INTRODUCTION Acuteappendicitis (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) Appendicitisis as old as man asevidence 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.
Individuallifetime 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 thetiming 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 “appendixvermiformis”.(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) ThomasG. Morton in 1887 successful operated and removed the perforated appendix along with draining of abscess.
Itwas Edward RCutler who performed one of the first “clean” unrupturedappendectomies 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 theclinical correlation of maximum tenderness at right iliac fossa withappendicitis and adviced for early operative intervention. (15) Morris, in 1898, indicated appendix asvestigial 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 leadsto appendicitis.(13)In1893, Charles McBurney published his muscle splitting technique duringappendectomy, 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 laparoscopicinstruments.
(16)In1986, Alvarado described the scoring system for early diagnosis of acuteappendicitis.(17) It was later modified by Kalan in 1994.(18) 2. EMBRYOGENESIS:A.
NORMAL DEVELOPMENT: The Appendix is derived from themidgut along with caecum. The Fourstructures that are considered as intestinal derivations of the midgut are :the small intestine (without the upperduodenal part), the cecum and vermiform appendix, the ascending colon, and the proximal 2/3rdof transverse colon.(19) The cecal diverticulum appears at 6th weeks as an outpouching of the caudal limb of the midgut loop. Duringfetal development the vermiform appendix (VA) is mostly located in subcecalregion. By the 12th week of gestational age, appendix acquires itscircular shape in cross-section At fifthmonth, it elongates into its vermiform shape.
(20) The first accumulations of lymphatic tissuedevelop during the 14th and15th weeks of gestation. The first minute accumulations of lymphaticcells are located directly below the epithelium. These lymphoid tissuesincreases until puberty after which they gradually decrease.(21) At birth appendix is located at tip of the cecum but dueto the unequal elongation of the lateral wall of the cecum as the child growsit aquires its adult location i.e.
its base at posteriormedial wall of thececum. (20) Following an initial growth period during early infancy up to about 3years, the appendix achieves its adult proportions and does not continue togrow throughout childhood.(22) Figure 1 : DEVEOPMENT OF VERMIFORMAPPENDIX B. CONGENITALANOMALIES Anomalies of the appendix arerare. Two of the common anomalies are agenesis and duplication.
Agenesis of thevermiform appendix accounts in approximately 1 in 100.000 laparotomiesperformed for suspected acute appendicitis.(23) Duplication of the vermiform appendix is reported to have incidenceof 0.004%.
(24) Diverticula of the appendix is rare and must be differentiatedfrom rudimentary duplication or pseudodiverticulum.(19) Appendix may be present in theleft side of abdomen in these two conditions: – the situs inversus (SI), and the midgut malrotation (MM) .(25) 3.
ANATOMYA. MORPHOLOGY OFAPPENDIX