APPENDIX o Lymphoid aggregates occur in the submucosal layer

Dr. Medina (March 5, 2019) and may extend into the muscularis mucosa
- PPT Physiology
- PPT - an immunologic organ that actively participated in the
- Book secretion of immunoglobulins, particularly
- Book immunoglobulin A
- Recording - may function as reservoir to recolonize the colon with
health bacteria
Historical Background
- Appendectomy: One of the most emergency procedures ACUTE APPENDICITIS
performed in contemporary medicine
- Human appendix was noted until 1942 Objective
- Leonardo da Vinci: depicted the appendix in his anatomic - To review current approach to patients with acute
drawings but not published until 18th century appendicitis: Diagnosis and Treatment
- Berengario Da Capri (1521) and Andreas Vesalius (1543):
published drawings recognizing appendix Level of Evidences:
- Jean Fernel: first describing appendiceal disease (1544) - I: RCT
- Lorenz Heister: 1st description of classic appendicitis (1711) - II: controlled trials no randomization, cohort, analytical
- Claudius Amyand: 1st known appendectomy (1736) studies, case series
- Reginald H. Fitz – presented his findings regarding - III: respected authorities, clinical experienced, descriptive
appendicitis and recommended consideration for studies, reports of expert committees
operative treatment (1866)
- Charles Mcburney: provided a landmark describing the Sensitivity
indications for early laparotomy for the treatment of - If a person has a disease, how often will the test be positive
appendicitis (true positive rate)?
- Embryology, Anatomy, and Physiology - Put another way, if the test is highly sensitive and the test
result is negative you can be nearly certain that they don’t
Embryology
have disease.
- 6th week of human embryonic development: appendix and
- A sensitive test helps rule out disease (when the result is
cecum appear as outpouchings from the caudal limb of
negative). Sensitivity rule out or “Snout”
midgut
- Sensitivity = true positive/ (true positive + false negative)
- 8th week: initial appendiceal outpouching
- 5th month: begins to elongate to achieve a vermiform
Specificity
appearance
- If a person does not have a disease how often will the test
- Situs Inversus
be negative (true negative rate)?
o Autosomal recessive congenital defect characterized
- In other terms, if the test result for a highly specific test is
by the transposition of abdominal and/or thoracic
positive you can be nearly certain that they actually have
organs
the disease.
Anatomy
- A very specific test rules in disease with a high degree of
- Length: 6 – 9cm; can vary from <1 - >30cm
confidence. Specificity rule in or “Spin”
- Outer Diameter: varies between 3 and 8mm
- Specificity = true negatives/ (true negative + false positive)
- Luminal Diameter: varies between 1 and 3mm
- Arterial Supply: ileocolic artery Predictive Value for a positive result (PV+)
- Lymphatic Drainage: lymph nodes that along the ileocolic
- PV + asks “if the test results positive what is the probability
artery
that the patient actually has the disease?”
- Nerve Supply
- PV + = true positive/ (true positive + false positive)
o Sympathetic: T10 – L1
o Parasympathetic: Vagus Nerve
Predictive value for a negative result (PV-)
- Histologic Feature
o Layers: - PV – asks “if f the test result is negative what is the
▪ Outer Serosa probability that the patient does not have disease?”
▪ Muscularis Layer - PV - = true negatives/ (true negative
▪ Submucosa - e + false positives)
▪ Mucosa

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Special Consideration
- Lifetime Risk: 12% Males; 25% Females (Ratio: 1.4:1 (M:F)
- Mean Age: <30y/o (69%)
- Rate of misdiagnosis: 15% (higher in females, 22.3 vs 9.3%)
- Negative appendectomy in women: 23.2% (highest in
reproductive age)
- Advance age: 50% – 70%m perforation (>70y/)
- Use of imaging modalities like CT scan ( 1 CT scan has 200x
radiation than x ray)
- Pregnancy: location of appendix has on AOG (use
ultrasound)
Special Circumstances
Acute Appendicitis in the Young
- Misdiagnosis and Delay in Diagnosis Factors
o Inability to give an accurate history
o Diagnostic delays by both parents and physicians
o Frequency of gastrointestinal distress
- Highest Sensitivity
o Maximal tenderness in RLQ
o Inability to walk or walking with a limp
o Pain with percussion
o Coughing
o Hopping
- 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.
- <5 y/o
o Negative appendectomy rate: 25%
o Appendiceal Rupture Rate: 45%
- 5 – 12 y/o
o Negative Appendectomy Rate: 10%
o Appendiceal Rupture Rate: 20%
- Laparoscopic appendectomy has been shown safe and
effective for the treatment of appendicitis
Acute Appendicitis in the Elderly
- More difficult diagnostic problem due to:
o Atypical presentation
o Expanded differential diagnosis
o Communication difficulty
- Perforation Rate: 50% - 70%
o increase with age >80y/o
- Presentations
o Lower abdominal pain
o RLQ tenderness is not as common as in younger
patients
o Periumbilical pain radiating to the RLQ is reported
infrequently
o Prioritization: 38 degrees C (100.4 degrees F) and a
shift to the left shift to the left leukocyte count of
more than 76%.
▪ Especially if the patients are male, anorexic or
have had pain of long duration before admission
- More problematic compared with younger patients
- Laparoscopy > Open Appendectomy
Acute Appendicitis During Pregnancy
- Most common surgical emergency
- Occur anytime during pregnancy but is rare during 3rd
trimester
- Negative Appendectomy Rate: 25% (2nd trimester > 3rd)
o Abdominal laxity may further complicate clinical
evaluation
o Removing normal appendix is associated with 4% risk
of fetal loss and 10% risk of early delivery.
- Should be suspected when (+) complains of abdominal
pain of new onset
- Most consistent sign encountered: pain in the right side of
the abdomen
- Laboratory evaluation is not helpful
- Abdominal Ultrasound may be beneficial when diagnosis is
in doubt (other option: MRI)
- Laparoscopy has been advocated in equivocal cases,
especially in early pregnancy, however, may be associated
with an increase in pregnancy-related complications
Pathophysiology:
- Early manifestation is in pain at the middle portion of
abdomen (visceral pain) because of its midgut origin
Obstruction
- Acute appendicitis is thought to begin with obstruction of
the lumen due to fecalith or hypertrophy of the lymphoid
tissue – proposed as main etiologic factor
- Obstruction can result from food mater, adhesions or
lymphoid hyperplasia
- Mucosal secretions continue to increase intraluminal
pressure resulting to distention which initially compromise
the venous system and later on the arterial system.
- Distention causes reflex nausea and vomiting, the visceral
pain increases.
Ischemia and Transmural Inflammation
- Transmural: invasion of inflammatory cells in all layer of
appendix
- Most tender: Right Iliac Fossa (indicates transmural
inflammation)
- Absence of pain is not an appendicitis diagnosis
- Pressure exceeds capillary perfusion and venous and
lymphatic drainage are obstructed
- The mucosal layer is susceptible to impairment of blood
supply; thus, its integrity is compromised early in the
process, which allows bacterial invasion.
- Poorest blood supply suffers the most: ellipsoidal infarcts
develop in the antimesenteric border
- Epithelial mucosa breaks down and bacterial invasion by
bowel flora occurs
Perforation
- Increased pressure also leads to arterial stasis and tissue
infarction
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- End result is perforation and spillage of infected - In some males, retroileal appendicitis can irritate the
appendiceal contents into the peritoneum – Peritonitis ureter and cause testicular pain
- As distention, bacterial invasion, compromise of the - Pelvic appendix may irritate the bladder or rectum causing
vascular supply and infarction progress, perforation suprapubic pain, pain with urination, or feeling the need to
occurs, usually on the antimesenteric border just beyond defecate
the point of obstruction.
Pain
- 1st time progressive pain
- Intraluminal distention triggers visceral afferent pain
fibers, which enter at the 10th thoracic vertebral level.
- The pain is generally vague and poorly localized
- Pain is typically felt in the periumbilical or epigastric area
- As inflammation continues, the serosa and adjacent
structures become inflamed
- This triggers somatic pain fibers, innervating the peritoneal
structures
- Typically causing pain in the RLQ
- Change in stimulation from visceral to somatic pain fibers
explains the classic migration of pain in the periumbilical
area to the RLQ (visceral to somatic describes as
progressive)
Physical Examination Features
Microbiology
- Moderately Useful: RLQ tenderness, rigidity, pain at
- Tissue specimens from the inflamed appendix wall (not
Mcburney’s point
luminal aspirates) virtually all grow E. coli and Bacteroides
- Mildly Useful: rebound tenderness, guarding, fever,
on culture.
percussion tenderness, Psoas sign
- Fusobacterium nucleatum/necrophorum, which is not
- Not Useful: rectal examination, increased skin temperature
present in the normal cecal flora, has been identified in
- Iliopsoas Sign
62% of inflamed appendices.
o Place patient in left lateral decubitus and extend right
- Other usual species (Peptostreptococcus, Pseudomonas,
leg at the hip (+) if there is pain
Bacteroides splanchnicus, Bacteroides intermedius,
o Sensitivity: 13% - 42%; Specificity: 79% - 95%
Lactobacillus), previously unreported fastidious gram (-)
- Rovsing’s Sign
anaerobic bacilli have been encountered.
o Abdominal pain in the RLQ while palpating the LLQ
- Patients with gangrene or perforated appendicitis appear
o Sensitivity 7% - 68%; Specificity: 58% - 96%
to have more tissue invasion by Bacteroides.
- Obturator Sign
o Passively flex the right hip and knee internally rotate
Historical Features
the hip. (+) if there is increased pain
- Moderately Useful: RLQ pain, migration of pain, pain o Sensitivity 8%; Specificity 94%
precedes vomiting, no history of prior similar pain
- Mildly Useful: vomiting, male gender, pain, worsened when Clinical Presentation
driving over speed bumps - The inflammatory process in the appendix presents as
- Not Useful: anorexia, nausea, pain worse with cough or pain, which is initially is of a diffuse visceral type and later
movement becomes more localized as the peritoneal linings gets
irritated.
Variability in Symptomatology
Symptoms
- Exceptions exist in the classic presentation due to - Usually starts with periumbilical pain and diffuse pain that
anatomic variability of the appendix eventually localizes to the right lower quadrant.
- Appendix can be retrocecal causing the pain to localize to - Most sensitive sign: RLQ pain
the right flank - Associated with gastrointestinal symptoms like nausea,
- In pregnancy, the appendix can be shifted and patients can vomiting and anorexia.
present with RUQ pain - GIT symptoms develop before onset of pain suggest a
- Multiple anatomic variations explain the difficulty in different etiology such as gastroenteritis.
diagnosing appendicitis - Diarrhea may occur in association with perforation,
especially in children.

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Signs
- Early in presentation, vital signs may be minimally altered
- The body temperature and pulse rate may be normal or
slightly elevated
- Physical findings are determined by the presence of
peritoneal irritation and are influenced by whether the
organ has already ruptured when the patient is first
examined.
- Patient usually move slowly and prefer to lie supine due to
peritoneal irritation.
- (+) abdominal tenderness with a maximum at or near
McBurney’s point.
Clinical Scoring System
- Alvarado score
o most useful widespread scoring system
o useful for ruling out appendicitis and selecting
patients for further diagnostic workup
- Appendicitis Inflammatory Response Score
o more graded variables
o includes CRP
Diagnosis
Laboratory Data
- Not sole basis to diagnosis; only supportive
- White blood cell count: not significant to used to diagnosed
or exclude acute appendicitis. >10,000 – 12,000/mm3
(sensitivity 62%, specificity 85%)
- C reactive protein: non-specific, systemic inflammatory
marker. CRP (>8-10mg/L). Sensitivity 65-85%, specificity
32-87%
- Urinalysis: hematuria, pyuria, bacteria (48%). >30rbc/hpf,
>20wbc/hpf – UTI
- Pregnancy Test
Imaging Test
- Imaging studies done suspect acute appendicitis
- Radiography
o Abnormal in 24- 95%
o No clinical Value
o Abnormal findings:
▪ Fecalith
▪ Appendiceal gas
▪ Localized paralytic ileus
▪ Blurred right psoas
▪ Free air
o Chest Radiograph
▪ Helpful to rule out referred pain from a right
lower lobe pneumonic process
- Graded Compression Ultrsound
o Reported sensitivity 75-90% and specificity 83-95%
o Normal bowel and appendix can be compressed
whereas an inflamed appendix cannot be compressed
o DX: noncompressible >6-7mm appendix,
appendicolith, periappendiceal abscess
o Limitations: retrocecal appendix may not be
visualized, perforations may be missed due to return
to normal diameter; More air = less accuracy;
radiologist dependent
o Highly suggestive of appendicitis
▪ Thickening of appendiceal wall
▪ Presence of periappendiceal fluid
o <5mm in diameter excludes the diagnosis of
appendicitis
- CT Scan with IV Contrast
o Best choice based on availability and alternative
diagnoses
o In one study, CT had greater sensitivity 94-100%,
specificity 91 – 100%, PPV 95-97%
o Even if appendix is not visualized, diagnosis can be
made with localized fat stranding in RLQ
o With high resolution helical CT, the inflamed appendix
appears dilated (>5mm), and the wall is thickened.
o There is often evidence of inflammation, which can
include periappendiceal fat stranding, thickened
mesoappendix, periappendiceal phlegmon, and free
fluid.
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 o Fecalith can be often visualized; however, their
presence is not pathognomonic of appendicitis.
o The additional use of rectal contrast does not improve
the results of CT scanning.
o Disadvantage:
▪ Expensive
▪ Exposes to significant radiation
▪ Limited use during pregnancy
▪ Allergy to iodine or contrast limits the
administration of contrast agents in some
patients
▪ Some cannot tolerate the oral ingestion of luminal
dye
- Magnetic Resonance Imaging
o Pregnant after inclusive US. No radiation, not operator
dependent.
o Increased cost, increase time to acquire images,
special skills.
o Sensitivity 85-100%; Specificity 95-99.2%; PPV –
92.4%; (-) PPV 99.7%
- Diagnostic Laparoscopy
o Invasive
o Requires general anesthesia
o Advantageous in women of reproductive age
- Technetium -99m-labeled Leukocyte Scan
o Has good results in diagnosing appendicitis but it is
relatively unavailable and impractical in daily use
Differential Diagnosis
- Acute Mesenteric Adenitis, AGE, Disease of male
urogenital system
- Meckel’s Diverticulitis, intussusception, perforated peptic
ulcer, colonic lesion, epiploic appendicitis
- UTI, gynecologic disease, Henoch-schonlein purpura
Differential Diagnosis
- Most common findings in the case of preoperative
diagnosis (75%)
1. Acute Mesenteric Adenitis
2. No organic pathologic condition
3. Acute Pelvic Inflammatory Disease
4. Twisted ovarian cyst or ruptured graafian follicle
5. Acute gastroenteritis
- Major Factors
o Anatomic location of the inflamed appendix
o Stage of the process (uncomplicated or complicated
o Patient’s age
o Patient’s gender
- Pediatrics: acute mesenteric adenitis (most often confused
with acute appendicitis)
- Elderly: Diverticulitis or perforating carcinoma of the
cecum or of a portion of the sigmoid that overlies the right
lower abdomen may be impossible to distinguish from
appendicitis
- Female Patient:
1. PID
▪ Usually bilateral but, if confined to the right tube,
may mimic acute appendicitis
▪ (+) nausea and vomiting
▪ Pain and tenderness are usually lower and motion
of the cervix is exquisitely painful
2. Ruptured graafian follicle
▪ Ovulation commonly results in the spillage of
sufficient amounts of blood and follicular fluid to
produce brief, mild lower abdominal pain. If the
amount of fluid is unusually copious and is from
the right ovary, appendicitis may be simulated.
Pain and tenderness may be rather diffuse, and
leukocytosis and fever minimal or absent.
Because this pain occurs at the midpoint of the
menstrual cycle, it is often called mittelschmerz.
3. Twisted ovarian cyst or tumor
▪ Serous cysts of the ovary are common and
generally remain asymptomatic.
▪ When right-sided cysts rupture or undergo
torsion, the manifestations are similar to those of
appendicitis.
▪ Patients develop right lower quadrant pain,
tenderness, rebound, fever, and leukocytosis.
▪ Both transvaginal ultrasonography and CT
scanning can be diagnostic.
▪ Torsion requires emergent operative treatment.
4. Endometriosis and Ruptured ectopic pregnancy
▪ Rupture of right tubal or ovarian pregnancies can
mimic appendicitis. Patients may give a history of
abnormal menses, either missing one or two
periods or noting only slight vaginal bleeding.
▪ The development of right lower quadrant or
pelvic pain may be the first symptom.
▪ The diagnosis of ruptured ectopic pregnancy
should be relatively easy.
▪ The presence of a pelvic mass and elevated levels
of human chorionic gonadotropin are
characteristic.
▪ Vaginal examination reveals cervical motion and
adnexal tenderness, and a more definitive
diagnosis can be established by culdocentesis.
▪ The presence of blood and particularly decidual
tissue is pathognomonic.
▪ The treatment of ruptured ectopic pregnancy is
emergency surgery.
- Immunosuppressed Patient
o The presentation of acute appendicitis in HIV-infected
patients is similar to that in noninfected patients.
o The majority of HIV infected patients with appendicitis
have fever, periumbilical pain radiating to the right
lower quadrant (91%), right lower quadrant
tenderness (91%), and rebound tenderness (74%).
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 o HIV-infected patients do not manifest an absolute
leukocytosis; however, if a baseline leukocyte count is
available, nearly all HIV-infected patients with
appendicitis demonstrate a relative leukocytosis.
o The risk of appendiceal rupture appears to be
increased in HIV-infected patients.
o A low CD4 count is also associated with an increased
incidence of appendiceal rupture.
o Opportunistic infections should be considered as a
possible cause of right lower quadrant pain.
o Neutropenic enterocolitis (typhlitis) should also be
considered in the differential diagnosis of right lower
quadrant pain in HIV-infected patients
Treatment
- Appendectomy is the standard of care. (Lap vs Open)
- Patients should be NPO, given IVF, and preoperative
antibiotics
- Antibiotics are most effective when given preoperatively
and to decrease SSI and abscess formation
Interval Appendectomy
- defined as performing an appendectomy following initial
successful nonoperative management in patients with no
further symptoms.
Incidental Appendectomy
- 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.
- These include children about to undergo chemotherapy,
the disabled who cannot describe symptoms or react
normally to abdominal pain, patients with Crohn’s disease
in whom the cecum is free of macroscopic disease, and
individuals who are about to travel to remote places where
there is no access to medical or surgical care.
Operational Definitions
Uncomplicated Appendicitis
- Two lines of observations in concept of nonoperative
treatment:
1. For patients in an environment where surgical
treatment is not available (e.g., submarines,
expeditions in remote areas), treatment with
antibiotics alone was noted to be effective.
2. Many patients with signs and symptoms
consistent with appendicitis who did not pursue
medical treatment would occasionally have
spontaneous resolution of their illness.
- However, surgical treatment is still the standard of care
Complicated Appendicitis
- Includes gangrenous appendicitis, perforated appendicitis,
localized purulent collection at operation, generalized
peritonitis and periappendiceal abscess
- Children less than 5 years of age and patients more than
65 years of age have the highest rates of perforation (45%
and 51%, respectively)
-
Treatment: Antibiotics
- Based on PCS-EBCPG (Philippine College of Surgeon –
Evidence Based Clinical Practice Guidelines)
o Uncomplicated Ap: Prophylaxis
1. Cefoxitin 2gms IV single dose (adults) & 40mg/kg
(children) (2nd Generation cephalosporin)
2. Ampicillin-Sulbactam
3. Amoxicillin-Clavulanate
o Complicated ap: Therapeutic
1. Ertapenem
2. Piperacillin-Tazobactam
3. Ciprofloxacin + Metronidazole (in patient with
hypersensitivity)
4. Ticarcillin-Clavulanic Acid (in children)
▪ Duration of therapy: 5-7 days
o What is the difference of prophylaxis from therapeutic
antibiotic?
▪ Prophylaxis is given -30 mins before surgery
▪ Therapeutic is given before and after surgery for
5-7 days.
Complications
- Perforation
- Abscess Formation
- Intestinal Obstruction
- Bacteremia
- Sepsis
- Fistula
- Liver Abscess
- Pyelophlebitis
Postoperative Care and Complications
- Uncomplicated Appendectomy: Postoperative antibiotic
therapy is unnecessary
- Complicated Appendectomy: Patients should be continued
on broad-spectrum antibiotics for 4-7 days.
- Postoperative ileus may occur, so diet should be started
based on daily clinical evaluation.
- Patients are at increased risk for surgical site infections.
Surgical Site Infection
- Following laparoscopic appendectomy, the extraction port
site is the most common site of surgical site infection.
- Patients with cellulitis can be started on antibiotics.
- Small abscesses can be simply treated with antibiotics;
however, larger abscesses require drainage.
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- Most commonly, percutaneous drainage with CT or
ultrasound guidance is effective.
- For abscesses not amenable to percutaneous drainage,
laparoscopic abscess drainage is a viable option.
Stump Appendicitis
- Incomplete appendectomy represents a failure of
removing the entire appendix on the initial procedure
- Patients presenting with stump appendicitis are more likely
to have complicated appendicitis, have an open procedure,
and undergo colectomy.
- Prevention
o Use of the “appendiceal critical view”
▪ appendix placed at 10 o’clock, taenia coli/libera at
3 o’clock, and terminal ileum at 6 o’clock
▪ identify the taeniae coli merge and disappear
✓ paramount to identifying and ligating the
base of appendix
▪ The remaining stump should be no longer than
0.5 cm
Neoplasms of the Appendix
- Appendiceal carcinoid and appendiceal adenomas are the
most common lesions identified
- There is no clear age
- relationship associated with the identification of these
masses.
Carcinoid
- firm, yellow, bulbar mass
- most common site of gastrointestinal carcinoid
- majority located in the tip of the appendix
- Malignant potential is related to size, with tumors <1 cm
rarely resulting in extension outside of the appendix or
adjacent to the mass.
- Mean tumor size: 2.5 cm
- Treatment
o ≤1 cm: appendectomy
o > 1 to 2 cm located at the base, involving the
mesentery, or with lymph node metastases: right
hemicolectomy
Adenocarcinoma
- rare neoplasm
- three major histologic subtypes:
o mucinous adenocarcinoma,
o colonic adenocarcinoma
o adenocarcinoid
- Presentations:
o acute appendicitis (most common)
o ascites or a palpable mass
o may be discovered during an operative procedure for
an unrelated cause.
- Treatment: right hemicolectomy.
- Patients with appendiceal adenocarcinoma are at
significant risk for both synchronous and metachronous
neoplasms, approximately half of which will originate from
the gastrointestinal tract.
Mucocele
- A mucocele of the appendix is an obstructive dilatation by
intraluminal accumulation of mucoid material.
- Four processes of causation:
o retention cysts
o mucosal hyperplasia
o cystadenomas
o cystadenocarcinomas. The
- clinical presentation is nonspecific and often it is an
incidental finding
- Management:
o resection of the appendix
o wide resection of the mesoappendix to include all the
appendiceal lymph nodes
o collection and cytologic examination of all
intraperitoneal mucus
o careful inspection of the base of the appendix.
o Right hemicolectomy or, preferably, ileocecectomy is
reserved for patients with a positive margin at the
base of the appendix or positive periappendiceal
lymph nodes.
Pseudomyxoma Peritonei
- rare condition in which diffuse collections of gelatinous
fluid are associated with mucinous implants on peritoneal
surfaces
- two to three times more common in females than in males
- invariably caused by neoplastic mucus-secreting cells
within the peritoneum
- These cells may be difficult to classify as malignant because
they may be sparse, widely scattered, and have a low-
grade cytologic appearance.
- Presentation:
o abdominal pain distention, or a mass
- usually does not cause abdominal organ dysfunction
- ureteral obstruction and obstruction of venous return can
be seen
- progresses slowly and in which recurrences may take years
to develop or become symptomatic.
- Lymph node metastasis and distant metastasis are
- uncommon.
- CT scanning is the preferred imaging modality.
- Peritoneal surfaces of the bowel are usually free of tumor.
- Thorough surgical debulking is the mainstay of treatment.
- All gross disease and the omentum should be removed.
- If not done previously, appendectomy is routinely
performed.
- Hysterectomy with bilateral salpingo-oophorectomy is
performed in women.
- Hyperthermic chemotherapy is advocated as a standard
adjunct to radical cytoreductive surgery.
Lymphoma
- extremely uncommon
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- The gastrointestinal tract is the most frequently involved
extranodal site for non-Hodgkin’s lymphoma.
- accounts for 1% to 3% of gastrointestinal lymphomas
- Appendiceal lymphoma usually presents as acute
appendicitis and is rarely suspected preoperatively.
- Findings on CT scan of an appendiceal diameter ≥2.5 cm or
surrounding soft tissue thickening should prompt suspicion
of an appendiceal lymphoma.
- Management:
o Appendectomy
o Right hemicolectomy is indicated if tumor extends
beyond the appendix onto the cecum or mesentery.
- A postoperative staging workup is indicated before
initiating adjuvant therapy.
- Adjuvant therapy is not indicated for lymphoma confined
to the appendix.

God bless! 😊

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