Appendicitis I.

Epidemiology

Appendectomy is the most common urgently performed surgical procedure. Lifetime risk of undergoing appendectomy is between 7% and 12%. The maximal incidence occurs in the second and third decades of life. The male:female ratio of approximately 2:1 gradually shifts after age 25 years toward a 1:1 ratio.

II. Pathophysiology A. Appendiceal obstruction Appendiceal obstruction is the most common initiating event of appendicitis.

Hyperplasia of the submucosal lymphoid follicles of the appendix accounts for approximately 60% of obstructions (most common in teens). In older adults and children, the fecalith is the most common etiology (35%).

B. Intraluminal pressure Intraluminal pressure of the obstructed appendiceal lumen increases secondary to continued mucosal secretion and bacterial overgrowth; the appendiceal wall thins, and lymphatic and venous obstruction occurs. C. Necrosis and perforation Necrosis and perforation develop when the arterial flow is compromised. III. Diagnosis The diagnosis of acute appendicitis is made by clinical evaluation. Although laboratory tests and imaging procedures can be helpful, they are of secondary importance. P.207 A. Clinical presentation

Classic presentation. Appendicitis typically begins with progressive, persistent midabdominal discomfort caused by obstruction and distention of the appendix, stimulating the visceral afferent autonomic nerves (levels T8 to T10). Anorexia and a low-grade fever (<38.5C) follow. As distention of the appendix increases, venous congestion stimulates intestinal peristalsis, causing a cramping sensation that is soon followed by nausea and vomiting. Symptoms include anorexia (90%), nausea and vomiting (70%), and diarrhea (10%). Once the inflammation extends transmurally to the parietal peritoneum, the somatic pain fibers are stimulated and the pain localizes to the RLQ. Peritoneal irritation is associated with pain on movement, mild fever, and tachycardia. One fourth of patients present with localized pain and no visceral symptoms. The onset of symptoms to time of presentation

is usually less than 24 hours for acute appendicitis and averages several hours. Unusual presentations o When the appendix is retrocecal or behind the ileum, it may be separated from the anterior abdominal peritoneum, and abdominal localizing signs may be absent. Irritation of adjacent structures can cause diarrhea, urinary frequency, pyuria, or microscopic hematuria depending on location. o When the appendix is located in the pelvis, it may simulate acute gastroenteritis, with diffuse pain, nausea, vomiting, and diarrhea. The diagnosis may be suspected if digital rectal examination produces pain. Pregnancy o Appendicitis is the most common nongynecologic surgical emergency during pregnancy. The incidence of appendicitis during pregnancy is 0.15 to 2.10/1,000 pregnancies (Can Fam Physician 2004;50:355); appendicitis occurs with a slightly lower frequency in the pregnant patient (Int J Epidemiol 2001;30:1281). o Appendicitis must be suspected in any pregnant woman with abdominal pain. The gravid uterus displaces the appendix superiorly and laterally toward the RUQ (Fig. 11-2), thereby complicating diagnosis. Separation of the visceral and parietal peritoneum due to the enlarging uterus limits localization of the pain by decreasing the somatic component of the pain. In addition, nausea and vomiting can be incorrectly attributed to the morning sickness that is common in the first trimester. o Operation is indicated in a pregnant patient as soon as the diagnosis of appendicitis is suspected. A negative laparotomy carries a risk of fetal loss of up to 3%, but fetal demise rates reach 35% in the setting of perforation and diffuse peritonitis.

B. Physical examination

The examination begins by assessing the patient's abdomen in areas other than the area of suspected tenderness. Location of the appendix is variable. However, the base is usually found at the level of the S1 vertebral body, lateral to the right midclavicular line at McBurney's point (two thirds of the distance from the umbilicus to the anterosuperior iliac spine). Rovsing's sign indicates peritoneal irritation. The degree of tenderness to direct right-lower-quadrant tenderness is appreciated. The degree of muscular resistance to palpation (guarding) parallels the severity of the inflammatory process. Cutaneous hyperesthesia is often present, overlying the region of maximal tenderness. Iliopsoas sign implies retrocecal appendicitis. A pelvic appendix may produce a positive obturator sign. Rectal examination is performed to evaluate the presence of localized tenderness or an inflammatory mass in the pararectal area. It is most

useful for atypical presentations suggestive of a pelvic or retrocecal appendix. In women, a pelvic examination is performed to assess for cervical motion tenderness and adnexal pain or masses. A palpable mass in the RLQ suggests a periappendiceal abscess or phlegmon.

Figure 11-2. Changes in location and direction of the appendix during pregnancy. The normal and postpartum positions of the base of the appendix are medial to McBurney's point. At the fifth month, the appendix is at the level of the umbilicus and iliac crest. (Adapted from Baer JL, Reis RA, Arens RA. Appendicitis in pregnancy with changes in position and axis of normal appendix in pregnancy. JAMA 1932;98:1359. ) C. Laboratory evaluation The following tests should be obtained preoperatively for patients with suspected appendicitis. A serum pregnancy test must be performed in all ovulating women. P.208

Complete blood cell count. A leukocyte count of greater than 10,000 cells/L, with polymorphonuclear cell predominance (>75%), carries a 77% sensitivity and 63% specificity for appendicitis (Radiology 2004;230:472). The total number of WBCs and the proportion of

immature forms increase if there is appendiceal perforation. In older adults, the leukocyte count and differential are normal more frequently than in younger adults. Pregnant women normally have an elevated WBC count that can reach 15,000 to 20,000 as their pregnancy progresses. Urinalysis is abnormal in 25% to 40% of patients with appendicitis. Pyuria, albuminuria, and hematuria are common. Large quantities of bacteria suggest UTI as the cause of abdominal pain. A urinalysis showing more than 20 WBCs per high-power field or more than 30 RBCs per high-power field suggests UTI. Significant hematuria should prompt consideration of urolithiasis. Serum electrolytes, blood urea nitrogen, and serum creatinine are obtained to identify and correct electrolyte abnormalities caused by dehydration secondary to vomiting or poor oral intake.

D. Radiologic evaluation Diagnosis of appendicitis can usually be made without radiologic evaluation. In complex cases, however, the following can be helpful.

X-rays are rarely helpful in diagnosing appendicitis. One study demonstrated an appendicolith on only 1.14% of the x-rays performed on patients with surgically P.209 proven appendicitis. Other suggestive radiologic findings include a distended cecum with adjacent small-bowel air-fluid levels, loss of the right psoas shadow, scoliosis to the right, and gas in the lumen of the appendix. A perforated appendix rarely causes pneumoperitoneum.

Ultrasound is most useful in women of child-bearing age and in children because other causes of abdominal complaints can be demonstrated. Findings associated with acute appendicitis include an appendiceal diameter greater than 6 mm, lack of luminal compressibility, and presence of an appendicolith. An enlarged appendix seen on US has a sensitivity of 86% and specificity of 81% (Radiology 2004;230:472). The perforated appendix is more difficult to diagnose and is characterized by loss of the echogenic submucosa and the presence of loculated periappendiceal or pelvic fluid collection. In women, ovarian pathology may be identified or excluded. The quality and accuracy of US are highly operator dependent. CT scan, originally recommended only in cases that were clinically complex or diagnostically uncertain, has emerged as the most commonly used radiographic diagnostic test. It is superior to US in diagnosing appendicitis, with a sensitivity of 94% and specificity of 95% (Ann Intern Med 2004;141:537). CT findings of appendicitis include a distended, thick-walled appendix with inflammatory streaking

of surrounding fat, a pericecal phlegmon or abscess, an appendicolith, or RLQ intra-abdominal free air that signals perforation. CT scan is particularly useful in distinguishing between periappendiceal abscesses and phlegmon. MRI is an alternative when one needs cross-sectional imaging that avoids ionizing radiation. It is particularly useful in a pregnant patient whose appendix is not visualized on US (Radiology 2006;238:891).

E. Diagnostic laparoscopy Diagnostic laparoscopy is most useful for evaluating ovulating women with an equivocal examination for appendicitis. In this subgroup, one third of women prove to have primary gynecologic pathology. The appendix may also be removed via the laparoscopic approach. Therefore, some surgeons advocate an initial laparoscopic approach in all ovulating women with suspected appendicitis. F. Differential diagnosis

Gastrointestinal diseases o Gastroenteritis is characterized by nausea and emesis before the onset of abdominal pain, along with generalized malaise, high fever, diarrhea, and poorly localized abdominal pain and tenderness. Although diarrhea is one of the cardinal signs of gastroenteritis, it can occur in patients with appendicitis. In addition, WBC count is often normal in patients with gastroenteritis. o Mesenteric lymphadenitis usually occurs in patients younger than 20 years old and presents with middle, followed by RLQ, abdominal pain but without rebound tenderness or muscular rigidity. Nodal histology and cultures obtained at operation can identify etiology, most notably Yersinia and Shigella species and Mycobacterium tuberculosis. Mesenteric lymphadenitis is known to be associated with upper respiratory tract infections. o Meckel diverticulitis presents with symptoms and signs indistinguishable from those of appendicitis, but it characteristically occurs in infants. o Peptic ulcer disease, diverticulitis, and cholecystitis can present clinical pictures similar to those of appendicitis. o Typhlitis, characterized by inflammation of the wall of the cecum or terminal ileum, is managed nonoperatively. It is most commonly seen in immunosuppressed patients undergoing chemotherapy for leukemia and in HIV-positive patients. It is difficult to distinguish preoperatively between typhlitis and appendicitis. Urologic diseases o Pyelonephritis causes high fevers, rigors, costovertebral pain, and tenderness. Diagnosis is confirmed by urinalysis with culture.

Ureteral colic. Passage of renal stones causes flank pain radiating into the groin but little localized tenderness. Hematuria suggests the diagnosis, which P.210 is confirmed by intravenous pyelography or noncontrast CT. Abdominal plain films frequently show renal stones.

Gynecologic diseases o Pelvic inflammatory disease can present with symptoms and signs indistinguishable from those of acute appendicitis, but the two often can be differentiated on the basis of several factors. Cervical motion tenderness and milky vaginal discharge strengthen a diagnosis of PID. In patients with PID, the pain is usually bilateral, with intense guarding on abdominal and pelvic examinations. Transvaginal US can be used to visualize the ovaries and to identify tubo-ovarian abscesses. o Ectopic pregnancy. A pregnancy test should be performed in all female patients of child-bearing age presenting with abdominal complaints. A positive test should prompt US investigation. o Ovarian cysts are best detected by transvaginal or transabdominal US. o Ovarian torsion. The inflammation surrounding an ischemic ovary often can be palpated on bimanual pelvic examination. These patients can have a fever, leukocytosis, and RLQ pain consistent with appendicitis. A twisted viscus, however, differs in that it produces sudden, acute intense pain with simultaneous frequent and persistent emesis. Ovarian torsion may be confirmed by Doppler US.

IV. Treatment A. Preoperative preparation Intravenous isotonic fluid replacement should be initiated to achieve a brisk urinary output and to correct electrolyte abnormalities. Nasogastric suction is helpful, especially in patients with peritonitis. Temperature elevations are treated with acetaminophen and a cooling blanket. Anesthesia should not be induced in patients with a temperature higher than 39C. B. Antibiotic therapy Antibiotic prophylaxis is generally effective in the prevention of postoperative infectious complications (wound infection, intra-abdominal abscess). Preoperative initiation is preferred, although some suggest that it can be delayed (Cochrane Database Syst Rev 2005;20:CD001439). For acute appendicitis, coverage typically consists of a second-generation cephalosporin. In patients with acute nonperforated appendicitis, a single dose of antibiotics is adequate. Antibiotic therapy in perforated or gangrenous appendicitis should be continued for 3 to 5 days.

C. Appendectomy With very few exceptions, the treatment of appendicitis is appendectomy. Patients with diffuse peritonitis or questionable diagnosis should be explored through a midline incision. The mortality after appendectomy is high in elderly patients. Equivocal diagnosis of appendicitis in this frail patient population warrants increased diagnostic efforts before emergent appendectomy (Ann Surg 2001;233:4). In most patients, a transverse incision (e.g., Rockey-Davis, Fowler-Weir) provides the best cosmetic appearance and allows easy extension medially for greater exposure. The external and internal oblique and transversus abdominis muscle layers may be split in the direction of their fibers. After entering the peritoneal cavity, obtain purulent fluid for Gram stain and culture. Once the cecum is identified, the anterior taenia can be followed to the base of the appendix. The appendix is gently delivered into the wound and any surrounding adhesions carefully disrupted. If the appendix is normal on inspection (5% to 20% of explorations), it is removed and appropriate alternative diagnoses are entertained. The cecum, sigmoid colon, and ileum are carefully inspected for changes indicative of diverticular (including Meckel diverticulum), infectious, ischemic, or inflammatory bowel disease (e.g., Crohn's disease). Evidence of mesenteric lymphadenopathy is sought. In women, the ovaries and fallopian tubes are inspected for evidence of PID, ruptured follicular cysts, ectopic pregnancy, or other pathology. Bilious peritoneal fluid suggests peptic ulcer or gallbladder perforation. D. Laparoscopic appendectomy Laparoscopic appendectomy is an accepted alternative to traditional open approaches. It is most useful when the diagnosis is uncertain or when the size of the patient would necessitate a large incision. Although recent studies suggest that postoperative lengths of stay may be marginally briefer (Surg Endosc 2006;20:495), most P.211 patients undergoing routine appendectomy can be safely discharged from the hospital on the first postoperative day. Irrespective of the choice of approach, care must be taken to ensure secure ligation of the appendiceal stump. E. Drainage of periappendiceal abscess Management of appendiceal abscesses remains controversial. Patients who have a well-localized periappendiceal abscess and are initially seen when symptoms are subsiding can be treated with systemic antibiotics and considered for percutaneous US- or CT-guided catheter drainage, followed by elective appendectomy 6 to 12 weeks later (Radiology 1987;163:23). This strategy is successful in more than 80% of patients. The appendix must be removed because the patient has a 60% risk of developing appendicitis again within 2 years. Systemic antibiotics are administered for at least 5 days or until the patient is afebrile and leukocytosis resolves. A recent study comparing immediate appendectomy (antibiotics, surgery) with expectant management (antibiotics, percutaneous drainage, and interval appendectomy) in patients with appendiceal abscesses found that the immediate-appendectomy group had a higher complication rate and longer hospital stay (Am Surg 2003;69:829).

F. Incidental appendectomy Incidental appendectomy is removal of the normal appendix at laparotomy for another condition. The appendix must be easily accessible through the present abdominal incision, and the patient must be clinically stable enough to tolerate the extra time needed to complete the procedure. Because most cases of appendicitis occur early in life, the benefit of incidental appendectomy decreases substantially once a person is older than 30 years. Crohn's disease involving the cecum, radiation treatment to the cecum, immunosuppression, and vascular grafts or other bioprostheses are contraindications for incidental appendectomy because of the increased risk of infectious complications or appendiceal stump leak. V. Complications of Acute Appendicitis A. Perforation Perforation is accompanied by severe pain and fever. It is unusual within the first 12 hours of appendicitis but is present in 50% of appendicitis patients younger than 10 years and older than 50 years. Acute consequences of perforation include fever, tachycardia, generalized peritonitis, and abscess formation. Treatment is appendectomy, peritoneal irrigation, and broadspectrum intravenous antibiotics for several days. During pregnancy, perforation substantially increases the risk of maternal mortality from negligible to 4%. Fetal death rates rises from 0% to 1.5% in uncomplicated appendicitis to 20% to 35% in the setting of perforation. B. Postoperative wound infection risk Postoperative wound infection risk can be decreased by appropriate intravenous antibiotics administered before skin incision. The incidence of wound infection increases from 3% in cases of nonperforated appendicitis to 4.7% in patients with a perforated or gangrenous appendix. Primary closure is not recommended in the setting of perforation (Surgery 2000;127:136). Wound infections are managed by opening, draining, and packing the wound to allow healing by secondary intention. Intravenous antibiotics are indicated for associated cellulitis or systemic sepsis. C. Intra-abdominal and pelvic abscesses Intra-abdominal and pelvic abscesses occur most frequently with perforation of the appendix. Postoperative intra-abdominal and pelvic abscesses are best treated by percutaneous CT- or US-guided drainage. If the abscess is inaccessible or resistant to percutaneous drainage, operative drainage is indicated. Antibiotic therapy can mask but does not treat or prevent a significant abscess. D. Other complications

Pyelephlebitis is septic portal vein thrombosis caused by Escherichia coli and presents with high fevers, jaundice, and eventually hepatic abscesses. CT scan demonstrates thrombus and gas in the portal vein. Prompt treatment (operative or percutaneous) of the primary infection is critical, along with broad-spectrum intravenous antibiotics. Enterocutaneous fistulae from a leak at the appendiceal stump closure occasionally require surgical closure, but most close spontaneously.

E. Small-bowel obstruction Small-bowel obstruction is four times more common after surgery in cases of perforated appendicitis than in uncomplicated appendicitis.