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Acute Appendicitis - Surgical Lecture
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Prof. Zahid Mahmood
Prof. Zahid Mahmood
1
2026-04-05T15:43:40Z
2026-04-05T15:43:40Z
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Acute AppendicitisA Comprehensive Surgical LectureProf. Zahid MahmoodDepartment of SurgeryFinal Year MBBS | UHS / CPSP Aligned CurriculumBailey & Love Style · Exam-Oriented · Viva Ready · Case-Based LearningPK
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02Learning Outcomes▶ Define acute appendicitis; describe anatomy and epidemiology accurately▶ Enumerate etiology, classify pathological stages of appendicitis▶ Recognise clinical features; apply Alvarado score for decision-making▶ Plan investigations, medical and surgical management; list complicationsProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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03Definition▶ Acute inflammation of vermiform appendix — No.1 acute surgical emergency▶ Incidence: 1 in 500/year; peak incidence age 10–30 years; slight male preponderance▶ Lifetime risk: 8.6% males, 6.7% females; 10% may run chronic/recurrent course▶ Hallmark: RIF pain after periumbilical migration — Murphy's classic sequenceProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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04Classification (Pathological Stages)▶ Stage I — Catarrhal (Simple): Mucosal hyperaemia; congestion; no transmural involvement▶ Stage II — Suppurative (Phlegmonous): Transmural inflammation; fibrinopurulent exudate▶ Stage III — Gangrenous: Vascular thrombosis → wall necrosis; foul-smelling, black appendix▶ Stage IV — Perforated: Rupture → localised abscess OR generalised faecal peritonitisProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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05Anatomical Variants — Clinical Significance▶ Retrocaecal (65%): Psoas sign positive; flank/back pain; RIF signs may be atypical▶ Pelvic (30%): Urinary frequency, dysuria, diarrhoea; rectal tenderness on PR exam▶ Subhepatic: RUQ pain; mimics acute cholecystitis — important diagnostic pitfall▶ Left-sided: Situs inversus / malrotation; LIF pain — always exclude with USS/CTProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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06Etiology / Causes▶ Luminal obstruction: Faecolith (commonest), lymphoid hyperplasia, tumour, calculi▶ Infective: E. coli, Bacteroides fragilis, Streptococcus — secondary bacterial invasion▶ Parasites: Oxyuris vermicularis, Ascaris lumbricoides — endemic in developing regions▶ Tumours: Carcinoid (commonest appendiceal tumour), adenocarcinoma, mucocele of appendixProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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07Pathophysiology — Stepwise Mechanism▶ Step 1: Luminal obstruction → mucus accumulation → intraluminal pressure rises▶ Step 2: Venous engorgement → mucosal ischaemia → bacterial translocation begins▶ Step 3: Transmural inflammation → suppuration → gangrenous wall necrosis (48–72 hrs)▶ Step 4: Perforation → walled-off abscess (omentum) OR generalised peritonitis + sepsisProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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08Clinical Features — Signs & Symptoms▶ Pain: Central/periumbilical → RIF migration to McBurney's point (ALWAYS first symptom)▶ GI: Anorexia (cardinal), nausea, vomiting — onset AFTER pain (key exam/viva point)▶ Systemic: Low-grade fever 37.5–38.5°C; tachycardia; high fever suggests perforation▶ Signs: Tenderness at McBurney's, Rebound, Rovsing's, Psoas, Obturator, Dunphy's signsProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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09Investigations — Labs & Imaging▶ Blood: TLC 10,000–18,000 (>18,000 suggests perforation); neutrophilia; CRP elevated▶ Urine: Exclude UTI/renal colic; microscopic pyuria (5 WBC) occurs in pelvic appendicitis▶ Ultrasound: Non-compressible, aperistaltic appendix >6 mm — sensitivity 75–90%▶ CT Abdomen (Gold Standard): Sensitivity 95–98%; identifies perforation, abscess, massProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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10Management Overview — Decision Framework▶ Alvarado (MANTRELS): Score ≥7 = high probability; Score ≤4 = low; Score 5–6 = grey zone▶ Resuscitation: IV Hartmann's, NBM, urinary catheter; correct fluid/electrolyte deficit▶ Analgesia: Opiates safe and MUST be given — improves diagnostic accuracy (NICE 2024)▶ Definitive: Appendicectomy (gold standard); non-operative reserved for selected casesProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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11Medical Management▶ IV Fluids: Normal saline / Hartmann's solution — correct dehydration and electrolytes▶ Antibiotics: Cefuroxime 1.5g IV + Metronidazole 500mg IV — perioperative prophylaxis▶ Analgesia: Morphine 0.1 mg/kg IV; avoid withholding — does NOT mask clinical signs▶ Non-operative (APPAC Trial): Antibiotics alone for uncomplicated; 30% recurrence at 5yrProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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12Surgical Management▶ Laparoscopic Appendicectomy: Treatment of choice (NICE); faster recovery, less infection▶ Open Appendicectomy: Gridiron / Lanz incision; use in perforation or limited resources▶ Appendiceal Mass: Ochsner-Sherren regime → interval appendicectomy after 6–8 weeks▶ Drain Placement: Only for generalised peritonitis / established abscess; not routineProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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13Complications — Early & Late▶ Early: Wound infection (5–10%), pelvic/subphrenic abscess, faecal fistula, haemorrhage▶ Early: Perforation (15–40%) → peritonitis → sepsis → multi-organ failure (high mortality)▶ Early: Portal pyaemia (rare) → pylephlebitis → liver abscess (pre-antibiotic era classic)▶ Late: Adhesive small bowel obstruction (commonest late); incisional hernia; infertilityProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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14Mnemonics & High-Yield Exam Points▶ MANTRELS: Migration · Anorexia · N/V · Tenderness RIF · Rebound · Elevated TLC · Leukocytosis · Shift▶ VIVA TRAP: 'Vomiting precedes pain' = WRONG; pain ALWAYS comes first — never forget▶ Negative appendicectomy: ≤20% acceptable; up to 35% in females — always document▶ Rovsing's sign: LIF pressure → RIF pain = peritoneal irritation confirmed in RIFProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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Clinical Scenario — Case-Based LearningCASE: A 22-year-old male presents with 18-hour history of central abdominal pain migrating to RIF. He is anorexic with one episode of vomiting. Temperature 37.8°C, pulse 96/min. Tenderness at McBurney's point with guarding and rebound tenderness. TLC = 14,500 with 85% neutrophilia. Urine analysis normal. Alvarado Score = 8.Q1: What is the most likely diagnosis?✔ Acute Appendicitis (Alvarado ≥7 = high probability — operate)Q2: What is the next best step in management?✔ Resuscitate → IV antibiotics → Laparoscopic appendicectomy (NICE 2024)Prof. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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MCQs — SBA Style (CPSP / UHS Pattern)1Q1. Commonest position of vermiform appendix in adults?A) Pelvic B) Retrocaecal ✔ C) Subcaecal D) Pre-ileal2Q2. Alvarado score ≥ 7 indicates which management?A) Observe & repeat USS B) Discharge with analgesia C) Proceed to appendicectomy ✔ D) CT alone3Q3. Commonest cause of luminal obstruction in acute appendicitis?A) Carcinoid tumour B) Parasite C) Faecolith ✔ D) Foreign body4Q4. Management of appendiceal mass (Ochsner-Sherren regime)?A) Emergency appendicectomy B) Conservative + interval appendicectomy ✔ C) Antibiotics alone lifelong D) CT-guided drain onlyProf. Zahid Mahmood | Acute Appendicitis | Final Year MBBS | UHS / CPSP CurriculumPK
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High-Yield Summary 1Acute appendicitis is the commonest surgical emergency; diagnose clinically using Alvarado score 2Faecolith is commonest cause; retrocaecal position is commonest variant (65%) — psoas sign 3CT abdomen is gold standard; laparoscopic appendicectomy is treatment of choice (NICE 2024) 4Perforation risk rises with delay; Ochsner-Sherren for mass; late complication = adhesive SBOProf. Zahid Mahmood | Acute Appendicitis | End of LecturePK
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