Difference between revisions of "Appendicitis"

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Appendicitis may histopathologically be defined as neutrophilic infiltrates of the wall of the appendix in the correct clinical context.
 
Appendicitis may histopathologically be defined as neutrophilic infiltrates of the wall of the appendix in the correct clinical context.
 
 
{{Fixation - general notes}}
 
{{Fixation - general notes}}
==Comprehensiveness==
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<noinclude>{{Comprehensiveness}}</noinclude>
{{Comprehensiveness}}
 
  
==Gross proccessing==
+
==Gross processing==
[[File:Acute Appendicitis.jpg|thumb|Acute suppurative appendicitis: The organ is enlarged and sausage-like (botuliform). This longitudinal section shows red inflamed mucosa with an irregular luminal surface. It was removed early in the disease, with no late complications like transmural necrosis, perforation, and abscess formation.]]
+
Standard sections if the appendix appears inflamed and there are no signs of malignancy. Describe abnormal signs including:
Standard sections if the appendix appears inflamed and there are no signs of malignancy.
+
<gallery mode=packed>
 +
File:Gross pathology of congested appendicitis.jpg|thumb|Appendicitis with '''congestion'''
 +
File:Gross pathology of appendicitis with a patchy purulent exudate, annotated.jpg|Serosa with a '''patchy purulent exudate'''.
 +
File:Gross pathology of appendicitis containing a blood-tinged purulent exudate.jpg|Appendicitis, with the lumen containing a '''blood-tinged purulent exudate'''.
 +
File:Acute Appendicitis.jpg|Longitudinal section showing a '''red inflamed mucosa''' with an '''irregular luminal surface''' (in a case of acute suppurative appendicitis).
 +
</gallery>
 
{{Further|Appendix}}
 
{{Further|Appendix}}
  
 
==Microscopic evaluation==
 
==Microscopic evaluation==
[[File:Histopathology of appendicitis.jpg|200px|thumb|Suppurative acute appendicitis, with ulceration seen at left in lumen.]]
 
 
*Evaluate '''depth''' of the inflammation.
 
*Evaluate '''depth''' of the inflammation.
 
*Look for any '''perforation''' of the wall.
 
*Look for any '''perforation''' of the wall.
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===Types===
 
===Types===
[[File:Acute suppurative appendicitis with perforation.jpg|thumb|Acute suppurative appendicitis with transmural inflammation, with associated perforation (at right).]]
 
 
{|class=wikitable
 
{|class=wikitable
 
|+ Classification of acute appendicitis based on gross pathology and light microscopy characteristics<ref name="Carr2000">Unless otherwise specified in rows, reference is:<br>- {{cite journal|last1=Carr|first1=Norman J.|title=The pathology of acute appendicitis|journal=Annals of Diagnostic Pathology|volume=4|issue=1|year=2000|pages=46–58|issn=10929134|doi=10.1016/S1092-9134(00)90011-X}}</ref>
 
|+ Classification of acute appendicitis based on gross pathology and light microscopy characteristics<ref name="Carr2000">Unless otherwise specified in rows, reference is:<br>- {{cite journal|last1=Carr|first1=Norman J.|title=The pathology of acute appendicitis|journal=Annals of Diagnostic Pathology|volume=4|issue=1|year=2000|pages=46–58|issn=10929134|doi=10.1016/S1092-9134(00)90011-X}}</ref>
 
|-
 
|-
! Pattern !! Gross pathology !! Light microscopy !! Clinical significance
+
! Pattern !! Gross pathology !! Light microscopy !! Image !! Clinical significance
 
|-
 
|-
 
! Acute intraluminal inflammation  
 
! Acute intraluminal inflammation  
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*Only '''neutrophils in lumen'''
 
*Only '''neutrophils in lumen'''
 
*No ulceration or transmural inflammation  
 
*No ulceration or transmural inflammation  
| Probably none
+
| [[File:Histopathology of acute intraluminal inflammation of the appendix.jpg|190px]]
 +
| Probably '''none'''
 
|-
 
|-
 
! Acute mucosal inflammation
 
! Acute mucosal inflammation
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*'''Neutrophils within mucosa''', and possibly in submucosa
 
*'''Neutrophils within mucosa''', and possibly in submucosa
 
*Mucosal '''ulceration'''
 
*Mucosal '''ulceration'''
| May be secondary to [[enteritis]].
+
|
 +
| May be '''secondary''' to [[enteritis]].
 
|-
 
|-
 
! Suppurative acute appendicitis  
 
! Suppurative acute appendicitis  
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*Commonly intramural '''abscesses'''
 
*Commonly intramural '''abscesses'''
 
*Possibly vascular '''thrombosis'''
 
*Possibly vascular '''thrombosis'''
| Can be presumed to be primary cause of symptoms
+
| [[File:Acute suppurative appendicitis with perforation.jpg|190px]]
 +
| Can be presumed to be primary '''cause''' of symptoms
 
|-
 
|-
 
! Gangrenous/necrotizing appendicitis
 
! Gangrenous/necrotizing appendicitis
 
|  
 
|  
*Friable wall
+
*'''Friable''' wall
 
*Purple, green or black color
 
*Purple, green or black color
 
|  
 
|  
*'''Transmural''' inflammation
+
*'''Transmural''' inflammation, obliterating normal histological structures
 
*'''Necrotic''' areas
 
*'''Necrotic''' areas
 
*Extensive mucosal '''ulceration'''
 
*Extensive mucosal '''ulceration'''
| Will perforate if untreated
+
| [[File:Histopathology of necrotizing appendicitis, high magnification.jpg|190px]]
 +
| Will '''perforate''' if untreated
 
|-
 
|-
 
! Periappendicitis
 
! Periappendicitis
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*Serosa may be congested, dull and exudative
 
*Serosa may be congested, dull and exudative
 
|  
 
|  
*'''Serosal and subserosal inflammation''', no further than outer muscularis propria
+
*'''Serosal and subserosal inflammation''', no further than outer muscularis propria to be called isolated.
| If isolated, probably secondary to other disease
+
| [[File:Histopathology of periappendicitis.jpg|190px]]
 +
| If isolated, probably '''secondary''' to other disease
 
|-
 
|-
 
! Eosinophilic appendicitis
 
! Eosinophilic appendicitis
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*>10 '''eosinophils'''/mm<sup>2</sup> in muscularis propria.
 
*>10 '''eosinophils'''/mm<sup>2</sup> in muscularis propria.
 
*No changes conforming to other types of appendicitis
 
*No changes conforming to other types of appendicitis
| Possibly parasitic, or eosinophilic enteritis.
+
|
 +
| Possibly '''parasitic''', or eosinophilic enteritis.
 
|-
 
|-
! Chronic appendicitis<ref name="SierakowskiPattichis2016">{{cite journal|last1=Sierakowski|first1=Kyra|last2=Pattichis|first2=Andrew|last3=Russell|first3=Patrick|last4=Wattchow|first4=David|title=Unusual presentation of a familiar pathology: chronic appendicitis|journal=BMJ Case Reports|year=2016|pages=bcr2015212485|issn=1757-790X|doi=10.1136/bcr-2015-212485}}</ref>
+
! [[Chronic appendicitis]]<ref name="SierakowskiPattichis2016">{{cite journal|last1=Sierakowski|first1=Kyra|last2=Pattichis|first2=Andrew|last3=Russell|first3=Patrick|last4=Wattchow|first4=David|title=Unusual presentation of a familiar pathology: chronic appendicitis|journal=BMJ Case Reports|year=2016|pages=bcr2015212485|issn=1757-790X|doi=10.1136/bcr-2015-212485}}</ref>
 
|  
 
|  
 
*Fibrosis
 
*Fibrosis
 
|  
 
|  
 
*Predominantly '''mononuclear''' infiltrate rather than neutrophilic.
 
*Predominantly '''mononuclear''' infiltrate rather than neutrophilic.
| Should preferably correlate with long-term or recurrent symptoms.
+
|
 +
| Should preferably correlate with '''long-term or recurrent''' symptoms.
 
|}
 
|}
 +
 +
===Further workup===
 +
{{Moderate-begin}}In acute suppurative appendicitis, still look for any periappendicitis. Also look by the lumen for parasites.{{Moderate-end}}
  
 
===Microscopy report===
 
===Microscopy report===
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;Example:
 
;Example:
 
{|class=wikitable
 
{|class=wikitable
| Acute appendicitis and periappendicitis with transmural necrosis
+
| {{Moderate-begin}}Appendix, resection (or appendectomy):{{Moderate-end}}<br>Acute appendicitis and periappendicitis with transmural necrosis and perforation.
 
+
|}
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Revision as of 19:20, 2 December 2022

Author: Mikael Häggström [note 1]
Appendicitis may histopathologically be defined as neutrophilic infiltrates of the wall of the appendix in the correct clinical context.

  See also: General notes on fixation


Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Gross processing

Standard sections if the appendix appears inflamed and there are no signs of malignancy. Describe abnormal signs including:

Further information: Appendix

Microscopic evaluation

  • Evaluate depth of the inflammation.
  • Look for any perforation of the wall.
  • Look for cancerous cells (which may have caused the appendicitis). Further information: Appendix
  • (Attempt to specify the type of appendicitis as either of the following:)

Types

Classification of acute appendicitis based on gross pathology and light microscopy characteristics[1]
Pattern Gross pathology Light microscopy Image Clinical significance
Acute intraluminal inflammation None visible
  • Only neutrophils in lumen
  • No ulceration or transmural inflammation
Histopathology of acute intraluminal inflammation of the appendix.jpg Probably none
Acute mucosal inflammation None visible
  • Neutrophils within mucosa, and possibly in submucosa
  • Mucosal ulceration
May be secondary to enteritis.
Suppurative acute appendicitis May be inapparent.
  • Dull mucosa
  • Congestion of surface vessels
  • Fibropurulent serosal exudate in late cases
  • Dilation of the appendix
  • Neutrophils in mucosa, submucosa and muscularis propria, potentially transmural.
  • Extensive inflammation
  • Commonly intramural abscesses
  • Possibly vascular thrombosis
Acute suppurative appendicitis with perforation.jpg Can be presumed to be primary cause of symptoms
Gangrenous/necrotizing appendicitis
  • Friable wall
  • Purple, green or black color
  • Transmural inflammation, obliterating normal histological structures
  • Necrotic areas
  • Extensive mucosal ulceration
Histopathology of necrotizing appendicitis, high magnification.jpg Will perforate if untreated
Periappendicitis May be inapparent.
  • Serosa may be congested, dull and exudative
  • Serosal and subserosal inflammation, no further than outer muscularis propria to be called isolated.
Histopathology of periappendicitis.jpg If isolated, probably secondary to other disease
Eosinophilic appendicitis None visible
  • >10 eosinophils/mm2 in muscularis propria.
  • No changes conforming to other types of appendicitis
Possibly parasitic, or eosinophilic enteritis.
Chronic appendicitis[2]
  • Fibrosis
  • Predominantly mononuclear infiltrate rather than neutrophilic.
Should preferably correlate with long-term or recurrent symptoms.

Further workup

(In acute suppurative appendicitis, still look for any periappendicitis. Also look by the lumen for parasites.)

Microscopy report

Should include, if detected:

  • Acute or chronic appendicitis
  • Depth of inflammation
  • Any abscess and\or perforation
  • Necrosis and\or ulceration, at least if transmural

(Classification into one or several types as per table above.)

Example
(Appendix, resection (or appendectomy):)
Acute appendicitis and periappendicitis with transmural necrosis and perforation.

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. Unless otherwise specified in rows, reference is:
    - Carr, Norman J. (2000). "The pathology of acute appendicitis ". Annals of Diagnostic Pathology 4 (1): 46–58. doi:10.1016/S1092-9134(00)90011-X. ISSN 10929134. 
  2. Sierakowski, Kyra; Pattichis, Andrew; Russell, Patrick; Wattchow, David (2016). "Unusual presentation of a familiar pathology: chronic appendicitis ". BMJ Case Reports: bcr2015212485. doi:10.1136/bcr-2015-212485. ISSN 1757-790X. 

Image sources