DISEASES OF THE APPENDIX

ALFONSO C. DANAC, MD, FPCS, FPSGS, FPALES Associate Professor, Department of Surgery Angeles University Foundation School of Medicine

dix

ology: becomes visible as a protuberance of the terminal portio cecum at 8 wks AOG

h rate is exceeded by the cecum during antenatal and postnatal resulting to medial displacement of the appendix medially towa the ileocecal valve

Appendix - narrow muscular tube containing large amounts of lymphoid tissue in its wall - attached to the posteromedial surface of the cecum about 2.5 cm below the ileocecal junction - has a complete peritoneal covering, which is attached to the mesentery of the small intestine by a short mesentery of its own, the mesoappendix - mesoappendix contains the appendicular vessels and nerves

Appendix - base of the appendix can be located inside the abdomen by tracing the taenia coli of the cecum and following them to the appendix, where they converge to form a continuous muscle coat - can vary in length from less than 1 cm to greater than 30 cm; most appendices are 6 to 9 cm in length - appendiceal absence, duplication, and diverticula have all been reported

Appendix Arterial Supply: Appendicular Artery, branch of posterior cecal artery Venous Drainage: appendicular vein, drains into the posterior cecal vein Lymphatic Drainage: one or two nodes in the mesoappendix and then to the superior mesenteric nodes Nerve Supply: sympathetic and vagus nerves from the superior mesenteric plexus

- relationship of the base of the appendix to the cecum remains constant - tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position - these anatomic considerations have significant clinical importance in the context of acute appendicitis - the three taenia coli converge at the junction of the cecum with the appendix and can be a useful

Appendix - erroneously viewed, in the past, as a vestigial organ with no known function - now well recognized as an immunologic organ that actively participates in the secretion of immunoglobulins, particularly immunoglobulin A (IgA) - an integral component of the gut-associated lymphoid tissue (GALT) system - function is regarded as not essential and appendectomy is not associated with any predisposition to sepsis or any other manifestation of immune compromise

Appendix - Lymphoid tissue first appears in the appendix approximately 2 weeks after birth - 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

Historical Background -first appendectomy by 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 hernia sac, Amyand found the appendix perforated by a pin. He successfully removed the appendix and repaired the hernia. 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

Historical Background In 1827, François Melier, a French physician, expounded on Louyer-Villermay's work. He reported six autopsy cases and was the first to suggest the antemortem recognition of appendicitis. 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.

Historical Background In 1839, a textbook authored by Bright and Addison titled Elements of Practical Medicine described the symptoms of appendicitis and identified the primary cause of inflammatory processes of the right lower quadrant. Reginald Fitz, a professor of pathologic anatomy at Harvard, is credited for coining the term "appendicitis." His landmark paper definitively identified the appendix as the primary cause of right lower quadrant inflammation.

Incidence lifetime rate of appendectomy is 12% for men and 25% for women, with approximately 7% of all people undergoing appendectomy for acute appendicitis. rate of appendectomy for appendicitis has remained constant at 10 per 10,000 patients per year. 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 to female predominance (M:F 1.2 to 1.3:1)

Incidence Despite an increased use of ultrasonography, computed tomography (CT) scanning, and laparoscopy between 1987 and 1997, the rate of misdiagnosis of appendicitis has remained constant (15.3%), as has the rate of appendiceal rupture. The percentage of misdiagnosis of appendicitis is significantly higher among women than men (22.2 vs. 9.3%). The negative appendectomy rate for women of reproductive age is 23.2%, with the highest rates identified in women age 40 to 49 years. The highest negative appendectomy rate is reported for women older than 80 years of age (

Etiology and Pathogenesis Obstruction of the lumen is the dominant causal factor Fecaliths are the usual cause of appendiceal obstruction. Less-common causes are hypertrophy of lymphoid tissue, inspissated barium from previous x-ray studies, tumors, vegetable and fruit seeds, and intestinal parasites. The frequency of obstruction rises with the severity of the inflammatory process. Fecaliths are found in 40% of cases of simple acute appendicitis, 65% of cases of gangrenous appendicitis without rupture, and nearly 90% of cases of gangrenous appendicitis with rupture.

Etiology and Pathogenesis There is a predictable sequence of events leading to eventual appendiceal rupture. Obstruction of lumen - increased intraluminal pressure -- distention of appendix (vague, dull, diffuse mid abdomen or lower epigastric or periumbilical pain) Congestion  suppuration  gangrene  perforation

Table 29-1 Common Organisms Seen in Patients with Acute Appendicitis Aerobic and Facultative Gram-negative bacilli Anaerobic Gram-negative bacilli

E. Coli Bacteroides fragilis Pseudomonas aeruginosa Bacteroides species Klebsiella species Fusobacterium species Gram-positive cocci Gram-positive cocci

Streptococcus anginosus Peptostreptococcus species Streptococcus species Gram-positive bacilli Enterococcus species Clostridium species

Peritoneal culture should be reserved for patients who are immunosuppressed, as a result of either illness or medication, and for patients who develop an abscess after the treatment of appendicitis. Antibiotic coverage is limited to 24 to 48 hours in cases of nonperforated appendicitis. For perforated appendicitis, 7 to 10 days is recommended. Intravenous antibiotics are usually given until the white blood cell count is normal and the patient is afebrile for 24 hours. The use of antibiotic irrigation of the peritoneal cavity and transperitoneal drainage through the wound are controversial.

Clinical Manifestations Symptoms Abdominal pain is the prime symptom of acute appendicitis. Anorexia nearly always accompanies appendicitis. vomiting occurs in nearly 75% of patients obstipation Diarrhea Fever

Signs Vital signs are minimally changed by uncomplicated appendicitis. Temperature elevation pulse rate is normal or slightly elevated usually prefer to lie supine, with the thighs, particularly the right thigh, drawn up, because any motion increases pain. If asked to move, they do so slowly and with caution. Tenderness is often maximal at or near McBurney's point. Direct rebound tenderness is usually present referred or indirect rebound tenderness is present Rovsing's sign—pain in the right lower quadrant when palpatory pressure is exerted in the left lower quadrant

Signs Cutaneous hyperesthesia in the area supplied by the spinal nerves on the right at T10, T11, and T12 Muscular resistance to palpation of the abdominal voluntary guarding becoming involuntary psoas sign indicates an irritative focus in proximity to that muscle. The test is performed by having patients lay on their left side as the examiner slowly extends the right thigh, thus stretching the iliopsoas muscle. The test is positive if extension produces pain. positive obturator sign of hypogastric pain on stretching the obturator internus indicates irritation in the pelvis. The test is performed by passive internal rotation of the flexed right thigh with the patient supine. Pararectal tenderness

Laboratory Findings CBC – leukocytosis with neutrophilic predominance Urinalysis – normal in most cases presence of pus cells may indicate bladder or ureteral irritation

Imaging Studies Plain film of the abdomen Barium enema Radionuclide tagged WBC Scan Graded compression sonography Abdominal CT scan – gold standard

Table 29-2 Alvarado Scale for the Diagnosis of Appendicitis Manifestations Migration of pain Anorexia Nausea/vomiting Signs RLQ tenderness Rebound 1 Elevated temperature Laboratory values Leukocytosis Left shift 2 1 Value 1 1 1 2 1

Symptoms

The likelihood of appendicitis can be ascertained using the Alvarado scale This scoring system was designed to improve the diagnosis of appendicitis and was devised by giving relative weight to specific clinical manifestation. Patients with scores of 9 to 10 are almost certain to have appendicitis; there is little advantage in further workup, and they should go to the operating room. Patients with scores of 7 to 8 have a high likelihood of appendicitis, while scores of 5 to 6 are compatible with, but not diagnostic of appendicitis. CT scanning is certainly appropriate for patients with Alvarado scores of 5 and 6, and a case can be built for imaging those with scores of 7 and 8. On the other hand, it is difficult to justify the expense, radiation exposure time, and possible

Appendiceal Rupture

Appendiceal rupture - occurs most frequently distal to the point of luminal obstruction along the antimesenteric border of the appendix - suspected in the presence of fever greater than 39°C (102°F) and a white blood cell count greater than 18,000/mm3. -In the majority of cases, rupture is contained and patients display localized rebound tenderness. - Generalized peritonitis will be present if the walling-off process is ineffective in containing the rupture. -In 2 to 6% of cases, an ill-defined mass will be detected on physical examination. - maybe a phlegmon, which consists of matted loops of bowel adherent to the adjacent inflamed appendix, or a periappendiceal abscess.

Appendiceal rupture -Patients who present with a mass have a longer duration of symptoms, usually at least 5 to 7 days - Phlegmons and small abscesses can be treated conservatively with intravenous antibiotics; well-localized abscesses can be managed with percutaneous drainage; complex abscesses should be considered for surgical drainage. - If operative drainage is required, it should be performed by using an extraperitoneal approach, with appendectomy reserved for cases in which the appendix is easily accessible. -Interval appendectomy performed at least 6 weeks following the acute event has classically been recommended for all patients treated either nonoperatively or with simple drainage of an abscess.

Differential Diagnosis - essentially the diagnosis of the "acute abdomen" - most common erroneous preoperative diagnoses -accounting for more than 75%—in descending order of frequency acute mesenteric lymphadenitis, no organic pathologic conditions, acute pelvic inflammatory disease, twisted ovarian cyst or ruptured graafian follicle, and acute gastroenteritis. differential diagnosis of acute appendicitis depends upon four major factors: the anatomic location of the inflamed appendix; the stage of the process (i.e., simple or ruptured); the patient's age; and the patient's sex.

Differential Diagnosis Acute Mesenteric Adenitis Acute Gastroenteritis Salmonella gastroenteritis (typhoid fever) Diseases of the Male Urogenital System Torsion of the testis Acute epididymitis, Seminal vesiculitis Meckel's Diverticulitis Intussusception Crohn's Enteritis

Differential Diagnosis Perforated Peptic Ulcer Colonic Lesions Diverticulitis perforating carcinoma of the cecum, or sigmoid clinical presentations. Epiploic Appendagitis Urinary Tract Infection Acute pyelonephritis Ureteral Stone Primary Peritonitis

Differential Diagnosis Henoch-Schönlein Purpura Yersiniosis (Yersinia enterocolitica or Y. pseudotuberculosis) Campylobacter jejuni Salmonella typhimurium Gynecologic Disorders pelvic inflammatory disease ruptured graafian follicle twisted ovarian cyst or tumor endometriosis ruptured ectopic pregnancy

Differential Diagnosis Other Diseases foreign-body perforations of the bowel closed-loop intestinal obstruction mesenteric vascular occlusion pleuritis of the right lower chest acute cholecystitis acute pancreatitis hematoma of the abdominal wall

Acute Appendicitis in the Young -Establishing diagnosis is more difficult than in the adult due to inability of young children to give an accurate history, diagnostic delays by both parents and physicians, and the frequency of gastrointestinal upset in children are all contributing factors. -more rapid progression to rupture and the inability of the underdeveloped greater omentum to contain a rupture lead to significant morbidity rates in children - Children younger than 5 years of age have a negative appendectomy rate of 25% and an appendiceal perforation rate of 45%. - negative appendectomy rate of less than 10% and a perforated appendix rate of 20% for children 5 to 12 years of age.

-appendix rate of 20% for children 5 to 12 years of age. -incidence of major complications after appendectomy in children is correlated with appendiceal rupture -wound infection rate after the treatment of nonperforated appendicitis in children is 2.8% as compared to a rate of 11% after the treatment of perforated appendicitis. -The incidence of intra-abdominal abscess is also higher after the treatment of perforated appendicitis as compared to nonperforated cases (6% vs. 3%). - treatment regimen for perforated appendicitis generally includes immediate appendectomy and irrigation of the peritoneal cavity.

Acute Appendicitis in the Young - Antibiotic coverage is limited to 24 to 48 hours in cases of nonperforated appendicitis. -For perforated appendicitis, 7 to 10 days of antibiotics is recommended. -Intravenous antibiotics are usually given until the white blood cell count is normal and the patient is afebrile for 24 hours. - The use of antibiotic irrigation of the peritoneal cavity and transperitoneal drainage through the wound are controversial. -Laparoscopic appendectomy has been shown to be safe and effective for the treatment of appendicitis in children. 62

Acute Appendicitis in the Elderly incidence of appendicitis in the elderly is lower than in younger patients, the morbidity and mortality are significantly increased in this patient population Delays in diagnosis, a more rapid progression to perforation, and comorbid disease are all contributing factors diagnosis of appendicitis may be subtler and less typical than in younger individuals, and a high index of suspicion should be maintained. In patients older than age 80 years, perforation rates of 49% and mortality rates of 21% have been reported

Acute Appendicitis During Pregnancy -most frequently encountered extrauterine disease requiring surgical treatment during pregnancy. -incidence is approximately 1 in 2000 pregnancies. -can occur at any time during pregnancy, but is more frequent during the first two trimesters. - As fetal gestation progresses, the diagnosis of appendicitis becomes more difficult as the appendix is displaced laterally and superiorly -nausea and vomiting after the first trimester or new-onset nausea and vomiting should raise the consideration of appendicitis.

Acute Appendicitis During Pregnancy Abdominal pain and tenderness will be present, although rebound and guarding are less frequent because of laxity of the abdominal wall. Elevation of the white blood cell count above the normal pregnancy levels of 15,000 to 20,000/L, with a predominance of polymorphonuclear cells, is usually present. When the diagnosis is in doubt, abdominal ultrasound may be beneficial. Laparoscopy may be indicated in equivocal cases, especially early in pregnancy.

Acute Appendicitis During Pregnancy The performance of any operation during pregnancy carries a risk of premature labor of 10 to 15%, and the risk is similar for both negative laparotomy and appendectomy for simple appendicitis. The most significant factor associated with both fetal and maternal death is appendiceal perforation. Fetal mortality increases from 3 to 5% in early appendicitis to 20% with perforation. The suspicion of appendicitis during pregnancy should prompt rapid diagnosis and surgical intervention

Appendicitis in Patients with AIDS or HIV Infection -incidence of acute appendicitis in HIV-infected patients is reported to be 0.5%. >higher than the 0.1 to 0.2% incidence reported for the general population. -presentation of acute appendicitis in HIV-infected patients is similar to that of noninfected patients - majority of HIV-infected patients with appendicitis will have fever, periumbilical pain radiating to the right lower quadrant (91%), right lower quadrant tenderness (91%), and rebound tenderness (74%) - HIV-infected patients will not manifest an absolute leukocytosis; however, if a baseline leukocyte count is available, nearly all will demonstrate a relative leukocytosis.

Appendicitis in Patients with AIDS or HIV Infection - increased risk of appendiceal rupture in HIV-infected patients. >43% of patients were found to have perforated appendicitis at laparotomy. >increased risk of appendiceal rupture may be related to the delay in presentation seen in this patient population. 68 - mean duration of symptoms prior to arrival in the emergency room has been reported to be increased in HIV-infected patients, with more than 60% of patients reporting the duration of symptoms to be longer than 24 hours - significant hospital delay also may have contributed to high rates of rupture.

Appendicitis in Patients with AIDS or HIV Infection - low CD4 count is also associated with an increase in appendiceal rupture >In one large series, patients with nonruptured appendices had CD4 counts of 158.75 ± 47 cells/mL 3 compared with 94.5 ± 32 cells/mL 3 in patients with appendiceal rupture -differential diagnosis of right lower quadrant pain is expanded in HIV-infected patients when compared to the general population >opportunistic infections should be considered as a possible cause of right lower quadrant pain >cytomegalovirus (CMV), Kaposi's sarcoma, tuberculosis, lymphoma, and other causes of infectious colitis

Appendicitis in Patients with AIDS or HIV Infection -CMV infection may be seen anywhere in the gastrointestinal tract. *CMV causes a vasculitis of blood vessels in the submucosa of the gut, leading to thrombosis. Mucosal ischemia develops, leading to ulceration, gangrene of the bowel wall, and perforation. -Spontaneous peritonitis may be caused by opportunistic pathogens including CMV, Mycobacterium avianintracellulare, M. tuberculosis, Cryptococcus neoformans, and strongyloides. - Kaposi's sarcoma and non-Hodgkin's lymphoma may present with pain and a right lower quadrant mass. Viral and bacterial colitis occur with a higher frequency in HIVinfected patients than in the general population

Appendicitis in Patients with AIDS or HIV Infection - Colitis should always be considered in HIV-infected patients presenting with right lower quadrant pain - Neutropenic enterocolitis (typhlitis) should also be considered in the differential diagnosis of right lower quadrant pain -obtain a thorough history and physical when evaluating any patient with right lower quadrant pain. -In the HIV-infected patient with classic signs and symptoms of appendicitis, immediate appendectomy is indicated. - In those patients with diarrhea as a prominent symptom, colonoscopy may be warranted. -In patients with equivocal findings, CT scan is usually helpful

Appendicitis in Patients with AIDS or HIV Infection -majority of pathologic findings identified in HIV-infected patients who undergo appendectomy for presumed appendicitis are typical - negative appendectomy rate is 5 to 10% - up to 25% of patients will have AIDS-related entities in the operative specimens, including CMV, Kaposi's sarcoma, and M. aviumintracellulare - 30-day mortality rate for patients undergoing appendectomy was reported to be 9.1%. *More recent series report 0% mortality

Appendicitis in Patients with AIDS or HIV Infection - Morbidity rates for HIV-infected patients with nonperforated appendicitis are similar to those seen in the general population - Postoperative morbidity rates appear to be higher in HIV-infected patients with perforated appendicitis - length of hospital stay for HIV-infected patients undergoing appendectomy is twice that of the general population - no series has been reported to date that addresses the role of laparoscopic appendectomy in the HIV-infected population.

Treatment -importance of early operative intervention should not be minimized - adequate hydration should be ensured; electrolyte abnormalities corrected; and pre-existing cardiac, pulmonary, and renal conditions should be addressed - efficacy of preoperative antibiotics in lowering the infectious complications in appendicitis - most surgeons routinely administer antibiotics to all patients with suspected appendicitis

Treatment - If simple acute appendicitis is encountered, there is no benefit in extending antibiotic coverage beyond 24 hours - If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count - for intra-abdominal infections of gastrointestinal tract origin of mild to moderate severity, the Surgical Infection Society has recommended single-agent therapy with cefoxitin, cefotetan, or ticarcillin-clavulanic acid - for more severe infections, single-agent therapy with carbapenems or combination therapy with a third- generation cephalosporin, monobactam, or aminoglycoside plus anaerobic coverage with clindamycin or metronidazole is indicated.

Open Appendectomy - McBurney (oblique) or Rocky-Davis (transverse) right lower quadrant muscle-splitting incision in patients with suspected appendicitis *centered over either the point of maximal tenderness or a palpable mass. If an abscess is suspected, a laterally placed incision is imperative to allow retroperitoneal drainage and to avoid generalized contamination of the peritoneal cavity -If the diagnosis is in doubt, a lower midline incision is recommended to allow a more extensive examination of the peritoneal cavity *especially relevant in older patients with possible malignancy or diverticulitis

Open Appendectomy -several techniques can be used to locate the appendix *because the cecum is usually visible within the incision, the convergence of the taeniae can be followed to the base of the appendix. A sweeping lateral to medial motion can aid in delivering the appendiceal tip into the operative field. - occasionally, limited mobilization of the cecum is needed to aid in adequate visualization. Once identified, the appendix is mobilized by dividing the mesoappendix, taking care to ligate the appendiceal artery securely.

Open Appendectomy - 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 *mucosa is frequently obliterated to avoid the development of mucocele -peritoneal cavity is irrigated and the wound closed in layers -if perforation or gangrene is found in adults, 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

Open Appendectomy - In children, who generally have little subcutaneous fat, primary wound closure has not led to an increased incidence of wound infection. -If appendicitis is not found, a methodical search for an alternative diagnosis must be performed * inspect cecum and mesentery then the small bowel is examined in a retrograde fashion beginning at the ileocecal valve and extending at least 2 feet - in females, special attention should be paid to the pelvic organs. - An attempt is also made to examine the upper abdominal contents

Open Appendectomy - peritoneal fluid should be sent for Gram's stain and culture. If purulent fluid is encountered, it is imperative that the source be identified - medial extension of the incision (Fowler-Weir), with division of the anterior and posterior rectus sheath, is acceptable if further evaluation of the lower abdomen is indicated if upper abdominal pathology is encountered, the right lower quadrant incision is closed and an appropriate upper midline incision performed

Laparoscopy -Semm first reported successful laparoscopic appendectomy in 1983, several years before the first laparoscopic cholecystectomy - However, the widespread use of the laparoscopic approach to appendectomy did not occur until after the success of laparoscopic cholecystectomy *appendectomy, by virtue of its small incision, is already a form of minimal-access surgery -Laparoscopic appendectomy is performed under general anesthesia. *usually requires the use of three ports *four ports may occasionally be necessary to mobilize a retrocecal appendix

Laparosocopy -utility of laparoscopic appendectomy in the management of acute appendicitis remains controversial *hesitant to implement a new technique because the conventional open approach has already proved to be simple and effective -duration of surgery and operation costs were higher for laparoscopic appendectomy than for open appendectomy - Wound infections were approximately half as likely after laparoscopic appendectomy than after open appendectomy -intra-abdominal abscess was three times greater after laparoscopic appendectomy than after open appendectomy

Laparosocopy - principal proposed benefit of laparoscopic appendectomy has been decreased postoperative pain - hospital length of stay also is statistically significantly less after laparoscopic appendectomy *more important determinant of length of stay after appendectomy is the pathology at operation, specifically whether a patient has perforated or nonperforated appendicitis - shorter period prior to return to normal activity, return to work, and return to sports

Laparosocopy -little benefit to laparoscopic appendectomy over open appendectomy in thin males between the ages of 15 and 45 years *Laparoscopic appendectomy should be considered an option in these patients, based on surgeon and patient preference - Laparoscopic appendectomy may be beneficial in obese patients in whom it may be difficult to gain adequate access through a small right lower quadrant incision. *decreased risk of postoperative wound infection

Laparosocopy -Diagnostic laparoscopy has been advocated as a potential tool to decrease the number of negative appendectomies performed. * However, the morbidity associated with laparoscopy and general anesthesia is acceptable only if pathology requiring surgical treatment is present and is amenable to laparoscopic techniques -question of leaving a normal appendix in situ is a controversial *17 to 26% of normal-appearing appendices at exploration have a pathologic histologic finding *availability of diagnostic laparoscopy may actually lower the threshold for exploration, thus impacting the negative appendectomy rate adversely

Laparosocopy - Fertile women with presumed appendicitis constitute the group of patients most likely to benefit from diagnostic laparoscopy *1/3 will not have appendicitis at exploration *most will have gynecologic pathology identified *diagnostic laparoscopy reduced the number of unnecessary appendectomies -It has not been resolved whether laparoscopic appendectomy is more effective at treating acute appendicitis than the time-proven method of open appendectomy

Laparosocopy - effective in the management of acute appendicitis. *should be considered part of the surgical armamentarium available to treat acute appendicitis - decision regarding how to treat any single patient with appendicitis should be based on surgical skill, patient characteristics, clinical scenario, and patient preference.

Interval Appendectomy -accepted algorithm 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 - provides much lower morbidity and mortality rates than immediate appendectomy - associated with added expense and longer hospitalization (8 to 13 vs. 3 to 5 days) - initial treatment consists of intravenous antibiotics and bowel rest. *9 to 15% failure rate, with operative intervention required at 3 to 5 days after presentation *Percutaneous or operative drainage of abscesses is not considered a failure of conservative therapy. 85

Interval Appendectomy - major argument against interval appendectomy is that approximately 50% of patients treated conservatively never develop manifestations of appendicitis, and those who do, can generally be treated nonoperatively. In addition, pathologic examination of the resected appendix is normal in 20 to 50% of cases. - timing of interval appendectomy is somewhat controversial. *Appendectomy may be required as early as 3 weeks following conservative therapy *2/3 of the cases of recurrent appendicitis occur within 2 years - associated with a morbidity rate of 3% or less and a hospitalization of 1 to 3 days in length.

Prognosis - overall mortality rate for a general anesthetic is 0.06% - overall mortality rate in ruptured acute appendicitis is about 3% - mortality rate of ruptured appendicitis in the elderly is approximately 15% - Death is usually attributable to uncontrolled sepsis—peritonitis, intra-abdominal abscesses, or gram-negative septicemia. - Pulmonary embolism continues to account for some deaths. – - Aspiration is a significant cause of death in the older patient group.

Prognosis Morbidity rates parallel mortality rates, being significantly increased by rupture of the appendix and to a lesser extent by old age abscess wound infection intra-abdominal abscesses Fecal fistula Intestinal obstruction inguinal hernia Incisional hernia

Chronic Appendicitis -true clinical entity has been questioned for many years - histologic criteria have been established *pain lasts longer and is less intense than that of acute appendicitis, but is in the same location *lower incidence of vomiting, but anorexia and occasionally nausea, pain with motion, and malaise are characteristic *Leukocyte counts are predictably normal and CT scans are generally nondiagnostic. - diagnosis established at operation - Laparoscopy can be effectively used - Appendectomy is curative. - symptoms resolve postoperatively in 82 to 93% of patients - Many of those whose symptoms are not cured or recur are ultimately diagnosed with Crohn's disease.

Appendiceal Parasites Ascaris lumbricoides - most common Enterobius vermicularis Strongyloides stercoralis Echinococcus granulosis - occlude the appendiceal lumen, causing obstruction - makes ligation and stapling of the appendix technically difficult. - therapy with helminthicide post op is necessary Amebiasis -can also cause appendicitis. -Invasion of the mucosa by trophozoites of Entamoeba histolytica incites a marked inflammatory process -Appendiceal involvement is a component of more generalized intestinal amebiasis - Appendectomy must be followed by appropriate antibiotic therapy (metronidazole).

Incidental Appendectomy -neither clinically nor economically appropriate - special circumstances during laparotomy or laparoscopy for other indications in which it should be performed children about to undergo chemotherapy disabled who cannot describe symptoms or react normally to abdominal pain Crohn's disease patients in whom the cecum is free of macroscopic disease individuals who are about to travel to remote places where t there is no access to medical/surgical care

Tumors Carcinoid -firm, yellow, bulbar mass in the appendix should raise the suspicion of an appendiceal carcinoid. - appendix is the most common site of gastrointestinal carcinoid, followed by the small bowel and then rectum. - Malignant potential is related to size, with tumors less than 1 cm rarely resulting in extension outside of the appendix or adjacent to the mass. Treatment rarely requires more than simple appendectomy For tumors smaller than 1 cm with extension into the mesoappendix, and for all tumors larger than 1.5 cm, a right hemicolectomy should be performed

Tumors Adenocarcinoma -rare neoplasm of three major histologic subtypes: mucinous adenocarcinoma, colonic adenocarcinoma, and adenocarcinoid -most common mode of presentation for appendiceal carcinoma is that of acute appendicitis - Patients may also present with ascites or a palpable mass, or the neoplasm may be discovered during an operative procedure for an unrelated cause. - The recommended treatment for all patients with adenocarcinoma of the appendix is a formal right hemicolectomy. -Appendiceal adenocarcinomas have a propensity for early perforation, although they are not clearly associated with a worsened prognosis. - Overall 5-year survival is 55% and varies with stage and grade.

Tumors Mucocele An appendiceal mucocele leads to progressive enlargement of the appendix from the intraluminal accumulation of a mucoid substance. Mucoceles are of four histologic types, and the type dictates the course of the disease and prognosis: retention cysts, mucosal hyperplasia, cystadenomas, and cystadenocarcinomas. A mucocele of benign etiology is adequately treated by a simple appendectomy.

Tumors Pseudomyxoma Peritonei rare condition in which diffuse collections of gelatinous fluid are associated with mucinous implants on peritoneal surfaces and omentum invariably caused by neoplastic mucous-secreting cells within the peritoneum. Appendectomy is routinely performed. Hysterectomy with bilateral salpingo-oophorectomy is performed in women. Ultra-radical surgery has not been shown to be of significant benefit. adjuvant intraperitoneal chemotherapy (with or without hyperthermia) or systemic postoperative chemotherapy have not been shown to be of benefit.

Tumors Lymphoma extremely uncommon frequently involved extranodal site for non-Hodgkin's lymphoma. frequency of primary lymphoma of the appendix ranges from 1 to 3% of gastrointestinal lymphomas management of appendiceal lymphoma confined to the appendix is appendectomy Right hemicolectomy is indicated if there is extension of tumor beyond the appendix onto the cecum or mesentery postoperative staging workup is indicated prior to initiating adjuvant therapy. Adjuvant therapy is not indicated for lymphoma confined to the appendix.

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