the appendix and contamination of the peritoneal cavity.

Secretion from the viable portions of the appendiceal mucosa, Continued high

intraluminal pressure finally leads to perforation through a gangrenous infarct, spilling

out accumulating pus. Perforated appendicitis now increases the morbidity and mortality.

22

Fortunately, in most cases, the obstruction that initially led to appendicitis blocks

continued spillage of faeces from the caecum through the perforated appendix.

If appendicitis has not progressed too rapidly, inflammatory adhesions form

between the loops of the bowel, peritoneum and omentum to hide the appendix.

Perforation in such cases leads to localized peritonitis. A peri-appendiceal abscess forms

eventually, if untreated.

This sequence is not inevitable. Some episodes of acute appendicitis apparently

subside spontaneously. Many patients, found at operation to have acute appendicitis, give

a of previous similar, but less severe, attacks of right lower quadrant pain.

Pathological examination of the appendices removed from these patients often

reveals thickening and scarring, suggesting old, healed, acute inflammation. Presumably,

obstruction of the lumen, when due to lymphoid hyperplasia or soft faecolith, can be

spontaneously relieved, allowing subsidence of appendiceal inflammation and attendant

symptoms.

CLINICAL DIAGNOSIS

The diagnosis of acute appendicitis is the classic example of the application of

clinical skills by the surgeon. Recently, algorithms and symptoms ranking systems, to

improve clinical examination, have been reported, but these aids have not really

improved the overall accuracy of preoperative diagnosis.

Sequence of events (26): The sequence of events in acute appendicitis is usually

characteristic and follows like this; it begins with diffuse abdominal pain, followed by

23

anorexia nausea and vomiting. Later, the pain shifts to the right side of the abdomen,

accompanied by a slight rise in the body temperature. Pain is present in all cases of

appendicitis, except in those with transeverse myelitis or similar disability.

Typical pain (26): This consists of an initial diffuse, central not very severe, visceral pain,

followed by somatic pain that is more severe and well localized to the right lower

quadrant.

Visceral pain(26) : This is steady, sometimes intermittent, cramping, and usually lasts 4-

6hrs (ranging from 1 –12 hrs). It is mild to moderately severe. The pain is felt around the

umbilicus. In the epigastrium or it may be generalized. It is due to the distension of the

appendix and irritation of the visceral peritoneum and hence is vague. This pain is

constant in non-obstructive and colicky in obstructive cases.

Somatic pain (26): Pain shifts to the point where the inflamed appendix irritates the

parietal peritoneum, which is highly sensitive. This pain is steady and very severe,

aggravated by motion or coughing and is usually located in the right lower quadrant.

The classic pain sequence in case of appendicitis is found in 55% of patients, but may

also occur in one fourth of the patients with other intra abdominal conditions.

Variations in the anatomical position of the appendix may account for variations in the

principal focus of the somatic pain. Long appendix with the tip located in the left iliac

fossa may cause pain in that area. A retrocaecal appendix may cause pain principally in

the flank or back. A pelvic appendix mainly causes pain in the suprabic area. While

24

postileal appendix may cause testicular pain, presumably from irritation of the spermatic

cord or ureters (23,29).

Anorexia, nausea and vomiting (29): About 95% of the patients have anorexia, nausea or

vomiting. Patient vomits only once or twice, a few hours after the onset of pain, but

anorexia persists even though nausea subsides.

Change in the Bowel and bladder habits (23,29): Patients may give history of obstipation

before the onset of abdominal pain and may feel that defecation will relieve their

abdominal pain. Diarrhea occurs in some patients especially in children. These symptoms

are probably due to proximity to the ileum, as in the postileal and preileal position of

the appendix or due to proximity to the rectum as in cases of pelvic position of the

appendix. Patients with pelvic appendicitis may have dysuria, and hematuria usually

microscopic. In retro-caecal appendicitis, urinary frequency may result from direct

irritation of the ureter.

Pain due to perforation: The pain of acute appendicitis was believed to be relieved

immediately after perforation. This older concept, which attributed this to sudden

decrease in pressure in the appendix, is disagreed upon in the present, as in most patients,

pain continues or increases in severity after perforation. In addition, the patient becomes

more ill with the distension of the abdomen beginning to develop because of supervening

diffuse peritonitis.

25

PHYSICAL EXAMINATION (23,26,29)

Appearance and Posture: Patient is usually flushed and in obvious pain.The patients

prefer to lie supine, with the thighs, particularly the right, drawn up because any motion

increases the pain due to irritation of the parietal peritoneum.

Temperature: Rarely rises above 38° C in uncomplicated appendicitis. Temperatures

above 38° C should always suggest the presence of perforation and peritonitis or abscess

formation. Normal temperature is sometimes present in advanced appendicitis, Children

usually present with higher temperatures, but very high pyrexia suggests some other

diagnosis like pyelitis or respiratory tract. Infection.

Pulse rate: Is normal or slightly elevated, especially in complicated appendicitis.

Tenderness: There cannot be acute appendicitis with out tenderness, which may be mild

and diffuse in early stages of the disease, later on localizing according to the position of

the appendix, In pelvic position suprapubic region is the site of maximum tenderness, in

retrocaecal position maximum tenderness is present posteriorly, extending toward, but

rarely as high as, the costo-vertebral angle (23).

Muscle guarding and rigidity: Muscle guarding and rigidity indicate the severity of the

inflammatory process. Especially in younger patients, early in the disease, resistance felt

is because of voluntary guarding. As the peritoneal irritation progresses, muscle spasm

increases guarding.

26

Cutaneous hyper-aesthesia (25): Over the area supplied by the spinal nerves T10, T11 &

T12 on the right side is frequent, but not constant, component of acute appendicitis. In

patients with obvious appendicitis, this sign is evident, but in some early cases, this may

be the first positive sign.

Rovsing’s sign: Pain in the right iliac fossa when pressure is exerted in the left iliac

fossa, is a manifestation of referred, rebound tenderness. It also indicates the site of

peritoneal irritation.

Psoas sign: The test is performed with the patient lying on the left side. The examiner

slowly extends the right thigh of the patient, thus stretching the ilio-psoas muscle. The

test is positive if extension produces pain. This indicates localized psoas muscle irritation

by the inflamed retrocaecal appendix (35).

Baldwin’s test: This test is, positive in retrocaecal appendicitis. While maintaining

fingertip pressure over the right flank, the patient is asked to lift the right lower limb off

the bed, keeping the knees extended. This test is positive if the patients complains of pain

or drops the limb with an expression of agony on the face (35).

Obturator sign: With the patient in supine position, passive internal rotation of the

flexed, right thigh, causes hypo-gastric or adductor pain. If positive, it indicates inflamed

pelvic appendix irritating the obturator internus muscle (35).

27

Mc Burney’s sign: Fingertip pressure is applied over the Mc Burney’s point. Patient

complains of pain on pressure. It is a predictive sign in early or sub-acute appendicitis.

Shifting tenderness: This sign is useful in the diagnosis of appendicitis in pregnant

women. Locate the tenderest spot & mark it on the skin. Then request the patient to turn

to the left side and wait for a full minute, should the tenderness be of uterine origin, like

concealed accidental hemorrhage or necrosis of a uterine fibroid, it will shift with the

uterus, whereas in appendicitis the position will remain constant.

Rectal examination: It is indicated primarily to exclude lesions such as ovarian cyst or

tubal pathology in females and to elicit tenderness in cases of pelvic appendicitis. In

about 1 in 3 patients with inflamed appendix, in or adjacent to the pelvis, the presence of

mass, or tenderness specifically localized to the right side may be elicited. In a few

subjects whose inflamed appendix lies entirely within the pelvis, tenderness on rectal

examination may be the only positive physical sign.

Diagnostic variability: Considering the range of possible presentations, the lack of

diagnostic accuracy comes as no surprise.

Gilmore et al (36) reported that senior consultants could accurately diagnose

appendicitis in 80% of the cases, while junior consultants may be wrong 50% of the time.

De Dombal and Leaper (37), who also said that young women were more commonly

misdiagnosed than any other age group, confirmed this. Pieper et al (38) found that 6 –

28

30% of patients do not have appendicitis on laparotomy, of which 4-13% of patients have

some other concurrent surgical disease, but almost 25% are negative laparotomies.

In women of reproductive age, this figure is as high as 45%, No other segment in

general surgery compares to this level of misdiagnosis (36,39).

Appendicitis is a disease with protean manifestations. The position of vermiform

appendix is not constant and there are suggestions that it could change with movement of

caecum (40).

Many presentations of appendicitis are atypical because of an atypical position of

the appendix, the patient’s age or the presence of associated conditions such as

pregnancy.

Retro-caecal or Post- ileal: These differ from the classical variety, since the inflamed

appendix is shielded from the anterior abdominal wall by the caecum and the ileum, there

is less of discomfort, and guarding may be absent (9)

In retro -caecal position patient may present with features of upper urinary tract

infection due to the proximity of the ureters and kidneys. Kao CT et al have described a

case of ruptured retro-caecal appendicitis presenting as peri-nephric abscess (41).

Harsha WT, and others believe that retro-caecal position of the appendix

whether fixed by the inflammatory process or during the development is felt by some

29

clinicians to present an enigmatic and challenging clinical problem when appendicitis

develops (42).

Collins argued: Acute retro-caecal appendicitis is largely responsible for the

atypical symptoms in cases of acute appendicitis that deceive the incautitious clinicians,

and cause many deaths. In his review of 751 cases of retro-caecal appendicitis he

emphasized the frequently bizarre nature of early signs and symptoms. Only 18.9% of his

patients presented with classic signs and symptoms of appendicitis (43).

Pelvic appendicitis: The pain is localized to the left in a number of patients. The urge to

defecate or urinate is prominent, and tenderness may be elicited on pelvic examination.

It may also present as prostatitis, in males, due to the extension of inflammation to the

prostate. In females it may present with, features of pelvic inflammatory disease (pelvic

adnexal mass, cervical motion tenderness (44).

An appendico-vesical fistula may develop, which presents as recurrent attacks of

cystitis, which is refractory to usual antibiotic treatment. Five cases of appendiceal-

ureteral fistulas have also been described (44).

In children acute appendicitis may very rarely present as acute urinary retention

Hoffmann has given the hypothesis that the prostatic urethra may become obstructed

either by the inflammatory mass, or the abscess itself, by sympathetic mechanism

leading, to sphincter spasm or as a result of prostatic congestion (44).

Appendicitis in infants and children (45): It is difficult to diagnose for obvious reasons.

Increased irritability may be the only symptom (45). The incidence of perforation is the

30

highest in children below 2 years of age. Harrington et al reported a perforation rate of

90% in infants (46).

Appendicitis in elderly: In elderly it is difficult to diagnose because of unclear

symptoms (47) and refusal by the treating physician to consider the diagnosis.

Appendicitis in pregnancy: The disease is no different in pregnant women than it is in

non-pregnant women, but diagnostic difficulty and delay and the severity and

complications add to its significance (48). Appendicitis is more prone to occur in the first 6

months (74%) (49). During this period, symptoms such as anorexia, nausea, vomiting and

abdominal pain may be attributed to the pregnancy. Physical findings of localized

tenderness, rebound tenderness, and muscle guarding are not altered by cephalad of

caecum by the enlarging uterus; caecal displacement, progressively cephalad after the

initial 6 months, tends to localize pain and tenderness to the upper quadrant and flank.

When inflammation extends to the parietal peritoneum (50). Stretched abdominal

musculature alters the reflex responses, and there is inability to examine the abdomen

satisfactorily. All of these contribute to the diagnostic dilemma (51).

Complications of acute appendicitis (23,26,29)

I. Perforation and its consequences

II. Abscess formation and its complications

- Appendico - cutaneous fistula.

- Appendico – vesical fistula. (In cases of pelvic appendicitis)

31

III. Diffuse peritonitis. (Usually seen in intraperitoneal position of the appendix)

- Due to contamination of the peritoneal cavity before defensive adhesion

formation.

- Secondary rupture of intra abdominal abscesses that were produced by

ruptured appendicitis. Perforation: A Serious complication of appendicitis, that results from a delay in

diagnosis and surgical treatment. Reports in the literature suggest an occurrence of

appendiceal perforation as high as 32% (52) and a startling frequency in children

(conservative estimates of 30-42% (53), with the extremes as high as 50-83% being

reported (54)).

62% of patients with perforation had been symptomatic for more than 24 hrs, in

contrast to 33% of those without perforation. This explains that delay in seeking medical

attention, is, probably, the most important factor leading to perforation. Scher reported

that the mean duration of symptoms was 2.5 days for those with perforation, compared to

1 to 5 days for those without perforation, he also reported that 30.6% of perforated cases

got operated after 24 hours as compared to 15.4% of non-perforated cases (52).

Perforation should be suspected when the duration of symptoms exceeds 24 hrs,

the temperature is more than 38º C and WBC count greater than 15,000 cells/cu.mm.

These are uncommon findings in non-perforated appendicitis.

A history of diffuse abdominal pain following symptoms confined to right lower

quadrant, accompanied by signs of diffuse peritonitis on physical examination indicates

that perforation has occurred.

32

If the perforation has been walled off into an appendicular abscess, a tender mass

can often be palpated in the right lower quadrant. If discomfort makes palpation of the

right lower quadrant difficult, it is helpful to examine the patient under anesthesia before

the incision is made. In retro-caecal appendicitis the abscess is usually outside the

peritoneal cavity and does not contaminate the peritoneum, hence it can be drained

extraperitoneally

.

LABORATORY INVESTIGATIONS AND SCORING (23,25,26,28)

Laboratory is a good servant but poor master

-Boyd.

This is very much true of acute appendicitis, as only laboratory investigations, with out

any clinical grounds, does not establish diagnosis.

I.Total WBC count and differential count (55).

Moderate leukocytosis, ranging from about 10,000 – 18,000 cells/cu.mm, with

neutrophilia, is the common picture in acute appendicitis.

With normal total & differential counts, the diagnosis of acute appendicitis is still

a possibility. If WBC count is > 18,000 cells/cu.mm and shift to the left is extreme,

perforated appendicitis or an acute inflammatory disease of greater magnitude than

33

appendicitis is more probable. Leukocytosis is usual, but by no means inevitable, and

seldom diagnostic (Fowler).

II Scoring systems

Scoring systems based on clinical and laboratory findings have been introduced.

Ramirez and Deus used Bayesian probability to produce a rationalized model of clinical

decision-making (56).

Some of the scoring systems currently in use are the ALVARODO’S SCORE (57)

Different weighed variables are taken to calculate a cumulative score to decide on the

diagnosis. These include symptoms signs and laboratory investigations.

TABLE No - 2 Alvarado Score (57)

SYMPTOMS SCORE

Shifting of pain to right lower quadrant 1

Anorexia 1

Nausea, vomiting 1

SIGNS

Tenderness in right lower quadrant 1

Rebound tenderness 1

Elevation of temperature 1

LABORATRORY CRITERIA

Leukocytosis 2

Shift to left 1

TOTAL 10

34

Fenyo G and Kang et al (58) used the Alvarado score as a determinant factor for surgical

intervention and found a score of less than or equal to 6 to be clinically dubious and more

than or equal to 7 to be typical.

Teicher et al (59) described a scoring system, after retrospectively studying 100

cases of acute appendicitis.

TABLE No – 3

TEICHER SCORING SYSTEM

SCORE POSITIVE PREDICTORS SCORE NEGATIVE PREDICTORS

+2 Male -1 Female

+3 Age 50 yrs -1 20-39 yrs

+2 Duration ½ day -3 Duration > 3 days

+1 Duration 2 days -3 Genito-urinary symptoms

-3 No right lower quadrant

spasm

-3 Rectal mass right side

+3 Involuntary right lower quadrant

spasm

-3 TC < 10,000 cells/cu.mm

35

A score greater than 3 was taken as a positive predictor of acute appendicitis. This system

if applied would have prevented negative laparotomies in 38% of the patients and 5%

would have been kept for observation.

Scoring systems help augment the clinical decision making with considerable

economy of resources and have a favorable cost benefit ratio.

IMAGING MODALITIES

I. Plain Radiography.

Plain radiography has been used for the diagnosis of the acute abdomen since

1906 (60). However there is no single sign that is pathognomonic of acute appendicitis

in a plain film. Brooks et al (60) in 1975 described several signs in a case of acute

appendicitis.

1. Presence of appendicolith.

2. Sentinel loop in right iliac fossa.

3. Dilated caecum.

4. Widening and blurring of pre-peritoneal fat line.

5. Haziness of right lower quadrant.

36

6. Scoliosis, concave to the right.

7. Right lower quadrant mass indenting the caecum.

8. Blurring of the right psoas outline.

9. Gas in the appendix (rare).

However, plain radiograph lacks specificity, with similar findings being found in normal

patients as well as in other conditions. It is relatively contraindicated in certain conditions

e.g. in pregnant patients. The low diagnostic yield (8% sensitivity) adds to its

unattractiveness as a diagnostic aid (61).

II. Barium meal follow through: (rarely done)

Schisgall et al (62) in 1983 reported an accuracy of 95% in the diagnosis of acute

appendicitis in children by barium meal follow through examination. This involved a

slightly higher (0.2 rad) radiation exposure as compared to a barium enema.

The signs of acute appendicitis are:

1. Non visualization of the appendix

2. Mass effect on the caecum.

III. Barium enema: (rarely done)

Barium enema examination is based on the rationale that the lumen of the normal

appendix can be demonstrated with barium enema, and appendiceal luminal obstruction

37

represents acute appendicitis, with extrinsic pressure effects (reverse 3 sign) on the

caecum.

Rajagopal et al (63) found the following signs highly suggestive of appendicitis on

barium enema examination:

1. Persistent non-visualization of the appendix.

2. Partial Visualization (Beheaded appendix)

3. Pressure effect on the caecum (Reverse 3 sign)

4. Irritability of the caecum and terminal ileum on fluoroscopy.

However, Persistent non-visualization of the appendix is a finding in 5- 10% of normal

individuals and may occur due to a faecolith (64).

The advantage of barium is that it does not require specialized equipment. It can

also diagnose certain conditions, which may mimic acute appendicitis like colonic

carcinoma, terminal ileitis and ischaemic colitis (64).

Fedyshin et al found the procedure cumbersome and that it entails exposure to

ionizing radiation, as its great drawbacks (65).

IV Ultrasound:

In the clinical management of suspected acute appendicitis, graded compression

ultrasonography is the examination of choice. It is mainly used to exclude the other

causes of abdominal pain, which mimic appendicitis like calculi, ruptured tubal gestation,

and other pelvic causes.

38

Currently the diagnostic criteria used for the diagnosis of acute appendicitis by

ultrasound are (After Jeffrey) (66)

1. Blind ending, immobile, non compressible, a peristaltic, tubular structure.

Measuring the diatance from the echogenic mucosa to the outer oedematous wall

that shows few echoes assesses mural thickness.

2. Cannot be displaced on pressure.

3. Bull’s eye or target lesion visualized in the transeverse plane with diameter >

6mm.

4. Faecolith in the lumen.

5. Peri-appendiceal collection.

6. Hypo or hyper – peristaltic loops in the right iliac fosssa.

7. Sonographic Mc Burney’s sign of maximum tenderness by the probe. This sign is

lost in appendicular perforation.

8. Miscellaneous signs: Cockade around target lesion. Tubular structure > 50 mm in

length.

Chesbrough et al have reported an increased diagnostic yield of ultrasound by self-

localization of the site of maximum tenderness (67).

Poor results have been reported in the diagnosis of appendicular perforation.

Puylaert et al (68) stated the following reasons:

1. Loss of localizing rebound tenderness.

2. Decompression of the target lesion and decrease in the diameter.

3. Ileus with dilated bowel loops with in the right iliac fossa.

39

The low sensitivity in the group with perforated appendicitis is not necessarily worrying,

as the need for an operation was obvious.

V. Colour Doppler: Colour Doppler Examination is based on the principle that

acute inflammation of the appendix is associated with increased blood flow to

the region. Quillin et al (69), in 1994, imaged 100 children concurrently with

Colour Doppler and gray scale ultrasonography, and found sensitivity of 87%

and a specificity of 97%, with an accuracy of 93%, using colour doppler,

compared to an accuracy of 90% by gray scale ultrasonography. A finding of

increased vascularity was considered positive for appendicitis and a

hyperemic right lower quadrant mass was suggestive of an abscess.

VI. Computed Tomographic scanning: Useful, Especially in the obese and

distended patients, where ileus makes visualization by ultrasound a problem

(70,71). It has been shown to be more accurate in advanced appendicitis in the

diagnosis of perforation (72), While diagnostic accuracy in early appendicitis is

still suspect.

In a study of 38 patients, Gale et al (72) found that C.T had a sensitivity of 92% and a

specificity of 79%. They described the common findings in acute appendicitis on C.T as:

1. Peri-caecal inflammation. (68%)

2. Abscess formation. (55%)

3. Calcified appendicolith. (23%)

40

4. Abnormal appendix. (18%)

Balthazar et al (70) analyzed 100 consecutive cases with both, ultrasound and C.T, and

found the accuracy to be 93% as contrasted to 84% by ultrasound. The sensitivity of C.T

was found to be 96%. C.T was found to be more useful in detecting location, nature and

extent of the disease process (70). Normal C.T does not rule out acute appendicitis without

peri- appendiceal inflammation (70,71).

VII Diagnostic Peritoneal Aspiration Cytology / Lavage:

Evans et al (73) in 1975 have investigated peritoneal lavage, as a diagnostic modality for

non-traumatic acute abdomen, and, Hoffman et al (74) confirmed its utility in 1988.

Complications reported were 2 cases of colonic perforation during the procedure. This

procedure is also contraindicated in the presence of a sub-umbilical midline scar.

Performance of this procedure was found to be difficult in the presence of paralytic ileus

or obesity. Caldwell et al (75) reported that a negative result does not definitely rule out

significant intra abdominal pathology. However leukocyte rich pus in the peritoneal

aspirate of a young male is diagnostic of acute appendicitis.

VIII. Miscellaneous Investigations

1. Urine analysis: The presence of haematuria or pyuria in acute appendicitis has been

demonstrated. Graham et al (76) found microscopic haematuria and pyuria in 9 patients of

41

62 positive appendectomies. An appendiceal tip being close to the ureter or the bladder

can cause haematuria and pyuria.

2. Phospho-lipase A2 levels: Group II phospholipase A2, in the serum is an acute phase

reactant. Gronroos et al (77) prospectively studied 186 patients, also using CRP and

leukocyte count. Whereas leukocyte count was the investigation of choice in acute

uncomplicated appendicitis, C-reactive protein and phospho-lipase A2 correlated better

with protracted inflammation and appendicular perforation. Increased phospholipase A2

values did not unequivocally indicate diagnosis but when all the values were normal,

appendicitis could be excluded with 100% certainty.

3. Creactive protein levels: C reactive protein is basically an acute phase reactant which

has been shown by Gronroos et al (77) to stay persistently elevated in cases of acute

appendicitis, unlike the total leukocyte count which progressively decreases with time.

Combined sequential assessment of CPR and total count has been proposed in the

subgroup of patients who have been kept for observation. Eriksson et al (78), in a study

of 227 patients, found that CRP had a sensitivity of 87% and a specificity of 50%.

4. Interleukin – 6 levels (IL-6) Assessment of IL-6 levels has been found to correlate

well with acute appendicitis, although specificity is uncertain (77).

5. Radio- isotope scanning: After a report in 1985 that there was a rapid accumulation of

radioisotope labeled leukocytes at the sites of infection, radioisotope studies, for the

diagnosis of acute appendicitis, were attempted.

42

This involved withdrawing 30 –90 ml of patient’s blood, separating of the leukocytes by

differential sedimentation and labeling them with radioisotope, usually Technetium 99 or

Indium 111. Scanning was done 2hrs after injection of the mixture.

Navvaro et al (79) used Indium 111 and found a sensitivity of 93% with an overall

accuracy rate of 91%.

It is however, unreliable in women, as gynecological conditions may mimic the scan

appearance of appendicitis.

6. Diagnostic laparoscopy: Kelling et al introduced diagnostic laparoscopy as early as

1902, but its use in acute abdomen was reported only as late as 1970 (25).

Diehl et al (80), Deutsh et al (81), Leape et al (82), highlighted its utility at

laparotomy in reducing the negative laparotomy rates for appendicitis. The negative

appendectomy rates reduced from 30% to 1-2% (61).

Hoffman (61) summed up the signs of acute appendicitis on laparoscopy.

1. Partial or complete visualization of inflamed appendix.

2. Pus in the right iliac fossa.

3. Omentum adherent to structure of the right iliac fossa.

4. Inflammation of the peri-caecal tissues.

The advantage of laparoscopy is positive visualization and the exclusion of the

differential diagnosis such as salphingitis, terminal ileitis, ectopic pregnancy,

endometriosis, ruptured corpus-luteal cysts, tumour infiltrates, Para ovarian cysts and

mittelschemerz syndrome.

Disadvantage: It cannot be done in obesity, previous laparotomy, sub- umbilical scar,

and abdominal distension due to ileus, pregnancy and ascites.

43

7. Abdominal thermography: Steele et al (83) measured the abdominal skin temperature

in patients undergoing emergency appendectomy and found to be significantly elevated

over the normal controls.

It is becoming very clear that the negative appendectomy rate of 20-25% accepted by

most surgeons is too high to justify, in the presence of modern systems of diagnosis. A

myriad of evolving modalities are available, which can reduce the negative laparotomy

rate to 1-2%.

TREATMENT (23,25,26,28,84)

The one and the only answer to the treatment of appendicitis and its

complications, is surgery, and the only dilemma it carries with it is, the timing of surgical

intervention.

There is a general agreement on the timing of the operation for three categories of

appendicitis already mentioned – acute appendicitis without rupture, ruptured appendix

with local peritonitis or phlegmon formation, and ruptured appendix with spreading

peritonitis, when appendectomy should be performed immediately.

There has been a difference of opinion, however, concerning the optimal timing

of operation for ruptured appendicitis with frank peritoneal abscess formation. A.T

Oschner advocated expectant treatment in 1901. If progression occurs, the abscess is

drained. If the patient improves, conservative treatment is continued. With these

measures, the majority of appendiceal abscesses resolve satisfactorily, although many

44

days of hospitalization are required. An elective appendectomy 6 weeks to 3 months later

is strongly advised, since the recurrence rate is very high.

Prompt surgery for all categories of appendicitis is especially important in

children, since expectant treatment of ruptured appendicitis has been less successful than

in adults.

NON – OPERATIVE therapy may be appropriate if (26) –

1. The patient is moribund with advanced peritonitis

2. The attack has already resolved.

3. An appendix mass has formed without evidence of generalized peritonitis

Preoperative preparation: All patients, but especially those in whom perforation and

peritonitis are suspected, should receive intensive pre-operative preparation, this rarely

requires more than 3-4hrs and often can be accomplished in an hour or less. Patients with

a palpable peri-appendiceal mass may in selected cases, be managed initially, without an

operation.

Fluid replacement with Ringer’s lactate solution and 5% dextrose in water is given as

rapidly as possible with the objective of establishing a good urinary output. Naso-gastric

suction is helpful in all the cases, particularly in those with peritonitis.

Antibiotics: These are administered preoperatively to help control any local or

generalized sepsis that may be present, and to reduce the incidence of post-operative

wound infection. These are especially useful in patients who have gangrenous or

perforated appendicitis.

45

Examination under anesthesia: With the patient under the effect of anesthesia, the

abdomen should be carefully and systematically palpated once more. On occasion, such

examination will show the gallbladder to be the real cause of the patient’s symptoms.

Incisions (26,28,84): There are a number of choices for an incision, each of which has its

advantages and disadvantages. The incision should be one that gives sufficient exposure,

Permits the needed exposure with least amount of tissue injury, and allows easy

extension, should it become necessary. Also to be considered is the likelihood of

complications directly attributable to the incision, such as dehiscence, incisional hernia,

denervation of the skin and muscle, and scar given by the incision itself.

There are a few standard incisions that may be applied to appendectomy,

transverse incision of Elliot-Rockey-Davis (so called Rockey- Davis), McArthur,

McBurney’s grid iron incision, with or without the medial Harrington-Weir-Fowler

extension (so called Weirs extension), or vertical Rutherford-Morrison extension,

Lanz incision, vertical right paramedian or pararectus (Battle) incision and midline

vertical incision.

The McBurney’s incision is undoubtedly the most popular, but it is the

Transverse or Rockey-Davis incision that meets the criteria for an appropriate incision

most closely. It is particularly useful in retro-caecal appendices & in those patients who

are obese.

46

Transverse or Rockey-Davis incision (84): It is centered on the midclavicular-

midinguinal line, usually made at the level 1-2 cm inferior to the umbilicus, depending on

the size of the patient’s abdomen and the location of maximum tenderness. The length of

the incision should be 1-2 cm longer than the width of the surgeon’s hand.

This approach gives rapid access to the right lower portion of abdomen. If the incision is

appropriately placed (i.e not too low), The exposure of the caecum and the appendix is

excellent. This incision produces minimal trauma to the muscle and other tissues and is

easily extended medially by further incising the rectus sheath and rarely, the rectus

muscle itself, converting it into a proper transverse abdominal incision.

However, there is a theoretical objection to transverse incision. The medial end of the

incision is relatively close to the midline, so that is localized pus is present and spillage

occurs, there is a danger of dissemination.

McArthur-McBurney’s incision (26,28,84): It is the time tested, muscle splitting incision

that probably is most widely used today for appendectomy. Its advantage, like that of

Rockey-Davis incision, is that the separation of the muscles in line with their fibers

produces a wound that does not entirely depend on sutures for establishment of tissue

continuity.

Nevertheless, a post-operative hernia can occur with both the incisions. The

McBurney’s incision provides good exposure when the appendix lies free in the

peritoneal cavity. However, if the appendix is in different positions such as retrocaecal,

exposure can be cumbersome. This incision can be extended medially by partially

47

transecting the rectus sheath as described by Weir, but produces a hockey stick type of

skin incision. Perhaps the greatest disadvantage of McBurney’s incision is that it follows

an oblique course in the right lower quadrant, cutting across the skin lines. The scar

widens with time thus producing a cosmetic result that is less than optimal.

The incision (7-10 cms) in length, lies at right angles to the line joining the

anterior superior iliac spine and the umbilicus, centered at the Mc Burney’s point i.e., at

the junction of the lateral and middle thirds of that line.

External oblique aponeurosis is split in the line of its fibers and the underlying muscles

split, to expose the transversalis fascia and peritoneum. Both these are picked up as one

layer and are incised. If more access us required in a medial direction, the incision is

extended as described by Weir. Under desperate circumstances, a Gridiron incision can

be extended vertically by dividing the oblique muscles at right angles to its fibers. This

method destroys the rationale of this incision, but is occasionally required to expose a

retro-caecal appendix.

The Lanz incision (28): This is a minor modification of the Gridiron incision. The skin

incision is made more or less transversely and curves so that it lies in the inter-spinous

crease. Thereafter, the muscles are divided as in a classic Gridiron approach. The method

has a definitive cosmetic value in producing an almost invisible scar, but difficulties are

encountered if the incision is to be enlarged.

48

Other incisions: Although some surgeons continue to use vertical, right paramedian

incision or a pararectus (Battle)(84) incision, neither of these provides good access to the

appendix as that achieved through either the Rockey-Davis or the Mc Burney’s incision.

The Battle incision is particularly susceptible to disruption, either acutely as dehiscence

or subsequently as a ventral hernia. It is likely to denervate substantial segments of the

rectus muscle as well as to interrupt its blood supply and exposure given is also not ideal.

ROUTINE APPENDECTONY (26,84)

After the incision is deepened through the fat and Scarpa’s fascia, the aponeurosis of the

External oblique muscle is exposed and incised in the line of the fibers. The fibers of

Internal oblique muscle, which are now exposed, are muscular and having normally

distinct fibers, which are now separated, followed by the separation of the fibers of

Transversus abdominis, which laterally becomes aponeurotic. The peritoneum is picked

up and incised in the line of incision. The caecum and the appendix are drawn out into the

wound, and the appendix is delivered. The mesoappendix is serially clipped with an

artery forceps, divided and subsequently ligated. Approximately 5mm distal to the base

of the appendix, the organ is crushed and the forceps is applied 7-8 mm distally. A silk

ligature is applied to the crushed area and the organ transected. The exposed mucous

membrane is then swabbed with a cauterizing agent either electrocautery or absolute

alcohol (this helps in sealing off the mucosa). The stump is invaginated (buried). Some

surgeons do not advocate burying of the stump, if the appendix is oedematous and turgid.

49

Wound closure: After removal, the operated area is irrigated ( in gangrenous or

perforated appendix) each fascial and muscular layer is closed with an absorbable suture

material. Skin is closed with non-absorbable sutures.

Advantages of invagination of the ligated stump: Better control of hemorrhage from

the stump, doubly secure closure of the caecal wall, less chance of peritoneal

contamination due to burial of infected stump and reduced risk of post-operative

adhesions by minimizing the extent of exposed, raw surface.

Disadvantages of invagination of the ligated stump: Internal abscess formation,

intussusceptions of the caecum following stump invagination, peritonitis resulting from

rupture of an intramural abscess, high incidence of adhesions following rupture of

intramural abscess.

Retrograde appendectomy (26,84): It is the retrograde removal of the appendix by

dividing the appendix at the base and thereafter dissecting till the tip. It is indicated if the

exposure of the appendix is difficult either because it is excessively long, or it occupies

the retrocaecal position, or if the appendix is densely adherent and inflamed distally.

Appendectomy-en –passant (Incidental appendectomy) (23) This is the removal of

normal appendix during the course of abdominal operation for other conditions. This

practice is readily rationalized when the appendix appears to be diseased, as in carcinoid

50

involvement. It seems to be reasonable at exploratory laparotomy for crohn’s disease,

when the appendix and caecum are not involved in the inflammatory process, because of

the recurrence rate and chronicity of the primary process and its tendency to stimulate

appendicitis. It should not be done in the face of other inflammatory intra-peritoneal

disease.

COMPLICATIONS OF APPENDECTOMY (23,26) :

Early complications:

1. Paralytic ileus invariably accompanies generalized peritonitis.

2. Sepsis – Local wound abscess, pelvic abscess, and subphrenic abscess.

3. Rupture of the stump or caecal wall. This is very rare, but occurs when a portion

of the stump or the caecal wall gives way in the first few days after

appendectomy.

4. Hemorrhage: Sudden abdominal pain and shock at any time during the first 72 hrs

after surgery means either leakage from the stump or a slipped arterial ligature,

both of which are now rare.

Late complications:

1. Intestinal obstruction due to local adhesive bands.

2. Incisional hernia.

51

LAPAROSCOPIC APPENDECTOMY (84,85,86)

This is the latest procedure introduced by Kurt Semm (85) in 1982. Advantages and

disadvantages of this procedure are weighed against those of conventional

appendectomy.

Advantages:

1. It is diagnostic as well as therapeutic tool.

2. It is minimally invasive surgery.

3. Less postoperative pain.

4. Hospital stay is minimized.

5. Fewer post operative adhesions.

6. Superior cosmetic results.

7. Early return to normal activities.

8. If the appendix is found normal, other organs can be visualized.

9. This is the procedure of choice in obese patients.

10. The incision is the same even in case of difficult appendectomies like in

retrocaecal appendix.

Disadvantages:

1. It is expensive compared to conventional method.

2. Expertise in technique is needed.

3. Procedure is not useful if perforation or peritonitis is present.

4. Operative time required is more compared to open appendectomy.

52

5. Setting up of instruments and team is difficult for emergency appendectomy.

In summary, laparoscopic appendectomy is a safe alternative to open appendectomy.

METHODOLOGY

For inflamed (clinical) cases

Materials for this study was obtained from patients admitted to Bowring and Lady curzon

Hospitals and Victoria Hospital attached to Bangalore medical college, Bangalore, from

May 2003 to August 2005 with a diagnosis of appendicitis. All cases were subjected to

clinical assessment using signs, symptoms and laboratory criteria, and also the position of

the appendix, which were recorded in the proforma. All patient were subjected to

ultrasound examination by a qualified radiologist to exclude any other associated

pathology and also to confirm the diagnosis in doubtful cases.

After admission to ward detailed history was taken regarding presenting complaints, their

duration severity, sequence of onset of symptoms, mode of onset, progression, change in

the pattern at the time of presentation and any atypical symptoms, Enquiry was made into

53

family history suggestive of appendicitis, menstrual and obstetric history and past history

of appendicitis.

A careful and detailed abdominal examination of each patient made including local

temperature, guarding / rigidity site of maximum tenderness any swelling or mass

formation, rebound tenderness, Rovsing’s sign, Poas sign, Obturator sign, Baldwin’s sign

and also per rectal examination is made to look for pelvic tenderness or mass formation.

Surgery was done either under general anesthesia or spinal anesthesia. Abdomen was

opened with Lanz or Mc Burney’s, or right lower Para median incision. At surgery the

Position of the appendix was first identified before disturbing the structures and the

position of the appendix identified and recorded together with the length of the appendix

and also weather it was fixed or freely mobile in the peritoneal cavity, peri-appendiceal

collection, presence of perforation or other complications of appendicitis. Also a note was

made of the status surrounding organs. After completion of the appendectomy the

specimen was subjected to histopathological examination by the qualified pathologist

only those cases, which were proved as, appendicitis by the histopathology were included

in the study. Those with normal appendix on histopathology were excluded from the

study.

For normal population (autopsy cases)

Materials for this study were obtained from all the fresh cadavers undergoing autopsy in

the Bowring and Lady curzon Hospitals mortuary attached to Bangalore medical college

Bangalore, from June 2003 to July 2005. These cases represented the position of the

appendix in normal population. The cases, which were included, were fresh cadavers

54

with intact torso, and those who have died because of some non-abdominal cause. All

cases were opened in a classical fashion and after opening the abdomen the position of

the appendix were noted before disturbing any of the structures, the length of the

appendix and also weather it is fixed or freely mobile in the peritoneal cavity is noted and

recorded as in the proforma.

Those cases, which were decomposed, and those in which the torso was mutilated as in

railway accidents were excluded from the study. The cases, in which only the extremities

were disrupted, were included in the study.

PROFORMA

For clinical cases (representing inflamed cases)

Serial No. Age: Sex

Name: Ward: Unit:

I.P.No. Occupation:

Address:

Date of admission:

Date of operation:

Date of discharge:

I. Presenting complaints:

a) Pain : Duration :

55

Nature : Typical /Atypical

Radiation :

b) Vomiting: Duration: Frequency:

Projectile / Regurgitated / bile stained / Not bile stained /

Pain relief after vomiting / contents of vomitus.

c) Fever: Duration: Intermittant / continuous

Associated with chills & rigors.

d) Diarrhoea / Constipation / Tenesmus / Blood & mucous.

e) Urinary complaints: Duration: Frequency:

Dysuria / Burning / Haematuria / Radiation of pain.

f) Any other complaints:

II. Family history

III. Past history: Number of similar attacks in the past:

Previous hospitalization & follow-up:

IV. Menstrual history: Regular / Irregular Spotting

______/_____days

Deliveries:

V. Per - Abdomen

Inspection : Normal / Fullness

Visible scar Pointing test : Umbilicus / RIF Palpation:

Site of maximum tenderness: RIF / Flank / Mc Burney’s point.

56

Rebound tenderness

Rovsing’s sign Psoas sign:

Local temperature Baldwin’s sign:

Mass: Obturator sign:

P.R : Tenderness - Yes / No Mass : Yess / No

VI. Investigations :

Hb:_____gm% TC: DC: ESR:

Urine : Albumin_____ , Sugar______ , Microscopy______

Ultrasound Abdomen:

RIF : APPENDIX - Length

- Diameter

- Mass / Abscess

- Appendicolith

- Probe tenderness

Pelvis:

Other findings:

VII. SURGERY:

Date: Time: Emergency/Elective

Preoperative diagnosis:

Postoperative diagnosis:

Incision:

57

Type of anaessthesia:

Operative findings: - Position: Preileal / Postileal / Retrocaecal /

Paracaecal / Subcaecal / Pelvic / Promonteric

- Length

- Appearance

- Intraperitoneal / Extraperitoneal

- Fixed / Mobile

Caecum:

Ileum:

Other organs:

PROFORMA

For autopsy cases (representing normal population)

Serial No: Age : Sex:

Name P.M. No.

Address

Date of postmortem:

Position of the appendix

- Retro-caecal

- Para-caecal

- Sub-caecal

58

- Pelvic

- Promonteric

- Post-ileal

- Pre-ileal

Length of the appendix

Intra-peritoneal / Extra-peritoneal

RESULTS

The total numbers of cases studied are 150; of this 50 are clinical group,

which were biopsy positive; hence these represent the inflamed appendices. The other

100 are of autopsy group, the cause of death of these cases being non-abdominal cause,

so that these represent the normal population.

Among the 50 cases two cases presented with generalized peritonitis (Case

No –25) & (Case No – 31) the position of appendix in these cases was Post-ileal and

Para-caecal respectively. Two cases (Case No – 26) & (Case No – 49) had previously

presented with appendicular mass hence these were managed conservatively and

subsequently underwent interval appendectomy. All the other cases presented as acute

appendicitis, which were either operated on emergency basis or electively, depending

upon the severity of inflammation. Totally 15 cases (30%) were operated on an

emergency basis and the rest as elective cases (70%).

59

In our series appendicitis was more common during the 3rd decade

(48%), followed by the 2nd decade (32%). Appendicitis is slightly more common in

males, M : F ratio is 2.8 : 1 in our series.

All the patients with acute appendicitis had pain and most of the patients

had pain in the right iliac fossa. Even though many of the patients presented with atypical

symptoms 21 of the 50 cases (42%) The site of maximum pain was in the right iliac fossa

in 41 of 50 cases. Only 9 cases had maximal pain at a site other than right iliac fossa.

Anorexia was seen in 76% of the cases, while nausea is less constant is

seen in 46% of the cases. Vomiting is rarely seen (28%) and is usually few episodes.

Tenderness in the right iliac fossa is a constant feature in all the cases of

appendicitis. The site of maximum tenderness was in the right iliac fossa in 40 of 50

cases even though few had tenderness at other sites leading to difficulty in the diagnosis.

Only 10 cases had maximal tenderness at a site other than right iliac fossa.

Leukocytosis or neutrophilia was present in 36 of the 50 cases, with an

accuracy of 72%.

Of the 15 cases, which were operated on an emergency basis, 6 (40%)

were complicated by perforation, abscess or gangrene, whereas among the 35 elective

cases only 8 were complicated (22.8%).

60

There was a preponderance of young patients in our study in the clinical

group 40 of 50 cases (80%) were in the 10-29 yrs age group and in the autopsy group 43

of the 100 cases (43%) were in the same age group.

The position of the appendix at laparotomy was variable with the most

common position being retro-caecal (36%). At autopsy also the retro-caecal position of

the appendix is the most common position (31%).

There length of the appendix is also quite variable, the smallest in our

series being 3cm and the longest being 18cm and the average of 8.70cm. In our study

females had a slightly longer appendix with an average of 9.10cm, and the males had

smaller appendix with an average length of 8.55cm.

The position of the appendix influences the clinical presentation of the

appendicitis with the retro-caecal position (44.4% of cases), post-ileal position (54.5% of

cases), and the Pelvic position (60% of cases) in all the other positions (9.09% of cases)

presenting with atypical symptoms.

In case of retro-caecal position 88.8% of the fixed retro-caecal cases,

which had got fixed, either because of the adhesions or the extra-peritoneal fixation of the

appendix during development presented atypically and none of the cases with mobile

appendix presented atypically. These patients presented with flank pain & tenderness and

also symptoms of the upper urinary tract infection

61

In post-ileal position, the patients presented atypically in 7cases (57.9%

of post-ileal cases) of which 3 cases were having mobile appendix, forming 27.3% of the

total post-ileal cases and all 4 cases of the fixed appendix, forming 30.6 % of the total

post-ileal cases.

In pelvic appendix the patients presented atypically in 4 of mobile and 2

cases of fixed appendix constituting 40% and 20% of the total pelvic cases respectively.

In all of the other positions the appendicitis presented with typical manner in all of the

cases except for one case of para-caecal location of the appendix.

Baldwin test and Psoas sign were positive in 8 cases of retro-caecal

appendicitis and in 1 case of sub-hepatic appendicitis, which were either fixed by

adhesions or by its extra-peritoneal location.

Obturator test was positive in 4 cases of pelvic appendicitis, which

presented with complications, in uncomplicated cases this test is rarely elicited.

The complications like gangrene, perforation, abscess or mass formation

or generalized peritonitis is seen in 50% of patients with retro-caecal and post-ileal

location of the appendix, who presented atypically, whereas in those with typical

presentation only 20% of the patients had complications. In pelvic position none of the

patients with typical presentation had any complications and 50% of the patients with

62

atypical presentation had complications. In all of the other positions complications were

not seen except in one case of para-caecal location of the appendix, which presented with

atypical symptoms.

Two cases with abscess and two cases with generalized peritonitis had

delayed recovery. One case with appendicular abscess developed fecal fistula, which

subsided with conservative management in 1-week duration but had persistent purulent

discharge from the wound for 2 weeks. The other case of abscess had persistent purulent

discharge. Those with generalized peritonitis, the oral intake was delayed for 5 days, and

one patient developed wound infection, the other had uneventful recovery

OBSERVATION TABLES

TABLE No - 4

Age and Sex distribution of cases

Clinical Group Autopsy Group Total Percentage Age Males Females Total Males Females Total 0-9 years

- - - - 03 cases

03 cases

03 cases

2.0%

10-19 years

10 cases

06 cases

16 cases

07 cases

07 cases

14 cases

30 cases

20.0%

20-29 years

18 cases

06 cases

24 cases

15 cases

14 cases

29 cases

53 cases

35.3%

30-39 years

04 cases

01 cases

05 cases

24 cases

- 24 cases

29 cases

19.3%

40-49 years

04 cases

- 04 cases

14 cases

02 cases

16 cases

20 cases

13.3%

50-59 years

01 cases

- 01 cases

08 cases

- 08 cases

09 cases

6.0%

60-69 years

- - - 01 cases

02 cases

03 cases

03 cases

2.0%

70-79 years

- - - 02 cases

01 cases

03 cases

03 cases

2.0%

Total 37 13 50 71 29 100 150 100%

63

cases cases cases cases cases cases cases

TABLE No - 5

Incidence of various positions of the appendix in our study

Position Clinical Group Autopsy Group Total

Males Females Total Males Females Total

Retro-caecal 14 04 18 21 10 31 49 (32.6%)

Para-caecal 03 02 05 06 01 07 12 (8.0%)

Post-ileal 08 03 11 22 07 29 40 (26.6%)

Pre-ileal 02 - 02 04 - 04 06 (4.0%)

Promonteric - - - 01 - 01 01 (0.6%)

Pelvic 06 04 10 14 08 22 32 (21.3%)

Sub-caecal 03 - 03 04 01 05 08 (5.3%)

Sub-hepatic 01 - 01 01 - 01 02 (1.3%)

Left sided - - - - - - 00 (0%)

Total 37 17 50 71 29 100 150 (100%)

TABLE No - 6

Length of the appendix (in cms) in our study

64

Males Females Combined

Shortest Longest Average Shortest Longest Average Shortest Longest Average

Clinical

Group

3 16 8.16 5 16 9.23 3 16 8.44

Autopsy

Group

5 18 8.76 4 14 9.03 4 18 8.84

Total 3 18 8.55 4 16 9.10 3 18 8.70

TABLE No - 7

Relationship between fixity of the appendix and clinical presentation

Position Typical Presentation Atypical Presentation

Mobile Fixed Mobile Fixed

Retro-caecal 9 (50%) 1 (5.6%) 0 (0%) 8 (44.4%)

Post-ileal 4 (36.3%) 0 (0%) 3 (27.3%) 4 (36.3%)

Pelvic 4 (40%) 0 (0%) 4 (40%) 2 (20%)

65

FIG -3

AGE AND SEX DISTRIBUTION OF CASES

0 10 20 30 40

0-9yrs10-19yrs20-29yrs30-39yrs40-49yrs50-59yrs60-69yrs70-79yrs Autopsy Group

FemalesAutopsy Group Males

Autopsy Group Total

Clinical GroupFemalesClinical Group Males

Clinical Group Total

FIG -4

VARIOUS POSITIONS IN THE CLINICAL AND AUTOPSY GROUP

66

05

101520253035

Retro-c

aeca

l

Pelvic

Post-il

eal

Pre-ile

al

Para-ca

ecal

Sub-ca

ecal

Promon

teric

Sub-he

patic

Clinical Group Total

Clinical Group Males

Clinical GroupFemalesAutopsy Group Total

Autopsy Group Males

Autopsy GroupFemales

Distribution of cases according to various age groups

2%20%

36%19%

13%

6% 2%2%0-9yrs10-19yrs20-29yrs30-39yrs40-49yrs50-59yrs60-69yrs70-79yrs

FIG - 5

67

FIG - 6

TYPICAL PRESENTAT APPENDICITISION OF

0123456789

10

RC Post I P PC Pre I SC SH

TotalUncomplicatedComplicated

FIG -7

ATYPICAL PRESENT OF APPENDICITISATION

68

012345678

RC Post-I P PC

TotalUncomplicatedComplicated

Sta

PO

Retr

Par

Po

Pr

Prom

P

RC => Retro-caecal PC => Para-caecal Post I => Post-ileal Pre-I => Pre-ileal P => Pelvic SC => Sub-caecal SH => Sub-hepatic

STATISTICAL DATA FOR THE STUDY

TABLE No - 8

tistical comparison of position of appendix in clinical and autopsy group

SITION CLINICAL GROUP AUTOPSYGROUP TOTAL

o-caecal 18 31 49

a-caecal 5 7 12

st-ileal 11 29 40

e-ileal 2 4 6

onteric 0 1 1

elvic 10 22 32

69

Sub-caecal 3 5 8

Sub-hepatic 1 1 2

TOTAL 50 100 150

Χ² = 2.05

Χ² Table for 7, d.f at 5% significance value (.05) = 14.07

Hence P value is not significant

TABLE No - 9 Statistical comparison of position of appendix with clinical presentation &

Complications

Position Typical Presentation Atypical Presentation Total

Un-compl

icated.

Compl

icated.

Un-compl

icated.

Compl

icated.

Un-compl

icated.

Compl

icated.

Retro-caecal 8 2 4 4 12 6

Post-ileal 4 1 3 3 7 4

Pelvic 4 - 3 3 7 3

Para-caecal 4 - - 1 4 1

Pre-ileal 2 - - - 2 -

Sub-caecal 3 - - - 3 -

Sub-hepatic 1 - - - 1 -

70

Total 26 3 10 11 36 14

The level of significance was calculated using ANOVA table (Analysis of variance)

F1 = 6.21

F2 = 14.09

Ftable for (6,6) d.f = 0.233

Ftable for (1,6) d.f = 0.0043

The value of F1 & F2 is greater than the Ftable value; hence the value is significant; hence

the difference in the complications and clinical presentation with regard to position is

significant.

DISCUSSION

Although surgeons have been confronting acute appendicitis as a clinical entity

for over a hundred years, an accurate preoperative diagnosis remains a challenge because

of the various other conditions, which mimic appendicitis. The problem is further

compounded by the variations in the position of the appendix and the associated varied

clinical picture of the appendicitis.

In our study two groups were taken the autopsy group, which represented the

normal population, and the clinical group, which represented the inflamed cases. In the

71

clinical group the cases were evaluated with clinical features at presentation, the position

of the appendix at laparotomy and also the associated complications. All cases in the

clinical group were confirmed by histo-pathology.

Our study found appendicitis to be more common in the third decade followed by

the second decade 48% and 32% respectively. The average mean age of presentation is

25.1 years. Lewis et al (39) (1975) in their study found that the 2nd and 3rd decades to be

the most common age groups for acute appendicitis.

The total no of male patients in the clinical group were 37 and the total no of female

patients were 13 Male to female ratio is 2.8 : 1. Men outnumbered women in our study,

men are believed to suffer from appendicitis more often because, probably the male is

being subjected to more stress and strain, as highlighted by Boyd (1961). Addis et al &

Korner et al, have reported a slight male preponderance (with male to female ratio of 1.2

to 1.3 : 1) (30,31)

Anorexia was seen in 76% of the cases, while nausea was present in 46%

of the cases. Vomiting is rarely seen (28%) and is usually few episodes. Lewis et al (39),

in his analysis, found anorexia, nausea or vomiting to be present in 66% of the cases.

Fever is uncommonly encountered among patients in our study, being

present in 46% of our patients; the fever was usually mild degree except in cases of

abscess and generalized peritonitis. Berry et al (87) in 1984 have in their analysis; found

that temperature elevation is rarely more than 10 C (1.80 F). Changes of greater

72

magnitude indicate that the complication has occurred or some other diagnosis should be

considered.

The various positions in the clinical group, representing the inflamed appendix and the

Autopsy group representing the normal appendix, were compared with Chi square test,

the P-value was >0.1. Hence the difference observed was not significant, indicating that

there is no increased predisposition of any position to get inflamed.

The position of the appendix and its relation to the clinical presentation and

course of acute appendicitis has been a subject of controversy with various authors giving

various results and conclusions.

Varshney et-al (7), have come to the conclusion that the retro-caecal position is

less prone to infection, by comparing the incidence of retro-caecal appendix in operated

cases with the previous autopsy studies. He hypothesized that the retro-caecal position of

the appendix is advantageous because, gravity aided drainage of the appendicular lumen,

may reduce the episodes of luminal obstruction, which reduce the incidence of

appendicitis. Shen GK, et-al (9), Williamson WA, et-al (10), has established that the retro-

caecal position does not alter the clinical course of appendicitis.

The theory of Varshney et-al (7) is not acceptable, as many of the autopsy studies do not

accept that the retro-caecal position, as the most common position (Maisel et-al (20),

Peterson et-al, describe pelvic position to be the most common).

73

In our study there is an increased incidence in the complications in those with

typical presentation, than those with atypical presentation, In case of retro-caecal position

20% with typical & 50% with atypical presentation, in post-ileal position 25% with

typical & 50% with atypical presentation, and in pelvic position 0% with typical & 50%

with atypical presentation, had complications. In all the other positions the number of

complications are very less. The difference obtained is significant as; the P value is <0.05

as obtained by the ANOVA table.

In case of retro-caecal position, the fixed appendix is associated with more

complications (55%) as opposed to (12%) of cases with mobile appendix. The difference

obtained is significant (P<0.001 obtained from chi square test). In other positions the

obtained for fixity and complications is not significant (P > 0.05), But the difference in

complications in relation to typical or atypical is significant as obtained by ANOVA table

described above.

Varshney et-al (7) have described that advanced appendicitis (perforation or gangrene) is

more common in those with retro-caecal appendicitis. They have given the explanation

that some early cases may have been misdiagnosed, as urinary tract infection, leading to

delay in the diagnosis, and increased incidence of complications.

74

In Collins (8) series of 751 patients with retro-caecal appendicitis, only 19% had typical

symptoms, 18% had non-localizing pain, 28% had right flank pain and 12% had right

shoulder pain. In his series 53% of the cases were perforated.

Guidry S et-al (4) in 1994, have concluded that the patients with gangrene and

perforation were more likely to have pain and tenderness at a site other than right lower

quadrant. The appendix was in hidden location (retro-caecal, retro-ileal, pelvic and extra-

peritoneal) in 15% of the patients with simple appendicitis as compared with 68% of the

patients with gangrenous or perforative appendicitis (P<0.001).

Poole GV (5) in1990 has found that the appendix was in one of the three sites

(extraperitoneal-retrocaecal, post-ileal, pelvic) in 69% of the patients with gangrenous or

perforative appendicitis. In contrast, the appendix was found in one of these sites in only

4 of the 75 patients (5%) with simple appendicitis.

TABLE No - 10

Here is a comparison of the various positions according to different authors.

Percentage occurrence of various positions of

appendix.

Author No. Of

Specimens Retro- caecal

Pelvic Post- ileal

Pre- ileal

Sub- caecal

Para-caecal

Wakeley, 1933

10,000 Autopsy

62 31 0.4 1 2 -

75

Shah &Shah, 1942

591 Autopsy & operative

51.4 16.6 15.6 11.7 4.7 -

Solanke TF. 1970

125 Autopsy

38.4 31.2 12 4 11.2 2.4

Varshney S. 1996

600 Operative

19 53 1 2 7 18

Golalipour MJ. 2003

117 Operative

32.4 33.3 2.6 18.8 12.8 -

Present report

150 Autopsy & operative

34 22 26.7 4 5.3 8

TABLE No - 11 Comparison of position of the appendix at autopsy according to various

authors

Percentage occurrence of various positions of appendix.

Author

No. of Specimens

Retro- caecal

Pelvic Post- ileal

Pre- ileal

Sub- caecal

Para-caecal

Wakeley, 1933

10,000 62 31 0.4 1 2 -

Shah &Shah, 1942

186 30.1 34.9 21.5 6.5 7 -

Solanke TF. 1970

125 38.4 31.2 12 4 11.2 2.4

76

Present report

100 32 23 29 4 5 7

TABLE No - 12 Comparison of Position of the appendix at surgery, according to various

authors.

Percentage occurrence of various positions of appendix.

Author

No. Of Specimens

Retro- caecal

Pelvic Post- ileal

Pre- ileal

Sub- caecal

Para-caecal

Shah &Shah, 1942

405 61.2% 8.2% 12.8% 14.1% 3.7% -

Varshney S. 1996

600 19% 53% 1% 2% 7% 18%

Golalipour MJ. 2003

117 32.4% 33.3% 2.6% 18.8% 12.8% -

Present report

50 38% 20% 22% 4% 6% 10%

TABLE No - 13 The comparison of the average length of the appendix according to

various authors

AUTHOR SHORTEST (In Cm.)

LONGEST (In Cm.)

AVERAGE (In Cm.)

Monks & Blake, 1902 1.0 24.0 7.9

Deaver, 1913 1.0 23.0 8.9

77

Lewis, 1918 2.0 20.0 8.3

Robinson, 1923 1.8 23.0 9.2

Royster, 1927 2.5 29.4 7.5

Hafferl, 1953 2.5 20.0 9.0

Solanke TF, 1970 4.0 20.0 9.6

Present report 3.0 18.0 8.7

78

FIG -8 SUB-HEPATIC CAECUM WITH PARACAECAL APPENDIX

(Appendix is lying by the side of the caecum, which is situated below liver)

FIG -9 SUB-CAECAL POSITION OF APPENDIX

(Appendix going down towards the mid-inguinal point)

79

FIG - 10RETRO-CAECAL POSITION OF APPENDIX

(Appendix is lying behind the caecum)

FIG - 11 POST-ILEAL POSITION OF APPENDIX

(Appendix lying behind the ileum, which is lifted forwards)

80

FIG -12 PARA-CAECAL POSITION OF APPENDIX

(Appendix lying by the side of the caecum)

FIG –13 PELVIC POSITION OF APPENDIX

(Appendix dipping into the pelvic cavity)

81

CONCLUSIONS

This study was conducted from May 2003 to August 2005, for a period of 28 months in

Bowring and Lady Curzon hospitals and Victoria hospital attached to Bangalore

Medical College, Bangalore, for clinical group. For autopsy group the study was

conducted from June 2003 to July 2005, for a period of 26 months at Bowring and Lady

Curzon hospitals mortuary. There were 50 cases in the clinical group, which were

biopsy positive for appendicitis, and 100 cases in the autopsy group.

The following conclusions were drawn from the present study

Appendicitis is commonest during the 3rd decade (48%), followed by the 2nd

decade (32%)

Appendicitis is slightly more common in males, M : F ratio is 2.8 : 1.

Pain occurred in all patients. Typical pain (58% of cases) is more common than

atypical pain (42% of cases) in acute appendicitis. Site of pain varies with

position of the appendix. In pelvic appendix patients had supra-pubic pain, in

retro-caecal appendix patient had pain in the right lumbar region or right flank, in

sub- hepatic position the patients had pain in the right hypochondriac region.

Atypical pain was more common in cases of fixed retro-caecal appendix and in

cases of pelvic appendicitis.

82

Patients with post-ileal and pelvic appendix had some sort of bowel disturbance

(constipation or diarrhea)

Patients with retro-caecal appendix had symptoms of upper urinary tract infection,

due to irritation of the adjacent ureter and pelvic appendix had symptoms of lower

urinary tract infection, due to irritation of the adjacent bladder.

Anorexia(76% of cases) is the most commonly seen in appendicitis, nausea(46%

of cases) and vomiting(28% of cases) are seen less commonly .

Incidence and severity of vomiting is more in patients with complicated

appendicitis (50%) as compared to simple acute appendicitis (19.4%). Vomiting

usually does not relieve pain.

Tenderness was present in all cases of acute appendicitis. Site of tenderness may

vary and depends on the position of the appendix. In retro-caecal position

tenderness may be present in the right flank or in the right lumbar region more so

if the appendix is fixed either by the adhesions or because of its extra-peritoneal

location (in these cases tenderness will be more in this region rather than right liac

fosasa). In case of pelvic position tenderness may be present in the suprapubic

region or the patient may have rectal tenderness. In sub-hepatic position patient

may have tenderness in the right hypochondriac region.

Tenderness in the right lower quadrant and rebound tenderness were the most

common signs (76% & 52% respectively)

Tenderness at the Mc Burney’s point is present in only 4 patients (8%) In all the

other cases tenderness was either medial or lateral to the Mc Burney’s point.

83

Psoas sign and Baldwin test though not consistently positive in all the cases of

retro-caecal appendicitis, they are positive in cases most cases of fixed retro-

caecal appendix (8 of 9 cases).

Obturator test though not positive in all the cases of pelvic appendicitis is positive

in most of the complicated appendicitis. All 3 cases of complicated cases of pelvic

appendicitis had positive obturator test and only 2 of the 7 uncomplicated cases

had positive obturator test.

Rectal examination detects pelvic peritonitis or pelvic abscess in case of pelvic

appendicitis. Rectal tenderness was present in 8 of the 10 cases of pelvic

appendicitis and in two cases of generalized peritonitis

Patients with mobile appendix presented with typical signs and symptoms,

whereas those with fixed appendix either by inflammatory process or by its extra-

peritoneal location mostly presented with atypical signs and symptoms.

The signs and symptoms are subtle or atypical in case of retro-caecal fixed, post-

ileal, pelvic appendicitis, leading to increased risk of complications in cases of

appendicitis in these positions. P – value <0.01.

Moderate leukocytosis with polymorphonuclear predominance nearly always

accompanies acute appendicitis. A higher WBC count suggests complications.

Leukocytosis was present in 72% of the cases.

The most common position both at surgery and autopsy was Retro-caecal,

followed by Pelvic, Post-ileal, Para-caecal & Sub-caecal.

There is no predisposition for any of the position of appendix to develop

appendicitis

84

The length of the appendix is slightly more in females than males both in autopsy

group (9.03cms : 8.76cms) and in the clinical group (9.23cms : 8.16cms).

There is increased risk of complications in those with atypical presentation than

those with typical presentation. Only 3 of 29 (10.3%) cases with typical

presentation had complications whereas 11 of the 21 cases (52.4%) with atypical

presentation had complications.

The patients with appendicular abscess and generalized peritonitis who were

operated had delayed recovery; in other patients there was no difference in the

post-operative recovery of the patients whether they were complicated or

uncomplicated.

85

SUMMARY

This study was conducted from May 2003 to August 2005, for a period of 28 months in

Bowring and Lady Curzon hospitals and Victoria hospital attached to Bangalore

Medical College, Bangalore, for clinical group. For autopsy group the study was

conducted from June 2003 to July 2005, for a period of 26 months at Bowring and Lady

Curzon hospitals mortuary. There were 50 cases in the clinical group, which were

biopsy positive for appendicitis, and 100 cases in the autopsy group.

Appendicitis is commonest during the 3rd decade (48%), followed by the 2nd

decade (32%)

Appendicitis is slightly more common in males, M : F ratio is 2.8 : 1.

The most common position of the appendix in our study is the retro-caecal

position both in the clinical and autopsy group, but contrary to the study

conducted by wakeley et al the frequency of retro-caecal position is much less,

also the frequency of the postileal appendix is more.

There was no statistically significant difference in the position of the appendix in

clinical and autopsy group, suggesting that there is no predilection of any position

of the appendix to get inflamed.

The position of the appendix influences the clinical presentation of the appendix

even though most of the patients experience pain and tenderness in the right iliac

fossa, depending on the position of the appendix patients may experience

additional symptoms and signs, which frequently results in delayed diagnosis.

86

In retro-caecal appendicitis the patient may experience flank pain and tenderness

and symptoms of upper urinary tract infection because of proximity of the

appendix to the ureters, these features are more common if the appendix is fixed

either because of adhesions or because of its extra-peritoneal location. In pelvic

appendicitis patients will present with supra-pubic pain and other symptoms of

lower urinary tract infection, patients will usually present with subtle symptoms

and may occasionally have bowel disturbances; tenderness on digital rectal

examination is a constant feature. In post-ileal position patients will have subtle

signs and symptoms and may occasionally have bowel disturbances.

Patients with fixed retro-caecal, post-ileal, and pelvic position of the appendix;

diagnosis was delayed because of the atypical clinical presentation leading to

increased incidence of complications in patients with these positions of the

appendix.

The length of the appendix is slightly more in females than males both in autopsy

group and in the clinical group.

87

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97

ANNEXURE MASTER CHART FOR AUTOPSY CASES

SL.No. P.M. No. NAME OF PATIENT DATE OF P.M

AGE SEX POSITION OF APPENDIX

IP / EP / IM

LENGTH (in cms)

1 551 / 03 Mr. Abdul Razzak 26 /06 / 03 70 M Pelvic IP 8 2 850 / 03 UNKNOWN 18 /10 / 03 35 M Retro-caecal IP 10 3 855 / 03 Mrs. Manjula 21 /10 / 03 24 F Pelvic IP 12 4 856 / 03 Mrs. Malathi 21 /10 / 03 20 F Retro-caecal EP 14 5 860 / 03 Mr. Babu 22 /10 / 03 20 M Pelvic IP 16 6 867 / 03 Mr. Selvaraj 25 /10 / 03 40 M Post-ileal IP 18 7 868 / 03 Mr. Anthony 26 /10 / 03 45 M Sub-caecal IP 6 8 869 / 03 Kum. Lakshmi 26 /10 / 03 3½ F Retro-caecal IP 8 9 873 / 03 Mrs. Anjali Singh 27 / 10 / 03 26 F Retro-caecal IP 5 10 875 / 03 Mr. Karim Basha 29 / 10 / 03 40 M Pre-ileal IP 6 11 876 / 03 Mr. M.D. Shivakumar 29 /10 / 03 34 M Post-ileal IP 8 12 891 / 03 Ms. Prascilla 05 / 11 / 03 15 F Pelvic IP 14 13 892 / 03 Mrs. Vimala 05 / 11 / 03 27 F Post-ileal IP 10 14 893 / 03 Mr. Krishnamurthy 05 / 11 / 03 33 M Post-ileal IP 12 15 906 / 03 Mr. Firoz Khan 08 / 11 / 03 23 M Sub-caecal IP 8 16 907 / 03 Mr. Das 08 / 11 / 03 43 M Sub-caecal IP 6 17 910 / 03 Mr. Vincent Prabhu 09 / 11 / 03 24 M Retro-caecal IP 12 18 906 / 04 Mr. Srinivasulu 13 / 11 / 04 28 M Post-ileal IP 8 19 907 / 04 Mr. Lokesh 13 / 11 / 04 24 M Retro-caecal IP 6 20 913 / 04 Mr. Dayalan Manohar 17 / 11 / 04 32 M Para-caecal EP 13 21 914 / 04 Mr. William 17 / 11 / 04 39 M Pelvic IP 9 22 915 / 04 Mr. Nyana Prakash 17 / 11 / 04 37 M Retro-caecal IP 8 23 930 / 04 Mr. Rajesh Chandra 20 / 11 / 04 30 M Post-ileal IP 8 24 1007 / 04 Mr. Yesu das 17 /12 / 04 40 M Paracaecal EP 12 25 7 / 05 Mr. Jyothish Das 03 / 01 / 05 23 M Post-ileal IP 6 26 8 / 05 Mrs. Archana 03 / 01 / 05 20 F Pelvic IP 9 27 11 / 05 Mr.Somashekar 04 / 01 / 05 21 M Para-caecal IP 7 28 12 / 05 Mr. Rajesh 04 / 01 / 05 25 M Post-ileal IM 6 29 26 / 05 Mr. Thimmegowda 08 / 01 / 05 37 M Retro-caecal EP 7 30 29 / 05 Mr. D. Vinod 08 / 01 / 05 24 M Pelvic IP 9 31 30 / 05 Mr. Narasimhaprasad 10 / 01 / 05 48 M Retro-caecal IP 6 32 32 / 05 UNKNOWN 10 / 01 / 05 40 M Retro-caecal IP 11 33 33 / 05 Mr. D. Krishna 10 / 01 / 05 45 M Post-ileal IP 10 34 36 / 05 UNKNOWN 11 / 01 / 05 50 M Pelvic IP 9 35 38 / 05 Mr.Gnana Prakash 11 / 01 / 05 30 M Promonteric IP 8 36 40 / 05 Mr.S. Shivaji 12 / 01 / 05 40 M Pelvic IP 9 37 42 / 05 Mr. M. Krishna 13 / 01 / 05 38 M Post-ileal IP 6 38 43 / 05 Mr. Revanna 15 / 01 / 05 50 M Post-ileal IP 8 39 47 / 05 Kum. B. Deepika 18 / 01 / 05 12 F Pelvic IP 7 40 48 / 05 Mushra 19 / 01 / 05 1½ F Retro-caecal IP 8 41 49 / 05 Mrs. Pulbansa 19 / 01 / 05 20 F Post-ileal IP 11 42 56 / 05 Mr.P.N. Jayaram 21 / 01 / 05 45 M Pelvic IP 9 43 57 / 05 UNKNOWN 22 / 01 / 05 15 M Post-ileal IP 6 44 59 / 05 Mr. Noor Basha 22 / 01 / 05 27 M Retro-caecal IP 10 45 61 / 05 Mr. Sandeep 23 / 01 / 05 19 M Pelvic IP 11 46 62 / 05 Kum. Divya 23 / 01 / 05 11 F Post-ileal IP 5 47 63 / 05 UNKNOWN 23 / 01 / 05 50 M Retro-caecal IP 8 48 65 / 05 Mr. D. Solay 24 / 01 / 05 55 M Pelvic IP 9 49 66 / 05 Mr. Lawrence 24 / 01 / 05 30 M Retro-caecal EP 11 50 67 / 05 Mr. Vijayendra 25 / 01 / 05 35 M Post-ileal IP 12 51 83 / 05 UNKNOWN 28 / 01 / 05 75 M Retro-caecal IP 5 52 84 / 05 Mr. Jawar 28 / 01 / 05 40 M Pre-ileal IP 6 53 85 / 05 Mr. Syed Sultan 28 / 01 / 05 48 M Post-ileal IP 6 54 86 / 05 Mrs. Lakshmi 28 / 01 / 05 40 F Retro-caecal IP 12 55 87 / 05 UNKNOWN 28 / 01 / 05 60 M Retro-caecal IP 6 56 89 / 05 Mr. Sharath Kumar 29 / 01 / 05 13 M Sub-caecal IP 10 57 90 / 05 Mr. Shaikh Basha 29 / 01 / 05 57 M Sub-hepatic IP 8 58 92 / 05 Mrs. Bhavya 30 / 01 / 05 22 F Post-ileal IP 6 59 103 / 05 Mr. Babulal 03 / 02 / 05 38 M Para-caecal IP 8 60 104 / 05 Mr.R. Muthu 03 / 02 / 05 30 M Retro-caecal IP 10 61 167 / 05 Mrs. Noorie 22 / 02 / 05 29 F Retro-caecal IP 9

98

MASTER CHART FOR AUTOPSY CASES (continued)

SL.No. P.M. No. NAME OF PATIENT

DATE OF P.M

AGE SEX POSITION OF APPENDIX

IP / EP / IM

LENGTH (in cms)

62 168 / 05 UNKNOWN 22 / 02 / 05 35 M Pre-ileal IP 9 63 169 / 05 Mr. Manjunath 23 / 02 / 05 18 M Pelvic IP 6 64 170 / 05 UNKNOWN 23 / 02 / 05 18 M Para-caecal IP 9 65 171 / 05 UNKNOWN 23 / 02 / 05 30 M Retro-caecal IP 11 66 172 / 05 Mr. Anandan 24 / 02 / 05 35 M Post-ileal IP 8 67 173 / 05 Mrs. Rajeshwari 24 / 02 / 05 18 F Post-ileal IP 10 68 174 / 05 Mrs. Ramakka 24 / 02 / 05 63 F Retro-caecal IP 14 69 227 / 05 Mrs. Hemalatha 14 / 03 / 05 21 F Retro-caecal EP 11 70 228 / 05 Mrs. S. Latha 14 / 03 / 05 28 F Pelvic IP 9 71 230 / 05 Mr. K. Balu 14 / 03 / 05 35 M Post-ileal IP 8 72 232 / 05 Mr. Siddaraju 15 / 03 / 05 42 M Pelvic IP 12 73 233 / 05 Mr. Deepak Rao 15 / 03 / 05 32 M Retro-caecal IP 12 74 286 / 05 Mr. Naresh Kumar 04 / 04 / 05 24 M Post-ileal IP 16 75 287 / 05 UNKNOWN 04 / 04 / 05 20 F Pelvic IP 7 76 289 / 05 Mrs.Sayanora 04 / 04 / 05 24 F Post-ileal IP 6 77 291 / 05 UNKNOWN 04 / 04 / 05 17 F Retro-caecal IP 8 78 292 / 05 UNKNOWN 05 / 04 / 05 40 M Para-caecal IP 9 79 293 / 05 Mr. Marimuthu 06 / 04 / 05 30 M Post-ileal IP 5 80 295 / 05 Mr. Manju 06 / 04 / 05 24 M Pelvic IP 6 81 426 / 05 Mr. Papanna 21 / 05 / 05 50 M Retro-caecal IP 8 82 427 / 05 Mr. Pashupathi 21 / 05 / 05 47 M Retro-caecal EP 9 83 428 / 05 Mrs. Mahalakshmi 21 / 05 / 05 26 F Pelvic IP 14 84 429 / 05 Mr. Manoj Maithan 21 / 05 / 05 39 M Postileal IP 15 85 432 / 05 Mrs. Sharadhamma 23 / 05 / 05 21 F Retro-caecal IP 11 86 433 / 05 Mr. B. Nagarjun 24 / 05 / 05 18 M Post-ileal IP 8 87 434 / 05 Mr. Manohar 24 / 05 / 05 20 M Pelvic IP 6 88 559 / 05 Mrs. Gowramma 05 / 07 / 05 65 F Pelvic IP 8 89 570 / 05 Mr. A. Solai 06 / 07 / 05 56 M Pelvic IP 13 90 586 / 05 Kum. Hema 13 / 07 / 05 7 F Pelvic IP 9 91 588 / 05 Mr. Girish G.S. 13 / 07 / 05 19 M Retro-caecal IP 8 92 589 / 05 Mr. Kannappa 14 / 07 / 05 55 M Pre-ileal IP 6 93 591 / 05 Mrs. Mohana 15 / 07 / 05 18 F Post-ileal IP 8 94 592 / 05 Mrs. Pachiamma 16 / 07 / 05 70 F Paracaecal EP 7 95 593 / 05 Mrs. Dhanalakshmi 16 / 07 / 05 18 F Sub-caecal IP 4 96 596 / 05 Mr. Samson Paul 18 / 07 / 05 29 M Retro-caecal IP 5 97 597 / 05 Mr. Sheikh 18 / 07 / 05 25 M Pelvic IP 9 98 598 / 05 Mrs. Bhagyavathi 19 / 07 / 05 48 F Post-ileal IP 6 99 603 / 05 UNKNOWN 20 / 07 / 05 35 M Retro-caecal IP 5 100 604 / 05 Mr. K.V. RajKumar 21 / 07 / 05 32 M Retro-caecal IP 8

99

100

MASTER CHART FOR CLINICAL CASES

No I.P.No. NAME OF

PATIENT

D.O.A SE

X

A

G

E

SO

MP

T/

A

U/

G/

B

F/

H

R/

A

BT /

PT

OT SOMT PR TC USG A/N EL/

EM

INCI

SION

POSIT

ION

LEN

GTH

IP/

EP

FINDIN

GS

SL.

No

I.P.No NAME OF

PÂTIENT

D.O.S SEX AGE SOM

P

T/

A

U/

G/

B

F/

H

R

/

A

BT/

PT

OT SOM

T

PR TC USG A/N EL

/EM

INCI

SION

POSI

TION

LEN

GTH

EP/

IP

FIND

INGS

1 7339 Mr..Md. Ibrahim 5/5/03 M 39 RIF T - - + - RIF N 11,200 AA SAB EM L RC 4 IP I, A, M

2

9553 Mrs.Pushpa 12/6/03 F 18 RIF T - - 3 - - RIF T 9,600 N SAB EL L Pel 8 IP I

3 10691 Mr.Dharamraj 3/7/03 M 36 RL A U - - + - RL N 17,000 AAb EA EL RPM RC 8 EP I, P, Ab

4 10753 Mr. Nagaraj 3/7/03 M 23 RIF T U - 5 - - RIF N 6,400 N SAB EL L RC 10 IP I

5 10994 Mrs. Sumathi 1/7/03 F 26 RIF T - - 3 - - RIF N 10,500 ND SAB EM MB PC 7 IP I

6 780161 Mr,Jayarathna 27/10/04 M 28 RIF T - - 2 - - MB N 8,900 N SAB E EL Pre I 6 IP I

7 11334 Mr. Syed Omar 10/7/03 M 13 RIF T - - - - - MB N 13,200 N SAB EL L Pre I 12 IP I

8 11335 Mr. Jayaraj 7/7/03 M 27 RIF A - - 2 - - MB N 10,300 AA SAB EL L Post I 10 IP I, A

9 12895 Mr. Muniraju 1/8/03 M 27 RF A U - - + - MB N 10,150 AA SAB EM MB RC 10 IP I, A

10 12926 Mrs. Sudha 2/8/03 F 23 RIF T - - - - - RIF N 11,500 AA SAB EM MB PC 15 IP I

11 13068 Mr. Venkatesh 7/8/03 M 16 RIF T - - 2 - - RIF N 10,100 N SAB EL L PC 16 IP I, A

12 13118 Mr. Wasim Khan 5/8/03 M 11 D A - - - + - RH N 11,200 AA GA EM RM SH 12 EP I

13 13290 Mr. Raju 8/8/03 M 24 RIF T - - 4 - - RIF N 8,200 N SAB EL L RC 5 IP I

14 13311 Mr. Krishnappa 8/8/03 M 30 RIF T - - - - - RIF N 16,900 AA SAB EL L SC 5 IP I

15 13312 Mrs. Chandramma 8/8/03 F 26 RIF T U - - - - RIF T 11,400 N SAB EL L Pel 6 IP I

16 13749 Mr. Manimairaj 17/8/03 M 29 RIF T - - - - - RIF N 14,000 N SAB EL L RC 12 IP I

17 13843 Mr. Jagannath 18/8/03 M 15 RIF A - - 7 - - RIF N 16,600 N SAB EL L Post I 10 IP I, F, D

18 13851 Mr. Prashanth 18/8/03 M 18 RIF A - - 3 - - RIF N 10,400 N SAB EL L Post I 9 IP I, A

19 14202 Mr. Vinod Kumar 25/8/03 M 14 RIF A - - 5 - + RIF N 10,200 N SAB EL L Pel 5 IP I, D

20 16483 Mr. John 4/10/03 M 20 RL A U - - + - RL N 16,200 AA GA EM PM RC 8 EP I, P

21 771781 Mr. Jayasingh Raj 21/7/04 M 45 RF A - - + - RL N 15,200 ND GA EM MB RC 6 EP G

22 773108 Mr. Anand 9/8/04 M 20 RIF T - 2 - - RIF N 9,400 AA SAB EL MB PC 9 IP I, A

23 777352 Mr. Chandregoda 1/9/04 M 28 RIF T - - - - - RIF N 10,120 AA SAB EL MB Post I 10 IP I

24 777372 Mr. Beeresh 1/9/04 M 16 RIF T - - - - - RIF T 7,300 AA SAB EM MB Pel 9 IP I

25 778393 Mrs. Nagarathna 22/9/04 F 30 -Generalized peritonitis- - - RIF T 16,900 ND GA EM RPM Post I 8 IP A, P

26 778739 Mr. Sampangappa 29/9/04 M 45 -For Interval Appendectomy- - - AM SAB EL MB RC 10 IP I, A

27 778752 Mr. Hucchegowda 29/9/04 M 55 RIF A U - 4 + - RIF N 5,900 AAb SAB EL RPM RC 8 IP I, A

28 779127 Mr. Imrankhan 6/10/04 M 16 RIF A G - 3 - - RIF T 13,400 AA SAB EM L Pel 8 IP I

29 779158 Mr. Rajappa 6/10/04 M 42 RIF T - - 3 - - RIF N 9,800 N SAB EL MB SC 3 IP I, A

30 779470 Ms. Shirin Sultan 13/10/04 F 16 RIF T - - 2 - - RIF N 12,150 AA SAB EL MB Post I 10 IP I

31 780177 Mr. Yellappa 27/10/04 M 30 -Generalized Peritonitis- - - RIF T 18,600 ND GA EM RPM PC 8 IP I, P, A

32 780328 Ms. Asha 30/10/04 F 16 RIF A U - - - + RIF N 14600 AA SAB EM MB Pel 16 IP I, P, A

33 780487 Mr. Selvakumar 3/11/04 M 25 RIF T - - - - - RIF N 12,650 AA SAB EM MB RC 8 IP I

34 780853 Mr. Basappa 10/11/04 M 27 RF A - - - + - RL N 11,170 AA SAB EM MB RC 6 IP I, A

35 780856 Mr. Raju 10/11/04 M 22 RIF T - - - - - RIF N 9,450 AA SAB EM MB Post I 8CM IP I

101

36 17760 Mr. Manjunath 13/11/04 M 25 RIF A - - - - - RIF T 14,140 N SAB EL L Post I 10 IP I,P

37

17762 Mr. Suresh 13/11/04 M 22 RIF A U - - - + RIF T 12,800 AA SAB EL L Pel 8 IP I,G,Ab

38 18213 Mr. Mallikarjuna 21/11/04 M 28 RIF A B - 2 - - RIF N 6,900 AM SAB EL L Post I 8 IP I, A

39 18269 Mr. Mutthappa 22/11/04 M 42 RIF T - - 2 - - RIF N 9,420 AA SAB EL L SC 6 IP I

40 19021 Mrs. Bhagyamma 6/12/04 F 22 RIF A G - 3 - + RIF T 11,140 AA SAB EL L Pel 8 IP I, G

41 4529 Mr. Balakumar 1/4/05 M 20 RF A U - 4 + - RL N 10,400 AA SAB EL L RC 7 IP I, A, D

42 4665 Mr. Venkatesh 4/4/05 M 21 RIF T - - - - - RIF N 12,200 AA SAB EL L RC 6 IP I

43 6705 Mrs. Bharathi 14/5/05 F 17 RIF T - - - - - RIF N 11,200 N SAB EL L RC 8 IP I

44 6817 Mr. Prashanth 16/5/05 M 26 RIF T - - - - - RIF T 10,600 N SAB EL L Pel 5 IP I

45 7938 Mrs. Umadevi 6/6/05 F 26 RIF A U - 2 + - RIF N 9,700 AA SAB EL L RC 12 IP I, A

46 8354 Ms. Siddiqtaj 13/6/05 F 13 RIF T - - 2 - - RIF N 12,300 AA SAB EL L RC 10 IP I

47 9004 Mr. Girish 27/6/05 M 18 RIF T - - 5 - - RIF N 11,300 AA SAB EL L Post I 9 IP I

48

10844 Ms. Marina 25/7/05 F 23 RIF T - - 6 - - RIF N 12,500 N SAB EL L RC 9 IP I

49 11159 Ms. Nazima Begum 1/8/05 F 19 - Interval Appendectomy - - - AM SAB EL L Post I 5 IP I, A

50 11189 Mr. Sadiq Pasha 1/8/05 M 17 RIF A U - - - + RIF N 11,600 AA SAB EL L Pel 6 IP I, A

102

KEY TO MASTER CHART

SEX: M- MALE

F – FEMALE

SYMPTOMS

U-URINARY SYMPTOMS

G-GYNECOLOGIC SYMPTOMS

B-BOWEL DISTURBANCES

PAIN:

SOMP – SITE OF MAXIMAL PAIN

T- TYPICAL

A- ATYPICAL

D.O.S-DATE OF SURGERY

INSPECTION: N-NORMAL

AN-ABNORMAL

PALPATION:

SOMT-SITE OF MAXIMAL TENDERNESS

RIF- RIGHT ILIAC FOSSA

RL- RIGHT LUMBAR

RF – RIGHT FLANK

RH- RIGHT HYPOCHONDRIAC

MB- Mc BURNEY’S POINT

BT-BALDWIN’S TEST

PT-PSOAS TEST

OT-OBTURATOR TEST

PER RECTAL EXAMINATON (PR)

N-NORMAL

T-TENDERNESS

TC - TOTAL COUNT

ULTRASOUND DIAGNOSIS (USG)

AA - ACUTE APPENDICITIS

AM - APPENDICULAR MASS

AAb – APPENDICULAR ABSCESS.

ANAESTHESIA (A/N):

SAB-SUBARACHNOID BLOCK

EA - EPIDURAL ANAESTHESIA

GA – GENERAL ANAESTHESIA

SURGERY: EL – ELECTIVE

EM – EMERGENCY

INCISION: MB – Mc. BURNEY’S

RM – RUTHERFORD MORISSON

L - LANZ

RPM – RIGHT PARAMEDIAN

POSITION OF APPENDIX:

RC – RETRO CAECAL

PEL – PELVIC

PRE I – PER ILEAL

POST I – POST ILEAL

PC - PARA CAECAL

SC - SUBCAECAL

SH – SUB HEPATIC

EP – EXTRA – PERITONEAL

IP - INTRA – PERITONEAL

FINDINGS:

I – INFLAMED

A -ADHESIONS

D – DISTENDED

G – GANGRENOUS

P – PERFORATED

M – MASS

Ab – ABSCESS

VARIABLES: + PRESENT - ABSENT N : NORMAL

103

105

SUB-HEPATIC CAECUM WITH PARACAECAL APPENDIX

(Appendix is lying by the side of the caecum, which is situated below liver)

SUB-CAECAL POSITION OF APPENDIX

(Appendix going down towards the mid-inguinal point)

RETRO-CAECAL POSITION OF APPENDIX

(Appendix is lying behind the caecum)

POST-ILEAL POSITION OF APPENDIX

(Appendix lying behind the ileum, which is lifted forwards)

PARA-CAECAL POSITION OF APPENDIX

(Appendix lying by the side of the caecum)

PELVIC POSITION OF APPENDIX (Appendix dipping into the pelvic cavity)

ANNEXURE MASTER CHART FOR AUTOPSY CASES

SL.No. P.M. No. NAME OF PATIENT DATE OF P.M

AGE SEX POSITION OF APPENDIX

IP / EP / IM

LENGTH (in cms)

1 551 / 03 Mr. Abdul Razzak 26 /06 / 03 70 M Pelvic IP 8 2 850 / 03 UNKNOWN 18 /10 / 03 35 M Retro-caecal IP 10 3 855 / 03 Mrs. Manjula 21 /10 / 03 24 F Pelvic IP 12 4 856 / 03 Mrs. Malathi 21 /10 / 03 20 F Retro-caecal EP 14 5 860 / 03 Mr. Babu 22 /10 / 03 20 M Pelvic IP 16 6 867 / 03 Mr. Selvaraj 25 /10 / 03 40 M Post-ileal IP 18 7 868 / 03 Mr. Anthony 26 /10 / 03 45 M Sub-caecal IP 6 8 869 / 03 Kum. Lakshmi 26 /10 / 03 3½ F Retro-caecal IP 8 9 873 / 03 Mrs. Anjali Singh 27 / 10 / 03 26 F Retro-caecal IP 5 10 875 / 03 Mr. Karim Basha 29 / 10 / 03 40 M Pre-ileal IP 6 11 876 / 03 Mr. M.D. Shivakumar 29 /10 / 03 34 M Post-ileal IP 8 12 891 / 03 Ms. Prascilla 05 / 11 / 03 15 F Pelvic IP 14 13 892 / 03 Mrs. Vimala 05 / 11 / 03 27 F Post-ileal IP 10 14 893 / 03 Mr. Krishnamurthy 05 / 11 / 03 33 M Post-ileal IP 12 15 906 / 03 Mr. Firoz Khan 08 / 11 / 03 23 M Sub-caecal IP 8 16 907 / 03 Mr. Das 08 / 11 / 03 43 M Sub-caecal IP 6 17 910 / 03 Mr. Vincent Prabhu 09 / 11 / 03 24 M Retro-caecal IP 12 18 906 / 04 Mr. Srinivasulu 13 / 11 / 04 28 M Post-ileal IP 8 19 907 / 04 Mr. Lokesh 13 / 11 / 04 24 M Retro-caecal IP 6 20 913 / 04 Mr. Dayalan Manohar 17 / 11 / 04 32 M Para-caecal EP 13 21 914 / 04 Mr. William 17 / 11 / 04 39 M Pelvic IP 9 22 915 / 04 Mr. Nyana Prakash 17 / 11 / 04 37 M Retro-caecal IP 8 23 930 / 04 Mr. Rajesh Chandra 20 / 11 / 04 30 M Post-ileal IP 8 24 1007 / 04 Mr. Yesu das 17 /12 / 04 40 M Paracaecal EP 12 25 7 / 05 Mr. Jyothish Das 03 / 01 / 05 23 M Post-ileal IP 6 26 8 / 05 Mrs. Archana 03 / 01 / 05 20 F Pelvic IP 9 27 11 / 05 Mr.Somashekar 04 / 01 / 05 21 M Para-caecal IP 7 28 12 / 05 Mr. Rajesh 04 / 01 / 05 25 M Post-ileal IM 6 29 26 / 05 Mr. Thimmegowda 08 / 01 / 05 37 M Retro-caecal EP 7 30 29 / 05 Mr. D. Vinod 08 / 01 / 05 24 M Pelvic IP 9 31 30 / 05 Mr. Narasimhaprasad 10 / 01 / 05 48 M Retro-caecal IP 6 32 32 / 05 UNKNOWN 10 / 01 / 05 40 M Retro-caecal IP 11 33 33 / 05 Mr. D. Krishna 10 / 01 / 05 45 M Post-ileal IP 10 34 36 / 05 UNKNOWN 11 / 01 / 05 50 M Pelvic IP 9 35 38 / 05 Mr.Gnana Prakash 11 / 01 / 05 30 M Promonteric IP 8 36 40 / 05 Mr.S. Shivaji 12 / 01 / 05 40 M Pelvic IP 9 37 42 / 05 Mr. M. Krishna 13 / 01 / 05 38 M Post-ileal IP 6 38 43 / 05 Mr. Revanna 15 / 01 / 05 50 M Post-ileal IP 8 39 47 / 05 Kum. B. Deepika 18 / 01 / 05 12 F Pelvic IP 7 40 48 / 05 Mushra 19 / 01 / 05 1½ F Retro-caecal IP 8 41 49 / 05 Mrs. Pulbansa 19 / 01 / 05 20 F Post-ileal IP 11 42 56 / 05 Mr.P.N. Jayaram 21 / 01 / 05 45 M Pelvic IP 9 43 57 / 05 UNKNOWN 22 / 01 / 05 15 M Post-ileal IP 6 44 59 / 05 Mr. Noor Basha 22 / 01 / 05 27 M Retro-caecal IP 10 45 61 / 05 Mr. Sandeep 23 / 01 / 05 19 M Pelvic IP 11 46 62 / 05 Kum. Divya 23 / 01 / 05 11 F Post-ileal IP 5 47 63 / 05 UNKNOWN 23 / 01 / 05 50 M Retro-caecal IP 8 48 65 / 05 Mr. D. Solay 24 / 01 / 05 55 M Pelvic IP 9 49 66 / 05 Mr. Lawrence 24 / 01 / 05 30 M Retro-caecal EP 11 50 67 / 05 Mr. Vijayendra 25 / 01 / 05 35 M Post-ileal IP 12 51 83 / 05 UNKNOWN 28 / 01 / 05 75 M Retro-caecal IP 5 52 84 / 05 Mr. Jawar 28 / 01 / 05 40 M Pre-ileal IP 6 53 85 / 05 Mr. Syed Sultan 28 / 01 / 05 48 M Post-ileal IP 6 54 86 / 05 Mrs. Lakshmi 28 / 01 / 05 40 F Retro-caecal IP 12 55 87 / 05 UNKNOWN 28 / 01 / 05 60 M Retro-caecal IP 6 56 89 / 05 Mr. Sharath Kumar 29 / 01 / 05 13 M Sub-caecal IP 10 57 90 / 05 Mr. Shaikh Basha 29 / 01 / 05 57 M Sub-hepatic IP 8 58 92 / 05 Mrs. Bhavya 30 / 01 / 05 22 F Post-ileal IP 6 59 103 / 05 Mr. Babulal 03 / 02 / 05 38 M Para-caecal IP 8 60 104 / 05 Mr.R. Muthu 03 / 02 / 05 30 M Retro-caecal IP 10 61 167 / 05 Mrs. Noorie 22 / 02 / 05 29 F Retro-caecal IP 9

MASTER CHART FOR AUTOPSY CASES (continued)

SL.No. P.M. No. NAME OF PATIENT

DATE OF P.M

AGE SEX POSITION OF APPENDIX

IP / EP / IM

LENGTH (in cms)

62 168 / 05 UNKNOWN 22 / 02 / 05 35 M Pre-ileal IP 9 63 169 / 05 Mr. Manjunath 23 / 02 / 05 18 M Pelvic IP 6 64 170 / 05 UNKNOWN 23 / 02 / 05 18 M Para-caecal IP 9 65 171 / 05 UNKNOWN 23 / 02 / 05 30 M Retro-caecal IP 11 66 172 / 05 Mr. Anandan 24 / 02 / 05 35 M Post-ileal IP 8 67 173 / 05 Mrs. Rajeshwari 24 / 02 / 05 18 F Post-ileal IP 10 68 174 / 05 Mrs. Ramakka 24 / 02 / 05 63 F Retro-caecal IP 14 69 227 / 05 Mrs. Hemalatha 14 / 03 / 05 21 F Retro-caecal EP 11 70 228 / 05 Mrs. S. Latha 14 / 03 / 05 28 F Pelvic IP 9 71 230 / 05 Mr. K. Balu 14 / 03 / 05 35 M Post-ileal IP 8 72 232 / 05 Mr. Siddaraju 15 / 03 / 05 42 M Pelvic IP 12 73 233 / 05 Mr. Deepak Rao 15 / 03 / 05 32 M Retro-caecal IP 12 74 286 / 05 Mr. Naresh Kumar 04 / 04 / 05 24 M Post-ileal IP 16 75 287 / 05 UNKNOWN 04 / 04 / 05 20 F Pelvic IP 7 76 289 / 05 Mrs.Sayanora 04 / 04 / 05 24 F Post-ileal IP 6 77 291 / 05 UNKNOWN 04 / 04 / 05 17 F Retro-caecal IP 8 78 292 / 05 UNKNOWN 05 / 04 / 05 40 M Para-caecal IP 9 79 293 / 05 Mr. Marimuthu 06 / 04 / 05 30 M Post-ileal IP 5 80 295 / 05 Mr. Manju 06 / 04 / 05 24 M Pelvic IP 6 81 426 / 05 Mr. Papanna 21 / 05 / 05 50 M Retro-caecal IP 8 82 427 / 05 Mr. Pashupathi 21 / 05 / 05 47 M Retro-caecal EP 9 83 428 / 05 Mrs. Mahalakshmi 21 / 05 / 05 26 F Pelvic IP 14 84 429 / 05 Mr. Manoj Maithan 21 / 05 / 05 39 M Postileal IP 15 85 432 / 05 Mrs. Sharadhamma 23 / 05 / 05 21 F Retro-caecal IP 11 86 433 / 05 Mr. B. Nagarjun 24 / 05 / 05 18 M Post-ileal IP 8 87 434 / 05 Mr. Manohar 24 / 05 / 05 20 M Pelvic IP 6 88 559 / 05 Mrs. Gowramma 05 / 07 / 05 65 F Pelvic IP 8 89 570 / 05 Mr. A. Solai 06 / 07 / 05 56 M Pelvic IP 13 90 586 / 05 Kum. Hema 13 / 07 / 05 7 F Pelvic IP 9 91 588 / 05 Mr. Girish G.S. 13 / 07 / 05 19 M Retro-caecal IP 8 92 589 / 05 Mr. Kannappa 14 / 07 / 05 55 M Pre-ileal IP 6 93 591 / 05 Mrs. Mohana 15 / 07 / 05 18 F Post-ileal IP 8 94 592 / 05 Mrs. Pachiamma 16 / 07 / 05 70 F Paracaecal EP 7 95 593 / 05 Mrs. Dhanalakshmi 16 / 07 / 05 18 F Sub-caecal IP 4 96 596 / 05 Mr. Samson Paul 18 / 07 / 05 29 M Retro-caecal IP 5 97 597 / 05 Mr. Sheikh 18 / 07 / 05 25 M Pelvic IP 9 98 598 / 05 Mrs. Bhagyavathi 19 / 07 / 05 48 F Post-ileal IP 6 99 603 / 05 UNKNOWN 20 / 07 / 05 35 M Retro-caecal IP 5 100 604 / 05 Mr. K.V. RajKumar 21 / 07 / 05 32 M Retro-caecal IP 8

MASTER CHART FOR CLINICAL CASES

No I.P.No. NAME OF

PATIENT

D.O.A SE

X

A

G

E

SO

MP

T/

A

U/

G/

B

F/

H

R/

A

BT /

PT

OT SOMT PR TC USG A/N EL/

EM

INCI

SION

POSIT

ION

LEN

GTH

IP/

EP

FINDIN

GS

SL.

No

I.P.No NAME OF

PÂTIENT

D.O.S SEX AGE SOM

P

T/

A

U/

G/

B

F/

H

R

/

A

BT/

PT

OT SOM

T

PR TC USG A/N EL

/EM

INCI

SION

POSI

TION

LEN

GTH

EP/

IP

FIND

INGS

1 7339 Mr..Md. Ibrahim 5/5/03 M 39 RIF T - - + - RIF N 11,200 AA SAB EM L RC 4 IP I, A, M

2

9553 Mrs.Pushpa 12/6/03 F 18 RIF T - - 3 - - RIF T 9,600 N SAB EL L Pel 8 IP I

3 10691 Mr.Dharamraj 3/7/03 M 36 RL A U - - + - RL N 17,000 AAb EA EL RPM RC 8 EP I, P, Ab

4 10753 Mr. Nagaraj 3/7/03 M 23 RIF T U - 5 - - RIF N 6,400 N SAB EL L RC 10 IP I

5 10994 Mrs. Sumathi 1/7/03 F 26 RIF T - - 3 - - RIF N 10,500 ND SAB EM MB PC 7 IP I

6 780161 Mr,Jayarathna 27/10/04 M 28 RIF T - - 2 - - MB N 8,900 N SAB E EL Pre I 6 IP I

7 11334 Mr. Syed Omar 10/7/03 M 13 RIF T - - - - - MB N 13,200 N SAB EL L Pre I 12 IP I

8 11335 Mr. Jayaraj 7/7/03 M 27 RIF A - - 2 - - MB N 10,300 AA SAB EL L Post I 10 IP I, A

9 12895 Mr. Muniraju 1/8/03 M 27 RF A U - - + - MB N 10,150 AA SAB EM MB RC 10 IP I, A

10 12926 Mrs. Sudha 2/8/03 F 23 RIF T - - - - - RIF N 11,500 AA SAB EM MB PC 15 IP I

11 13068 Mr. Venkatesh 7/8/03 M 16 RIF T - - 2 - - RIF N 10,100 N SAB EL L PC 16 IP I, A

12 13118 Mr. Wasim Khan 5/8/03 M 11 D A - - - + - RH N 11,200 AA GA EM RM SH 12 EP I

13 13290 Mr. Raju 8/8/03 M 24 RIF T - - 4 - - RIF N 8,200 N SAB EL L RC 5 IP I

14 13311 Mr. Krishnappa 8/8/03 M 30 RIF T - - - - - RIF N 16,900 AA SAB EL L SC 5 IP I

15 13312 Mrs. Chandramma 8/8/03 F 26 RIF T U - - - - RIF T 11,400 N SAB EL L Pel 6 IP I

16 13749 Mr. Manimairaj 17/8/03 M 29 RIF T - - - - - RIF N 14,000 N SAB EL L RC 12 IP I

17 13843 Mr. Jagannath 18/8/03 M 15 RIF A - - 7 - - RIF N 16,600 N SAB EL L Post I 10 IP I, F, D

18 13851 Mr. Prashanth 18/8/03 M 18 RIF A - - 3 - - RIF N 10,400 N SAB EL L Post I 9 IP I, A

19 14202 Mr. Vinod Kumar 25/8/03 M 14 RIF A - - 5 - + RIF N 10,200 N SAB EL L Pel 5 IP I, D

20 16483 Mr. John 4/10/03 M 20 RL A U - - + - RL N 16,200 AA GA EM PM RC 8 EP I, P

21 771781 Mr. Jayasingh Raj 21/7/04 M 45 RF A - - + - RL N 15,200 ND GA EM MB RC 6 EP G

22 773108 Mr. Anand 9/8/04 M 20 RIF T - 2 - - RIF N 9,400 AA SAB EL MB PC 9 IP I, A

23 777352 Mr. Chandregoda 1/9/04 M 28 RIF T - - - - - RIF N 10,120 AA SAB EL MB Post I 10 IP I

24 777372 Mr. Beeresh 1/9/04 M 16 RIF T - - - - - RIF T 7,300 AA SAB EM MB Pel 9 IP I

25 778393 Mrs. Nagarathna 22/9/04 F 30 -Generalized peritonitis- - - RIF T 16,900 ND GA EM RPM Post I 8 IP A, P

26 778739 Mr. Sampangappa 29/9/04 M 45 -For Interval Appendectomy- - - AM SAB EL MB RC 10 IP I, A

27 778752 Mr. Hucchegowda 29/9/04 M 55 RIF A U - 4 + - RIF N 5,900 AAb SAB EL RPM RC 8 IP I, A

28 779127 Mr. Imrankhan 6/10/04 M 16 RIF A G - 3 - - RIF T 13,400 AA SAB EM L Pel 8 IP I

29 779158 Mr. Rajappa 6/10/04 M 42 RIF T - - 3 - - RIF N 9,800 N SAB EL MB SC 3 IP I, A

30 779470 Ms. Shirin Sultan 13/10/04 F 16 RIF T - - 2 - - RIF N 12,150 AA SAB EL MB Post I 10 IP I

31 780177 Mr. Yellappa 27/10/04 M 30 -Generalized Peritonitis- - - RIF T 18,600 ND GA EM RPM PC 8 IP I, P, A

32 780328 Ms. Asha 30/10/04 F 16 RIF A U - - - + RIF N 14600 AA SAB EM MB Pel 16 IP I, P, A

33 780487 Mr. Selvakumar 3/11/04 M 25 RIF T - - - - - RIF N 12,650 AA SAB EM MB RC 8 IP I

34 780853 Mr. Basappa 10/11/04 M 27 RF A - - - + - RL N 11,170 AA SAB EM MB RC 6 IP I, A

35 780856 Mr. Raju 10/11/04 M 22 RIF T - - - - - RIF N 9,450 AA SAB EM MB Post I 8CM IP I

36 17760 Mr. Manjunath 13/11/04 M 25 RIF A - - - - - RIF T 14,140 N SAB EL L Post I 10 IP I,P

37

17762 Mr. Suresh 13/11/04 M 22 RIF A U - - - + RIF T 12,800 AA SAB EL L Pel 8 IP I,G,Ab

38 18213 Mr. Mallikarjuna 21/11/04 M 28 RIF A B - 2 - - RIF N 6,900 AM SAB EL L Post I 8 IP I, A

39 18269 Mr. Mutthappa 22/11/04 M 42 RIF T - - 2 - - RIF N 9,420 AA SAB EL L SC 6 IP I

40 19021 Mrs. Bhagyamma 6/12/04 F 22 RIF A G - 3 - + RIF T 11,140 AA SAB EL L Pel 8 IP I, G

41 4529 Mr. Balakumar 1/4/05 M 20 RF A U - 4 + - RL N 10,400 AA SAB EL L RC 7 IP I, A, D

42 4665 Mr. Venkatesh 4/4/05 M 21 RIF T - - - - - RIF N 12,200 AA SAB EL L RC 6 IP I

43 6705 Mrs. Bharathi 14/5/05 F 17 RIF T - - - - - RIF N 11,200 N SAB EL L RC 8 IP I

44 6817 Mr. Prashanth 16/5/05 M 26 RIF T - - - - - RIF T 10,600 N SAB EL L Pel 5 IP I

45 7938 Mrs. Umadevi 6/6/05 F 26 RIF A U - 2 + - RIF N 9,700 AA SAB EL L RC 12 IP I, A

46 8354 Ms. Siddiqtaj 13/6/05 F 13 RIF T - - 2 - - RIF N 12,300 AA SAB EL L RC 10 IP I

47 9004 Mr. Girish 27/6/05 M 18 RIF T - - 5 - - RIF N 11,300 AA SAB EL L Post I 9 IP I

48

10844 Ms. Marina 25/7/05 F 23 RIF T - - 6 - - RIF N 12,500 N SAB EL L RC 9 IP I

49 11159 Ms. Nazima Begum 1/8/05 F 19 - Interval Appendectomy - - - AM SAB EL L Post I 5 IP I, A

50 11189 Mr. Sadiq Pasha 1/8/05 M 17 RIF A U - - - + RIF N 11,600 AA SAB EL L Pel 6 IP I, A

KEY TO MASTER CHART

SEX: M- MALE

F – FEMALE

SYMPTOMS

U-URINARY SYMPTOMS

G-GYNECOLOGIC SYMPTOMS

B-BOWEL DISTURBANCES

PAIN:

SOMP – SITE OF MAXIMAL PAIN

T- TYPICAL

A- ATYPICAL

D.O.S-DATE OF SURGERY

INSPECTION: N-NORMAL

AN-ABNORMAL

PALPATION:

SOMT-SITE OF MAXIMAL TENDERNESS

RIF- RIGHT ILIAC FOSSA

RL- RIGHT LUMBAR

RF – RIGHT FLANK

RH- RIGHT HYPOCHONDRIAC

MB- Mc BURNEY’S POINT

BT-BALDWIN’S TEST

PT-PSOAS TEST

OT-OBTURATOR TEST

PER RECTAL EXAMINATON (PR)

N-NORMAL

T-TENDERNESS

TC - TOTAL COUNT

ULTRASOUND DIAGNOSIS (USG)

AA - ACUTE APPENDICITIS

AM - APPENDICULAR MASS

AAb – APPENDICULAR ABSCESS.

ANAESTHESIA (A/N):

SAB-SUBARACHNOID BLOCK

EA - EPIDURAL ANAESTHESIA

GA – GENERAL ANAESTHESIA

SURGERY: EL – ELECTIVE

EM – EMERGENCY

INCISION: MB – Mc. BURNEY’S

RM – RUTHERFORD MORISSON

L - LANZ

RPM – RIGHT PARAMEDIAN

POSITION OF APPENDIX:

RC – RETRO CAECAL

PEL – PELVIC

PRE I – PER ILEAL

POST I – POST ILEAL

PC - PARA CAECAL

SC - SUBCAECAL

SH – SUB HEPATIC

EP – EXTRA – PERITONEAL

IP - INTRA – PERITONEAL

FINDINGS:

I – INFLAMED

A -ADHESIONS

D – DISTENDED

G – GANGRENOUS

P – PERFORATED

M – MASS

Ab – ABSCESS

VARIABLES: + PRESENT - ABSENT N : NORMAL