Professional Documents
Culture Documents
Hiroshi ISHIKAWA
Abstract: The diagnosis and treatment of acute appendicitis are described with
emphasis on the significance of ultrasonography, computed tomography (CT), and
laparoscopic appendectomy. The diagnosis of acute appendicitis has traditionally
been made by physical examination and blood tests. However, use of ultra-
sonography and CT as well as these conventional methods makes more precise
diagnosis possible. These imaging modalities are useful for determining whether
surgery is necessary. Ultrasonography is easy to perform and minimally invasive,
making it essential for diagnosis. This examination can visualize hypertrophy, dis-
turbance, and disruption of the layered structure of the appendiceal wall, accumu-
lation of purulent fluid, and the presence of a fecolith in the appendix. In catarrhal
appendicitis, the wall of the appendix consists of three layers. In phlegmonous
appendicitis, these layers become unclear, and in gangrenous appendicitis, the
layered structure is lost. CT is superior to ultrasonography in objectivity, but is
unable to depict the layers of the appendiceal wall. It is useful for demonstrating
periappendiceal fat, ascites, and abscess formation, and for determining whether
an operation is necessary based on these findings. Laparoscopic appendectomy
is one of the choices for obese patients, young women, and patients in whom a
condition other than acute appendicitis is suspected.
Key words: Acute appendicitis; Imaging diagnosis;
Abdominal ultrasonography; Laparoscopic appendectomy
grenous appendicitis. They concluded that, the and nil orally. For outpatient management,
severity of appendicitis could be assessed by antibiotics are administered and the course is
preoperative ultrasonography, so that unneces- followed closely.
sary appendectomy could be avoided.
As described above, ultrasonography is an 2. Surgical therapy
indispensable modality because it can be used Phlegmonous or more advanced appendi-
to both diagnose appendicitis and assess its citis should be treated surgically. Ultrasono-
severity. graphic findings are the most important factor
(2) Abdominal CT for deciding whether surgery is necessary. In
CT is superior to ultrasonography in some addition to the symptoms of phlegmonous
respects, because its findings are more objec- appendicitis described above in the section on
tive and it is not affected by the presence of diagnosis, the presence of ascites or an abscess
intestinal gas. The diagnosis of appendicitis by indicates the necessity for surgery. Among the
CT depends on hypertrophy of the appendiceal abdominal findings on physical examination,
wall, enlargement of the appendix, periappen- the presence of peritoneal irritation is critical.
diceal abscess formation, the presence of a If this is positive, an operation is indicated.
fecalith, increased density of periappendiceal In the field of surgery for acute appendicitis,
adipose tissue, and/or the presence of ascites laparoscopic appendectomy is attracting much
in the pouch of Douglas.1) CT can depict an attention (Fig. 3). This procedure has become
enlarged appendix, but cannot visualize the established in Japan and other countries.
structure of the wall unlike ultrasonography. Although its usefulness has been gradually
Thus, ultrasonography is superior to CT for accepted, whether it is superior to conventional
assessing the severity of appendicitis depend- open appendectomy remains controversial, so
ing on the mural changes. it is not yet considered to be a standard therapy
for acute appendicitis. The advantages and
drawbacks of this procedure are described
Management of Acute Appendicitis
next. For the technical details that are not
1. Medical therapy described in this article, see the relevant text-
Catarrhal appendicitis should be treated con- books and reports.
servatively. It is diagnosed by physical exami- For the patient, the advantages of laparo-
nation, blood tests, ultrasonography, and CT, or scopic appendectomy are reported to include
is characterized by tenderness without perito- decreased postoperative pain, faster recovery
neal irritation. On ultrasonography, the appen- of muscle tone, earlier return to normal activi-
dix cannot be visualized or is not enlarged if it ties, minimal scarring, a low risk of wound
is detected. Patients with catarrhal appendicitis infection, no ventral hernia, and a reduced risk
should generally be hospitalized for treatment of postoperative adhesions.4) On the other hand,
with antibiotics, bed rest, intravenous fluids, conventional open appendectomy seldom causes
Conclusion
The diagnosis and management of acute
Instrument table appendicitis have been described with a focus
on some current issues. For diagnosis, findings
on ultrasonography and CT are important.
Monitor For management, laparoscopic appendectomy
should be considered as a possible choice if
Fig. 3 Illustration of the arrangement of personnel and
apparatus for laparoscopic appendectomy4) there are indications for this procedure.
REFERENCES
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