APPENDICITIS
Bernard M. Jaffe, MD
Professor of Surgery,
Emeritus
INCIDENCE
•
•
•
•
•
•
Very Common, 1 in 10,000/year
12% of Men, 25% of Women
Mean Age 31 Years
Rare in Infancy
M:F Ratio 1.2-1.3 to 1.0
Misdiagnosis 22% in Women, 9% in
Men
CAUSES
• Appendiceal Obstruction
• Children- Lymphoid Hyperplasia
• Adults- Fecalith
•
Carcinoid
Mucinous Carcinoma
•
Cecal Carcinoma
•
Parasites
PATHOGENESIS
•
•
•
•
•
•
•
Obstruction of Appendiceal Lumen
↓
Appendiceal Distention (Mucus)
↓
Venous Ischemia/Gangrene
↓
Perforation at Base (Widest Portion)
BACTERIOLOGY
Aerobes
• E. coli
• Klebsiella Species
• Pseudomonas
aeroginosa
• Staphylococcal
Species
• Enterococcus
Anaerobes
• Bacteroides fragilis
• Fusobacterium
Species
• Peptostreptococcus
• Clostridium Species
SYMPTOMS
• Abdominal Pain
• Classically, Peri-Umbilical to Right
Lower Quadrant
• Constant, Not Colicky
• Increased With Increased IntraAbdominal Pressure
• Comes on Fairly Abruptly
SYMPTOMS
• Anorexia, Nausea, Vomiting
• Bowel Movements Unpredictable
• Pain on Walking and Moving
Abdominal Muscles
• Fever, Chills, Sweating
• Shortness of Breath
PHYSICAL FINDINGS
• Right Lower Quadrant and Referred
Tenderness
• Involuntary Guarding
• Psoas, Obturator Signs
• Decreased Diaphragmatic Excursion
• Direct and Referred Rebound
• Distention, Decreased Bowel Sounds
• Tachycardia, Tachypnea, Flushing
DIAGNOSIS
• Made on Clinical Findings
• Anorexia as First Symptom Fairly
Suggestive
• White Blood Cell Count Unreliable
• Additional Studies Rarely Necessary
• Imaging Grossly Overused and Rarely
Helpful
•
•
•
•
•
•
•
DIFFERENTIAL DIAGNOSIS
Crohn’s Disease
Meckel’s Diverticulitis
Sigmoid/Cecal Diverticulitis
Pelvic Inflammatory Disease
Cholecystitis
Mesenteric Adenitis
Ruptured Ectopic Pregnancy, Ovarian
Cyst, Torsion
ALVARADO SCALE
•
•
•
•
•
•
•
•
Migration of Pain
Value 1
Anorexia
1
Nausea, Vomiting
1
Right Lower Quadrant Tenderness 2
Rebound
1
Elevated Temperature
1
Leukocytosis
2
Left Shift
1
ALVARADO SCALE
• Often Used as Diagnostic Tool
• Add Up Values to Determine Likelihood
• 9-10 Positive
• 7-8 High Liklihood
• 5-6 Equivocal
• 0-4 Very Unlikely
IMAGING
•
•
•
•
•
•
•
For Equivocal Presentations
To Detect Complications
CT Equal Results as Ultrasound
Has Not Lowered Rates of
False Pos/Neg Diagnosis
Perforation
IMAGING
• Findings• Dilated Appendix (>7cm)
• Thick Walled Appendix
• Peri-Appendiceal Fluid/Edema
• Adjacent Mesenteric Fat Stranding
• Free Air Uncommon After Perforation
• Failure to Fill With Contrast Unreliable
APPENDICEAL RUPTURE
•
•
•
•
•
•
•
•
Overall Rate 26%
Higher Rates in Children <5- 45%
Elderly >65- 51%
Perforation Difficult to Diagnose
Increases with Length of Symptoms
Suspicion- T > 39
WBC >18,000
PROGNOSIS
•
•
•
•
•
•
•
Mortality Rate Overall 0.2/100,000
Ruptured Appendix 3%
Ruptured in Elderly 15%
Death Usually from Uncontrolled Sepsis
Morbidity Nonperforated 3%
Perforated 47%
Wound Infection Most Common
LAPAROSCOPIC APPENDECTOMY
• ? More Effective Than Open
• Compared to Open- More Expensive
•
Longer Operation
•
Fewer Wound
Infections
•
3-X More Abcesses
•
Same Mortality
Rate
ABCESS
• More Common After Perforation
•
Gangrene
• Sites- Interloop (Often Multiple)
•
Appendiceal Fossa
•
Subhepatic Space
•
Pelvis (Pouch of Douglas)
PELVIC ABCESSES
• Common After Perforated Appendicitis
• Usually Recognized 5-8 Days After
Operation
• Drainage- Surgical (Open or Lap)
•
Percutaneous (Can Be Tough)
•
Transrectal- Most Direct
•
Most Effective
•
Transvaginal in Women
PREGNANCY
•
•
•
•
Incidence 1 in 2,000 Pregnancies
More Common First, Second Trimesters
Appendix Rises as Uterus Grows
Leukocytosis Confusing- 15-20,000
Normally in Pregnancy
• Perforation Doubles Rate of Fetal
Mortality
• Operation- 10-25% Premature Labor
RLQ MASS
•
•
•
•
•
•
•
Imaging Determines Therapeutic Plan
Abcess- Percutaneous Drainage
Antibiotics
Phlegmon- Operation More Dangerous
Antibiotics
Operate for Acute Abdomen
For Both, Once Well- Perform Interval
Appendectomy
INTERVAL APPENDECTOMY
•
•
•
•
•
More Expensive
Two Hospitalizations, Each 1-3 Days
Morbidity 3%
Can Be Done Laparoscopically
Controversy If It Is Necessary???
INTERVAL APPENDECTOMY
•
Pro• 40% Need Appendectomy Earlier Than
Planned
• Late Failure, Persistent, Recurrent
Appendicitis 35%
• At Operation, 80% Have Peri-Appendiceal
Abcess or Adhesions
• Occasional Appendiceal Tumor
INTERVAL APPENDECTOMY
•
Con-
• 50% Never Have Subsequent Clinical
Appendicitis
• 25-50% Have Normal Histology
• Despite Minimal Procedure, It is
Another Operation
• Requires Recuperation
CHRONIC APPENDICITIS
• Pain Same Location, Less Intense, Lasts
Longer
• Anorexia, Nausea, Less Vomiting
• Normal WBC Counts, Imaging
• Surgeons Establish Diagnosis With
94% Specificity, 78% Sensitivity
• Good Correlation Symptoms With Findings
• Appendectomy Cures 94%
INCIDENTAL APPENDECTOMY
• Need 36 Appendectomies to Prevent One
Appendicitis
• Spend $20 Million to Save $6 Million
• Special Circumstances•
Disabled Patients
•
Crohn’s Disease (at Other Operation)
•
Children About to Start Chemotherapy
•
Travel to Remote Places
APPENDICEAL TUMORS
•
•
•
•
•
Rare, 0.9 to 1.4% Appendectomies
0.12 Per 1,000,000 People/Year
Rarely Suspected Pre-Op
Only 50% Diagnosed at Operation
Mucocele (Benign or Malignant) More
Common Than Carcinoid
• Also Lymphoma- Very Rare