DISSERTATION ON
CLINICO-PATHOLOGICAL FEATURES AND OUTCOME OF ACUTE APPENDICITIS – A PROSPECTIVE STUDY IN OUR INSTITUTION
M.S.DEGREE EXAMINATION BRANCH – I
GENERAL SURGERY
STANLEY MEDICAL COLLEGE AND HOSPITAL THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY
CHENNAI MAY – 2018
CERTIFICATE
This is to certify that dissertation entitled, clinico-pathological features and outcome of acute appendicitis – a prospective study in our institution; is a bonafide record of work done by Dr. Kokila S. , in the Department of General Surgery, Stanley Medical College, Chennai, during his Post Graduate Course from 2015-2018 under the guidance and supervision of Prof. Dr. S. MANISELVI, M.S., This is submitted in partial fulfilment for the award of M.S. DEGREE EXAMINATION- BRANCH I (GENERAL SURGERY) to be held in May 2018 under the Tamilnadu, DR.M.G.R. Medical University, Chennai.
Prof. Dr.PONNAMBALAM NAMASIVAYAM, M.D., The Dean
Stanley Medical College Chennai
Prof. Dr.S. MANISELVI M.S., Professor
Department of General Surgery Stanley Medical College, Chennai
PROF.DR.A.K.RAJENDRAN M.S.,
Professor and Head
Department of General Surgery Stanley Medical College, Chennai.
DECLARATION
I declare that this dissertation entitled “clinico-pathological features and outcome of acute appendicitis – a prospective study in our institution” is a record of work done by me in the Department of General Surgery, Stanley Medical College, Chennai, during my Post Graduate Course from 2015-2018 under the guidance and supervision of my unit chief PROF.DR. S. MANISELVI M.S. It is submitted in partial fulfilment for the award of M.S. DEGREE EXAMINATION – BRANCH I (GENERAL SURGERY) to be held in May 2018 under the Tamilnadu Dr.M.G.R. Medical University, Chennai. This record of work has not been submitted previously by me for the award of any degree or diploma from any other university.
Dr. Kokila S.
ACKNOWLEDGEMENT
I express my extreme gratitude to Prof. S. Maniselvi M.S., my unit chief, for his constant guidance and suggestion throughout my study period.
I express my profound gratitude to Prof. Dr. M.V.Udayachandar M.S., professor of Surgery for his support and help during my study.
I owe a great depth of gratitude to Prof.Dr.S.Ponnambalam Namasivayam, Dean, Government Stanley Medical College and Hospital, Chennai for his kind permission and making this study possible.
I am grateful to Dr.T.Babu Antony M.S. and Dr.Ponmuthu M.S., assistant professors of General Surgery for their kind assistance and timely guidance throughout my course.
I thank the DEAN, Stanley Medical College for permitting me to use the hospital facilities for my study
I express my sincere thanks to all patients, who in spite of their physical and mental sufferings have co-operated and obliged to my request for regular follow up, without whom my study would not have been possible.
CONTENTS
Chapter Title Page
No.
1 INTRODUCTION 1
2 AIM AND OBJECTIVE OF THE STUDY 3
3 REVIEW OF LITERATURE 4
4 MATERIALS AND METHODS 58
5 RESULTS 61
6 DISCUSSION 74
7 CONCLUSION 77
8 BIBLIOGRAPHY 78
9 PROFORMA 85
10 MASTER CHART 86
1
1. INTRODUCTION:
Appendiceal disease is a frequent reason for emergency hospital admission and, most commonly performed abdominal emergency surgery is an appendectomy. The decision for surgery is based on clinical examination.
Improper management of acute appendicitis will result in significant morbidity and mortality. In spite of recent advances in technology, it is difficult to diagnose using a specific laboratory test or examination with sensitivity and specificity.
For males Incidence rate is 8.6% and for females is 6.7%. It is more common in males than females.
Clinical diagnosis with accuracy is the challenging step in surgeons practice. Rapid detection will lead to a better treatment outcome. The main presenting complaint is abdominal pain. Murphy was the one who first describes the characteristic symptoms of acute appendicitis, sequence of abdominal pain followed by vomiting and migratory pain to the right iliac fossa. This presentation is seen only in 50% of the patients. Abdominal pain, vomiting, fever, right iliac fossa tenderness is enough for any surgeon to proceed with surgery. We rarely need a specialist investigation to make the diagnosis of appendicitis as it is predominantly a clinical diagnosis. Use of bedside tests and laboratory investigation can give us additional evidence in the diagnosis of acute appendicitis and help us to exclude the important differential diagnosis. Delay in the diagnosis will lead to the complications. In view to decrease the complications
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early diagnosis and prompt treatment is needed, which will lead us to negative laparotomy (25%).
As it is a clinical diagnosis, it’s impossible to diagnose with accuracy pre- operatively. Complete history and clinical examination still remains mainstay for the diagnosis. This present study was conducted to know the various and common presentations with investigation co-relation, per operative findings, common post op complications and Histo-pathological findings in our institution, surgical emergency ward, Government Stanley medical college. Most common surgical emergency performed in our institution are emergency open appendectomy
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2. AIMS AND OBJECTIVES OF THE STUDY:
• To study the various clinical presentation of acute appendicitis
• To study the age and sex distribution
• Role of ultra-sonogram in diagnosis
• Per operative appearance of appendix and peritoneal cavity.
• Postoperative complications and follow up
• HPE report of appendix after appendectomy
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3. REVIEW OF LITERATURE:
3.1 HISTORY:
Despite the prevalent role appendix plays in healthcare today, human appendix was not noted until 1492. Leonardo DA Vinci depicted the appendix in his anatomical drawings, but these were not published until the eighteenth century.
In 1521, Berengario DA Capri published drawings recognizing the appendix.
In 1543, Andreas Vesalius published his drawings in “ De Human Corporis Fabrica”.
In 1544, French physician, Jean Fernel first describing Appendiceal disease in a paper. He reported that a 7-year-old girl came with diarrhea, which was treated by him using doses of quince, used in folk remedies. Quince is an apple-like fruit. After that, she developed abdominal pain and died. At the time of autopsy, the lumen of the appendix was found to obstructed by the quince which causing necrosis and perforation.
In 1710, verneys was first coined the term “Appendix vermiformis”.
In 1710, Giova Morgagni was illustrated the appendix in “ Adversion Anatomica”
In 1711, the first description of classic Appendicitis mentioned by Lorenz Heister
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In 1736 , Claudius Amyand was first performed known appendectomy in London . He operated in an 11-year-old boy presented with a scrotal hernia with a complication of fecal fistula. Amyand found a perforated appendix within the hernia Sac which was surrounded by omentum. The appendix and omentum were surgically amputated. The patient was discharged in good condition a month later. For over a century later, early appendectomy advocated as treatment before the appendicitis was recognized as a common cause for right lower quadrant Pain.
There was also extensive discussion of typhlitis and perityphlitis throughout this period as it was also the common etiologies of right lower quadrant pain. Only sporadic cases were treated with appendectomy.
In 1742, Leonardo da vanci first illustrate the appendix and he named it “orecchio” which denotes as an auricular appendage of caecum.
In 1812, John Parkinson recorded a case of acute appendicitis.
In 1824, Louyer-Villermay presented a paper which emphasizes the importance of acute appendicitis before the Royal Academy of Medicine in Paris.
He reported two cases of appendicitis in autopsy In 1827, a French physician Francois Melier, expounded on Louyer-
Villermay’s work. He was the one who suggest the antemortem findings of appendicitis in reported six autopsy cases.
In 1848, Hancock was carried the first surgical treatment for appendicitis without abscess.
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In 1880, Lawson Tait, who was a pioneer of abdominal surgery, was first performed transabdominal appendectomy in a girl presented with gangrenous appendicitis.
In 1883, Fergus was performed the first elective appendectomy in canada
In 1886, Kronlein published the first account of appendectomy for appendicitis.
In 1886, Reginald H. Fitz first recommended the consideration for operative treatment for acute appendicitis.
In 1889 Mc Burney’s described the Mc Burney’s point as ”maximum tenderness when examined with the finger tips is , in adults, one half to two inches inside the right anterior spinous process of the ilium on a line drawn to the Umbilicus”.
In 1890, Fredrick Treves advocated conservative treatment followed by interval appendectomy for acute appendicitis after a period of interval.
In 1902, surgeon from Chicago, Albert Oschner who recommended a conservative approach in the patients with appendicular perforation presented with generalised peritonitis followed by surgical intervention at later date
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During the following decade, the surgical treatment was discussed intensely and appendectomy became a more expectant management for acute appendicitis. It was recognized that appendicitis in most instances, could resolve without any surgical management. But it was difficult to identify the disease progression as it was often lethal form. Eventually, early appendectomy was accepted as standard care to prevent perforation. This change in practice in the first decade of the twentieth century resulted in increase in number of appendectomies. However, this surgery almost had no impact in perforated appendicitis incidence rate or mortality rate of appendicitis.
In the 1970s, the negative appendectomy rate of uninflamed appendix increased. So there was a gradual shift towards conservative approach.
In 1982, Semm was credited widely for performing a laparoscopic appendectomy.
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TABLE 1: Anatomic and surgical history of appendix:
Leonardo da Vinci
1492 Showed appendix in drawings and called it "orecchio"
(little ear); published in the 18th century Berengario da
Carpi
1521 First person to describe the appendix
Andreas Vesalius
1543 Showed the appendix in a drawing but did not describe it in the text
Jean Fernel 1544 Early description of appendicitis Von Hilden 1652 Early description of appendicitis
Lorenz Heister 1711 Unequivocal description of perforated appendix with abscess formation
Giovanni Battista Morgagni
1719 First detailed anatomic description of appendix
Claudius Amyand
1736 Performed the first appendectomy? or Tait, 1980? or Krönlein, 1884?
Mestivier 1759 Described perforation of the appendix by a pin;
considered perforation the cause of the abscess; the second unequivocal case identifying appendix as site of disease
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John Hunter 1767 Described gangrenous appendix at autopsy
John Parkinson 1812 Described autopsy findings of 5-year-old child with perforated appendix containing a fecalith
Louyer- Villemay
1824 Described fatal gangrenous appendix in two young men; first clinical history of acute suppurative appendicitis
Francois Melier 1827 Presented six autopsy descriptions of appendicitis and suggested that perhaps surgical removal of the appendix was in order
Goldbeck 1830 Described acute suppurative appendicitis but said cause was irritation of cecum; first use of term
"perityphlitis"
Guillaume Dupuytren
1835 Ascribed RLQ abscesses to pericecal origin without mention of appendix
Stokes 1838 Used large doses of opium to treat intraabdominal inflammations
Thomas Addison and
1839 Described symptomatology of appendicitis; stated that appendix was the cause of many or
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Richard Bright most of the inflammatory processes of the right iliac fossa
A. Grisolle 1839 Advocated drainage of abdominal abscesses following watchful waiting until fluctuation
Volz 1846 Identified the appendix as the origin of RLQ inflammatory process
Henry Hancock 1848 Recommended earlier operation for drainage of abscesses
Willard Parker 1867 Recognized obstructive origin of appendicitis; reported four cases of abscess secondary to perforated appendix;
advised surgical drainage after the 5th day of the disease, but did not advise operation before perforation Lawson Tait 1880 Removed a gangrenous appendix; in 1890 abandoned
appendectomy Abraham
Groves
1883 Removed an inflamed appendix; not published until 1934
Mikulicz 1884 Removed the appendix but patient did not survive Krönlein 1884 Perhaps, rather than Amyand in 1736, was first to
perform appendectomy
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Charter- Symonds
1885 Extraperitoneal removal of fecolith
Reginald Heber Fitz
1886 Advocated early surgical removal of acute appendix;
first used term "appendicitis"
R.J. Hall 1886 Successfully removed perforated appendix within an irreducible inguinal hernia with pelvic
abscess
John Homans 1886 Operated on an 11-year-old boy, draining the abscess with good recovery
Thomas G.
Morton
1887 Successful operative removal of perforated appendix with draining of abscess
Edward R.
Cutler
1887 Performed one of the first "clean" unruptured appendectomies; reported in 1889
Henry Sands 1888 Removed two fecoliths and closed the perforation of the appendix
Charles Mc Burney
1889 Described abdominal point tenderness (Mc Burney's point)
June, 1894
Presented "gridiron incision" (Mc Burney's incision) to Chicago Medical Society (CMS)
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Lewis L.
McArthur
July, 1894
Published his vertical midline incision technique, which was postponed from presentation at June meeting of CMS
G.R. Fowler 1894 to 1895
Advocated "cuffing" of appendiceal stump
R.H.M.
Dawbarn
1895 Advocated invagination of appendiceal stump to prevent postoperative fistula
William Henry Battle
1897 Advocated a vertical incision through the lateral edge of the right rectus sheath; others also advocated it, and incision sometimes is referred to as Battle-Jalaguier- Kammerer incision
A.C. Bernays 1898 Reported 71 consecutive appendectomies without mortality
Harrington,
Weir, and
Fowler
1899 Described medial extension of gridiron incision by dividing lateral portion of rectus sheath (Fowler-Weir extension)
A.J. Ochsner 1902 Advocated nonoperative treatment to localize spreading peritonitis
John B. Murphy 1904 Reported 2000 appendectomies without death
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H.A. Kelly 1905 Advocated against "ligating, amputating, and burying the little stump"
A. E. Rockey, 1905 Each advocated transverse skin incision (later called Rockey-Davis incision)
G. G. Davis 1906
P. Masson 1921 Described neuromas of the appendix; studied relationship between neuroendocrine cells and origin of carcinoid tumors
Arthur Rendle Short
1925 Investigated appendicitis as "a disease of Western civilization," low-fiber diet
LeGrand Guerry
1926 Cited 2,959 personal cases of appendectomy
A.J.E. Cave 1936 Described appendiceal duplications and abnormalities D.C. Collins 1951 Described agenesis of the appendix
1955 Study of 50,000 human appendix specimens 1963 Study of 71,000 human appendix specimens
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Skandalakis et
al. 1962
Collective review of cases of smooth muscle tumors of the colon and appendix as reported in the world literature
O'Neill 1966 Described use of appendix as fallopian tube
E. Higa et al. 1973 Described proliferative epithelial tumors of appendiceal mucosa
de Kok 1977 Laparoscope-aided appendectomy with mini- laparotomy
A.P. Dhillon, L.
Papadaki, J.
Rode
1982 to 1983
Studied subepithelial neuroendocrine cells;
immunoreactivity for serotonin
Semm 1983 Laparoscopic appendectomy
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3.2 EMBRYOLOGY:
In the sixth week of human embryonic development, the appendix and cecum appear as outpouchings from the caudal limb of the midgut.
Initially the appendiceal outpouching is noted in the eighth week which begins to elongate to achieve a vermiform appendix during the fifth month. Throughout the development of appendix, it maintains the position at the tip. Further unequal growth of the cecum lateral wall will causes the appendix to take its position posteromedially , just below the ileocecal valve. By following Longitudinally along the taeniae coli, the appendicular base can be located.
Based on the tip of the appendix, its position may vary from retrocaecal, pelvic, pre-ileal, post-ileal, paracaecal, promonteric (subileal/subcaecal) in the right lower quadrant.
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In midgut malrotation and situs inversus, the appendix as well as caecum will not locate in an usual location (right lower quadrant). In midgut malrotation, the small bowel and proximal colon is fails to rotate or incompletely rotates around the superior mesenteric artery axis during fetal development. The position of appendix in this anomaly is in the left upper quadrant of the abdomen. In situs inversus, the position of appendix is in the left lower quadrant of the abdomen
Position Incidence
Retrocecal 74% Commonest position Pelvic 21% 2nd Commonest position
Pre-ileal 1%
Post- ileal 0.5%
Paracaecal 2%
Promontoric(Subileal /subcaecal)
1.5%
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3.3. ANATOMY:
In the adult, the average length of the appendix is 6 to 9 cm;
however, it can vary in length from 1 to 30 cm. The outer diameter varies between 3 and 8 mm, whereas the luminal diameter varies between 1 and 3 mm.
3.3.1BLOOD SUPPLY:
ARTERIAL SUPPLY:
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The appendix receives its arterial supply from the appendicular branch of the ileocolic artery. This artery originates posterior to the terminal ileum, entering the mesoappendix close to the base of the appendix.
VENOUS AND LYMPHATIC DRAINAGE:
Appendicular Vein, which drains into the ileocolic vein which drains into the superior mesenteric vein which drains into portal vein.
The lymphatic drainage of the appendix flows into lymph nodes that lie along the ileocolic artery.
3.3.2 NERVE SUPPLY:
Innervation of the appendix is derived from sympathetic elements contributed by the superior mesenteric plexus (T10-L1) and afferents from the parasympathetic elements via the vagus nerves.
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3.3.3 HISTOLOGY OF APPENDIX:
The histologic features of the appendix are contained within the three following layers: the outer serosa, which is an extension of the peritoneum; the muscularis layer, which is not well defined and may be absent in certain locations; and finally, the submucosa and mucosa. Lymphoid aggregates occur in the submucosal layer and may extend into the muscularis mucosa. Lymphatic channels are prominent in regions underlying these lymphoid aggregates. The mucosa is like that of the large intestine, except for the density of the lymphoid follicles. The crypts are irregularly sized and shaped, in contrast to the more uniform appearance of the crypts in the colon. Neuro-endocrine complexes
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composed of ganglion cells, Schwann cells, neural fibers and neurosecretory cells are positioned just below the crypts.
3.4. PHYSIOLOGY:
For many years, the appendix was erroneously believed to be a vestigial organ with no known function. It is now well recognized that the appendix is an immunologic organ that actively participates in the secretion of immunoglobulins, particularly immunoglobulin A.
3.5 ACUTE APPENDICITIS:
Acute appendicitis is one of the most common causes of an abdominal emergency and accounts for approximately 1% of all surgical operations. Although rare in infants, appendicitis becomes increasingly common throughout childhood and reaches its maximal incidence between the ages of 10 and 30 years. After 30 years of age, the incidence declines, but appendicitis can occur in individuals of any age. Among teenagers and young adults, the male-to- female ratio is about 3:2. After age 25 years, the ratio gradually declines until the sex ratio is equal by the mid-30s.
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3.5.1 PATHOPHYSIOLOGY:
The most commonly accepted theory of the pathogenesis of appendicitis is that it results from obstruction followed by infection. The lumen of the appendix becomes obstructed by hyperplasia of submucosal lymphoid follicles, a fecolith, tumor, or other pathologic condition.
Once the lumen of the appendix is obstructed, the sequence of events leading to acute appendicitis is probably as follows:
Mucus accumulates within the lumen of the appendix →pressure within the organ increases →Virulent bacteria convert the accumulated mucus into pus→ Continued secretion combined with the relative inelasticity of the serosa → further rise in pressure within the lumen → obstruction of the lymphatic drainage→ edema of the appendix, diapedesis of bacteria, and the appearance of mucosal ulcers → Continued secretion→ increasing edema → further rise in intra-luminal and tissue pressure → venous obstruction and isch- emia→ diapedesis of bacteria→ acute suppurative appendicitis→ pathologic process continues→ venous and arterial thromboses→ gangrenous appendicitis→ small infarcts→ escape of bacteria and contamination of the peritoneal cavity→ Perforating appendicitis→ spilling of accumulated pus.
At initial stage, the disease is still localized to the appendix;
therefore, the pain perceived by the patient is visceral and is localized to the epigastrium or peri umbilical area.
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In acute suppurative appendicitis, Somatic pain occurs when the inflamed serosa of the appendix comes in contact with the parietal peritoneum and results in the classic shift of pain to the right lower quadrant.
3.5.2 SYMPTOMS:
The symptomatic history in acute appendicitis may vary, but cardinal symptoms are usually present. The history usually begins with abdominal pain often localized to the epigastrium or the periumbilical area, followed by anorexia and nausea. Vomiting, if it occurs, appears next. After a variable period, usually about 8 hours, the pain shifts to the right side and usually into the right lower quadrant. At the time of presentation, the duration of pain is less than 24 hours in 75% of patients.
PAIN:
The typical pain of acute appendicitis initially consists of diffuse, central, minimally severe visceral pain, which is followed by somatic pain that is more severe and usually well localized to the right lower quadrant. Failure to follow the classic visceral-somatic sequence is common in acute appendicitis, occurring in up to 45% of patients who are proved subsequently to have appendicitis. Atypical pain may be somatic and localized to the right lower quadrant from its initiation. Conversely, the pain may remain diffuse and may never become localized. In older patients, atypical pain patterns occur more frequently. Patients with high retrocecal appendicitis may present with only
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diffuse pain in the right flank. Similarly, patients in whom the entire appendix is within the true pelvis may never experience somatic pain and, instead, may have tenesmus and vague discomfort in the suprapubic area.
ANOREXIA, NAUSEA, AND VOMITING:
Anorexia and nausea are present in almost all patients with acute appendicitis, but vomiting occurs in less than 50% of patients. The presence or absence of vomiting is not a criterion for the diagnosis of appendicitis. When vomiting does occur, it is usually not persistent, and most patients vomit only once or twice. If vomiting occurs, it occurs after the onset of pain with such regularity that if it precedes pain, the diagnosis of appendicitis should be questioned.
CONSTIPATION AND DIARRHEA:
A history of the recent onset of constipation or diarrhea is not helpful in the diagnosis of appendicitis. A greater percentage of patients with appendicitis complain of constipation, but some give a history that defecation relieves the pain.
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3.5.3 PHYSICAL EXAMINATION
Typical physical signs of acute appendicitis include localized tenderness in the right lower quadrant, muscle guarding, and rebound tenderness.
Cutaneous hyperesthesia and right-sided pelvic tenderness on rectal often the temperature is normal, fever up to 38° C or higher may occur. In the usual case of acute, non-perforated appendicitis, higher fever occurs infrequently.
TENDERNESS AND MUSCLE GUARDING
On routine abdominal examination, an area of maximal tenderness often is elicited in the area of Mc Burney point, which is located two- thirds of the distance along a line from the umbilicus to the right anterior superior iliac spine. If the appendix is in a high retrocecal position or is entirely within the true pelvis, point tenderness and muscle rigidity might not be elicited. In high retrocecal appendicitis, tenderness may occur over a large area, and there may be no signs of muscle rigidity. In pelvic appendicitis, neither tenderness nor muscle guarding may be present. Both signs are often lacking or only minimally expressed in the aged population.
Signs of peritoneal inflammation or irritation in the right lower quadrant are also helpful in the diagnosis of acute appendicitis and can be demonstrated by many methods. Asking the patient to cough or bounce on the heels elicits this type of pain in 85% of patients.
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Rebound tenderness is elicited by the sudden release of abdominal palpation pressure.
Rovsing sign—pain elicited in the right lower quadrant with palpation pressure in the left lower quadrant—is a sign of acute appendicitis.
Muscle guarding is manifested as resistance to palpation, increases as the severity of inflammation of the parietal peritoneum increases.
Initially, there is only voluntary guarding, but this is replaced by reflex involuntary rigidity.
ABDOMINAL MASS
As the disease process progresses, it may be possible to palpate a tender mass in the right lower quadrant. Although the mass may be caused by an abscess, it can also result from adherence of the omentum and loops of intestine to an inflamed appendix. When appendicitis becomes advanced enough that there is a large, inflamed mass and the anterior abdominal wall is involved, the patient often avoids sudden movements that can cause pain.
PSOAS SIGN
The right hip is often kept in slight flexion to keep the ilio psoas muscle relaxed. Stretching the muscle by extension of the hip or further flexion against resistance can initiate a positive psoas sign, indicating irritation of the muscle by an inflamed appendix. A psoas sign is seldom seen in early
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appendicitis and can be elicited in patients without any pathologic condition (false positive).
RECTAL EXAMINATION
Although essential in all patients with suspected appendicitis is helpful in only a few of them. In patients with an uncomplicated appendicitis, the finger of the examiner cannot reach high enough to elicit pain on rectal examination.
If the appendix ruptures, the physical examination will change.
If the infection is contained, a tender mass will often develop in the right lower quadrant, and the area of tenderness will now encompass the entire right lower quadrant. Involuntary guarding becomes evident and rebound tenderness more marked. The patient’s temperature will be more like that seen with abscess formation and may rise to 39° C with a corresponding tachycardia.
If appendiceal rupture fails to localize, signs and symptoms of diffuse peritonitis will develop. Tenderness and guarding become generalized, the temperature remains higher than 38° C with spikes to 40° C, and the pulse rate increases to more than 100 beats/min.
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3.5.4 LABORATORY TESTS
In the early diagnosis of acute appendicitis, laboratory tests are of little value. Up to one-third of patients, particularly older patients have a normal total leukocyte count with acute appendicitis, and more than half have, at most, a mild elevation. Even when the total leukocyte count and the differential white blood cell (WBC) count are abnormal, the degree of abnormality does not correlate well with the degree of appendiceal inflammation.
Even when the total WBC count is normal, the differential WBC count often reveals a shift to the left with an increase in the percentage of polymorphonuclear neutrophils. Less than 4% of patients with appendicitis have both a normal total WBC count and a normal differential count. Patients with a normal WBC count and normal C-reactive protein rarely have appendicitis. The most important fact to remember when considering the diagnosis of appendicitis is that the clinical findings take precedence over the WBC count when they are at variance.
Urinalysis is helpful in the differential diagnosis of patients with lower abdominal pain only when it reveals significant numbers of red blood cells (RBCs), WBCs, or bacteria. Minimal numbers of RBCs, WBCs, and bacteria are seen in normal patients as well as in patients with appendicitis.
Patients with advanced appendicitis and abscess formation or generalized peritonitis may have abnormalities in liver function tests that mimic obstructive jaundice, biliary stasis, or other primary liver problems.
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CLINICAL SCORING SYSTEM:
The Alvarado score is the most widespread scoring system. It is especially useful for ruling out appendicitis and selecting patients for further diagnostic workup.
The Appendicitis Inflammatory Response Score resembles the Alvarado score but uses more graded variables and includes CRP. Studies have shown it to perform better than the Alvarado score in accurately predicting appendicitis.
However, clinical scoring systems have not gained widespread acceptance in making the diagnosis of appendicitis.
Alvarado Score Interpretation
Findings
Migratory right iliac fossa pain Anorexia
Nausea or vomiting
right iliac fossa Tenderness Rebound tenderness
Fever ≥36.3°C
Leukocytosis ≥10,000
Shift to the left of neutrophils
Points 1 1 1 2 1 1 2 1
Score:
<3: Low likelihood of appendicitis
4–6: Consider further imaging
≥7: High likelihood of appendicitis
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Appendicitis Inflammatory Response Score Findings
Vomiting
Pain in the right inferior fossa
Rebound tenderness or muscular defense Light
Medium Strong
Body temperature ≥38.5C Polymorphonuclear leukocytes
70%–84%
≥85%
White blood cell count
10,000–14,900 ≥15,000 C-reactive protein concentration
10–49 g/L ≥50 g/L
Points 1 1
1 2 3 1
1 2
1 2
1 2
Score:
0–4: Low probability.
Outpatient follow-up.
5–8: Indeterminate group.
Active observation or diagnostic laparoscopy.
9–12: High probability.
Surgical exploration.
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3.5.5 RADIOGRAPHIC EXAMINATION PLAIN X-RAY ABDOMEN:
Plain Roentgenologic examination of the abdomen is of little help in the differential diagnosis of acute appendicitis. The exceptions are when a fecolith is demonstrated (usually in the right lower quadrant) and when other diagnoses such as acute cholecystitis, perforating duodenal ulcer, perforating colon cancer, acute diverticulitis, and pyelonephritis are being excluded.
It is usual to see caecal distention or a sentinel loop of distended small intestine in the right lower quadrant in patients with acute appendicitis. In late appendicitis with perforation and abscess formation, a mass can often be demonstrated that is extrinsic to the cecum. There may be scoliosis to the right, lack of the right psoas shadow, lack of small bowel gas in the right lower quadrant with abundant gas elsewhere in the small bowel, and signs of edema of the abdominal wall. With late appendicitis and generalized peritonitis, there is an ileus pattern with generalized gas throughout the small and large intestine.
BARIUM ENEMA:
Barium enema (BE) examination was recommended in the past in young women in whom the diagnosis was still in question after hours of observation and in patients with a debilitating systemic disease, such as leukemia, in whom the operative risk is markedly increased. The findings of significance on barium enema include lack of filling or partial filling of the appendix and an
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extrinsic pressure defect on the cecum (the “reverse 3” sign). It was replaced by CT and USG.
ULTRASONOGRAPHY (USG):
As demonstrated in many studies, an experienced radiologist is able to diagnose acute appendicitis using US with accuracy greater than 90%.
Appendicitis is diagnosed if the maximal cross-sectional diameter of appendix exceeds 6 mm, if it is non-compressible, if an appendolith is present, or if a complex mass is demonstrated. There are other criteria that are not universally agreed on, such as rigidity and nonmobility. Nonvisualization of the appendix is not a criterion for appendicitis.
US can also be helpful in the diagnosis of perforated appendicitis with abscess formation. Studies that compared US and CT have demonstrated CT to be more accurate than US in the diagnosis of appendicitis in clinically equivocal cases. Therefore, US should be used only when an experienced radiologist with an interest in appendicitis is available.
COMPUTED TOMOGRAPHY (CT)
• Although more expensive, CT has also been demonstrated to be of benefit in the diagnosis of acute appendicitis and has an accuracy greater than 94%.
The cost can be reduced with no significant loss in diagnostic accuracy by performing a limited, unenhanced CT. Appendicitis is diagnosed when the appendix is thickened with a diameter greater than 6 mm; a phlegmon, fluid, or abscess is present; there is an appendolith; and there are
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inflammatory changes in the periappendiceal fat (streaking and poorly defined increased attenuation). The presence of pericecal inflammation without the presence of an inflamed appendix or an appendolith without the presence of periappendiceal inflammation are both insufficient to diagnose acute appendicitis.
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• An important consideration for CT in the diagnosis of acute appendicitis is when to use it. In one study, CT scanning excluded appendicitis in almost half of the patients in the study and identified an alternative diagnosis in 51% of those patients. The authors stated that the routine use of CT in patients with suspected appendicitis avoids unnecessary appendectomies and unnecessary delays before surgical treatment and saves money. In another institution, the routine use of CT scanning for the evaluation of suspected appendicitis has led to a decrease in the negative appendectomy rate from 23% to 1.7%.
• CT is not indicated in patients with an unequivocal diagnosis of appendicitis or in patients with a low risk of the diagnosis. In menstruating women and any patient with an equivocal diagnosis, a CT scan is probably indicated. An added benefit of the use of CT is that an identified abscess can be percutaneously drained during the same procedure
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3.6.1 ACUTE APPENDICITIS IN INFANTS AND YOUNG CHILDREN The diagnosis of acute appendicitis is difficult in infants and young children for many reasons. The patient is unable to give an accurate history, and although appendicitis is infrequent, acute nonspecific abdominal pain is common in infants and children. Because of such factors, the diagnosis and treatment are often delayed, and complications develop.
The clinical presentation of appendicitis in children can be quite similar to nonspecific gastroenteritis; thus, the suspicion of appendicitis often is not entertained until the appendix has ruptured and the child is obviously ill. Two-thirds of young children with appendicitis have had symptoms for more than 3 days before appendectomy. Because children often cannot give an accurate history of their pain, the physical examination and other aspects of the history must be relied on to make the diagnosis. Vomiting, fever, irritability, flexing of the thighs, and diarrhea are likely early complaints. Abdominal distention is the most consistent physical finding.
Among the most common atypical findings in children with appendicitis are absence of fever, absence of Rovsing sign, normal or increased bowel sounds, and absence of rebound pain. As in adults, the total leukocyte count is not a reliable test.
The incidence of perforation in infants younger than 1 year of age is almost 100%, and although it decreases with age, it is still 50% at 5 years of age. The mortality rate in this age group remains as high as 5%. In one
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series, nearly 40% of children with complicated appendicitis had been seen previously by a physician who failed to make the diagnosis of appendicitis.
3.6.2 APPENDICITIS IN YOUNG WOMEN
Although the overall incidence of negative laparotomy in patients suspected of having appendicitis is as high as 20%, the incidence in women younger than 30 years of age is as high as 45%. Pain associated with ovulation; diseases of the ovaries, fallopian tubes, and uterus; and urinary tract infections (cystitis) account for most of the misdiagnoses. If a young woman has atypical pain, no muscular guarding in the right lower quadrant, and no fever, leukocytosis, or leftward shift in the differential WBC count, it is best to observe the patient with frequent reexaminations. If after several hours, the patient’s signs and symptoms remain stable, it is appropriate to perform a CT scan.
3.6.3 APPENDICITIS DURING PREGNANCY
The risk of appendicitis during pregnancy is the same as it is in non-pregnant women of the same age; the incidence is 1 in 2000 pregnancies. Appendicitis occurs more frequently during the first two trimesters, and during this period the symptoms of appendicitis are similar to those seen in non-pregnant women. Surgery should be performed during pregnancy when appendicitis is suspected, just as it would be in a non-pregnant woman. As in the non-pregnant patient, the effects of a laparotomy that produces no findings are minor, whereas the effects of ruptured appendicitis can be catastrophic. Recent
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studies indicate that there is no increase in morbidity and mortality with laparoscopic appendectomy versus open appendectomy for the patient or the fetus.
During the third trimester of pregnancy, the cecum and appendix are displaced laterally and are rotated by the enlarged uterus. This results in localization of pain either more cephalad or laterally in the flank, leading to delay in diagnosis and an increased incidence of perforation. Factors such as displacement of the omentum by the uterus also impair localization of the inflamed appendix and result in diffuse peritonitis.
In cases of uncomplicated appendicitis, the prognosis for the infant following appendectomy is directly related to the infant’s birth weight.
If peritonitis and sepsis ensue, infant mortality increases because of prematurity and the effects of sepsis.
The selection of imaging studies for the workup of suspected appendicitis during pregnancy is often controversial. The use of ionizing radiation on a developing fetus should always be avoided. Ultrasound and magnetic resonance imaging (MRI) have been shown to be both sensitive and specific in evaluating patients; however, their lack of immediate availability in most hospitals may delay diagnosis. The effects of radiation on the fetus are significantly decreased after the first trimester.
Acute appendicitis can be confused with pyelitis and torsion of an ovarian cyst. However, death from appendicitis during pregnancy is
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mainly caused by a delay in diagnosis. In the final analysis, early appendectomy is the appropriate therapy in suspected appendicitis during all stages of pregnancy.
3.6.4 APPENDICITIS IN THE ELDERLY POPULATION
Appendicitis has a much greater mortality rate among elderly persons when compared with young adults. The increased risk of mortality appears to result from delay in seeking medical care and delay in making the diagnosis. The presence of other diseases associated with aging contributes to mortality, but the major reason for the increased mortality of appendicitis in the aged is delay in treatment.
Classic symptoms are present in elderly persons but are often less pronounced. Right lower quadrant pain localizes later and may be milder in elderly persons. On initial physical examination, the findings are often minimal, although right lower quadrant tenderness will eventually be present in most patients.
Approximately 25% of elderly patients will have a rup- tured appendix at the time of operation. Although other factors play a role, delay in seeking care and in making the diagnosis are the major reasons for perforation.
Routine CT scanning appears to be reducing the delay in diagnosis often associated with appendicitis in the elderly. It is imperative, therefore, that once the diagnosis of acute appendicitis is made, an urgent operation must be advised.
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3.7 DIFFERENTIAL DIAGNOSIS
The differential diagnosis of abdominal pain is a stimulating exercise. When the classic symptoms of appendicitis are present, the diagnosis of appendicitis is usually easily made and is seldom missed. When the diagnosis is not obvious, knowledge of the differential diagnosis becomes important. Most of the entities in the differential diagnosis of appendicitis also require operative therapy or are usually not made worse by an exploratory laparotomy. Therefore, it is essential that one eliminate those diseases that do not require operative therapy and can be made worse by operation, such as pan- creatitis, myocardial infarction, and basilar pneumonia.
YOUNG CHILDREN:
The diseases in young children that are most frequently mistaken for acute appendicitis are gastroenteritis, mesenteric lymphadenitis, Meckel diverticulum, pyelitis, small intestinal intussusception, enteric duplication, and basilar pneumonia.
• In mesenteric lymphadenitis, an upper respiratory tract infection is often present or has recently subsided.
• Acute gastroenteritis is usually associated with crampy abdominal pain and watery diarrhea.
• Intestinal intussusception occurs most frequently in children younger than 2 years of age, an age at which appendicitis is uncommon. With intussus- ception, a sausage-shaped mass is frequently palpable in the right lower
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quadrant. The preferred diagnostic procedure is a gentle BE, which, in addition to making the diagnosis, usually reduces the intussusception.
TEENAGERS AND YOUNG ADULTS
• The differential diagnosis is different in men and women. In young women, the differential diagnosis includes ruptured ectopic pregnancy, mittelschmerz, endometriosis, and salpingitis. Chronic constipation also needs to be considered in young women. The symptoms that accompany the acute onset of regional enteritis can mimic acute appendicitis, but a history of cramps and diarrhea and the lack of an appropriate history for appendicitis are hints that the diagnosis is regional enteritis.
• In young men, the potential list of differential diagnoses is smaller and includes the acute onset of regional enteritis, right-sided renal or ureteral calculus, torsion of the testes, and acute epididymitis.
OLDER PATIENTS:
• The differential diagnosis of acute appendicitis includes diverticulitis, a perforated peptic ulcer, acute cholecystitis, acute pancreatitis, intestinal obstruction, perforated cecal carcinoma, mesenteric vascular occlusion, rupturing aortic aneurysm, and the disease entities already mentioned for young adults.
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3.8 TREATMENT:
3.8.1 PREOPERATIVE PREPARATION
It is not necessary to rush a patient with a presumed diagnosis of acute appendicitis directly to the operating room. Retrospective reviews of operative delays of more than 12 hours do not negatively effect patient outcomes. All patients, especially those with a presumed diagnosis of peritonitis, should be adequately prepared before being taken to the operating room. Selected patients with a palpable right lower quadrant mass, periappendiceal phlegmon, or abscess on imaging may be managed without operation.
Intravenous fluid replacement should be initiated and the patient resuscitated as rapidly as possible, especially when peritonitis is suspected. Once the patient has a good urinary output, it can be assumed that resuscitation is complete. Nasogastric suction is especially helpful in patients with peritonitis and profound ileus. If the patient’s body temperature is higher than 39° C, appropriate measures should be taken to reduce fever before beginning an operation.
A broad-spectrum antibiotic should be administered preoperatively to help control sepsis and to reduce the incidence of postoperative wound infections. If, at the time of operation, the patient has early appendicitis, antibiotic administration should be stopped after one postoperative dose.
Antibiotics should be continued as clinically indicated in patients who have gangrenous or ruptured appendicitis with localized or generalized peritonitis.
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3.8.2 EXAMINATION UNDER ANESTHESIA
After the induction of anesthesia, the patient’s abdomen should be systematically palpated. Such an examination may, on occasion, demonstrate another pathologic condition to be the cause of the patient’s symptoms, such as acute cholecystitis. It also may be possible to palpate an appendiceal mass that will confirm the suspected diagnosis.
3.8.3 Uncomplicated Appendicitis without a Palpable Mass
In this circumstance, when the diagnosis of acute appen- dicitis has been made and there is no reason to suspect that the appendix has ruptured, an appendectomy should be performed.
• One recommended incision for a routine appendectomy is a transverse one (i.e., Rocky- Davis, Fowler–Weir Mitchell incisions). The incision is made in a transverse direction, 1 to 3 cm below the umbilicus, and is centered on the midclavicular line. The length of the incision should be approximately 1 cm longer than the breadth of the surgeon’s hand.
• The aponeurosis and muscles of the abdominal wall are split or incised in the direction of their fibers.
• Exposure of the appendix through this incision is better when compared with that obtained through the classic McBurney incision, particularly in patients with a retrocecal appendix and in those who are obese.
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• The other recommended incision, the gridiron, or muscle-splitting one (McBurney incision), can be used. This is the most widely used incision in uncomplicated appendicitis. The skin incision is made through a point one- third of the way along a line from the anterosuperior spine of the ileum to the umbilicus. The incision is made obliquely, beginning inferiorly and medially, and extending laterally and superiorly. It should be 8 to 10 cm in length, with its most medial extent being the lateral edge of the rectus muscle.
• The aponeurosis and muscles of the abdominal wall are split or incised in the direction of their fibers in such a manner that the entire skin incision can be used for exposure.
• After entering the peritoneum, the appendix is found as described for the transverse incision. The exposure through a McBurney incision, especially for a retrocecal appendix, can be awkward unless the appendix lies immediately below the incision. If necessary, the incision can be extended medially, partially transecting the rectus sheath, but this maneuver is usually helpful only in a pelvic appendicitis. If there is doubt about the diagnosis of acute appendicitis and an exploratory laparotomy is indicated, a vertical midline incision is more appropriate. An appendectomy can be performed with little difficulty through such an incision.
• After the peritoneum is opened, the appendix is identified by following the anterior cecal taenia to the base of the appendix. The inflamed appendix is
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coaxed into the wound by gentle traction and the transection of adhesions, if present. If the appendix is retrocecal or retroperitoneal, or if the local inflammation and edema are intense, exposure is improved by dividing the lateral peritoneal reflection of the cecum. At the end of this maneuver, the cecum should lie within the wound and the appendix should be at the level of the anterior abdominal wall so that continuing vigorous retraction is unnecessary while removing the appendix.
• If the appendix is not adherent, its base can be identified easily because the entire appendix often pops into the operative field. If the appendix is adherent, however, its base may be difficult to recognize. Aids in recognition include the following:
1. All three taeniae lead to and end at the base of the appendix.
2.The ileocecal junction can usually be identified, just below which is the base of the appendix.
• If the appendix does not come into the wound but the base has been identified, an Allis clamp can be placed around but not on the appendix for traction. An effort is made to deliver the tip of the appendix into the opera- tive field. If the appendix is not adherent to surrounding tissues, traction on the Allis clamp is usually successful in delivering the appendix.
• Once the appendix has been freed up, the mesoappendix is transected beginning at its free border, taking small bites of the mesoappendix between pairs of hemostats placed approximately 1 cm from and parallel
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to the appendix. This process should be repeated until the base of the appendix is reached. If exposure of a long, adherent appendix is difficult, the mesoappendix can be transected in a retrograde manner beginning at the base of the appendix.
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Steps of Open Appendectomy
• There are three ways to handle the appendiceal stump: simple ligation, inversion, and a combination of ligation and inversion. Either simple ligation or inversion is acceptable and has a comparable incidence of complications. The combination of ligation and inversion is not recommended, because it does not reduce the risk of septic complications, but it does create conditions conducive to the development of an intramural
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abscess or mucocele. Also, the ligated and inverted appendiceal stump may later appear on a subsequent BE as a cecal “tumor” and be a source of diagnostic difficulties.
• Simple ligature of the appendiceal stump is accomplished by crushing the appendix at its base with a hemostat, then moving the hemostat and replacing it on the appendix just distal to the crushed line. A ligature of monofilament suture is placed in the groove caused by the crushing clamp and is tied tightly . The appendix is transected just proximal to the hemostat and removed
Clamping and ligating the appendiceal base
• Inversion of an unligated stump using a Z-stitch rather than the more conventional purse-string suture, is preferred. The upper level of the Z- stitch is placed as a Lembert suture in the cecum, just distal to the base of the appendix. The suture is then brought around the base of the appendix
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and continued as a second Lembert suture beneath the base of the appendix.
The appendix is then transected between clamps, the stump is inverted into the cecum, the proximal clamp is removed, and the ends of the Z-stitch are tied over the stump of the appendix. The appendiceal stump is not ligated.
If the appendiceal stump is unsuitable for inversion because of edema, it should simply be ligated and not inverted.
Inversion of the appendiceal base
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LAPAROSCOPIC APPENDECTOMY
• Laparoscopic and minimal access surgery continues to expand in the field of general surgery, and diagnostic laparoscopy and laparoscopic appendectomy have become accepted procedures in many surgeons’
practices.
• The early use of diagnostic laparoscopy in patients with right lower quadrant abdominal pain and suspected appendicitis reduces the risk of appendiceal perforation and the negative appendectomy rate to less than 10%.
• Diagnostic laparoscopy is particularly useful in women of reproductive age and in the obese. In the former, frequently confounding gynecologic disorders can be well visualized to provide the diagnosis, and in the latter, laparoscopy can eliminate the morbidity risks of a large incision. Per- forming an appendectomy with a normal-appearing appendix has a relatively low risk and will remove appendicitis from the differential diagnosis of right lower quadrant pain in the future. However studies have shown that it is safe to not proceed with appendectomy if the appendix appears normal.
• Conversion of diagnostic laparoscopy to therapeutic laparoscopy is easily accomplished by the addition of other ports. Trocar placement for laparoscopic appendectomy is a matter of surgeon choice with consideration of the triangle rule for port placement.
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• Diagnostic laparoscopy is usually performed through a periumbilical port, with a 10/11-mm port added midway between the umbilicus and pubis and a 5-mm port placed over the appendix or the right midlateral abdomen if appendectomy is performed.
Ports for laparoscopic appendectomy
• Once the diagnosis is confirmed, the mesoappendix can be taken down with either hemoclips or the Harmonic Scalpel.
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Steps of Laparoscopic appendectomy
• The appendix is amputated from the cecum between endoloops or with an endo-GIA stapler. The appendix can then be removed from the abdomen with a specimen pouch or withdrawn into the 10/11-mm port. Care should be taken to prevent contact of the appendix or its contents with the wound edges.
• There is general agreement that patients undergoing laparoscopic appendectomy have less postoperative pain, a lower rate of wound infection, a lower overall complication rate, a more rapid return to diet, a shorter hospital stay, a longer operative time, and more equipment charges in the operating room. In contrast, a more rapid return to work and a lower
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complication rate are more controversial claims because prospective studies show differing results.
• Laparoscopic appendectomy results in a lower wound infection rate compared with an open procedure but has a higher intraabdominal abscess rate if the appendix is perforated.
• Relative contraindications to laparoscopic appendectomy include previous abdominal surgery precluding safe trocar placement, uncontrolled coagulopathy, and significant portal hypertension.
• Laparoscopic appendectomy appears to be safe and efficacious. It provides a rapid diagnosis and a significant reduction in negative appendectomy rates in females of childbearing age with suspected appendicitis.
• Minimal access surgery reduces the morbidity risk in obese patients who require an appendectomy
3.8.4 Perforated or Gangrenous Appendicitis with a Periappendiceal Mass
• When a mass is detected by examination under anesthesia, a transverse incision is made over the most prominent portion of the mass. The muscles and aponeuroses are split along their lines of cleavage in gridiron fashion.
After entering the peritoneal cavity, the wound should be packed immediately to prevent contamination of the abdominal cavity. As mentioned earlier, the mass may be made up of omentum and loops of small intestine adherent to the inflamed appendix, and an abscess may not
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be present. If feasible, an appendectomy is then performed; usually it will not be possible to invert the stump, so simple ligation is preferred.
• It is not necessary to place a subfascial drain in a patient with a gangrenous appendix and minimal or no periappendiceal pus.
• If there is a periappendiceal abscess and the tissues are fixed so as to create a dead space, the cavity should be drained with one or more closed-suction drains brought out through a separate stab incision.
• Before fascial closure, the right iliac fossa and the wound should be liberally irrigated. Muscles and aponeuroses should be closed with interrupted nonabsorbable sutures. The skin should be left open, to be closed with adhesive paper tapes on the fifth or sixth postoperative day.
Parenteral antibiotics should be continued for 5 days after operation or until clinical signs indicate no infection.
3.8.5 Perforated Appendicitis With Localized Abscess Formation
• If, at the time of initial physical examination, a well-localized periappendiceal mass is found and the patient’s symptoms are improving, it is acceptable in healthy adults to initiate parenteral antibiotic treatment and to follow the patient expectantly. This form of therapy is not appropriate in children, pregnant women, or elderly patients.
• In these groups, an emergency operation is indicated. In two-thirds of patients, expectant treatment of an appendiceal mass succeeds, and an
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interval appendectomy can be performed at a later date or can be avoided altogether.
• In one-third of patients, symptoms do not subside and an emergency CT scan should be performed. If an abscess is identified on CT scan, an attempt should be made to drain the abscess percutaneously under CT or US guidance. If not successful, the abscess should be drained surgically.
• The skin incision for drainage of a periappendiceal abscess is made just medial to the crest of the ilium at the level of the abscess. Using a muscle- splitting technique, the lateral edge of the peritoneum is exposed and pushed medially so that the abscess is approached from its lateral aspect.
Once the abscess is entered, a finger should be used to break up the loculations. If the appendix can be freed up without breaking down adhesions, an appendectomy should be performed.
• If an appendectomy is not performed, an interval appendectomy can be done 3 to 6 months after drainage from the abscess has ceased and the wound has completely healed.
• After the wound has been thoroughly irrigated with normal saline, a closed- suction drain should be inserted into the abscess cavity and brought out through a separate stab wound in the flank. The muscles and aponeuroses are closed with interrupted nonabsorbable sutures, and the skin and subcutaneous tissues are packed open with saline-soaked gauze. The drain
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should be left in place until it is draining less than 50 mL/day and then advanced progressively until removed.
• Systemic antibiotics should be continued for 5 days postoperatively or until signs of sepsis have cleared. A daily rectal examination should be done to detect pelvic abscess. The patient may be discharged from the hospital when there is no fever 48 hours after the discontinuation of antibiotic therapy.
3.8.6 Perforated Appendicitis with Diffuse Peritonitis
• The major cause of mortality from appendicitis is generalized peritonitis.
Therefore, immediate exploration is indicated in a patient with a diagnosis of acute appendicitis in whom the physical findings are consistent with diffuse peritonitis.
• If a perforated appendix and diffuse peritonitis are documented at operation, an appendectomy should be performed and the abdomen thoroughly irrigated.
• The use of drains in diffuse peritonitis is not recommended unless there are localized abscesses requiring drainage.The wound and postoperative care should be handled as described in a patient with a periappendiceal abscess.
3.8.7 Normal Appendix When Appendicitis Is Suspected
• If a patient undergoes exploratory laparotomy (especially through a right lower quadrant incision) for suspected acute appendicitis, and a normal
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appendix is subsequently found, a careful search for another pathologic condition should be made and an appendectomy performed.
• The abdomen should not be closed until the cause of the symptoms has been identified and treated or the surgeon is sure that no lesion requiring treatment is present. The normal appendix is removed to obviate diagnostic confusion in the future.
• If the history and physical examination were appropriate for the diagnosis of acute appendicitis, it is not an error to perform an exploratory laparotomy and remove what appears to be a normal appendix.
• A policy of early surgical intervention on the basis of clinical suspicion has been demonstrated overall to reduce both the morbidity and mortality of acute appendicitis.
• In the past, a negative appendectomy rate of 20% was acceptable. Studies have suggested that rates of 10% to 15% and lower are feasible without an unacceptably high rate of perforated appendix.
3.9 COMPLICATIONS :
• Postoperative complications occur in 5% of patients with an unperforated appendix but in more than 30% of patients with a gangrenous or perforated appendix. The most frequent complications after appendectomy are wound infection, intra abdominal abscess, fecal fistula, pylephlebitis, and intestinal obstruction.
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• Subcutaneous tissue infection is the most common complication after appendectomy. The organisms most frequently cultured are anaerobic Bacteroides species and the aerobes Klebsiella, Enterobacter, and Escherichia coli. When early signs of wound infection (undue pain and edema) are present, the skin and subcutaneous tissue should be opened.
The wound should be packed with saline-soaked gauze and reclosed with Steri-Strips in 4 to 5 days.
• Pelvic, subphrenic, or other intraabdominal abscesses occur in up to 20%
of patients with a gangrenous or perforated appendicitis. They are accompanied by recurrent fever, malaise, and anorexia of insidious onset.
CT scanning is of great help in making the diagnosis of intraabdominal abscess. When an abscess is diagnosed, it should be drained either operatively or percutaneously.
• Some fecal fistulas close spontaneously, provided that there is no anatomic reason for the fistula remaining open. Those that do not close spontaneously obviously require operation.
• Pylephlebitis, or portal pyemia, is characterized by jaundice, chills, and high fever. It is a serious illness that frequently leads to multiple liver abscesses. The infecting organism is usually E. coli. This complication has become rare with the routine use of antibiotics in complicated appendicitis.
