INTRODUCTION varies greatly depending on the experience of

                                          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.

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(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