INTRODUCTION varies greatly depending on the experience of

                                          INTRODUCTION

 

Acute
appendicitis (AA)  is  the 
acute  inflammation  of 
the  vermiform  appendix 
which  is a  hollow, muscular,  closed-ended 
tube  arising  from 
the  posterior  medial 
surface  of  the cecum, about  3 cm 
below  the  ileocecal 
valve.(1)  Appendicitis
is  as 
old  as  man  as
evidence  by  an 
Egyptian  mummy  of 
Byzantine  era  in 
which  old  appendicitis 
was suggested  by  adhesions 
in  the  right 
upper  quadrant.(2)

 

Acute  appendicitis 
is  a  common 
causes  of  acute 
abdomen  in  young 
adults  with  surgical 
emergencies.  It  is 
rare  below  3 
years  of  age 
but  people  are 
also  vulnerable  to 
it  in  extremes 
of  their  ages 
and  complication  rate 
is  higher  in 
those  groups.(3)
 It 
is relatively  more  prevalent 
in  male  in 
comparsion  to  females 
worldwide.  Individual
lifetime  risk  for 
acute  appendicitis  is  7%.(1)

 

The  diagnosis  of 
acute  appendicitis  is 
mainly  dependent  on 
history  and  clinical examination.  The  accuracy  of  the  clinical  examination  has  been  reported
 to  range  from  71%
 to  97%  and
 varies  greatly  depending  on  the  experience  of  the  examiner. Diagnosis  is 
further  reinforced  by 
laboratory  investigations  such 
as  leucocyte  count, differential  count 
(proportion  of  neutrophill 
and  lymphocyte)  and 
C  reactive  protein. Imaging  modalities 
like  ultrasound  have 
further  helped  in 
decreasing  the  negative appendectomy  rate.(4)   Despite  advances
 in  diagnostic  modalities  the  diagnosis  is  still
 doubtful  in  30-40 %  of  cases.(3)  

 

Over  the 
years  various  studies 
have  looked   for 
different  markers  to 
improve  diagnostic  accuracy. 
WBC  count  and 
CRP  are  now 
often  used.  When 
these  markers  are 
normal  the  diagnosis 
of  appendicitis  is 
unlikely.(5)  Studies 
have  shown  that 
WBC  count  and  
CRP  not  only 
helps  in  diagnosis 
but  also  help 
in  predicting  the 
severity  of  acute 
appendicitis.(4)

 

Simple  appendicitis
 can  progress  to  perforation,
 which  is  associated  with  a  much higher  morbidity  and 
mortality  and  surgeons  have  therefore
 been  inclined  to  operate
  when  the  diagnosis  is  probable  rather  than  wait  until
 it  is  certain.(6)   However 
at  present  some 
surgeons  are  taking 
conservative  approach  for 
uncomplicated  appendicitis  as 
studies  have  shown 
that  antibiotic  therapy 
is  not  inferior 
to  appendectomy  for 
uncomplicated  appendicitis  and 
two  third  of  the  patients 
with  uncomplicated  appendicitis 
can  be  managed 
without  surgery.(7) (8) (9)    

Since  its 
discovery  in  1930, 
C  reactive   protein  has  been  studied  as  a  screening  device  for  occult  inflammation,  as  a  marker  of  disease
 activity,  and  as  a  diagnostic  tool.(10)
  The  diagnostic  accuracy  of  the  CRP  is  not  significantly
 greater  than  the  WBC
 and  NP.  The  increased 
value  of  the 
CRP  is  directly  related  to  the  severity 
of  the  inflammation 
and  hence  can 
predict  complications .  The 
combination  of  the 
CRP ,  WBC  count  
and   NP  has 
greater  diagnostic  accuracy 
and  can  predict 
severity   in  acute
 appendicitis.(5)
(4)

 

 

After  a  patient  is  diagnosed 
with  appendicitis ,  surgeons  generally  want  to
 determine  the  severity  before  they  can  select  the  optimal  treatment . 
If  a  surgeon  could  predict  the  severity  of  appendicitis ,  one  could  determine
 the  therapeutic  method  and  the
timing  of  the  operation .  A  surgical  indication  marker 
such  as the  WBC 
count ,  NP  or  CRP
 would  be  useful  for
 deciding  between  treating  the  patient
 with  surgery  or  antibiotics.(11)

 

This  study 
finds  the  role 
of   WBC  count , NP 
and  CRP  to 
predict  the  severity 
of  acute  appendicitis.

 

 

 

 

 

 

 

 

 

 

 

                                      LITERATURE REVIEW  

 

 

1.      HISTORY:

 

The 
appendix  was  first 
described  by  the 
physician,  anatomist  Berengario 
Da  Carpi  in 1521. Appendix  was 
clearly  depicted  in 
the  anatomical  drawings 
of  Leonardo  da 
vinci,  made  in 1492, 
but  published  in  18th  century. (12)
” Defabrica  Corporis  Humani 
Fabrica ”   by Anderes  Versalius 
in  1543  illustrated 
normal  appendix  and 
its relation  to  surrounding structures. (13)  Verheye in 1710  coined the term “appendix
vermiformis”.(14) 

In  1735  Claudius 
performed  the  first 
surgical removal   of   appendix  
in   long   standing  
scrotal   hernia  and  
feacal   fistula   that  
occurred   due   to  
perforation   of   the  
appendix   by   a  
pin.  Lawson  Tait 
performed first  appendectomy  and 
removed  a  gangrenous 
appendix  in  1880. (14)

John  Parkinson 
in 1812  described  autopsy 
findings  of  5–year-old 
child  with  perforated 
appendix  containing  a 
fecalith.  In  1839  Thomas 
Addis  and  Richard 
Bright  described symptomatology  of 
appendicitis  and  stated 
that  appendix  was 
the  cause  of 
many  or  most 
of the  inflammatory  processes 
of  the  right 
iliac  fossa.(12)

In  1886,
Reginald  Fitz  presented 
” perforating  inflammation  of 
vermiform  appendix  ” 
after  which  for 
the  first  time 
the  term  “appendicitis”  was 
used.  In  1889, 
Tait  split opened  and 
drained  an  inflamed 
appendix  without   removing 
it. (14) 

Thomas
G. Morton in 1887 successful operated and removed the perforated   appendix along with draining of abscess. It
was Edward RCutler who performed one of the first “clean” unruptured
appendectomies and reported in 1889. The same year, Charles McBurney presented
“gridiron incision” (McBurney’s incision) to Chicago Medical Society
(CMS). In his paper,he  described the
clinical correlation of maximum tenderness at right iliac fossa with
appendicitis and adviced for early operative intervention. (15)

   Morris, in 1898, indicated appendix as
vestigial organ and a source of potential life threatening infection.  It was in I893 when Ribbert of Germany,
proposed the hypothesis that obliteration of appendix lumen at its base leads
to appendicitis.(13)

In
1893, Charles McBurney published his muscle splitting technique during
appendectomy, which was later modified by Robert Fulton Weir in 1900. (14)

In 1902, Dr. A. J. Ochsner  of 
Chicago  published  the 
first  edition  of 
a  handbook  of appendicitis  which 
advocated  nonoperative  treatment 
for  spreading  peritonitis. 
Dr. Ochsner  insisted  that 
a  regimen  of 
absolutely  nothing  by 
mouth,  frequent  gastric 
lavage, and  nutrient  enemas 
would  allow  the 
peritonitis  to  localize 
and  permit  a 
safer operation.  In  1904,  
Dr. John  B.  Murphy 
of  Chicago  reported 
a  personal  experience 
with  2000 appendectomies  of 
which  approximately  two – thirds 
were  interval  appendectomies,  and 
so  it  was 
clear  that  interval 
appendectomy  is  safer 
and  is  one 
of  the  indication 
in  acute   appendicitis. (2)

 Kurt  Semm 
performed  the  first 
laparoscopic appendectomy  in  1981 and he also invented  different types of laparoscopic
instruments.(16)

In
1986, Alvarado described the scoring system for early diagnosis of acute
appendicitis.(17)  It was later modified by Kalan in 1994.(18)

 

 

2.      EMBRYOGENESIS:

A.    NORMAL DEVELOPMENT:

          The Appendix is derived from the
midgut along with caecum.  The Four
structures that are considered as intestinal derivations of the midgut are :
the  small intestine (without the upper
duodenal part), the cecum and vermiform appendix, the  ascending colon, and the proximal 2/3rd
of  transverse colon.(19)

 

        The cecal diverticulum appears  at 6th  weeks as an outpouching of the caudal limb of the midgut loop.  During
fetal development the vermiform appendix (VA) is mostly located in subcecal
region. By the 12th week of gestational age, appendix acquires its
circular shape in cross-section At fifth
month, it elongates into its vermiform shape. (20)

 

    The first accumulations of lymphatic tissue
develop during the 14th  and
15th weeks of gestation. The first minute accumulations of lymphatic
cells are located directly below the epithelium. These lymphoid tissues
increases until puberty after which they gradually decrease.(21)

 

     At birth appendix is located at tip of the cecum but due
to the unequal elongation of the lateral wall of the cecum as the child grows
it aquires its adult location i.e. its base at posteriormedial wall of the
cecum. (20)

 

         
Following an initial growth period during early infancy up to about 3
years, the appendix achieves its adult proportions and does not continue to
grow throughout childhood.(22)

                                      Figure 1 : DEVEOPMENT OF VERMIFORM
APPENDIX

 

B.     CONGENITAL
ANOMALIES

 

             Anomalies of the appendix are
rare. Two of the common anomalies are agenesis and duplication. Agenesis of the
vermiform appendix accounts in approximately 1 in 100.000 laparotomies
performed for suspected acute appendicitis.(23) Duplication of the vermiform appendix is reported to have incidence
of 0.004%. (24) Diverticula of the appendix is rare and must be differentiated
from rudimentary duplication or pseudodiverticulum.(19)

             Appendix may be present in the
left side of abdomen in these two conditions:  – the  situs inversus (SI), and the  midgut malrotation (MM) .(25)

 

3.      ANATOMY

A.    MORPHOLOGY OF
APPENDIX