Appendicitis

48
Jurgen Schleef and Prem Puri

Contents 48.1 Introduction

48.1 Introduction .............................................. 477
48.2 Epidemiology ............................................ 477
48.3 Etiology ..................................................... 477
48.4 Diagnosis ................................................... 478
48.5 Differential Diagnosis .............................. 479
48.6 Operative Techniques .............................. 479
48.7 Open Appendectomy ............................... 480
48.8 Laparoscopic Appendectomy .................. 480
48.9 Appendicitis in Preschool Children ........ 480
48.10 Perforated Appendicitis ........................... 481
48.11 Appendix Mass ......................................... 482
48.12 Mortality ................................................... 483
48.13 Long-Term Outcomes .............................. 483
Further Reading .................................................... 483
Acute appendicitis is the most common surgical
emergency in childhood. Appendicitis may present at
any age, although it is uncommon in preschool chil-
dren. Approximately one-third of children with acute
appendicitis have perforation by the time of operation.
Despite improved fluid resuscitation and better antibi-
otics, appendicitis in children, especially in preschool
children, is still associated with significant morbidity.
48.2 Epidemiology
The incidence of acute appendicitis has been reported
to vary substantially by country, geographic region,
race, sex and season, but the reasons for these varia-
tions are unknown. An epidemiological study of acute
appendicitis in California revealed that the incidence
of appendicitis in blacks and Asians was less than half
that in whites. Epidemiological studies of acute appen-
dicitis and perforation rates in California and New
York have shown higher incidence rates of appendici-
tis among Hispanics than African Americans and
Whites with Hispanics, Asians and African Americans
having a higher risk of perforation than whites.

48.3 Etiology

The exact etiology and pathogenesis of appendicitis are

poorly understood. While invasion of the appendiceal
wall by micro-organisms is the ultimate pathological
event, the primary initiating condition is not known.

P. Puri and M. Höllwarth (eds.), Pediatric Surgery: Diagnosis and Management, 477
DOI: 10.1007/978-3-540-69560-8_48, © Springer-Verlag Berlin Heidelberg 2009
478 Part VI Gastrointestinal

Obstruction of the appendix lumen, from whatever

cause, with resulting distension and disturbance of blood
flow, is still considered the major factor in the pathogen-
esis of acute appendicitis. Other factors include low
dietary fiber intake and bacterial and viral infections.
Andersson et al. investigated temporospatial clustering
and outbreaks (characteristics of infectious diseases)
among appendicitis cases and found that appendicitis
does occur in space-time clusters and outbreaks, thus
supporting an infectious etiology theory. Recently,
Gauderer et al. investigated the relationship between
heredity and appendicitis and found that children with
appendicitis are at least twice as likely to have a positive
family history of appendicitis as compared with chil-
dren with right lower quadrant pain without appendicitis
or controls without abdominal pain.

48.4 Diagnosis

The diagnosis of acute appendicitis in childhood can
sometimes be difficult. Definite diagnosis is made in
only 43–72% of patients at the time of initial assess-
ment. The rate of negative pediatric appendectomy is
in the range 4–50% in various reports. The patient’s
history and clinical examination are the most impor-
tant tools for the diagnosis of appendicitis. Periumbilical
pain is often the first symptom, followed by vomiting
and fever. When the inflammation progresses, the pain
localizes to the right lower quadrant, and right lower
quadrant tenderness develops. Appendices located in
the retrocaecal position may cause pain, radiating to
the back. Appendices in pelvic position may present
with diarrhea. Clinical examination in a typical case
with appendicitis reveals tenderness, guarding and
rigidity in the right lower quadrant of abdomen.
Laboratory investigations and plain radiographs
are neither sensitive nor specific in the diagnosis of
appendicitis. Barium enema is an unreliable test
because of its high false-positive and false-negative
rates. In recent years, graded compression ultrasonog-
raphy of the right lower quadrant has been shown to
be a useful tool in the evaluation of patients with clini-
cal findings that are suggestive but not diagnostic of
appendicitis, with a sensitivity of 80–100%, a speci-
ficity of 78–98%, and an overall accuracy of 91%.
Ultrasound is portable, fast, and free of irradiation
exposure, of modest incremental cost and of use in
Fig. 48.1 Ultrasonography in a 12-year-old patient with acute
appendicitis—enlarged and thickened (1.1 cm) appendix
delineating gynecologic disease. However, it is of
limited use in obese adolescents and is highly user-
dependent. The only sonographic sign that is specific
for appendicitis is an enlarged, non-compressible
appendix measuring greater than 6 mm in maximal
diameter (Fig. 48.1). The appendix may not be visible
following perforation. Recently, computed tomogra-
phy (CT) has been used as an adjunct to the diagnosis
of appendicitis and appeared to have an immediate
impact, reducing negative appendectomy rates to
4.1% and perforation rates to 14.7%. The principal
advantages of CT are its operator independency and
enhanced delineation of disease extent in perforated
appendicitis. Sensitivity, specificity and accuracy for
unenhanced limited CT have approached 97%, 100%
and 99%, respectively. However, with this improved
diagnostic accuracy came a reduction in the degree of
significance put on the initial clinical evaluation by
the responsible surgical team. This management strat-
egy must take into account the significant risk of
exposure of the child to the CT dose of ionizing radia-
tion. Recent studies have suggested that CT has not
increased the accuracy of diagnosing appendicitis
48 J. Schleef and P. Puri ● Appendicitis 479

when compared to a careful history and physical Table 48.1 Appendicitis

examination performed by an experienced surgeon. Most frequent differential diagnosis
In patients with an uncertain diagnosis of acute • Abdominal pain of unknown origin
abdominal pain, a policy of active observation in • Gastroenteritis
• Mesenteric lymphadenitis
hospital is usually practiced. A repeated structured
• Intussusception
clinical examination is simple and noninvasive. • Meckel’s diverticulitis
However, the argument against this policy is that it • Primary peritonitis
may lead to a delay in specific management of these • Inflammatory bowel disease
patients and may result in a high incidence of perfora- • Neoplasm (carcinoid, lymphoma)
tion. Bachoo et al. achieved a positive predictive value • Urinary tract infection
of 97.9% and a normal appendectomy rate of 2.6% • Testicular torsion
• Omental torsion
with active observation alone and showed no correla-
• Ruptured ovarian cyst
tion between post-operative morbidity and timing of • Ovarian torsion
surgery with this protocol. We have shown that the • Ectopic pregnancy
delay in appendectomy in children observed in a hos- • Pelvic inflammatory disease
pital setting does not increase the incidence of com-
plicated appendicitis.

48.5 Differential Diagnosis 48.6 Operative Techniques

Several conditions must be considered where an
infant is being evaluated for appendicitis. Table 48.1
gives the list of common differential diagnoses.
Differential diagnoses are more frequent in small
children (connatal malformations, intussusceptions)
and adolescent girls (ovarian pathology, pelvic
inflammatory disease).
Children with appendicitis are assessed for degree of
sepsis and dehydration. Intravenous fluids are indi-
cated preoperatively because most patients would have
vomited and not eaten for over 24 h. Broad-spectrum
antibiotics should be administered pre- and postopera-
tively in order to prevent infectious complications
(Table 48.2).

Table 48.2 Appendicitis

480
48.7 Open Appendectomy
A transverse right lower quadrant skin crease incision is
recommended. The muscular layers are split in the
direction of their fibers. The peritoneum is opened and
fluid sent for culture. Recent studies have suggested it is
unnecessary to send routine peritoneal fluid cultures.
The mesoappendix is divided and the appendiceal base
clamped and ligated. Stump inversion is optional.
Engstrom and Fenyo found no difference as regards to
wound infection and postoperative fever between one
group in which the appendix was ligated and doubly
invaginated and another group in which it was simply
ligated. If pus is present, the abdomen should be irri-
gated with saline. The abdominal wall is closed in lay-
ers. The skin is usually closed by subcuticular absorbable
sutures even in the case of perforation. Primary wound
closure after perforated appendicitis is safe, economical
and advantageous in pediatric practice.
48.8 Laparoscopic Appendectomy
An infraumbilical port is inserted using an open rather
than percutaneous technique. Two 5 mm infraumbilical
incisions are placed on either side of the midline. A
third right lower quadrant incision is optional. After
mobilization of the appendix, the mesoappendix is
divided, the appendiceal stump is ligated with endoloops
or an endoscopic stapler, and the appendix is removed.
In recent years, laparoscopic appendectomy has
become an option as a safe alternative in the pediatric
age group (Fig. 48.2). Although the rate at which
laparoscopy is utilized in the treatment of appendicitis
varies dramatically from center to center (range
0–95%), it is undoubtedly a reasonable surgical alter-
native to open appendectomy for the treatment of acute
appendicitis in children. Recent studies have demon-
strated that laparoscopic appendectomy is at least as
safe and effective as open appendectomy. Despite the
fact that laparoscopic appendectomy takes longer to
perform at a marginally increased cost compared to
open appendectomy, it has multiple advantages.
A large database study of adults and children in the
United States showed laparoscopic appendectomy to
be associated with a shorter median hospital stay and
lower rates of wound infection, gastrointestinal com-
plications and overall complications.
Part VI Gastrointestinal
Fig. 48.2 A 14-year-old boy with phlegmon appendicitis dur-
ing laparoscopy
The increased operative expense of laparoscopic
appendectomy appear to be offset by an earlier return
to normal daily activities.
48.9 Appendicitis in Preschool Children
Acute appendicitis in the preschool child accounts for
a small fraction of all pediatric admissions with this
diagnosis. In children under 2 years of age, it repre-
sents 1% of all cases of appendicitis in childhood. In a
large series from Dublin, Puri et al. found that only
4.3% of their patients with appendicitis presented dur-
ing the first 3 years of life. A recent 28-year review of
appendicitis in children less than 3 years of age from
Toronto showed that all children had perforated appen-
dicitis at presentation. This resulted in very high mor-
bidity (wound infection/abscess/dehiscence, pneumonia,
small bowel obstruction, incisional hernia and entero-
cutaneous fistula) affecting 59% of these patients and
although appendicitis is uncommon in this age group,
it should be considered in the differential diagnosis of
preschool children presenting with abdominal pain,
tenderness or vomiting.
The diagnosis of appendicitis in preschool children
can be difficult, resulting in delay and more severe dis-
ease. The young child’s inability to communicate ade-
quately with the parents, atypical disease presentation,
and other associated illnesses may delay the diagnosis.
Surana et al. reviewed 132 patients under 5 years of
age treated for acute appendicitis in the two Dublin
48 J. Schleef and P. Puri ● Appendicitis
children’s hospitals between 1987 and 1991, in order
to identify factors that contribute to more serious dis-
ease in this age group. Of the 132 preschool children,
63 (48%) had perforated appendicitis and 29 (22%)
had an appendix mass, 36 (27%) had uncomplicated
appendicitis and 4 (3%) had a normal appendix. All
the classic symptoms were present in the majority of
patients. Atypical symptoms were found in many chil-
dren and included diarrhea, cough/sore throat, dysuria,
headache and earache. A diagnosis other than appendi-
citis was suspected in 53 (40%) patients, leading to a
delay in management. Mean duration of symptoms
before admission was as follows: acute appendicitis 39
hours, perforated appendicitis 53 h, and appendix mass
82 h. Postoperatively an intra-abdominal abscess
occurred in 5% of the patients with perforated appen-
dicitis and none with uncomplicated appendicitis:
these patients were treated using antimicrobial agents,
with complete resolution clinically and on ultrasound
in all cases. One patient required laparotomy for adhe-
sive intestinal obstruction. There were no deaths.
In view of the frequency of atypical presentation
and the increased incidence of advanced appendicitis,
a high index of suspicion is necessary in preschool
children presenting with acute abdominal pain. Early
diagnosis is the key to reducing morbidity from appen-
dicitis in this age group.
48.10 Perforated Appendicitis
The reported incidence of perforated appendicitis in
children is 18–40%. Two recent large series of appen-
dicitis in children have reported 18% and 20% inci-
dence respectively. The incidence is much higher in
preschool children (see above).
Nowadays mortality is very rare. Several controver-
sies have arisen over the years regarding the best
approach to reduce the morbidity from appendicitis,
especially infectious complications such as intra-
abdominal abscess and wound infection. Many of the
controversies relating to perforated appendicitis have
been resolved. Several studies have confirmed the
efficacy of antibiotics in reducing morbidity. Probably,
the first preoperative dose of antibiotics is the most
important. There is still some disagreement about the
duration of antibiotic therapy and which drugs to use.
Wound drainage is no longer thought to be beneficial,
481
and has been associated with an increased risk of infec-
tion. Current opinion overwhelmingly favors the
approach of confining the use of drains to only those
cases in which a clearly localized abscess cavity can be
demonstrated. The placement of a peritoneal drain fol-
lowing perforated appendicitis has not been shown to
improve outcome, with no reduction in the duration of
hospitalization or nasogastric drainage time and is
therefore not advocated. Intraoperative irrigation of
the peritoneal cavity is a valuable procedure in perfo-
rated appendicitis. The majority of pediatric surgeons
nowadays favor a protocol of irrigation, with or with-
out antibiotics, until a clear effluent is returned.
Subcuticular skin closure is safe after perforated
appendicitis; wound infection rates are low and thus
there is no compelling reason to opt for delayed clo-
sure of the appendectomy incision.
In Dublin, the protocol for the management of per-
forated appendicitis consists of preoperative adminis-
tration of antibiotics that are continued for 5 days
postoperatively. Intraoperative irrigation of the perito-
neal cavity is carried out and the appendectomy wound
is closed using subcuticular absorbable sutures. During
a 5-year period (1987–1991), a total of 870 patients
underwent emergency appendectomy for appendicitis
at Our Lady’s Hospital for Sick Children. One hundred
and fifty-eight (18%) of the patients (98 boys) were
found to have a perforated appendix. Their ages ranged
from 18 months to 15 years (mean 7.8 years). Thirteen
patients (8%) developed postoperative complications.
Nine (5.6%) had a wound infection, which was man-
aged by local drainage and antibiotics. Five children
(3.2%), including one with a wound infection, devel-
oped an intra-abdominal abscess, which was confirmed
by ultrasonography and resolved with antibiotic ther-
apy (Fig. 48.3). Nine of the 13 patients with postopera-
tive infective complications were readmitted to
hospital; their mean hospital stay was 9.4 days (range
3–18). The mean duration of hospital stay in the 158
patients with perforated appendicitis, including those
who were readmitted, was 6.8 days (range 3–47).
There were no deaths.
An analysis of three recent studies of perforated
appendicitis, using a protocol of preoperative antibio-
tics, intraoperative irrigation of the peritoneal cavity,
primary subcuticular skin closure and a short course of
postoperative antibiotics showed an intra-abdominal
abscess rate of 1.3–3.2%, a wound infection rate of
1.3–5.7%, no deaths, and a mean hospital stay of
482
Fig. 48.3 Ultrasonography of a subdiaphragmatic abscess after
complicated appendicitis (same patient as in Fig. 1)
6.8–11.4 days. These results set new standards in
wound management, infectious complications and
length of hospital stay in perforated appendicitis.
48.11 Appendix Mass
An appendix mass results from appendicitis that is
localized by edematous, adherent omentum and loops
of small bowel. In contrast, the appendiceal abscess is
a localized suppurative process that may occur at any
time in the course of appendicitis, or may complicate
an appendiceal mass. Clinically, it is not possible in
most cases to distinguish with certainty between the
two conditions. An appendiceal mass at the time of
presentation is discovered in about 10% of children
with appendicitis. The incidence is higher during the
first 3 years of life, when one-third of the patients with
appendicitis have been reported to present with an
appendiceal mass.
The management of an appendiceal mass in chil-
dren is controversial. Many authors recommend non-
operative management of an appendix mass, with
Part VI Gastrointestinal
antibiotics followed by delayed appendectomy as the
treatment of choice. Others favor immediate appen-
dectomy in every case of appendicitis. Controversy
around conservative management of appendiceal mass
has arisen mainly from the belief that children, and
particularly infants, have a poor ability to localize
intraperitoneal inflammatory processes, and so chil-
dren with an appendiceal mass should be managed
operatively. The senior author has previously shown
that a child’s ability to localize appendiceal inflamma-
tion is well developed, even in infancy, and that one
half of the patients developing appendicitis during the
first 2 years of life, and one-third of those developing
appendicitis during the first 3 years of life, have an
appendiceal mass at the time of presentation.
Initial conservative management of appendiceal
masses, followed by interval appendectomy, has been
practiced at the author’s institution for over 30 years.
Gillick et al. recently reviewed the results of conser-
vative management of patients with an appendix mass
from Dublin. During the period 1982–2000, 427 chil-
dren presented to one of Dublin’s three pediatric hos-
pitals with a diagnosis of appendix mass. There were
222 boys and 205 girls. Their ages ranged from 2
months to 18 years (mean 7.3 years). The duration of
symptoms ranged from a few hours to 21 days, with
266 (62.3%) having had symptoms for longer than 3
days. The diagnosis was made clinically in 136
(31.9%) children, by ultrasonography in 61 (14.3%),
by examination under anesthesia in 229 (53.6%) and
by computed tomography in one child (0.2%). All
were initially managed conservatively with intrave-
nous antibiotics, nasogastric suction as required and
intravenous fluids until oral fluids and diet were toler-
ated. In 346 (84.2%) of the 411 patients the mass
resolved completely. The mean duration of hospital
stay in this group was 6 days. Three hundred and
thirty-one children had an elective appendectomy as
planned, 4–6 weeks after discharge. Of these elective
appendec-tomies, 15 (4.5%) were performed laparo-
scopically. The complication rate following elective
appendectomy was 2.3% (five wound infections, two
intra-abdominal abscesses and one hematoma).
Histological assessment of the appendices removed
electively demonstrates acute of subacute inflamma-
tion in 51% of the specimens. Two specimens had a
carcinoid tumor. Sixty-five (16%) children with an
appendix mass failed to respond to initial non-opera-
tive management: 17 required early appendectomy for
48 J. Schleef and P. Puri ● Appendicitis
ongoing symptoms and 27 developed an appendix
abscess that required drainage and subsequent appen-
dectomy. These data, as well as other studies, support
the contention that initial nonoperative management
of appendiceal mass, followed by an appendectomy, is
a safe and effective policy.
We recommend interval appendectomy following
resolution of the appendiceal mass. Some investigators
have questioned the need for appendectomy after
conservative management, on the assertion that the
incidence of recurrent appendicitis is low and the
complication rate with interval appendectomy is high.
However, complications following interval appendec-
tomy in children in our series were uncommon.
Moreover, histological evidence of inflammation was
present in almost 51% of these appendices. It is possi-
ble that the inflammation in some cases might have
resolved spontaneously, but some patients develop
recurrent appendicitis. Therefore, we recommend ini-
tial nonoperative management of appendiceal masses
with antibiotics, followed by appendectomy 6–8 weeks
later.
48.12 Mortality
In the United Kingdom, the number of deaths from
acute appendicitis in children has decreased dramati-
cally since the 1930s, largely as a result of the decline
in incidence of appendicitis but also because of a
marked reduction in the hospital case-fatality rate
during the last 30 years. Three national audits
between 1963 and 1997 covering all children dying
of appendicitis in England and Wales showed an
483
85% decrease in the hospital case-fatality rate. This
almost certainly reflects improvements in clinical
care, which have occurred in parallel with expansion
of specialist pediatric surgery and anesthesia. Delay
in referral to hospital and/or diagnosis of acute
appendicitis are the dominant factors responsible for
the residual small number of avoidable deaths.
48.13 Long-Term Outcomes
The long-term outcome of the vast majority of patients
who undergo appendectomy for childhood appendici-
tis is excellent. A small number of patients develop
late adhesive intestinal obstruction. The belief that per-
forated appendicitis in girls is associated with reduced
fertility rate in later life has been based on a few reports
that do not stand up to critical analysis.
Further Reading
Esposito C, Borzi P, Valla JS et al (2007) Laparoscopic versus
open appendectomy in children: A retrospective comparative
study of 2,332 cases. World J Surg 31:750–755
Kosloske AM, Love CL, Rohrer JE, Goldthorn JF, Lacey SR
(2004) The diagnosis of appendicitis in children: Outcomes
of a strategy based on pediatric surgical evaluation. Pediatrics
113:29–34
Morrow SE, Newman KD (2007) Current management of
appendicitis. Semin Pediatr Surg 16:34–40
Puri P, Mortell A (2007) Appendicitis. In MD Stringer, KT
Oldham, PDE Mouriquand (eds) Paediatric Surgery and
Urology: Long-term outcomes, 2nd edn. Cambridge
University Press, New York, pp 374–384
Jasonni V (2006) Appendectomy. In P Puri, ME Höllwarth (eds)
Pediatric Surgery, Springer Surgery Atlas Series. Springer-
Verlag, Berlin, Heidelberg, New York, pp 321–326