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Note: Large images and tables on this page may necessitate printing in landscape mode. Copyright © The McGraw-Hill Companies. All rights reserved. Schwartz's Principles of Surgery > Chapter 30. The Appendix >

1. Appendectomy for appendicitis is the most commonly performed emergency operation in the world. 2. Despite the increased use of ultrasonography, computed tomographic scanning, and laparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture. The percentage of misdiagnosed cases of appendicitis is significantly higher among women than among men. 3. Appendicitis is a polymicrobial infection, with some series reporting up to 14 different organisms cultured in patients with perforation. The principal organisms seen in the normal appendix, in acute appendicitis, and in perforated appendicitis are Escherichia coli and Bacteroides fragilis. 4. Antibiotic prophylaxis is effective in the prevention of postoperative wound infection and intra-abdominal abscess. Antibiotic coverage is limited to 24 to 48 hours in cases of nonperforated appendicitis. For perforated appendicitis, 7 to 10 days of treatment is recommended. 5. Compared with younger patients, elderly patients with appendicitis often pose a more difficult diagnostic problem because of the atypical presentation, expanded differential diagnosis, and communication difficulty. These factors contribute to the disproportionately high perforation rate seen in the elderly. 6. The overall incidence of fetal loss after appendectomy is 4% and the risk of early delivery is 7%. Rates of fetal loss are considerably higher in women with complex appendicitis than in those with negative appendectomy and those with simple appendicitis. Removing a normal appendix is associated with a 4% risk of fetal loss and 10% risk of early delivery. 7. Recent data on appendiceal malignancies from the Surveillance, Epidemiology, and End Results program identified mucinous adenocarcinoma as the most frequent histologic diagnosis, followed by adenocarcinoma, carcinoid, goblet cell carcinoma, and signet-ring cell carcinoma.

The appendix first becomes visible in the eighth week of embryologic development as a protuberance off the terminal portion of the cecum. During both antenatal and postnatal development, the growth rate of the cecum exceeds that of the appendix, so that the

development, the growth rate of the cecum exceeds that of the appendix, so that the appendix is displaced medially toward the ileocecal valve. The relationship of the base of the appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position (Fig. 30-1). These anatomic considerations have significant clinical importance in the context of acute appendicitis. The three taeniae coli converge at the junction of the cecum with the appendix and can be a useful landmark to identify the appendix. The appendix can vary in length from <1 cm to >30 cm; most appendices are 6 to 9 cm long. Appendiceal absence, duplication, and diverticula have all been described. 1â!“4

Fig. 30-1.

Various anatomic positions of the vermiform appendix.

For many years, the appendix was erroneously viewed as 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. Although there is no clear role for the appendix in the development of human disease, recent studies demonstrate a potential correlation between appendectomy and the development of inflammatory bowel disease. There appears to be a negative age-related association between

inflammatory bowel disease. There appears to be a negative age-related association between prior appendectomy and subsequent development of ulcerative colitis. In addition, comparative analysis clearly shows that prior appendectomy is associated with a more benign phenotype in ulcerative colitis and a delay in onset of disease. The association between Crohn's disease and appendectomy is less clear. Although earlier studies suggested that appendectomy increases the risk of developing Crohn's disease, more recent studies that carefully assessed the timing of appendectomy in relation to the onset of Crohn's disease demonstrated a negative correlation. These data suggest that appendectomy may protect against the subsequent development of inflammatory bowel disease; however, the mechanism is unclear.4 Lymphoid tissue first appears in the appendix approximately 2 weeks after birth. The amount of lymphoid tissue increases throughout puberty, remains steady for the next decade, and then begins a steady decrease with age. After the age of 60 years, virtually no lymphoid tissue remains within the appendix, and complete obliteration of the appendiceal lumen is common. 1â!“4

ACUTE APPENDICITIS Historical Background
Although ancient texts have scattered descriptions of surgery being undertaken for ailments sounding like appendicitis, credit for performing the first appendectomy goes to Claudius Amyand, a surgeon at St. George's Hospital in London and Sergeant Surgeon to Queen Ann, King George I, and King George II. In 1736, he operated on an 11-year-old boy with a scrotal hernia and a fecal fistula. Within the hernial sac, Amyand found the appendix perforated by a pin. He successfully removed the appendix and repaired the hernia. 5 The appendix was not identified as an organ capable of causing disease until the nineteenth century. In 1824, Louyer-Villermay presented a paper before the Royal Academy of Medicine in Paris. He reported on two autopsy cases of appendicitis and emphasized the importance of the condition. In 1827, François Melier, a French physician, expounded on LouyerVillermay's work. He reported six autopsy cases and was the first to suggest the antemortem recognition of appendicitis. 5 This work was discounted by many physicians of the era, including Baron Guillaume Dupuytren. Dupuytren believed that inflammation of the cecum was the main cause of pathology of the right lower quadrant. The term typhlitis or perityphlitis was used to describe right lower quadrant inflammation. In 1839, a textbook authored by Bright and Addison entitled Elements of Practical Medicine described the symptoms of appendicitis and identified the primary cause of inflammatory processes of the right lower quadrant. 6 Reginald Fitz, a professor of pathologic anatomy at Harvard, is credited with coining the term appendicitis. His landmark paper definitively identified the appendix as the primary cause of right lower quadrant inflammation. 7 Initial surgical therapy for appendicitis was primarily designed to drain right lower quadrant abscesses that occurred secondary to appendiceal perforation. It appears that the first

abscesses that occurred secondary to appendiceal perforation. It appears that the first surgical treatment for appendicitis or perityphlitis without abscess was carried out by Hancock in 1848. He incised the peritoneum and drained the right lower quadrant without removing the appendix. The first published account of appendectomy for appendicitis was by Krönlein in 1886. However, this patient died 2 days after operation. Fergus, in Canada, performed the first elective appendectomy in 1883.5 The greatest contributor to the advancement in the treatment of appendicitis was Charles McBurney. In 1889, he published his landmark paper in the New York State Medical Journal describing the indications for early laparotomy for the treatment of appendicitis. It is in this paper that he described the McBurney point as follows: "maximum tenderness, when one examines with the fingertips is, in adults, one half to two inches inside the right anterior spinous process of the ilium on a line drawn to the umbilicus."8 McBurney subsequently published a paper in 1894 describing the incision that bears his name. 9 However, McBurney later credited McArthur with first describing this incision. Semm is widely credited with performing the first successful laparoscopic appendectomy in 1982.10 The surgical treatment of appendicitis is one of the great public health advances of the last 150 years. Appendectomy for appendicitis is the most commonly performed emergency operation in the world. Appendicitis is a disease of the young, with 40% of cases occurring in patients between the ages of 10 and 29 years. 11 In 1886, Fitz reported the associated mortality rate of appendicitis to be at least 67% without surgical therapy. 7 Currently, the mortality rate for acute appendicitis with treatment is reported to be <1%. 12

The lifetime rate of appendectomy is 12% for men and 25% for women, with approximately 7% of all people undergoing appendectomy for acute appendicitis during their lifetime. Over the 10-year period from 1987 to 1997, the overall appendectomy rate decreased in parallel with a decrease in incidental appendectomy. 11,13 However, the rate of appendectomy for appendicitis has remained constant at 10 per 10,000 patients per year. 14 Appendicitis is most frequently seen in patients in their second through fourth decades of life, with a mean age of 31.3 years and a median age of 22 years. There is a slight male:female predominance (1.2 to 1.3:1).11,13 Despite the increased use of ultrasonography, computed tomography (CT), and laparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture. The percentage of misdiagnosed cases of appendicitis is significantly higher among women than among men (22.2 vs. 9.3%). The negative appendectomy rate for women of reproductive age is 23.2%, with the highest rates in women aged 40 to 49 years. The highest negative appendectomy rate is reported for women >80 years of age (Fig. 302). 13,14

Distention of the appendix stimulates the nerve endings of visceral afferent stretch fibers. and continuing normal secretion by the appendiceal mucosa rapidly produces distention. Fecaliths are the most common cause of appendiceal obstruction. The frequency of obstruction rises with the severity of the inflammatory process. Distention of this magnitude usually causes reflex nausea and vomiting. dull.Fig. Less common causes are hypertrophy of lymphoid tissue. vegetable and fruit seeds. Traditionally the belief has been that there is a predictable sequence of events leading to eventual appendiceal rupture. producing vague. and in nearly 90% of cases of gangrenous appendicitis with rupture. (Adapted from Flum et al. Fecaliths are found in 40% of cases of simple acute appendicitis. inspissated barium from previous x-ray studies. The luminal capacity of the normal appendix is only 0. diffuse pain in the midabdomen or lower epigastrium. The proximal obstruction of the appendiceal lumen produces a closed-loop obstruction. in 65% of cases of gangrenous appendicitis without rupture. Peristalsis also is stimulated by the rather sudden distention.5 mL of fluid distal to an obstruction raises the intraluminal pressure to 60 cm H 2O. and the .1 mL. Rate of negative appendectomy by age group. 13.14) Etiology and Pathogenesis Obstruction of the lumen is the dominant etiologic factor in acute appendicitis. so that some cramping may be superimposed on the visceral pain early in the course of appendicitis. Distention increases from continued mucosal secretion and from rapid multiplication of the resident bacteria of the appendix. Secretion of as little as 0. and intestinal parasites. 30-2. tumors.

which produces the characteristic shift in pain to the right lower quadrant. is susceptible to impairment of blood supply. bacterial invasion.appendix. with some series reporting the culture of up to 14 different organisms in patients with perforation. suggesting old. The inflammatory process soon involves the serosa of the appendix and in turn parietal peritoneum in the region.17 Bacteriology The bacterial population of the normal appendix is similar to that of the normal colon. As pressure in the organ increases. recent epidemiologic studies have suggested that nonperforated and perforated appendicitis may. Perforation generally occurs just beyond the point of obstruction rather than at the tip because of the effect of diameter on intraluminal tension. but less severe. Appendicitis is a polymicrobial infection. compromise of vascular supply. This bacterium is seen only in adults. and infarction progress. This sequence is not inevitable. thus its integrity is compromised early in the process. resulting in engorgement and vascular congestion.18 The bacteria cultured in cases of appendicitis are therefore similar to those seen in other colonic infections such as diverticulitis. As progressive distention encroaches on first the venous return and subsequently the arteriolar inflow. healed acute inflammation. the area with the poorest blood supply suffers most: ellipsoidal infarcts develop in the antimesenteric border. The principal organisms seen in the normal appendix.16 The strong association between delay in presentation and appendiceal perforation supported the proposition that appendiceal perforation is the advanced stage of acute appendicitis. venous pressure is exceeded. and in perforated appendicitis are Escherichia coli and Bacteroides fragilis. however. in fact. and some episodes of acute appendicitis apparently subside spontaneously. 15. be different diseases. and the diffuse visceral pain becomes more severe. Many patients who are found at operation to have acute appendicitis give a history of previous similar.18 Table 30-1 Common Organisms Seen in Patients with Acute Appendicitis Aerobic and Facultative Anaerobic . Capillaries and venules are occluded. in acute appendicitis. The mucosa of the GI tract. a wide variety of both facultative and anaerobic bacteria and mycobacteria may be present (Table 30-1). however.18â!“21 However. Pathologic examination of the appendices removed from these patients often reveals thickening and scarring. perforation occurs. usually through one of the infarcted areas on the antimesenteric border. As distention. which allows bacterial invasion. Distention of this magnitude usually causes reflex nausea and vomiting. but arteriolar inflow continues. including the appendix. attacks of right lower quadrant pain. The appendiceal flora remains constant throughout life with the exception of Porphyromonas gingivalis.

as a result of either illness or medication. IV antibiotics are usually given until the white blood cell count is normal and the patient is afebrile for 24 hours. For perforated appendicitis. testicular pain. pain is initially diffusely centered in the lower epigastrium or umbilical area. sometimes with intermittent cramping superimposed. For example. the number of organisms cultured and the ability of a specific laboratory to culture anaerobic organisms vary greatly. 7 to 10 days of therapy is recommended. a pelvic appendix. By the time culture results are available. and for patients who develop an abscess after the treatment of appendicitis. the pain of appendicitis begins in the right lower quadrant and remains there. Classically. .Gram-negative bacilli Escherichia coli Pseudomonas aeruginosa Klebsiella species Gram-positive cocci Streptococcus anginosus Other Streptococcu s species Enterococcus species Gram-negative bacilli Bacteroides fragilis Other Bacteroide s species Fusobacterium species Gram-positive cocci Peptostreptococcus species Gram-positive bacilli Clostridium species The routine culture of intraperitoneal samples in patients with either perforated or nonperforated appendicitis is questionable. In some patients. This classic pain sequence. principally suprapubic pain. Variations in the anatomic location of the appendix account for many of the variations in the principal locus of the somatic phase of the pain.24 Clinical Manifestations SYMPTOMS Abdominal pain is the prime symptom of acute appendicitis. and a retroileal appendix. a long appendix with the inflamed tip in the left lower quadrant causes pain in that area. After a period varying from 1 to 12 hours.23 Antibiotic coverage is limited to 24 to 48 hours in cases of nonperforated appendicitis. A retrocecal appendix may cause principally flank or back pain. 20â!“22 Antibiotic prophylaxis is effective in the prevention of postoperative wound infection and intra-abdominal abscess. and is steady. Peritoneal culture should be reserved for patients who are immunosuppressed. although usual. but usually within 4 to 6 hours. and therefore broad-spectrum antibiotics are indicated. In addition. is moderately severe. is not invariable. Intestinal malrotation also is responsible for puzzling pain patterns. the pain localizes to the right lower quadrant. the flora is known. As discussed earlier. The visceral component is in the normal location. presumably from irritation of the spermatic artery and ureter. Antibiotic irrigation of the peritoneal cavity and the use of transperitoneal drainage through the wound are controversial. the patient often has recovered from the illness. but the somatic component is felt in that part of the abdomen where the cecum has been arrested in rotation.

Cutaneous hyperesthesia in the area supplied by the spinal nerves on the right at T10. but in some early cases.8 Direct rebound tenderness usually is present. Early in the disease.25 Patients with appendicitis usually prefer to lie supine. If vomiting precedes the onset of pain. because any motion increases pain. Hyperesthesia is elicited either by needle prick or by gently picking up the skin between the forefinger and thumb. which indicates localized peritoneal irritation. it is neither prominent nor prolonged. they do so slowly and with caution. In patients with obvious appendicitis. Temperature elevation is rarely >1°C (1. particularly children. the diagnosis of appendicitis should be questioned. Diarrhea occurs in some patients. resistance. In addition. anorexia is the first symptom. muscle spasm increases and becomes largely involuntary. The classic right lower quadrant physical signs are present when the inflamed appendix lies in the anterior position. true reflex rigidity due to contraction of muscles directly beneath the inflamed parietal peritoneum. consists mainly of voluntary guarding. it may be the first positive sign. As peritoneal irritation progresses. which is followed. Vital signs are minimally changed by uncomplicated appendicitis. Muscular resistance to palpation of the abdominal wall roughly parallels the severity of the inflammatory process. if present. and most patients vomit only once or twice. this sign is superfluous. as well as by whether the organ has already ruptured when the patient is first examined. particularly the right thigh. with the thighs. In >95% of patients with acute appendicitis. Most patients give a history of obstipation beginning before the onset of abdominal pain. 25 The Rovsing signâ!”pain in the right lower quadrant when palpatory pressure is exerted in the left lower quadrantâ!”also indicates the site of peritoneal irritation. in turn. Although vomiting occurs in nearly 75% of patients. . followed by abdominal pain. The sequence of symptom appearance has great significance for the differential diagnosis. Vomiting is caused by both neural stimulation and the presence of ileus. referred or indirect rebound tenderness is present. by vomiting (if vomiting occurs). This referred tenderness is felt maximally in the right lower quadrant. that is. SIGNS Physical findings are determined principally by what the anatomic position of the inflamed appendix is. Changes of greater magnitude usually indicate that a complication has occurred or that another diagnosis should be considered. If asked to move. however. and T12 frequently accompanies acute appendicitis. It is so constant that the diagnosis should be questioned if the patient is not anorectic. T11. drawn up. so that the pattern of bowel function is of little differential diagnostic value.8°F) and the pulse rate is normal or slightly elevated. Tenderness often is maximal at or near the McBurney point. and many feel that defecation would relieve their abdominal pain.Anorexia nearly always accompanies appendicitis.

The technique is inexpensive. Similarly. the appendix is identified as a blind-ending. can be performed rapidly. If the appendix fills on barium enema. ranging from 10. LABORATORY FINDINGS Mild leukocytosis.000 cells/mm 3.Anatomic variations in the position of the inflamed appendix lead to deviations in the usual physical findings. A chest radiograph is sometimes indicated to rule out referred pain from a right lower lobe pneumonic process.000 to 18. bacteriuria in a urine specimen obtained via catheter generally is not seen in acute appendicitis. Sonographically. The presence of a fecalith is rarely noted on plain films but. usually is present in patients with acute. rarely are helpful in diagnosing acute appendicitis. however. It is unusual for the white blood cell count to be >18. White blood cell counts above this level raise the possibility of a perforated appendix with or without an abscess. if the appendix does not fill. pain is felt in the suprapubic area as well as locally within the rectum. Graded compression sonography has been suggested as an accurate way to establish the diagnosis of appendicitis. is highly suggestive of the diagnosis. the anterior abdominal findings are less striking. and the diagnosis may be missed unless the rectum is examined. When the inflamed appendix hangs into the pelvis. Although several white or red blood cells can be present from ureteral or bladder irritation as a result of an inflamed appendix. appendicitis is excluded. the diameter of the appendix is measured in the anteroposterior . White blood cell counts are variable. The test result is positive if extension produces pain. Additional radiographic studies include barium enema examination and radioactively labeled leukocyte scans. The test is performed by passive internal rotation of the flexed right thigh with the patient supine. does not require a contrast medium. The psoas sign indicates an irritative focus in proximity to that muscle. However. The test is performed by having the patient lie on the left side as the examiner slowly extends the patient's right thigh. no determination can be made. there has not been enough experience with radionuclide scans to assess their utility. and tenderness may be most marked in the flank. nonperistaltic bowel loop originating from the cecum. if present. Signs of localized muscle irritation also may be present. and can be used even in pregnant patients. In patients with acute appendicitis. With maximal compression. With a retrocecal appendix. On the other hand. plain radiographs can be of significant benefit in ruling out other pathology. one often sees an abnormal bowel gas pattern. uncomplicated appendicitis and often is accompanied by a moderate polymorphonuclear predominance.000 cells/mm 3 in uncomplicated appendicitis. although frequently obtained as part of the general evaluation of a patient with an acute abdomen. Urinalysis can be useful to rule out the urinary tract as the source of infection. As the examining finger exerts pressure on the peritoneum of Douglas' cul-de-sac. 27 To date. thus stretching the iliopsoas muscle. a positive obturator sign of hypogastric pain on stretching the obturator internus indicates irritation in the pelvis. abdominal findings may be entirely absent. which is a nonspecific finding. 26 Imaging Studies Plain films of the abdomen.

30-3. which is an easily compressible.28â!“30 Sonography is similarly effective in children and pregnant women. Sonographic demonstration of a normal appendix. . The study results are considered inconclusive if the appendix is not visualized and there is no pericecal fluid or mass. the pelvic organs must be adequately visualized either by transabdominal or endovaginal ultrasonography to exclude gynecologic pathology as a cause of acute abdominal pain. The presence of an appendicolith establishes the diagnosis.With maximal compression. The sonographic diagnosis of acute appendicitis has a reported sensitivity of 55 to 96% and a specificity of 85 to 98%. Thickening of the appendiceal wall and the presence of periappendiceal fluid is highly suggestive. Scan results are considered positive if a noncompressible appendix ≥6 mm in the anteroposterior direction is demonstrated (Fig. blind-ending tubular structure measuring ≤5 mm in diameter. although its application is somewhat limited in late pregnancy. When the diagnosis of acute appendicitis is excluded by sonography. excludes the diagnosis of acute appendicitis. a brief survey of the remainder of the abdominal cavity should be performed to establish an alternative diagnosis. In females of childbearing age. Fig. the diameter of the appendix is measured in the anteroposterior dimension. 30-3).

Falsenegative sonogram results can occur if appendicitis is confined to the appendiceal tip. A false-positive scan result can occur in the presence of periappendicitis from surrounding inflammation. the appendix is markedly enlarged and mistaken for small bowel.33 The positive and negative predictive values of ultrasonography have impressively been reported as 91 and 92%.0 mm in maximal anteroposterior diameter in both the noncompression (A ) and compression (B) views. However.32 Sonography also decreases the time before operation.Sonogram of a 10-year-old girl who presented with nausea. the technique has limitations and results are user dependent. and abdominal pain. in a recent prospective multicenter study. Sonography identified appendicitis in 10% of patients who were believed to have a low likelihood of the disease on physical examination. Although sonography can easily identify abscesses in cases of perforation. a dilated fallopian tube can be mistaken for an inflamed appendix. the appendix is retrocecal. vomiting.31 Some studies have reported that graded compression sonography improved the diagnosis of appendicitis over clinical examination. routine ultrasonography did . respectively. and. or the appendix is perforated and therefore compressible. The appendix measured 10. the appendix may not be compressible because of overlying fat. inspissated stool can mimic an appendicolith. in obese patients. specifically decreasing the percentage of negative explorations for appendectomies from 37 to 13%.

respectively. There is usually evidence of inflammation. . An important suggestive abnormality is the arrowhead sign. with "dirty fat. which funnels contrast agent toward the orifice of the inflamed appendix. 30-4). High-resolution helical CT also has been used to diagnose appendicitis. but their presence is not necessarily pathognomonic of appendicitis. 30-4. in a recent prospective multicenter study. However. the inflamed appendix appears dilated (>5 cm) and the wall is thickened. CT scanning is also an excellent technique for identifying other inflammatory processes masquerading as appendicitis. routine ultrasonography did not improve diagnostic accuracy or rates of negative appendectomy or perforation compared with clinical assessment. Fecaliths can be easily visualized. and even an obvious phlegmon (Fig." thickened mesoappendix. Fig. This is caused by thickening of the cecum. On CT scan.

particularly in the presence of nausea and vomiting. all of these techniques have yielded essentially identical rates of diagnostic accuracy: 92 to 97% sensitivity. because one of the disadvantages of using CT scanning in the evaluation of right lower quadrant pain is dye allergy. including focused and nonfocused CT scans and enhanced and nonenhanced helical CT scanning. CT lowered the rate of negative appendectomies from 19 to 12% in one study. Finally. not all studies have documented the utility of CT scanning in all . and cannot be used during pregnancy. A number of studies have documented improvement in diagnostic accuracy with the liberal use of CT scanning in the work-up of suspected appendicitis. and 75 to 95% positive and 95 to 99% negative predictive values. Note the thick-walled and dilated appendix (A ) and mesenteric streaking and "dirty fat" (B). and others cannot tolerate the oral ingestion of luminal dye.37 and the incidence of negative appendectomies in women from 24 to 5% in another. 34â !“36 The additional use of a rectally administered contrast agent did not improve the results of CT scanning. Allergy contraindicates the administration of IV contrast agents in some patients. exposes the patient to significant radiation. there are significant disadvantages. 90 to 98% accuracy. CT scanning is expensive. 85 to 94% specificity. 38 The use of this imaging study altered the care of 24% of patients studied and provided alternative diagnoses in half of the patients with normal appendices on CT scan. Nonenhanced helical CT scanning is important. Surprisingly. Several CT techniques have been used.Computed tomographic scans with findings positive for appendicitis.39 Despite the potential usefulness of this technique.

ultrasound positively impacted the management of 19% of patients. CT scanning is certainly appropriate for patients with Alvarado scores of 5 and 6. radiation exposure. and lowered the per-patient cost by $447. specificity of 93 and 94%.40 A number of studies have compared the effectiveness of graded compression sonography and helical CT in establishing the diagnosis of appendicitis. Patients with scores of 7 or 8 have a high likelihood of appendicitis. respectively. CT scanning has consistently proven superior.46. Rao and associates documented that CT scanning prevented 13 unnecessary appendectomies. Patients with scores of 9 or 10 are almost certain to have appendicitis. diagnostic accuracy of 89 and 95%. 30 In another study. This has been documented by several studies in which imaging was performed based on an algorithm or protocol. saved 50 inpatient hospital days. 600 ultrasounds and 317 CT scans demonstrated sensitivity of 80 and 97%. and a case can be built for imaging for those with scores of 7 and 8.nausea and vomiting. as well as establishment of an alternative diagnosis in 50% of patients. documenting that surgeon accuracy approached that of the imaging study and expressing concern that the imaging studies could adversely delay appendectomy in affected patients. this group documented that CT scanning led to a fall in the negative appendectomy rate from 20 to 7% and a decline in the perforation rate from 22 to 14%. published in the New England Journal of Medicine. appendicitis. The concept that all patients with right lower quadrant pain should undergo CT scanning has been strongly supported by two reports by Rao and his colleagues at the Massachusetts General Hospital. Finally. . and they should go to the operating room.43 This question may be moot. and negative predictive value of 88 and 98%. because CT scanning routinely is ordered by emergency physicians before surgeons are even consulted. not all studies have documented the utility of CT scanning in all patients with right lower quadrant pain. in a third study.45 In contrast. positive predictive value of 91 and 92%.47 The rational approach is the selective use of CT scanning.44 In the second study. On the other hand. In one. 42 One issue that has not been resolved is which patients are candidates for imaging studies. the negative appendix rate was 17% for patients studied by ultrasonography compared with a negative appendix rate of 2% for patients who underwent helical CT scanning.48 The likelihood of appendicitis can be ascertained using the Alvarado scale (Table 30-2). Table 30-2 lists the eight specific indicators identified. 41 One concern about ultrasonography is the high intraobserver variability. but not diagnostic of. compared with 73% of patients for CT. For example. Finally. it is difficult to justify the expense. several other studies failed to prove an advantage of routine CT scanning. and possible complications of CT scanning in patients whose scores of 0 to 4 make it extremely unlikely (but not impossible) that they have appendicitis. whereas scores of 5 or 6 are compatible with. there is little advantage in further work-up. in one study. Although the differences are rather small. 49 This scoring system was designed to improve the diagnosis of appendicitis and was devised by giving relative weight to specific clinical manifestation.

adds the expertise of the radiologist and his or her imaging study. 50 Fig. 30-5.49 Selective CT scanning based on the likelihood of appendicitis takes advantage of the clinical skill of the experienced surgeon and. .Table 30-2 Alvarado Scale for the Diagnosis of Appendicitis Manifestations Symptoms Migration of pain Anorexia Nausea and/or vomiting Signs Right lower quadrant tenderness Rebound Elevated temperature Laboratory values Leukocytosis Left shift in leukocyte count Value 1 1 1 2 1 1 2 1 Total points 10 Source: Reproduced with permission from Alvarado. when indicated. Figure 30-5 proposes a treatment algorithm addressing the rational use of diagnostic testing.

50 Copyright © Massachusetts Medical Society.Clinical algorithm for suspected cases of acute appendicitis.51 It has been suggested that delays in presentation are responsible for the majority of perforated appendices. . The overall rate of perforated appendicitis is 25.8%. 30-6. Recent studies suggest that. All rights reserved. There is no accurate way of determining when and if an appendix will rupture before resolution of the inflammatory process. respectively) (Fig. If gynecologic disease is suspected. Laparoscopy is probably most useful in the evaluation of females with lower abdominal complaints. (Reproduced with permission from Paulson et al. 17.15. observation and antibiotic therapy alone may be an appropriate treatment for acute appendicitis.) Laparoscopy can serve as both a diagnostic and therapeutic maneuver for patients with acute abdominal pain and suspected acute appendicitis. 14. 30-6).52 Fig. Children <5 years of age and patients >65 years of age have the highest rates of perforation (45 and 51%. because appendectomy is performed on a normal appendix in as many as 30 to 40% of these patients. Appendiceal Rupture Immediate appendectomy has long been the recommended treatment for acute appendicitis because of the presumed risk of progression to rupture. in selected patients. Differentiating acute gynecologic pathology from acute appendicitis can be effectively accomplished using the laparoscope. a pelvic and endovaginal ultrasound examination is indicated.

This could represent a phlegmon. usually at least 5 to 7 days. but it is important to make the distinction because their treatment differs. Generalized peritonitis will be present if the walling-off process is ineffective in containing the rupture. CT scan may be beneficial in guiding therapy.000 cells/mm 3. MD. an ill-defined mass is detected on physical examination. In 2 to 6% of cases. Interval appendectomy performed at least 6 weeks after the acute event has classically been recommended for all patients treated either nonoperatively or with simple drainage of an abscess. In the majority of cases.) Appendiceal rupture occurs most frequently distal to the point of luminal obstruction along the antimesenteric border of the appendix. Distinguishing acute. well-localized abscesses can be managed with percutaneous drainage. (Personal communication from David Flum. Patients who present with a mass have experienced symptoms for a longer duration. with appendectomy reserved for cases in which the appendix is easily accessible. Rupture should be suspected in the presence of fever with a temperature of >39°C (102°F) and a white blood cell count of >18. Phlegmons and small abscesses can be treated conservatively with IV antibiotics.Rate of appendiceal rupture by age group. uncomplicated appendicitis from acute appendicitis with perforation on the basis of clinical findings is often difficult. it should be performed using an extraperitoneal approach. or a periappendiceal abscess. complex abscesses should be considered for surgical drainage. If operative drainage is required. rupture is contained and patients display localized rebound tenderness. which consists of matted loops of bowel adherent to the adjacent inflamed appendix.53.54 .

the group raised the rate of acute appendicitis found at operation to 94%. but true rigidity is rare. immediate exploration is the safest course of action. The most common erroneous preoperative diagnosesâ!”together accounting for >75% of casesâ!”are. because this may mean that some patients with atypical. simple or ruptured). However. This is because clinical manifestations are not specific for a given disease but are specific for disturbance of a given physiologic function or functions. Almost invariably. twisted ovarian cyst or ruptured graafian follicle. an upper respiratory tract infection is present or has recently subsided. and tenderness is not as sharply localized as in appendicitis. If it is consistently less. and acute gastroenteritis.54 Differential Diagnosis The differential diagnosis of acute appendicitis is essentially the diagnosis of the acute abdomen (see Chap. Much less frequently. no organic pathologic condition. The differential diagnosis of acute appendicitis depends on four major factors: the anatomic location of the inflamed appendix. although a relative lymphocytosis. Laboratory procedures are of little help in arriving at the correct diagnosis. the perforation rate at the hospital at which the study took place was 26. A diagnostic accuracy rate that is consistently >90% should also cause concern. Voluntary guarding is sometimes present.e. acute appendicitis is found after a preoperative diagnosis of another condition.abscess. has shown that this is not invariably true. Thus.. A normal appendix is found in 32 to 45% of appendectomies performed in women 15 to 45 years of age. in descending order of frequency. it is likely that some unnecessary operations are being performed. The accuracy of preoperative diagnosis should be approximately 85%. when present. . acute mesenteric lymphadenitis. an essentially identical clinical picture can result from a wide variety of acute processes within the peritoneal cavity that produce the same alterations of function as does acute appendicitis.7%. suggests mesenteric adenitis. and the patient's sex.14 A common error is to make a preoperative diagnosis of acute appendicitis only to find some other condition (or nothing) at operation. Generalized lymphadenopathy may be noted. and a more rigorous preoperative differential diagnosis is in order. the patient's age.5%.55 Before that group's study. because it is a self-limited disease. and acute appendicitis was found in 80% of the patients undergoing operation. By implementing a policy of intensive inhospital observation when the diagnosis of appendicitis was unclear.53. however. 56â!“60 ACUTE MESENTERIC ADENITIS Acute mesenteric adenitis is the disease most often confused with acute appendicitis in children. 35). The pain usually is diffuse.55 The rate of false-negative appendectomies is highest in young adult females. if the differentiation remains in doubt. The Haller group. but the perforation rate remained unchanged at 27. cases of acute appendicitis are being "observed" when they should receive prompt surgical intervention. acute pelvic inflammatory disease. Observation for several hours is in order if the diagnosis of mesenteric adenitis seems likely. the stage of the process (i. but bona fide.

Pain and tenderness are usually lower. twisted ovarian cyst or tumor. in approximate descending order of frequency. colitis. pelvic inflammatory disease. but they may lead to systemic disease with a high fatality rate if untreated. Both transvaginal ultrasonography and CT scanning can be diagnostic if a mass is not palpable. Salmonella typhimurium infection causes mesenteric adenitis and paralytic ileus with symptoms similar to those of appendicitis. Patients develop right lower quadrant pain. Pelvic Inflammatory Disease In pelvic inflammatory disease the infection usually is bilateral but. The organisms are usually sensitive to tetracyclines. and motion of the cervix is exquisitely painful. If the mass is palpable on physical examination. but in only approximately 50% of those with pelvic inflammatory disease. The careful clinical use of these features has reduced the incidence of negative findings on laparoscopy in young women to 15%.Human infection with Yersinia enterocolitica or Yersinia pseudotuberculosis. and leukocytosis. Approximately 6% of cases of mesenteric adenitis are caused by Yersinia infection. tenderness. causes mesenteric adenitis as well as ileitis. transmitted through food contaminated by feces or urine. rebound. The organism can be cultured from stool. Leukocytosis and fever are minimal or absent. Because this pain occurs at the midpoint of the menstrual cycle. ampicillin. Many of the infections are mild and self limited. A preoperative suspicion of the diagnosis should not delay operative intervention. streptomycin. the diagnosis can be made easily. Campylobacter jejuni causes diarrhea and pain that mimics that of appendicitis. . When right-sided cysts rupture or undergo torsion. Nausea and vomiting are present in patients with appendicitis. Ruptured Graafian Follicle Ovulation commonly results in the spillage of sufficient amounts of blood and follicular fluid to produce brief. endometriosis. and ruptured ectopic pregnancy. the manifestations are similar to those of appendicitis. GYNECOLOGIC DISORDERS Diseases of the female internal reproductive organs that may erroneously be diagnosed as appendicitis are. mild lower abdominal pain. The ratio of cases of appendicitis to cases of pelvic inflammatory disease is low in females in the early phase of the menstrual cycle and high during the luteal phase. and kanamycin. because appendicitis caused by Yersinia cannot be clinically distinguished from appendicitis due to other causes. if confined to the right tube. Intracellular diplococci may be demonstrable on smear of the purulent vaginal discharge. may mimic acute appendicitis. Twisted Ovarian Cyst Serous cysts of the ovary are common and generally remain asymptomatic. appendicitis may be simulated. it is often called mittelschmerz. Pain and tenderness are rather diffuse. fever. ruptured graafian follicle. The diagnosis can be established by serologic testing. and acute appendicitis. If the amount of fluid is unusually copious and is from the right ovary.

The diagnosis of ruptured ectopic pregnancy should be relatively easy. nausea. Leakage of ovarian cysts resolves spontaneously. appendectomy is indicated. Meckel's diverticulitis is associated with the same complications as appendicitis and requires the same treatmentâ !”prompt surgical intervention. and a more definitive diagnosis can be established by culdocentesis. nausea. the hematocrit level falls as a consequence of the intra-abdominal hemorrhage.Torsion requires emergent operative treatment. Gastroenteritis is characterized by profuse diarrhea. right lower quadrant pain and tenderness. The development of right lower quadrant or pelvic pain may be the first symptom. and there are no localizing signs. either missing one or two periods or noting only slight vaginal bleeding. ACUTE GASTROENTERITIS Acute gastroenteritis is common but usually can be easily distinguished from acute appendicitis. 24. The abdomen is relaxed between cramps. The treatment of ruptured ectopic pregnancy is emergency surgery. and leukocytosisâ!”often simulate acute appendicitis. and is best treated nonoperatively. If the torsion is complete or longstanding. The presence of blood and particularly decidual tissue is pathognomonic. In cases of an acutely inflamed distal ileum with no cecal involvement and a normal appendix. Progression to chronic Crohn's ileitis is . The presence of a pelvic mass and elevated levels of chorionic gonadotropin are characteristic. Meckel's diverticulum is located within the distal 2 ft of the ileum. Crohn's Enteritis The manifestations of acute regional enteritisâ!”fever. and vomiting favor a diagnosis of enteritis. The presence of diarrhea and the absence of anorexia. Vaginal examination reveals cervical motion and adnexal tenderness. and the ovary and tube become gangrenous and require resection.000 cells/mm 3). OTHER INTESTINAL DISORDERS Meckel's Diverticulitis Meckel's diverticulitis gives rise to a clinical picture similar to that of acute appendicitis. Hyperperistaltic abdominal cramps precede the watery stools. however. Rupture of right tubal or ovarian pregnancies can mimic appendicitis. Although the leukocyte count rises slightly (to approximately 14.56â!“61 Ruptured Ectopic Pregnancy Blastocysts may implant in the fallopian tube (usually the ampullary portion) and in the ovary. the pedicle undergoes thrombosis. but this is not sufficient to exclude acute appendicitis. Unfortunately. patients do not always realize they are pregnant. or laparoscopically. and vomiting. extended if necessary. the diagnosis is first made at the time of operation for presumed acute appendicitis. Resection of the segment of ileum bearing the diverticulum with end-to-end anastomosis can nearly always be done through a McBurney incision. Laboratory values vary with the specific cause. In an appreciable percentage of patients with chronic regional enteritis. Patients may give a history of abnormal menses.

epididymitis. The wound infection rate after the treatment of nonperforated appendicitis in children is 2. Pain shift is unusual. appendectomy is indicated. and hopping were found to have the highest sensitivity for appendicitis. 23 The treatment regimen for perforated appendicitis generally includes immediate appendectomy and irrigation of the peritoneal .62 In children the physical examination findings of maximal tenderness in the right lower quadrant. closed-loop intestinal obstruction. nausea and vomiting are unusual. pleuritis of the right lower chest. Children <5 years of age have a negative appendectomy rate of 25% and an appendiceal perforation rate of 45%. testicular torsion. The patient does not look ill. acute pancreatitis. Acute Appendicitis in the Young The establishment of a diagnosis of acute appendicitis is more difficult in young children than in the adult. Localized tenderness over the site is usual and often is associated with rebound without rigidity. lasting several days. primary peritonitis. and the frequency of GI upset in children are all contributing factors. urinary tract infection. Progression to chronic Crohn's ileitis is uncommon. 3%). These entities should be considered in older patients. ureteral stone. may be impossible to distinguish from appendicitis.a normal appendix. hematoma of the abdominal wall. and pain with percussion. OTHER DISEASES Diseases or conditions not mentioned in the preceding sections that must be considered in the differential diagnosis include foreign body perforations of the bowel. coughing.8% compared with a rate of 11% after the treatment of perforated appendicitis. The inability of young children to give an accurate history. and appetite generally is unaffected. pain persists or recurs until the infarcted epiploic appendage is removed. or there may be continuous abdominal pain in an area corresponding to the contour of the colon.14 The incidence of major complications after appendectomy in children is correlated with appendiceal rupture. In 25% of reported cases.13. Symptoms may be minimal. and Henoch-Schönlein purpura. 63 The more rapid progression to rupture and the inability of the underdeveloped greater omentum to contain a rupture lead to significant morbidity rates in children. the inability to walk or walking with a limp. acute cholecystitis. Colonic Lesions Diverticulitis or perforating carcinoma of the cecum. and there is no diagnostic sequence of symptoms. CT scanning is often helpful in making a diagnosis in older patients with right lower quadrant pain and atypical clinical presentations. or of that portion of the sigmoid that lies in the right side. diagnostic delays by both parents and physicians. These rates may be compared with a negative appendectomy rate of <10% and a perforated appendix rate of 20% for children 5 to 12 years of age. The incidence of intra-abdominal abscess also is higher after the treatment of perforated appendicitis than after nonperforated appendicitis (6% vs. Epiploic appendagitis probably results from infarction of the colonic appendage(s) secondary to torsion. mesenteric vascular infarction.

Laparoscopic appendectomy has been shown to be safe and effective for the treatment of appendicitis in children. localized right lower quadrant tenderness is present in only 80 to 90% of patients. the perforation rate appears to increase with age >80 years. For perforated appendicitis IV antibiotics usually are given until the white blood cell count is normal and the patient is afebrile for 24 hours. A history of periumbilical pain migrating to the right lower quadrant is reported infrequently. are anorectic. but on clinical examination. and hospital length of stay are increased in the elderly compared with younger populations with appendicitis. 65 As a result of increased comorbidities and an increased rate of perforation. compared with 50 to 70% in the elderly. This is particularly true . laparoscopic appendectomy offers elderly patients with appendicitis a shorter length of hospital stay.66 Although currently there are no criteria that definitively identify elderly patients with acute appendicitis who are at risk of rupture. and communication difficulty. mortality. expanded differential diagnosis.69 A higher rate of negative appendectomy is seen in the second trimester.64 Acute Appendicitis in the Elderly Compared with younger patients. 66 Elderly patients usually present with lower abdominal pain. Antibiotic coverage is limited to 24 to 48 hours in cases of nonperforated appendicitis. and the lowest rate is in the third trimester. The diversity of clinical presentations and the difficulty in making the diagnosis of acute appendicitis in pregnant women is well established. elderly patients with appendicitis often pose a more difficult diagnostic problem because of the atypical presentation. especially if they are male. Acute appendicitis can occur at any time during pregnancy. and a greater chance of discharge to home (independent of further nursing care or rehabilitation). The usefulness of the Alvarado score appears to decline in the elderly.68. it appears that elderly patients benefit from a laparoscopic approach to treatment of appendicitis. postoperative morbidity. These factors may be responsible for the disproportionately high perforation rate seen in the elderly. Fewer then 50% of the elderly with appendicitis have an Alvarado score of ≥7. or have had pain of long duration before admission.68 The overall negative appendectomy rate during pregnancy is approximately 25% and appears to be higher than the rate seen in nonpregnant women. The use of laparoscopy in the elderly has significantly increased in recent years. In the general population. In general. prioritization should be given to patients with a temperature of >38°C (100. The use of antibiotic irrigation of the peritoneal cavity and transperitoneal drainage through the wound are controversial. The incidence is approximately 1 in 766 births. a reduction in complication and mortality rates.appendicitis generally includes immediate appendectomy and irrigation of the peritoneal cavity.4°F) and a shift to the left in leukocyte count of >76%. perforation rates range from 20 to 30%.67 Acute Appendicitis during Pregnancy Appendectomy for presumed appendicitis is the most common surgical emergency during pregnancy. 65 In addition. Although no randomized trials have been conducted.

London: Mosby. ASIS = anterior superior iliac spine. 30-7) and increased abdominal laxity that may further complicate clinical evaluation. Fig. Laboratory evaluation is not helpful in establishing the diagnosis of acute appendicitis during pregnancy. 2001. [Reproduced with permission from Metcalf A: The appendix. This is particularly true in the late second trimester and the third trimester. 30-7. Williamson RCN (eds): Surgery. Seventy-four percent of patients report pain located in the right lower abdominal quadrant. during pregnancy there are anatomic changes in the appendix (Fig. in Corson JD. Only 57% of patients present with the classic history of diffuse periumbilical pain migrating to the right lower quadrant. with no difference between early and late pregnancy. The most consistent sign encountered in acute appendicitis during pregnancy is pain in the right side of the abdomen. In addition.] Appendicitis in pregnancy should be suspected when a pregnant woman complains of abdominal pain of new onset. when many abdominal symptoms may be considered pregnancy related. Location of the appendix during pregnancy. There is no association between appendectomy and subsequent fertility. The physiologic .diagnosis of acute appendicitis in pregnant women is well established.

73 The risk of appendiceal rupture appears to be increased in HIV-infected patients. HIV-infected patients do not manifest an absolute leukocytosis. Another option is magnetic resonance imaging.70 Laparoscopy has been advocated in equivocal cases. with increased . right lower quadrant tenderness (91%). which has no known deleterious effects on the fetus. periumbilical pain radiating to the right lower quadrant (91%). 68 Recent data suggest that the incidence of perforated or complex appendicitis is not increased in pregnant patients.31 increased odds of fetal loss over open surgery. In one large series of HIV-infected patients who underwent appendectomy for presumed appendicitis. nearly all HIV-infected patients with appendicitis demonstrate a relative leukocytosis.69 When the diagnosis is in doubt.74 The mean duration of symptoms before arrival in the emergency department has been reported to be increased in HIV-infected patients. The physiologic leukocytosis of pregnancy has been defined as high as 16. 69 The overall incidence of fetal loss after appendectomy is 4% and the risk of early delivery is 7%. it appears that the greatest opportunity to improve fetal outcomes is by improving diagnostic accuracy and reducing the rate of negative appendectomy. In one series only 38% of patients with appendicitis had a white blood cell count of >16. Rates of fetal loss are considerably higher in women with complex appendicitis than in those with a negative appendectomy and with simple appendicitis. 43% of patients were found to have perforated appendicitis at laparotomy. especially early in pregnancy.000 cells/mm 3.2% incidence reported for the general population. laparoscopy was found to be associated with a 2. however laparoscopic appendectomy may be associated with an increase in pregnancy-related complications.74 The increased risk of appendiceal rupture may be related to the delay in presentation seen in this patient population. This is higher than the establishing the diagnosis of acute appendicitis during pregnancy. 72 However.03%). The American College of Radiology recommends the use of nonionizing radiation techniques for front-line imaging in pregnant women. 68â!“71 Appendicitis in Patients with AIDS or HIV Infection The incidence of acute appendicitis in HIV-infected patients is reported to be 0.72 In early series. abdominal ultrasound may be beneficial. significant hospital delay also may have contributed to high rates of rupture. In an analysis of outcomes in California using administrative databases.1 to 0. Maternal mortality after appendectomy is extremely rare (0. Removing a normal appendix is associated with a 4% risk of fetal loss and 10% risk of early delivery.72.5%.000 cells/mm 3. if a baseline leukocyte count is available. The majority of HIV-infected patients with appendicitis have fever. and rebound tenderness (74%).72 The presentation of acute appendicitis in HIV-infected patients is similar to that in noninfected patients.72. however. It is important to note that a negative appendectomy is not a benign procedure. Because the incidence of ruptured appendix is similar in pregnant and nonpregnant women and because maternal mortality is so low. with >60% of patients reporting the duration of symptoms to be longer than 24 hours.

Mucosal ischemia develops. In the HIV-infected patient with classic signs and symptoms of appendicitis. patients with nonruptured appendices had CD4 counts of 158. and M. Mycobacterium aviumintracellulare complex.75 A thorough history and physical examination is important when evaluating any patient with right lower quadrant pain. 72 More recent series report 0% mortality in this group of patients.75 Morbidity rates for HIV-infected patients with nonperforated appendicitis are similar to those seen in the general population. Mycobacterium tuberculosis .5 ± 32 cells/mm 3 in patients with appendiceal rupture. Colitis should always be considered in HIVinfected patients presenting with right lower quadrant pain. immediate appendectomy is indicated. and Strongyloides. Kaposi's sarcoma and non-Hodgkin's lymphoma may present with pain and a right lower quadrant mass. 72 The differential diagnosis of right lower quadrant pain is expanded in HIV-infected patients compared with the general population. tuberculosis. lymphoma. the 30-day mortality rate for patients undergoing appendectomy was reported to be 9. CT scan is usually helpful. gangrene of the bowel wall. and other causes of infectious colitis. which leads to thrombosis. In addition to the conditions discussed elsewhere in this chapter.72. 72 However. Neutropenic enterocolitis (typhlitis) should also be considered in the differential diagnosis of right lower quadrant pain in HIV-infected patients. in up to 25% of patients AIDS-related entities are found in the operative specimens. leading to ulceration.75 No series has been reported to date that addresses the role of laparoscopic appendectomy in the HIV-infected population. In those patients with diarrhea as a prominent symptom. In one large series. opportunistic infections should be considered as a possible cause of right lower quadrant pain.1%. In addition.74 In a retrospective study of 77 HIV-infected patients from 1988 to 1995. with increased understanding of abdominal pain in HIV-infected patients.73.delay also may have contributed to high rates of rupture. 72. However. The negative appendectomy rate is 5 to 10%. Postoperative morbidity rates appear to be higher in HIV-infected patients with perforated appendicitis.75 ± 47 cells/mm 3 compared with 94. Kaposi's sarcoma. Cryptococcus neoformans . Spontaneous peritonitis may be caused by opportunistic pathogens. . aviumintracellulare complex. hospital delay has become less prevalent. In patients with equivocal findings. and perforation. CMV infection causes a vasculitis of blood vessels in the submucosa of the gut.75 A low CD4 count is also associated with an increased incidence of appendiceal rupture. Viral and bacterial colitis occur with a higher frequency in HIVinfected patients than in the general population. including CMV. Kaposi's sarcoma. the length of hospital stay for HIV-infected patients undergoing appendectomy is twice that for the general population. including CMV. CMV infection may be seen anywhere in the GI tract.72. colonoscopy may be warranted.72â!“75 Such opportunistic infections include cytomegalovirus (CMV) infection. The majority of pathologic findings identified in HIV-infected patients who undergo appendectomy for presumed appendicitis are typical.

the Surgical Infection Society has recommended single-agent therapy with cefoxitin. single-agent therapy with carbapenems or combination therapy with a third-generation cephalosporin. the appendix is mobilized by dividing the mesoappendix. cefotetan. a lower midline incision is recommended to allow a more extensive examination of the peritoneal cavity. the patient should be prepared for the operating room. a laterally placed incision is imperative to allow retroperitoneal drainage and to avoid generalized contamination of the peritoneal cavity. If perforation or gangrene is found in adults. If simple acute appendicitis is encountered. or aminoglycoside plus anaerobic coverage with clindamycin or metronidazole is indicated. monobactam. If an abscess is suspected. The mucosa is frequently obliterated to avoid the development of mucocele. limited mobilization of the cecum is needed to aid in adequate visualization. the skin and subcutaneous tissue should be left open and allowed to heal by secondary intent or closed in 4 to 5 days as a delayed primary closure. The appendiceal stump can be managed by simple ligation or by ligation and inversion with either a purse-string or Z stitch. the stump can be safely ligated with a nonabsorbable suture. with care taken to ligate the appendiceal artery securely. A large metaanalysis has demonstrated the efficacy of preoperative antibiotics in lowering the infectious complications in appendicitis. If the diagnosis is in doubt. Occasionally. or ticarcillin-clavulanic acid. . electrolyte abnormalities should be corrected. For more severe infections.Treatment Despite the advent of more sophisticated diagnostic modalities. Once identified. the importance of early operative intervention should not be minimized. 23 Most surgeons routinely administer antibiotics to all patients with suspected appendicitis. As long as the stump is clearly viable and the base of the cecum is not involved with the inflammatory process. Adequate hydration should be ensured. who generally have little subcutaneous fat. For intra-abdominal infections of GI tract origin that are of mild to moderate severity. the convergence of the taeniae can be followed to the base of the appendix. The peritoneal cavity is irrigated and the wound closed in layers. there is no benefit in extending antibiotic coverage beyond 24 hours. The incision should be centered over either the point of maximal tenderness or a palpable mass. Because the cecum usually is visible within the incision. A sweeping lateral to medial motion can aid in delivering the appendiceal tip into the operative field.76 OPEN APPENDECTOMY For open appendectomy most surgeons use either a McBurney (oblique) or Rocky-Davis (transverse) right lower quadrant muscle-splitting incision in patients with suspected appendicitis. Once the decision to operate for presumed acute appendicitis has been made. Several techniques can be used to locate the appendix.24 The recommendations are similar for children. primary wound closure has not led to an increased incidence of wound infection. In children. antibiotics are continued until the patient is afebrile and has a normal white blood cell count. This is especially relevant in older patients with possible malignancy or diverticulitis. pulmonary. and renal conditions should be addressed. and pre-existing cardiac. If perforated or gangrenous appendicitis is found.

or staples (Fig.79 Fig. One trocar is placed in the umbilicus (10 mm). The placement of the third trocar (5 mm) is variable and usually is either in the left lower quadrant. the laparoscopic approach to appendectomy did not come into widespread use until after the success of laparoscopic cholecystectomy. One assistant is required to operate the camera. the small bowel should be examined in a retrograde fashion beginning at the ileocecal valve and extending at least 2 ft. 30-8B and 308C). 30-8. If appendicitis is not found. a methodical search must be made for an alternative diagnosis. Harmonic Scalpel. Peritoneal fluid should be sent for Gram's staining and culture. Dissection at the base of the appendix enables the surgeon to create a window between the mesentery and the base of the appendix (Fig. If upper abdominal pathology is encountered. The surgeon usually stands to the patient's left. . is acceptable if further evaluation of the lower abdomen is indicated. epigastrium. Next. and a second trocar is placed in the suprapubic position. This may be due to the fact that appendectomy. it is often best to divide the appendix first with a linear stapler and then to divide the mesoappendix immediately adjacent to the appendix with clips. If purulent fluid is encountered. Placement is based on location of the appendix and surgeon preference. the right lower quadrant incision is closed and an appropriate upper midline incision is made. An attempt also should be made to examine the upper abdominal contents. The cecum and mesentery should first be inspected. The base of the appendix and the mesoappendix should be evaluated for hemostasis. Laparoscopic appendectomy usually requires the use of three ports. Four ports may occasionally be necessary to mobilize a retrocecal appendix. special attention should be paid to the pelvic organs. The base of the appendix is not inverted.10 However. electrocautery. In females. Some surgeons place this second port in the left lower quadrant. 308A). the abdomen is thoroughly explored to exclude other pathology. Trocars are removed under direct vision. The suprapubic trocar is either 10 or 12 mm. by virtue of its small incision. Initially. depending on whether or not a linear stapler will be used.incidence of wound infection. The appendix is identified by following the anterior taeniae to its base. The mesentery and base of the appendix are then secured and divided separately. with division of the anterior and posterior rectus sheath. or right upper quadrant. The right lower quadrant should be irrigated. 9 LAPAROSCOPIC APPENDECTOMY Semm first reported successful laparoscopic appendectomy several years before the first laparoscopic cholecystectomy.78. it is imperative that the source be identified. A medial extension of the incision (Fowler-Weir). When the mesoappendix is involved with the inflammatory process. is already a form of minimal-access surgery. A nasogastric tube and a urinary catheter are placed before obtaining a pneumoperitoneum. The appendix is removed from the abdominal cavity through a trocar site or within a retrieval bag. 77 Laparoscopic appendectomy is performed under general anesthesia.

Laparoscopic resection of the appendix. Ricardo AE: Surgery of the appendix and colon. in Moody FG (ed): Atlas of Ambulatory Surgery. [Reproduced with permission from Ortega JM. if the appendix and mesoappendix are extremely inflamed. Finally the mesoappendix can be easily divided using the linear stapler. Philadelphia: WB Saunders.] . B. it is easier to divide the appendix at its base before division of the mesoappendix. Occasionally. 1999. C. A. The linear stapler is then used to divide the appendix at its base. A window is created in the mesoappendix close to the base of the appendix.

intra-abdominal abscess rates were not reported. In these patients. similar data have been obtained in children. laparoscopic appendectomy is associated with a shorter period before return to normal activity. Open appendectomy has been associated with outstanding results for several decades. Surgeons may be hesitant to implement a new technique because the conventional open approach already has proved to be simple and effective. Although the majority of studies have been performed in adults. In nearly all studies. Laparoscopic appendectomy should be considered an option in these patients. the difference has been calculated to be only 8 points on a 100-point visual analogue scale. 39 of which were studies of adult patients. However. and there were fewer open wounds. 64 The largest meta-analysis comparing open to laparoscopic appendectomy included 47 studies. 64.80â!“84 However.77. whereas the wounds closed primarily in only 58% of obese patients who underwent open appendectomy. investigators have failed to perform prestudy sample size analysis for the outcomes studied. 64. postoperative length of stay was significantly shorter in the group undergoing laparoscopic appendectomy. In a retrospective study of 116 patients with a mean body mass index of 35. return to work.64. controlled trials and 6 meta-analyses. in whom it may be difficult to gain adequate access through a small right lower quadrant incision. This analysis demonstrated that the duration of surgery and costs of operation were higher for laparoscopic appendectomy than for open appendectomy. whether a patient has perforated or nonperforated appendicitis.77. There was no difference in rates of wound infection. In all obese patients in whom the procedure was completed laparoscopically the incisions closed primarily. A number of articles in peer-reviewed journals have compared laparoscopic and open appendectomy.64 There appears to be little benefit to laparoscopic appendectomy over open appendectomy in thin males between the ages of 15 and 45 years. This difference is below the level of pain that an average patient is able to perceive.77 It appears that a more important determinant of length of stay after appendectomy is the pathology found at operationâ!”specifically. 64 A principal proposed benefit of laparoscopic appendectomy has been decreased postoperative pain. 62 Hospital length of stay also is statistically significantly less after laparoscopic appendectomy. including >20 randomized. controlled trials has been limited by the failure to blind patients and providers as to the treatment modality used. Wound infections were approximately half as likely after laparoscopic appendectomy as after open appendectomy. Furthermore.80â!“84 The overall quality of these randomized. Patient-reported pain on the first postoperative day is significantly less after laparoscopic appendectomy. However. Laparoscopic appendectomy may be beneficial in obese patients.The utility of laparoscopic appendectomy in the management of acute appendicitis remains controversial. 85 . However. the rate of intra-abdominal abscess was three times higher after laparoscopic appendectomy than after open appendectomy. treatment and subject bias may have a significant impact on the data. the diagnosis usually is straightforward. based on surgeon and patient preference. in most studies this difference is <1 day. and return to sports.

The question of leaving a normal appendix in situ is a controversial one. already-existing external orifice. 80 The availability of diagnostic laparoscopy may actually lower the threshold for exploration and thus adversely impact the negative appendectomy rate. 87 In summary. it has not been resolved whether laparoscopic appendectomy is more effective in treating acute appendicitis than the time-proven method of open appendectomy. prospective. Laparoscopic appendectomy should be considered part of the surgical armamentarium available to treat acute appendicitis. diagnostic laparoscopy reduced the number of unnecessary appendectomies. The hoped-for advantages associated with this method include the reduction of postoperative wound pain. Recent data suggest that acute appendicitis and acute appendicitis with perforation may be separate disease entities with distinct . over time. the morbidity associated with laparoscopy and general anesthesia is acceptable only if pathology requiring surgical treatment is present and is amenable to treatment using laparoscopic techniques. clinical scenario. In this procedure. In most of the patients without appendicitis. NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY Natural orifice transluminal endoscopic surgery (NOTES) is a new surgical procedure using flexible endoscopes in the abdominal cavity. The decision on how to treat a specific patient with appendicitis should be based on surgical skill. patient characteristics. 88 Much work remains to determine if NOTES provides any additional advantages over the laparoscopic approach to appendectomy. ANTIBIOTICS AS DEFINITIVE THERAPY Traditional management of acute appendicitis has emphasized emergent surgical management. the number of women without a final diagnosis was smaller. As a result. Up to one third of these patients do not have appendicitis at exploration. and patient preference. Additional well-controlled. with resulting increases in morbidity and mortality. 86 Fertile women with presumed appendicitis constitute the group of patients most likely to benefit from diagnostic laparoscopy. This approach has been based on the theory that. Seventeen to 26% of appendices that appear normal at exploration are found to have pathologic features on histologic analysis.64 In addition. blinded studies are needed to determine which subsets of patients may benefit from any given approach to the treatment of appendicitis.Diagnostic laparoscopy has been advocated as a potential tool to decrease the number of negative appendectomies performed. shorter convalescence. However. It does appear that laparoscopic appendectomy is effective in the management of acute appendicitis. gynecologic pathology is identified. avoidance of wound infection and abdominal-wall hernias. It appears that leaving a normal-appearing appendix in fertile women with identifiable gynecologic pathology is safe. and the absence of scars. a relatively high negative appendectomy rate has been accepted to avoid the possibility of progression to perforation. simple appendicitis will progress to perforation. access is gained by way of organs that are reached through a natural. 87 A large meta-analysis demonstrated that in fertile women in whom appendectomy was deemed necessary. The first case of transvaginal removal of a normal appendix has recently been reported.

and 1 year. surgery still remains the gold standard of care for patients with acute appendicitis. 89 Many acute abdominal conditions such as acute diverticulitis and acute cholecystitis are managed with urgent but not emergent surgery. especially those populations known to have higher perforation rates. In five of these patients a perforated appendix was found at operation. The rate of recurrence within 1 year was 15% (16 patients) in the group treated with antibiotics. Participants were evaluated after 1 week. In addition. A time series analysis performed on a 25-year data set did not find a significant negative relationship between the rates of negative appendectomy and perforation. an appendectomy was performed. . in many patients the disease will have an indolent course. First. if symptoms did not improve within the first 24 hours. this study included only men between the ages of 18 and 50 and may not have broad applicability to all patients with appendicitis. Acute appendicitis was found in 97% of the 124 patients randomly assigned to surgery. 15 patients (12%) underwent operation within the first 24 hours due to lack of improvement in symptoms and apparent local peritonitis. the incidence of perforation was 9% in the antibiotic group when patients requiring operation in both the acute and delayed settings are considered.17 A study analyzing time to surgery and perforation demonstrated that risk of rupture is minimal within 36 hours of symptom onset. This compares unfavorably with the perforation rate of 5% for those patients operated on immediately. In one study 10 of the 18 patients who did not undergo operation for ≥6 days after their symptoms began did not experience rupture. Of the 128 patients enrolled in the antibiotic group. evidence from submarine personnel who develop appendicitis suggests that nonoperative management of appendicitis may be a viable treatment option. the study follow-up was only 1 year. Second. Finally. which suggests that patients receiving only antibiotic therapy may still be at risk for the development of appendicitis. Moreover.52 Although it initially appears from these data that the use of antibiotics alone may be reasonable therapy for acute appendicitis.16 Because no laboratory test or clinical investigation can reliably distinguish patients whose appendicitis is potentially amenable to conservative treatment.acute appendicitis with perforation may be separate disease entities with distinct pathophysiology. At operation seven patients (5%) had perforation. The complication rate in the surgery group was 14% (17 of 124). Six patients (5%) had perforated appendices. They are successfully treated with antibiotics and fluids days to weeks after the initial attack until the ship can surface and they can be transferred to a hospital for care. However. Two hundred and fifty-two men 18 to 50 years of age with the presumptive diagnosis of appendicitis were enrolled in the study between March 1996 and June 1999. there is about a 5% risk of rupture in each ensuing 12-hour period. Beyond this point. 90 A randomized study comparing antibiotic treatment with immediate appendectomy has been completed. there are several issues to take into account. when patients are treated with antibiotics alone it is possible that diagnoses of significant pathology such as carcinoid or carcinoma may be delayed. Sailors who develop appendicitis while stationed on submarines do not have access to prompt surgical care. 6 weeks. For patients randomly assigned to antibiotic therapy.

almost 50% have histologic evidence of inflammation in the organ itself. Although this therapy is generally effective. right lower quadrant pain. pathologic examination of the resected appendix shows normal findings in 20 to 50% of cases.9 per 100. this treatment is associated with greater expense and longer hospitalization time (8 to 13 days vs. the rate of late failure as a consequence of acute disease averages 20%. antibiotics. and this is the outside limit.000 in 1939 to 0. the need for subsequent operation has been questioned. The major argument against interval appendectomy is that approximately 50% of patients treated conservatively never develop manifestations of appendicitis. and those who do generally can be treated nonoperatively. IV fluids. Interval appendectomy is associated with a morbidity rate of ≤3% and a hospitalization time of 1 to 3 days. In addition. interval appendectomy.16 The timing of interval appendectomy is somewhat controversial. there is a 9 to 15% failure rate. Several neoplasms also have been detected in the resected appendices. the data clearly support the need for interval appendectomy.appendicitis. This technique has been quite successful and produces much lower morbidity and mortality rates than immediate appendectomy. Principal factors influencing mortality are whether rupture occurs before surgical treatment and the age of the patient. INTERVAL APPENDECTOMY The accepted approach for the treatment of appendicitis associated with a palpable or radiographically documented mass (abscess or phlegmon) is conservative therapy with interval appendectomy 6 to 10 weeks later. and blood products. 3 to 5 days).93 Prognosis The mortality from appendicitis in the United States has steadily decreased from a rate of 9. Appendectomy may be required as early as 3 weeks after conservative therapy. In a prospective series. persistent periappendiceal abscesses and adhesions are found in 80% of patients.2 per 100. 91 The initial treatment consists of IV antibiotics and bowel rest. 19 of 48 patients (40%) who were successfully treated conservatively needed appendectomy at an earlier time (mean of 4.3 weeks) than the 10 weeks planned because of bouts of appendicitis. or redevelop. Two thirds of the cases of recurrent appendicitis occur within 2 years. An additional 14% of patients either continue to have. interval appendectomy was performed successfully using the laparoscopic approach in all 35 patients. 92 In a more recent study in children. The laparoscopic approach has been used and has been successful in 68% of procedures. with operative intervention required at 3 to 5 days after presentation. Although the appendix may occasionally be pathologically normal. Percutaneous or operative drainage of abscesses is not considered a failure of conservative therapy. Unfortunately. even in those of children. In addition. On the other hand. has usually been carried out. 91 Overall. The overall .000 today. Although the second stage of this treatment plan. Among the factors responsible are advances in anesthesia.

Most of the serious early complications are septic and include abscess and wound infection. and between loops of intestine. it rarely occurs in a McBurney incision. Transrectal drainage is preferred for an abscess that bulges into the rectum. In the latter site abscesses are usually multiple. Adhesive band intestinal obstruction after appendectomy does occur. The incidence of intra-abdominal abscess secondary to peritoneal contamination from gangrenous or perforated appendicitis has decreased markedly since the introduction of potent antibiotics. Leukocyte counts are predictably normal and CT scans are generally nondiagnostic. the subhepatic space. There is an excellent correlation between clinical symptomatology. complication of appendectomy that may be caused by sloughing of the portion of the cecum inside a constricting pursestring suture. In one report. Morbidity rates parallel mortality rates and are significantly increased by rupture of the appendix and. Death is usually attributable to uncontrolled sepsisâ!”peritonitis. The incidence of inguinal hernia is three times higher in patients who have had an appendectomy. appendiceal stump. which is accomplished by reopening the skin incision. or gram-negative septicemia. but not inverted. Wound infection is common but is nearly always confined to the subcutaneous tissues and responds promptly to wound drainage. but anorexia and occasionally nausea. intra-abdominal abscesses. Characteristically. clinical data document the existence of this uncommon disease. pain with motion. pouch of Douglas. 94 CHRONIC APPENDICITIS Whether chronic appendicitis is a true clinical entity has been questioned for many years. Intestinal obstruction. There is a much lower incidence of vomiting. complete dehiscence rarely occurs in a McBurney incision. but much less frequently than after pelvic surgical therapy. The overall mortality rate in acute appendicitis with rupture is approximately 1%. 95 Histologic criteria have been established. the pain lasts longer and is less intense than that of acute appendicitis but is in the same location. Late complications are quite uncommon. and it is not uncommon in a lower right paramedian incision. Incisional hernia is like wound dehiscence in that infection predisposes to it. or by necrosis from an abscess encroaching on the cecum. may occur with slowly resolving peritonitis with loculated abscesses and exuberant adhesion formation. The mortality rate of appendicitis with rupture in the elderly is approximately 5%â!”a fivefold increase from the overall rate. The sites of predilection for abscesses are the appendiceal fossa. Fecal fistula is an annoying. complications occurred in 3% of patients with nonperforated appendicitis and in 47% of patients with perforations. Wound infection predisposes the patient to wound dehiscence. Laparoscopy can be used effectively in the management of this . The type of incision is relevant. Pulmonary embolism continues to account for some deaths. surgeons can establish the diagnosis with 94% specificity and 78% sensitivity. and malaise are characteristic. However. initially paralytic but sometimes progressing to mechanical obstruction. by old age. by slipping of the ligature off a tied. but not particularly dangerous. intraoperative findings. At operation. to a lesser extent. and histologic abnormalities.are whether rupture occurs before surgical treatment and the age of the patient.

including Enterobius vermicularis . At a higher rate of reimbursement. the annual incidence fell. the preoperative diagnosis was correct in 91. $20.000. 36 incidental appendectomies had to be performed to prevent one patient from developing appendicitis. The presence of parasites in the appendix at operation makes ligation and stapling of the appendix technically difficult. 310. On an annual basis.11 During this period. Beyond age 19 years. Appendectomy must be followed by appropriate antiamebic therapy (metronidazole). Once appendectomy has been performed and the patient has recovered.000 population). Among those >45 years of age.000 cost of appendicitis. 97 For open appendectomy. The live parasites occlude the appendiceal lumen. 96 The financial aspects of the decision to perform incidental appendectomy were assessed. When the life table technique was used. The highest annual incidence of appendicitis was in patients 9 to 19 years of age (23. the incidence during teenage years was 27.and histologic abnormalities. it was cost effective to perform incidental appendectomy only in patients <25 years of age and only if the reimbursement for surgeons was 10% of the usual and customary charges. therapy with helminthicide is necessary to clear the remainder of the GI tract.6 in males and 20.7% of those in women. Based on these data. Laparoscopy can be used effectively in the management of this clinical entity. Appendectomy is curative.000 females. and Echinococcus granulosis. Males were more likely to develop appendicitis than females. Amebiasis also can cause appendicitis. Although Ascaris lumbricoides is the most common. causing obstruction. Symptoms resolve postoperatively in 82 to 93% of patients. Invasion of the mucosa by trophozoites of Entamoeba histolytica incites a marked inflammatory process. the data identified a lifetime risk of appendicitis of 8. Strongyloides stercoralis .2 vs. a wide spectrum of helminths have been implicated. Accordingly.2% of men and 78.000 had to be spent to save the $6. With the laparoscopic approach.000. Although men were more likely to develop appendicitis.6% of women.5 in females per 10. Many of those whose symptoms are not cured or recur are ultimately diagnosed with Crohn's disease.000 population per year.000 males and 4 in 10. 95 APPENDICEAL PARASITES A number of intestinal parasites cause appendicitis.7% in women. Appendiceal involvement is a component of more generalized intestinal amebiasis. .3 per 10. there was a financial disincentive to perform incidental appendectomy.8%). In contrast to the number of cases of appendicitis. perforation occurred more commonly in men than in women (19. INCIDENTAL APPENDECTOMY Decisions regarding the efficacy of incidental appendectomy should be based on the epidemiology of appendicitis. Similarly.000 cases of appendicitis occurred annually in the United States. 62% of the total appendectomies in men and 17. The best data were published by the Centers for Disease Control and Prevention based on the period from 1979 to 1984.6% in men and 6.000 incidental appendectomies were performed between 1979 and 1984. the annual incidence was 6 in 10. an average of 250. 17.

Epidemiology. The mean tumor size for carcinoids is 2. Treatment for tumors ≤1 cm is appendectomy. right hemicolectomy is indicated (Fig. The appendix is the most common site of GI carcinoid. which occur in 2.9 to 1.101 The majority of carcinoids are located in the tip of the appendix.99. 30-9). carcinoid (17%).5 cm. goblet cell carcinoma (15%). incidental appendectomy was not cost effective in any age group. These include children about to undergo chemotherapy. 16. whereas those with signet-ring cell cancers have the lowest (18%). 98 Appendectomy is routinely carried out during performance of Ladd's procedure for malrotation.100. although the tumor can occasionally obstruct the appendiceal lumen much like a fecalith and result in acute appendicitis. TUMORS Appendiceal malignancies are extremely rare. SEER data indicate . and individuals who are about to travel to remote places where there is no access to medical or surgical care.4% of appendectomy specimens. Primary appendiceal cancer is diagnosed in 0. For tumors larger than 1 to 2 cm located at the base or with lymph node metastases. yellow. followed by adenocarcinoma (26%).16. representing >50% of the primary lesions of the appendix.12 cases per 1. 99 Data from the SEER program identified mucinous adenocarcinoma as the most frequent histologic diagnosis (38% of total reported cases).000. because displacement of the cecum into the left upper quadrant would complicate the diagnosis of subsequent appendicitis. At a higher rate of reimbursement. and signet-ring cell carcinoma (4%). with tumors <1 cm rarely resulting in extension outside of the appendix or adjacent to the mass. Symptoms attributable directly to the carcinoid are rare. bulbar mass in the appendix should raise the suspicion of an appendiceal carcinoid. Although incidental appendectomy is generally neither clinically nor economically appropriate. there are some special patient groups in whom it should be performed during laparotomy or laparoscopy for other indications.99 A review from the National Cancer Institute's Surveillance. Patients with carcinoid tumors have the best 5-year survival (83%). 100 Carcinoid tumors usually present with localized disease (64%).16 These tumors are only rarely suspected preoperatively.000 people per year. Malignant potential is related to size. followed by the small bowel and then the rectum.99 Most series report that carcinoid is the most common appendiceal malignancy. the disabled who cannot describe symptoms or react normally to abdominal pain. and End Results (SEER) program found the age-adjusted incidence of appendiceal malignancies to be 0.98.100 Carcinoid The finding of a firm. Carcinoid syndrome is rarely associated with appendiceal carcinoid unless widespread metastases are present. Despite these recommendations.surgeons was 10% of the usual and customary charges.9% of cases. Fewer than 50% of cases are diagnosed at operation. patients with Crohn's disease in whom the cecum is free of macroscopic disease.99 Fiveyear survival for appendiceal malignancies varies by tumor type.

Despite these recommendations. 100 Fig. colonic adenocarcinoma. 30-9. The recommended treatment for all patients with adenocarcinoma of the appendix is a formal right hemicolectomy.101 Overall 5-year survival is 55% and varies with stage and grade. Appendiceal adenocarcinomas have a propensity for early perforation. Patients with appendiceal adenocarcinoma are at significant risk for both synchronous and metachronous neoplasms.hemicolectomy is indicated (Fig. Mucoceles may be caused by one of four processes: retention cysts. and adenocarcinoid. SEER data indicate that proper surgery for carcinoids is not performed at least 28% of the time. 30-9). and cystadenocarcinomas. Adenocarcinoma Primary adenocarcinoma of the appendix is a rare neoplasm with three major histologic subtypes: mucinous adenocarcinoma. Algorithm for the management of patients with appendiceal carcinoid. cystadenomas.99 The most common mode of presentation for appendiceal carcinoma is that of acute appendicitis. mucosal hyperplasia. The clinical presentation of a . Patients also may present with ascites or a palpable mass. or the neoplasm may be discovered during an operative procedure for an unrelated cause. approximately half of which will originate from the GI tract.99 Mucocele A mucocele of the appendix is an obstructive dilatation by intraluminal accumulation of mucoid material. although they are not clearly associated with a worsened prognosis.

101 Pseudomyxoma Peritonei Pseudomyxoma peritonei is a rare condition in which diffuse collections of gelatinous fluid are associated with mucinous implants on peritoneal surfaces and omentum. Primary pseudomyxoma usually does not cause abdominal organ dysfunction. when a mucocele is visualized at the time of laparoscopic examination. An intact mucocele presents no future risk for the patient. The clinical presentation of a mucocele is nonspecific. left paracolic gutter. widely scattered. with subsequent referral to a specialized center for consideration of re-exploration and hyperthermic intraperitoneal chemotherapy. If not done previously. CT scanning is the preferred imaging modality. collection and cytologic examination of all intraperitoneal mucus. 103 Lymph node metastasis and distant metastasis are uncommon. Peritoneal surfaces of the bowel are usually free of tumor. as described earlier. Recent immunocytologic and molecular studies suggest that the appendix is the site of origin for the overwhelming majority of cases of pseudomyxoma. the opposite is true if the mucocele has ruptured and epithelial cells have escaped into the peritoneal cavity. The use of imaging before surgery is advantageous to plan surgery. These cells may be difficult to classify as malignant because they may be sparse. laparotomy allows for thorough abdominal exploration to rule out the presence of mucoid fluid accumulations. Pseudomyxoma is invariably caused by neoplastic mucussecreting cells within the peritoneum. and have a low-grade cytologic appearance. All gross disease and the omentum should be removed. The principles of surgery include resection of the appendix. cystadenomas. is reserved for patients with a positive margin at the base of the appendix or positive periappendiceal lymph nodes. or preferably cecectomy. and the ovaries in women. However. however. 76% of patients developed recurrences within the abdomen. As a result. right retrohepatic space. At surgery a variable volume of mucinous ascites is found together with tumor deposits involving the right hemidiaphragm. ligament of Treitz. conversion to open laparotomy is recommended. Right hemicolectomy. This approach includes a thorough but minimally aggressive approach at initial laparotomy. Conversion from a laparoscopic approach to a laparotomy ensures that a benign process will not be converted to a malignant one through mucocele rupture.102 In a series from the Mayo Clinic. Recently. In addition. and cystadenocarcinomas. or a mass. wide resection of the mesoappendix to include all the appendiceal lymph nodes. Thorough surgical debulking is the mainstay of treatment.99 The presence of a mucocele of the appendix does not mandate performance of a right hemicolectomy. distention. Hysterectomy with bilateral salpingo-oophorectomy is performed in . ureteral obstruction and obstruction of venous return can be seen.102 Pseudomyxoma is a disease that progresses slowly and in which recurrences may take years to develop or become symptomatic. and careful inspection of the base of the appendix. and often it is an incidental finding at operation for acute appendicitis.mucosal hyperplasia. Pseudomyxoma is two to three times more common in females than in males. Patients with pseudomyxoma usually present with abdominal pain. a more aggressive approach to ruptured appendiceal neoplasms has been advocated. appendectomy is routinely performed.

have also been reported. [PMID: 16265384] 2. Survival is associated with initial patient performance status. Appendiceal lymphoma usually presents as acute appendicitis and is rarely suspected preoperatively. A postoperative staging work-up is indicated before initiating adjuvant therapy. 105 Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy is a long. 1. Fitz RH: Persistent omphalo-mesenteric remains: Their importance in the causation of intestinal duplication. and fistulas.104â!“106 Any recurrence should be investigated completely. 1884. morbidity (38%) and mortality (6%) are high. 2005.108. Ajmani ML. adjuvant intraperitoneal hyperthermic chemotherapy is advocated as a standard adjunct to radical cytoreductive surgery. length and arterial supply of vermiform appendix. anastomotic leaks. Recurrences are usually treated by additional surgery.109 REFERENCES Entries Highlighted in Bright Blue Are Key References. Survival is better in patients who undergo R0 or R1 resection than in patients who undergo R2 resection (visible gross disease remaining). Findings on CT scan of an appendiceal diameter ≥2. In addition. such as Burkitt's. Ajmani K: The position. Geboes K: Appendiceal function and dysfunction: What are the implications for inflammatory bowel disease? Nat Clin Pract Gastroenterol Hepatol 2:338.104 Because 5-year survival of mucinous appendiceal neoplasms is only 30%. It is important to note that surgery for recurrent disease is usually difficult and is associated with an increased incidence of unintentional enterotomies. as well as leukemia. 102. Right hemicolectomy is indicated if tumor extends beyond the appendix onto the cecum or mesentery. and obstruction.107 Other types of appendiceal lymphoma. [PMID: 6881534] 3. tedious procedure with operative times of 300 to 1020 minutes reported.5 cm or surrounding soft tissue thickening should prompt suspicion of an appendiceal lymphoma. .routinely performed. Anat Anz 153:369. 1983. The management of appendiceal lymphoma confined to the appendix is appendectomy. cyst formation. Adjuvant therapy is not indicated for lymphoma confined to the appendix. 108 Primary lymphoma of the appendix accounts for 1 to 3% of GI lymphomas. The GI tract is the most frequently involved extranodal site for non-Hodgkin's lymphoma.103 Lymphoma Lymphoma of the appendix is extremely uncommon. Am J Med Sci 88:30. Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy is associated with a 5-year survival of between 53 and 78%. Hysterectomy with bilateral salpingo-oophorectomy is performed in women.

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