APPENDICITIS - WHAT WE ALL FORGOT

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APPENDICITIS - WHAT WE ALL FORGOT (or never knew
in the first place!)
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APPENDICITIS

• History

• Berengario DaCarpi, a physician-anatomist,
• made the first description of the appendix in
  1521
• Leonardo DaVinci demonstrated the appendix in
  drawings made in 1492 but not published until the
  18th century.
• Lorenz Heister gave the first unequivocal account
  of appendicitis in 1711
• The appendix is clearly illustrated in De Humani
  Corporis Febrica Liber V by Andreas Vesalius
  published in 1543

Vesalius A. De Humani Corporis Fabrica Liber V.
Basel Iohannis Oporini 1543.
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APPENDICITIS

• History

• Heister, a student of Boerhaave, described a
  perforation of the appendix with a small abscess
  adjacent to a gangrenous appendix
• Heister speculated that the appendix might be the
  site of acute inflammation. He described the
  autopsy on the body of a criminal
• Francois Melier, a Parisian physician, described
  6 cases of appendicitis at autopsy and first
  suggested the possibility of removing the
  appendix in 1827

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APPENDICITIS

• History

• Claudius Amyand, Sergeant Surgeon to George II,
  performed the first known appendectomy in 1735.
  He operated on an 11-year-old boy with a right
  scrotal hernia and a fistula. He identified the
  appendix, perforated by a pin, within the
  scrotum. He ligated the appendix and removed it.

Shepherd JA. Acute appendicitis a historical
survey. Lancet 19542299-302.
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APPENDICITIS

• History

• Fitz 1886
• Proposed that the appendix is the cause of most
  inflammatory disease of the right lower quadrant.
  He went on to describe the clinical features of
  appendicitis and, importantly, proposed early
  surgical removal of the appendix

Fitz RH. Perforating inflammation of the
vermiform appendix with special reference to its
early diagnosis and treatment. Am J Med Sci
188692321-46.
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APPENDICITIS

• History

• In 1889, McBurney of New York published the first
  of several important papers regarding the
  appendix. He suggested early operative
  intervention and developed the muscle-splitting
  incision that bears his name and is commonly used
  today

• McBurney C. Experience with early operative
  interference in cases of disease of the
• vermiform appendix. NY Med J 188950676-84.
• McBurney C. The incision made in the abdominal
  wall in cases of appendicitis,
• with a description of a new method of operation.
  Ann Surg 18942038-43.

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APPENDICITIS

• Introduction

• Lifetime risk 6 to 7
• Peak age Adolescents and young adults
• Uncommon lt5 and gt50 yrs
• 1 in 35 men
• 1 in 50 women
• MaleFemale 1.31

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APPENDICITIS

• Introduction

• More common in industrialised nations (refined,
  low fibre diet)
• Presumably, this diet leads to hard stool, higher
  intracolic pressure and faecolith formation
• Familial association is simply due to similar
  environment and dietary habits

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APPENDICITIS

• Pathophysiology

• Small lumen to length ratio
• Predisposed to closed loop obstruction,
  especially with proximal swelling or faecolith
• Ongoing mucosal secretion leads to elevated
  intraluminal pressure
• Venous pressure is exceeded and
• ischaemia develops
• Hypoxic mucosa begins to ulcerate
• Bacterial translocation

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APPENDICITIS

• Clinical Features

• Begins as peri-umbilical discomfort poorly
  localised and unrelieved by stools.
• Loss of Appetite (80)
• Nausea (- vomiting)
• Diarrhoea (uncommon)
• 6-12 hours later localised to RIF (localised
  peritonism)
• Less tenderness in retrocaecal or pelvic appendix
• Pyrexia (37.5 to 38) 25 to 50 have temp lt37.5

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APPENDICITIS

• Clinical Features

• Leukocytosis
• Cardall and colleagues showed that fever and
  leukocytosis were not always present and cannot
  be wholly relied upon in the diagnosis
• Pieper and colleagues reported 493 patients in
  which only 67 had a leukocyte count greater than
  11.0
• CRP

Cardall T, Glasser J, Guss DA. Clinical value of
the total white blood cell count and termperature
in the evaluation of patients with suspected
appendicitis. Acad Emerg Med 2004111021-7 Piepe
r R, Kager L, Nasman P. Acute appendicitis a
clinical study of 1018 cases of emergency
appendectomy. Acta Chir Scand 19824851-62.
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APPENDICITIS

• Clinical Features

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APPENDICITIS

• Clinical Features

PSOAS SIGN
The psoas sign. Pain on passive extension of the
right thigh. Patient lies on left side. Examiner
extends patient's right thigh while applying
counter resistance to the right hip.
Anatomic basis for the psoas sign inflamed
appendix is in a retroperitoneal location in
contact with the psoas muscle, which is stretched
by this manoeuvre.
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APPENDICITIS
OBTURATOR SIGN
Pain on passive internal rotation of the flexed
thigh. Examiner moves lower leg laterally while
applying resistance to the lateral side of the
knee resulting in internal rotation of the femur.
Anatomic basis for the obturator sign inflamed
appendix in the pelvis is in contact with the
obturator internus muscle, which is stretched by
this manoeuvre.
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APPENDICITIS

• Perforation - Clinical Features

• Occurs in 20-30
• Longer duration of symptoms before presentation
• Age lt3yrs and gt50yrs
• Increasing abdominal pain (severity and sight)
• Temperature gt 38
• The morbidity of a negative appendectomy is
  preferable to the morbidity of perforated
  appendicitis

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APPENDICITIS

• Peri-appendiceal Abscess - Clinical Features

• Occurs in 10
• Scenario Develops RIF pain and fever for 1-2
  days then resolves, then recurs 7-10 days later
• Palpable mass
• Ultrasound or CT to confirm diagnosis
• Avoid surgery if possible, especially if appendix
  is difficult to find (discussed later)

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APPENDICITIS

• Recurrent Appendicitis

• Debatable existence
• Sinanan has shown it to be a real entity
• Recurrent attacks of RIF pain
• If interval appendectomy not done after medical
  Rx, 10-80 recurrence
• Histology in recurrent pain pts- chronic AND
  acute inflammation

Sinanan M. Acute Abdomen and Appendix. In
Greenfield LJ, Mulholland MW, Oldham KT, Zelenock
GB, editors. Surgery Scientific Principles and
Practice. Philadelphia JB Lippincott 1993, pp
1120-42.
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APPENDICITIS

• Chronic Appendicitis

• Chronic RIF pain
• If appendectomy relieves pain, and histology
  shows chronic inflammation Diagnosis is made
  retrospectively

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APPENDICITIS

• Atypical Presentations

• 3 factors
• 1) Extremes of age
• 2) Variable appendiceal position
• 3) Associated conditions (e.g. pregnancy,
  Crohns, antibiotics, steroids, recent abdominal
  surgery)

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APPENDICITIS

• Atypical Presentations

• 3 factors
• 1) Extremes of age

• Age 1-5 has 70 perforation rate
• Age lt 1yr has almost 100 perforation rate
• REASONS
• Communication
• Shorter, incompletely formed omentum

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APPENDICITIS

• Atypical Presentations

• 3 factors
• 3) Associated conditions (e.g. pregnancy,
  Crohns, antibiotics, steroids, recent abdominal
  surgery)

• Pregnancy causes delays in diagnosis
• Abdominal pain, nausea, vomiting, leukocytosis
  all normal for pregnancy
• Appendix moves to RUQ in 3rd trimester

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APPENDICITIS

• Differential Diagnosis

CHILDREN

• Extra-abdominal (Otitis, pneumonia, meningitis,
  URTI can all present with abdominal pain,
  nausea, vomiting.
• Diarrhoea usually suggestive of gastroenteritis
• Mesenteric Lymphadenitis
• Meckels diverticulitis
• Intussusception (Tender mass and red-currant
  stools)
• Typhlitis (neutropaenic child)

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APPENDICITIS

• Imaging

A SHORT NOTE

• If the diagnosis is apparent from the history,
  examination and lab findings then surgery is
  indicated without imaging.
• Imaging is reserved for doubtful diagnosis

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APPENDICITIS

• Imaging

PLAIN RADIOGRAPHS

• Faecolith (5-8)
• Gas in the appendix
• Localised paralytic ileus
• Loss of caecal shadow
• Blurring of R Psoas
• R scoliosis of lumbar spine
• Free air (rare)

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APPENDICITIS

• Imaging

PLAIN RADIOGRAPHS

• Study of 821 patients no x-ray was sensitive or
  specific
• Use to rule out other condition (obstruction,
  renal calculus, perforation)
• Overall not cost effective

Rao PM, Rhea JT, Rao JA, Conn AK. Plain abdominal
radiography in clinically suspected appendicitis
diagnostic yield, resource use, and comparison
with CT. Am J Emerg Med 199917325-8.
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APPENDICITIS

• Imaging

ULTRASOUND

• Deutsch and Leopold visualised appendix in 1981
• Graded pressure technique (compresses the bowel
  overlying the appendix)
• Immobile, non-compressible, blind-ending
  structure consisting of an anechoic lumen
  surrounded by an echogenic mucosa and hypoechoic
  thickened wall adjacent to the caecum.

Deutsch A, Leopold GR. Ultrasonic demonstration
of the inflamed appendix case report. Radiology
1981140163-4.
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APPENDICITIS

• Imaging

ULTRASOUND

• The diagnostic accuracy of graded compression
  ultrasound has been reported to range from 71 to
  97, with sensitivities and specificities in the
  76 to 96 and 47 to 94 ranges, respectively
• Operator dependent
• Normal appendix must be visualised to rule out
  appendicitis (60-82)
• Retrocaecal appendix difficult to visualise

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APPENDICITIS

• Imaging

ULTRASOUND

• Appendicitis features
• Appendiceal diameter gt 6-7mm (sensitivity 100,
  specificity 64)
• Target sign
• Loculated peri-caecal fluid (rupture)
• Appendicolith
• Absence of gas in appendix lumen

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APPENDICITIS

• Imaging

ULTRASOUND - summary

• Disadvantages
• Low specificity
• Discomfort for patient with probe pressure
• Advantages
• Inexpensive
• Non-invasive
• No radiation
• Can find other abdominal pathology

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APPENDICITIS

• Imaging

CT SCAN

• Accuracy of 93-98
• Sensitivity 87-100
• Specificity 95-99
• Enlarged appendix
• Appendiceal wall thickening
• Peri-appendiceal fat stranding
• Appendiceal wall enhancement

Rao PM, Rhea JT, Novelline RA. Sensitivity and
specificity of the individual CT signs of
appendicitis experience with 200 helical
appendiceal CT examinations. J Comput Assist
Tomogr 199721686-92.
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APPENDICITIS

• Imaging

CT SCAN

• Study of 908 patients
• Drop in perforation rate (22 to 14)
• Drop in negative appendectomy rate (20 to 7)

Rao P, Rhea JT, Rattner DW, Wenus LG, Novelline
RA. Introduction of appendiceal CT impact on
negative appendectomy and appendiceal
perforation rates. Ann Surg 1999229344-9. .
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APPENDICITIS

• Imaging

CT vs. ULTRASOUND

• CT advantages
• Higher diagnostic accuracy
• Operator independence
• CT Disadvantages
• Contrast problems
• Radiation
• Cost

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APPENDICITIS

• Antibiotics

• Large meta-analysis of 9576 patients
• Proven to prevent wound infection and
  intra-abdominal abscess
• Cover Gram negative and anaerobic organisms

Andersen BR, Kallehave FL, Andersen HK.
Antibiotics versus placebo for prevention of
postoperative infection after appendicectomy.
Cochrane Database Syst Rev 200441-64
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APPENDICITIS

• Surgery

• Generally indicated unless
• Symptoms resolved when patient presents
• Peri-appendiceal abscess without peritonitis
  percutaneous drainage
• Interval appendectomy
• Optimise patient before surgery

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APPENDICITIS

• Open Appendectomy

• Normal appendix?
• Check Caecum, ileum (and sigmoid) for
  diverticular disease.
• Check for Meckels
• Gall Bladder
• Iiflammatory Bowel Disease
• Perforated Duodenal Ulcer
• GUT (females PID, follicular cysts, ectopic)
• Mesenteric lymphadenpathy
• NB if pus, full exploration required

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APPENDICITIS

• Open Appendectomy

• Normal appendix?
• Do appendectomy anyway (presence of the scar,
  etc.)
• Exception is diseased caecum (e.g. Crohns) where
  a fecal fistula may form

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APPENDICITIS

• Peri-appendiceal Abscess

• CT or Sonar guided percutaneous catheter
• 7-10 days of drainage
• Interval appendectomy at 6-8 weeks
• If laparotomy done
• Open abscess
• Appendectomy only if safe
• If caecum friable, leave it and do interval
  appendectomy (10 to 80 risk of recurrence)

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APPENDICITIS

• Laparoscopic Appendectomy

• Kurt Semm 1983
• Major meta-analysis, still major controversy
• Dependent on expertise and equipment
• Allows for better visualisation of the abdomen

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APPENDICITIS

• Laparoscopic Appendectomy

CONTRA-INDICATIONS

• Lack of surgeons experience
• Inability to tolerate GA
• Refractory coagulopathy
• Diffuse peritonitis with haemodynamic compromise
• Previous abdominal surgery (relative)
• Portal Hypertension (relative)
• Advanced pregnancy (relative)
• Severe cardiac failure (relative)

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Selected randomized trials of laparoscopic versus
open appendectomy
Reference number number OR Time Conversion rate() LOS ltdaysgt OR Time Conversion rate() LOS ltdaysgt OR Time Conversion rate() LOS ltdaysgt OR Time Conversion rate() LOS ltdaysgt OR Time Conversion rate() LOS ltdaysgt
Reference L 0 L O L 0
Long et al (2002) 93 105 107 91 16 2.6 3.4
Pedersen et al (2001) 282 301 60 40 23 2 2
Ozmen et al (1999) 35 35 28 38 1.6 3.7
Hellberg et al (1999) 244 256 60 35 12 2 2
Heikkinen et al (1998) 19 21 31 41 5.3 2 2
Klinger et al. (1998) 87 82 35 31 0 3 4
Reiertsen et al (1997) 42 42 51 25 0 3.5 3.2
Minne et al (1997) 27 23 82 67 7.4 1.1 1.2
Macarulla et al (1997) 106 104 55 45 8.3 3.4 4.8
Ortega et al (1995) 167 86 68 58 6.5 2.6 2.8
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APPENDICITIS

• Laparoscopic Appendectomy

• Laparoscopic longer by 15-20 minutes
• 5 - 25 conversion
• Hospital stay same or 1 day in favour of
  laparoscopic
• Return to normal activity 5-7 days earlier
• Results of complication rates mixed
• No difference in cost
• (equipment/length vs. hospital stay)
• Jury is still out