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Clinical Practice Guidelines on Appendicitis

Clinical Practice Guidelines on Appendicitis

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Published by: Romberg's sign on Oct 14, 2011
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Acute appendicitis is the most common surgical emergency of the abdomen while appendectomy is oneof the most frequently performed surgical procedures. Quite fortunately, the mortality rateparticularly from perforated appendicitis has improved from near certain death a century ago to10-20 per cent 50 years ago, 5 per cent during the 1960s and 1 per cent or less from the 1970s tothe present. The morbidity rate, however, remains significant especially with appendiceal rupturewhere the incidence ranges from 17 per cent to 40 per cent with a median of 20 per cent. Toreduce the incidence of perforation, the surgical community traditionally accepts thatapproximately 15 per cent of appendectomies over-all and 20 per cent in women will yield a non-inflamed appendix. In certain populations of patients, the rate of misdiagnosis may even reach 40per cent.Despite gaining a century of clinical experience with acute appendicitis however, the rates of unnecessaryappendectomies and perforation have remained relatively high. The dramatic expansion of diagnostic testing options and the introduction of innovative surgical approaches during the lastdecade has actually caused even more debate and disagreement than resolution of issues.In an attempt to better define the appropriate roles of the available diagnostic modalities and to formulatean efficient and cost-effective management scheme, the Philippine College of Surgeons throughthe Committee on Surgical Infections decided to formulate these “Evidence-Based ClinicalPractice Guidelines on the Diagnosis and Treatment of Acute Appendicitis.” It is hoped that theapplication of this set of standards will be rewarded with a marked decrease in morbidity rates.With the proper use of the recommended ancillary diagnostic tests and management strategies,surgeons should be able to realize a steady improvement in the balance between the two primaryadverse outcomes in the management of appendicitis, that is, a low rate of misdiagnosis or negative laparotomies coupled with a reduced incidence of perforation.The clinical practice guidelines to be presented herein are statements that bring together the best clinicalevidence and other knowledge necessary for decision-making in the diagnosis and treatment of acute appendicitis. They were formulated to identify the most efficacious interventions in order tomaximize the benefits for individual patients.These guidelines, however, must be integrated with the surgeon’s clinical expertise in deciding whether and how they match their patient’s clinical state, predicament and preferences. The guidelinesbuild on and reinforce the surgeon’s clinical skills, judgment and experience. Guidelines areintended to inform, but can never replace, individual clinical expertise and it is this expertise thatdecides whether the guidelines apply to a particular patient and how the guidelines should beintegrated into the clinical decision-making process.To further ensure the validity of the recommendations and to prevent any bias that would appear to favor a pharmaceutical company, the Philippine College of Surgeons invited surgeons, internists andpediatricians who were not employed by any drug firm to comprise the technical working groupand the panel of experts. The extent of participation of our friends from the pharmaceuticalindustry was likewise limited to their assistance with respect to technical matters.The following clinical questions were addressed by the guidelines:1. When should one suspect acute appendicitis?2. What clinical findings are most helpful in diagnosing acute appendicitis?3. What diagnostic tests are helpful in the diagnosis of acute appendicitis?4. What is the appropriate treatment for acute appendicitis?5.What is the recommended approach to the surgical management of acute appendicitis?6.What is the role of laparoscopic appendectomy in the management of acute appendicitis in children?7.What is the role of antibiotics in the management of acute appendicitis?a. Is antibiotic prophylaxis indicated for uncomplicated appendicitis?b. What antibiotic/s is/are recommended for prophylaxis in uncomplicatedappendicitis an what is the appropriate dose and route of administration?c. What antibiotic/s is/are recommended for the treatment of complicated appendicitis and whatis the appropriate dose, route and duration of administration?8. Should gram stain and culture and sensitivity be routinely done in acute appendicitis?9. How should localized peritonitis be managed?10. What is the appropriate method of wound closure in patients with complicated
appendicitis?11. What is the optimal timing of surgery for patients with periappendiceal abscess?
A search of publications was carried out using a sensitive search strategy combining MESH and free textsearches. This strategy included an extensive search of the following databases:1.Medline (1966 to present)2.Cochrane Library (2002 issue 2)3.Health Research and Development Network (Herdin)4.Phil. Journal of Surgical Specialties CD-ROM (1975 to 1999) and hand searches from 2000 to thepresentFrom the search results, the Technical Working Group (TWG) selected relevant articles for full-textretrieval using the Nominal Group Technique. Retrieved studies were then assessed for eligibilityaccording to the criteria set by the guideline developers. The methodologic quality of the studies wasappraised by two independent reviewers using a quality assessment instrument developed by thePhilippine Cardiovascular Research Group.The pertinent results of the selected articles as based on the clinical questions were summarized andcompared. When appropriate and where relevant data were available, the sensitivities,specificities, accuracies, predictive values and likelihood ratios, including the 95 per centconfidence intervals were calculated for diagnostic articles; the relative risks, risk differences, andthe number needed to treat (NNT) were computed and compared for articles on therapy.The clinical evidence was then rated according to the assessment system of the Infectious DiseaseSociety of America:Level I – Evidence from at least one properly designed randomized controlled trial or meta-analysisLevel II - Evidence from at least one well-designed clinical trial without proper randomization, from cohort or case-controlled analytic studies (preferablyfrom one center), from multiple time-series, or from dramatic results in uncontrolledexperimentsLevel III- Evidence from opinions of respected authorities on the basis of clinicalexperience, descriptive studies, or reports of expert committeesThe members of the Technical Working Group prepared the evidence-based reportbased on the articles retrieved and appraised. A total of 832 article titles with abstracts wereretrieved by the electronic literature search. After evaluation and validity appraisal, 68 articleswere chosen and used to answer the clinical questions. The TWG then held several meetings todiscuss each clinical question and the corresponding evidence, formulate the initialrecommendations and thereafter reach a consensus utilizing the Nominal Group Technique. Aconsensus was reached after having attained 70 per cent agreement among the members of theTWG.The TWG together with the panel of experts reviewed the interim report during theSurgical Infection Forum held at the Fontana Leisure Park, Clark Special Economic Zone,Pampanga on November 24, 2002. Each clinical question, the evidence and therecommendations were analyzed and the participants given the opportunity to express their opinions and views. The modified Delphi Technique was then used to determine the degree of consensus regarding the recommendations.The strength of the recommendations for the guidelines was categorized according to the level of agreement of the panel of experts after a votation of the participants:Category A – Recommendations that were approved by consensus (at least 75 per cent of the multi-sectoral expert panel)Category B - Recommendations that were somewhat controversial and did notmeet consensusCategory C – Recommendations that caused real disagreements among themembers of the panelThe draft guidelines were then presented to the stakeholders during the PhilippineCollege of Surgeons Annual Convention held at the EDSA Shangri-la Hotel, Mandaluyong City onDecember 4, 2002. The invited participants included practicing surgeons and representativesfrom the pharmaceutical companies and concerned government agencies.
The Evidence-Based Clinical Practice Guidelines on the Diagnosis and Treatment of Acute Appendicitis was then submitted to the 2003 PCS Board of Regents for final approval inFebruary 2003.
OPERATIONAL DEFINITIONSUncomplicated Appendicitis
- includes the acutely inflamed, phlegmonous, suppurative, or mildlyinflamed appendix with or without peritonitis
Complicated Appendicitis
- includes gangrenous appendicitis, perforated appendicitis, localizedpurulent collection at operation, generalized peritonitis and periappendiceal abscess
Equivocal Appendicitis
– a patient with right lower quadrant abdominal pain who presents with anatypical history and physical examination and the surgeon cannot decide whether to discharge or tooperate on the patient
EXECUTIVE SUMMARYWhen should one suspect acute appendicitis?
Consider the diagnosis of acute appendicitis when a patient presents with right lower quadrantabdominal pain.
LEVEL III EVIDENCECATEGORY A RECOMMENDATIONWhat clinical findings are most helpful in diagnosing acute appendicitis?
Acute appendicitis should be suspected in any patient (especially male) who presents with a high intensityof perceived abdominal pain of at least 7-12 hours duration, with migration to the right lower quadrant,and followed by vomiting.Although symptoms alone have a low discriminating power, the diagnosis of acute appendicitis becomesmore certain when the physical examination findings include right lower quadrant tenderness, guarding,rebound tenderness and other signs of peritoneal irritation.
What diagnostic tests are helpful in the diagnosis of acute appendicitis?
Although the diagnosis of acute appendicitis is primarily based on the clinical findings, the followingexaminations may be helpful:A. All Cases1.White blood cell withdifferential count
LEVEL I EVIDENCECATEGORY RECOMMENDATIONB. Equivocal Appendicitis in Adults 1.CT scan 2.Ultrasound
Whenever feasible, CT scan should be preferred over ultrasonography in clinically equivocalappendicitis in adults because of its superior accuracy.
LEVEL I EVIDENCECATEGORY A RECOMMENDATIONC. Equivocal Appendicitis in the Pediatric Age Group
1. Ultrasound(graded compression)2. CT scanAlthough CT scan and ultrasound have comparable accuracy in the diagnosis of appendicitis inthe pediatric age group, ultrasound is preferred because of its lack of radiation, cost-effectiveness andavailability compared to CT scan.

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