In appendicitis, the initial periumbilical pain is eventually localized to right iliac fossa because of
Ans. a (Peritoneum) (Ref. Bailey and Love Surgery 25th//pg. 1207).With progressive inflammation of the appendix, the parietal peritoneum in the right iliac fossa becomes irritated, producing more intense, constant and localised somatic pain that begins to predominate. Patients often report this as an abdominal pain that has shifted and changed in character. Typically, coughing or sudden movement exacerbates the right iliac fossa pain. The classic visceral-somatic sequence of pain is present in only about half of those patients subsequently proven to have acute appendicitis.APPENDICITISClinical Diagnosis of Acute Appendicitis -- Symptoms# Peri-umbilical colic, n Pain shifts to the right iliac fossa n Anorexia n Nausea.Clinical Diagnosis of Acute Appendicitis -- Signs# The patient is then asked to point to where the pain began and to where it moved (Pointing sign).# Rebound tenderness.# Deep palpation of the left iliac fossa may cause pain in the right iliac fossa (Rovsing's sign).# Occasionally an inflamed appendix lies on the psoas muscle and the patient, often a young adult, will lie with the right hip flexed for pain relief (Psoas sign).# Spasm of the obturator intemus is sometimes demonstrable when the hip is flexed and internally rotated. If an inflamed appendix is in contact with the obturator intemus, this manoeuvre will cause pain in the hypogastrium (Obturator sign) (Zachary Cope).# Cutaneous hyperaesthesia may be demonstrable in the right iliac fossa, but is rarely of diagnostic value.Special Features, According to Position of the Appendix# Retrocaecal- HYPEREXTENSION OF THE HIP JOINT may induce abdominal pain when the degree of psoas spasm is insufficient to cause flexion of the hip.0# Pelvic- Rectal examination reveals tenderness in the rectovesical pouch or the pouch of Douglas, especially on the right side. Spasm of the psoas and obturator internus muscles may be present with appendix in this position. An inflamed appendix in contact with the bladder may cause frequency of micturition.# Post ileal- Although this is rare, it accounts for some of the cases of missed appendix'.- Tenderness, if any, is ill-defined, although it may be present immediately to the right of the umbilicus.Special Features, According to Age# Infants- Appendicitis is relatively rare in infants under 36 months of age and for obvious reasons the patient is unable to give a history. Because of this, diagnosis is often delayed and thus the incidence of perforation and postoperative morbidity is considerably higher than in older children. Diffuse peritonitis can develop rapidly due to the underdeveloped greater omentum, which is unable to give much assistance in localising the infection.# The elderly- Gangrene and perforation occur much more frequently in elderly patients. Elderly patients with lax abdominal walls or obesity may harbour a gangrenous appendix with little evidence of it, and the clinical picture may simulate subacute intestinal obstruction. These features coupled with coincident medical conditions produce a much higher mortality for acute appendicitis in the elderly.# PregnancyAlder's test is useful for diagnosis.
Peritoneum
Iliopsoas
Colon
Caecum
Vermiform Appendix