43.

APPENDICITIS 4) Inflammation soon involves the serosa and

Harrison’s Chapter 356 (pp 1985-1989)
Schwartz’s Chapter 30 (pp 1241-1256)
Epidemiology
- Appendicitis remains to be the most common
emergency surgical disease affecting the abdomen
- 9% of men and 7% of women will experience
appendicitis in their lifetime
- Occur most commonly in 10- to 19-year olds
- PERFORATION common cause of morbidity and
mortality; increasing incidence
o 20% of all patients have evidence of perforation
at presentation
o Risk of perforation is higher in <5 and >65 years
Anatomy and Histology
- Arterial Supply: Appendicular Br. of Ileocolic Artery
- Innervation: Superior Mesenteric Plexus (T10-L1)
and Vagus Nerves
- 3 Layers: Serosa, Muscularis, Submucosa/Mucosa
o Submucosa LYMPHOID aggregates
- Function: secretion of immunoglobulins (IgA)
Pathophysiology
parietal peritoneum causing shift to RLQ pain
5) Vascular thrombosis and ischemic necrosis with
PERFORATION of distal appendix occurs
o DISTAL poorest blood supply
o Patients who have had symptoms for >48
HOURS are more likely to perforate
o Perforation near the base should raise
concerns about another disease process
o Simple disease DOES NOT always progress
to perforation
Simple acute appendicitis may resolve
spontaneously or with antibiotic therapy
Recurrent disease is remotely possible
6) When perforation occurs, the resulting leak may
be contained by the omentum or surrounding
tissues to form an ABSCESS
7) FREE perforation typically causes severe
PERITONITIS
o These patients may develop infective
suppurative thrombosis of the portal vein
along with intrahepatic abscess
o Prognosis is very poor with this complication
Differential Diagnosis

- Factors leading to appendicitis:

o Fecaliths
Fecaliths are found in ~50% of patients with
gangrenous appendicitis who perforate
Rarely identified in simple disease
o Incompletely digested food residue
o Lymphoid hyperplasia
o Intraluminal scarring
o Tumors
o Bacteria and viruses
The flora of the inflamed appendix DIFFERS
from that of the normal appendix:
Anaerobes
Clinical Manifestations
E. coli
Bacteroides gangrene and perforated “Appendicitis should be included in the differential
Fusobacterium diagnosis of abdominal pain for every patient in any age
o Inflammatory bowel disease (IBD) group unless it is certain that the organ has been
previously removed.”
- Steps in the Pathophysiology:
1) CLOSED-LOOP OBSTRUCTION of appendiceal - The appendix’s anatomical location, which varies,
lumen and continuous secretion directly influences the patient’s presentation
2) Obstruction leads to bacterial overgrowth and o RUQ – Pregnancy
luminal distention o LUQ – Midgut Malrotation
o Stimulates nerve endings of visceral afferent o LLQ – Situs Inversus
stretch fibers producing vague, dull, diffuse
epigastric or periumbilical pain
o Reflex nausea and vomiting occurs as
visceral pain increases
3) Increase in intraluminal pressure inhibits flow of
lymph and blood
o Capillaries and venules are occluded but
arterial inflow continues causing congestion
 Classic History of Appendicitis
1) Non-specific complaints occur first:
o Changes in bowel habits
o Malaise
o Vague, intermittent, crampy abdominal pain
in epigastric or periumbilical region
2) Pain migrates to Right Lower Quadrant over 12
TO 24 HOURS where it is sharper and can be
definitely localized
o Transmural inflammation when appendix
irritates the parietal peritoneum
3) Parietal peritoneal irritation may be associated
with local muscle rigidity and stiffness
4) Nausea and vomiting, if present, follows the
development of abdominal pain
o GASTROENTERITIS nausea before pain
o Vomiting is mild and scant
5) ANOREXIA is so common that the diagnosis of
appendicitis should be questioned in its absence
- Presentation of PELVIC APPENDICITIS:
o Dysuria
o Urinary Frequency
o Diarrhea
o Tenesmus
o Pain in Suprapubic Region on rectal/pelvic exam
Physical Examination
- All patients should undergo a RECTAL
EXAMINATION
o An inflamed appendix located behind the cecum
or below the pelvic brim may prompt very little
tenderness of the anterior abdominal wall
- A PELVIC EXAMINATION in women is mandatory to
rule out urogynecologic conditions:
o Pelvic Inflammatory Disease
o Ectopic Pregnancy
o Ovarian Torsion
- Patients with simple appendicitis will normally only
appear MILDLY ILL
o Pulse rate and temperature only slightly above
normal
- If T > 38.3 C and with presence of rigors, consider
COMPLICATIONS:
o Perforation
o Phlegmon – matted loops of bowel adherent to
the adjacent inflamed appendix
o Abscess Formation
- Classic Signs of Appendicitis:
1) DIRECT RLQ TENDERNESS
o The entire abdomen must be examined
systematically starting in an area where the
patient does not report discomfort
o MCBURNEY’S POINT
Point of maximal tenderness in RLQ
Located 1/3 of the way along a line
originating from the ASIS, running to the
umbilicus
2) DUNPHY’S SIGN
o Patient’s lie still to avoid peritoneal irritation
caused by movement
o Report discomfort from a bumpy car ride,
coughing, sneezing and other movements
that replicate a Valsalva maneuver
3) ROVSING’S SIGN
o INDIRECT REBOUND TENDERNESS
o Palpating in the LEFT LOWER QUADRANT
causes pain in the RLQ
o Can be indirectly elicited by gentle abdominal
percussion, jiggling the patient’s bed or mildly
bumping the feet
4) OBTURATOR SIGN
o INTERNAL ROTATION of the right hip
causes pain
o Suggesting the possibility of PELVIC
appendicits
5) ILIOPSOAS SIGN
o EXTENDING the right hip causes pain along
the posterolateral back and hip
o Suggesting RETROCECAL appendicitis
Clinical Scoring Systems
- Useful for ruling out appendicitis and selecting
patients for further diagnostic work-up
[INSERT: Alvarado Score / AIRS from Schwartz!]
Ancillary Diagnosis
Laboratory Testing
- Laboratory testing DOES NOT identify patients with
appendicitis but may help with differentials
- WBC count is mildly to moderately elevated;
leukocytosis 10,000-18,000 cells/uL; neutrophilic
predominance or “LEFT SHIFT”
- Serum AMYLASE and LIPASE should be measured
- URINALYSIS is indicated to exclude genitourinary
conditions
o Inflamed appendix that abuts the ureter or urinary
bladder may cause sterile pyuria or hematuria
- Every woman of childbearing age should have a
PREGNANCY TEST
Imaging
- Done when Hx/PE is suggestive but not convincing
- PLAIN FILMS are rarely helpful so are not routinely
done; <5% will have opaque fecalith in RLQ
- ULTRASOUND
o Highly operator dependent
o Suggestive Findings:
Wall thickening
Increased appendiceal diameter
Presence of free fluid
- CT SCAN
o High negative predictive value
o Suggestive Findings:
Dilatation >6mm
Wall thickening
Lumen does NOT fill with enteric contrast
Fatty tissue stranding
Air surrounding the appendix
o Non-visualization of the appendix is a non-
specific finding that SHOULD NOT be used to
rule out the presence of appediceal or
periappendiceal inflammation
Management
- All patients should be prepared for SURGERY and
have fluid and electrolyte abnormalities corrected
- Uncomplicated Appendicitis: OPEN
LAPAROSCOPIC APPENDECTOMY
o When the diagnosis in uncertain, observe the
patient and repeat abdominal exam OVER 6-8
HOURS
- Phlegmon or Abscess:
o Broad-spectrum Antibiotics
o Drainage if abscess is >3 cm in diameter
o Parenteral fluids and bowel rest
o Appendix can be safely removed AFTER 6 TO 12
WEEKS when inflammation has diminished
- DISCHARGE: within 24 TO 40 HOURS of operation
- Most common POST-OP COMPLICATIONS: FEVER
AND LEUKOCYTOSIS
o Persistence > 5 days should raise concern for
INTRAABDOMINAL ABSCESS
Open Appendectomy
- Performed under General Anesthesia
- Patient initially placed in supine position then placed
in slight Trendelenburg with rotation of bed to the left
once incision is made
- Types of Incisions:
1) NON-PERFORATED Appendicitis RLQ Incisions:
a. MCBURNEY OBLIQUE
b. ROCKY-DAVIS TRANSVERSE
2) PERFORATED Appendicitis MIDLINE Incisions:
a. LOWER MIDLINE Laparotomy
- Pregnancy DOES NOT change the proportion of
patients with the appendiceal base within 2 cm of
McBurney’s point
- Identifying the Appendix:
o Locate the cecum
o Trace the TAENIA LIBERA (aka Anterior Taenia)
Most visible of the 3 Taenia Coli
o Base of the appendix is identified distally
Laparoscopic Appendectomy
- Advantages:
o Less post-op pain
o Shorter hospital stay
o Faster recovery
o Fewer wound infections
o Facilitates exposure in the very obese
- Disadvantage
o HIGHER risk of intraabdominal abscess
formation
- APPENDICEAL CRITICAL VIEW
o 10 o’clock Appendix
o 3 o’clock Taenia Coli
o 6 o’clock Terminal Ileum
Post-Operative Care
- Uncomplicated Appendectomy:
or
o Most patients can quickly be started on a diet and
discharged home the following day
o Post-op ANTIBIOTICS are UNNECESSARY!
- Complicated Appendectomy:
o Patients should be continued on BROAD
SPECTRUM ANTIBIOTICS for 4 TO 7 DAYS
o Post-op ILEUS may occur so died should be
started based on daily clinical evaluation
o Increased risk for SURGICAL SITE
INFECTIONS
Tx: Open the incision and obtain culture
o STUMP APPENDICITIS
Results from incomplete appendectomy
Presents ~9 years after initial surgery
The remaining stump should be no longer
than 0.5 cm
Appendicitis in Pediatric Patients
- Establishment of diagnosis is more difficult
- PE Findings with Highest Sensitivity:
o Maximal tenderness in RLQ
o Inability to walk or walking with a limp
o Pain with percussion, coughing or hopping
- More rapid progression to rupture and the inability of
the underdeveloped omentum to contain a rupture
lead to significant morbidity in children
Appendicitis in Pregnancy
- Appendicitis is the most common surgical
emergency during pregnancy
- Appendicitis could occur anytime during pregnancy
but is RARE in the 3rd Trimester
- Incidence of perforated or complex appendicitis is
NOT increased in pregnant patients
- Laparoscopy was associated with 2.31 times
increased risk of fetal loss compared to open
- Appendectomy is associated with 4% risk of fetal
loss and 7-10% risk of early delivery
ALLIE 2018