Acute Appendicitis Epidemiology Addiss and associates13 estimated the incidence of acute appendicitis in the United States population

to be 11 cases per 10,000 population annually. The disease is slightly more common in males, with a male:female ratio of 1.4:1. In a lifetime, 8.6% of males and 6.7% of females can be expected to develop acute appendicitis. Young age is a risk factor, as nearly 70% of patients with acute appendicitis are less than 30 years of age. The highest incidence of appendicitis in males is in the 10- to 14-yearold age group (27.6 cases per 10,000 population), while the highest female incidence is in the 15- to 19-year-old age group (20.5 cases per 10,000 population). Patients at extremes of age are more likely to develop perforated appendicitis. Overall, perforation was present in 19.2% of cases of acute appendicitis. This number was significantly higher, however, in patients under 5 and over 65 years of age. Although less common in people over 65 years old, acute appendicitis in the elderly progresses to perforation more than 50% of the time.13 Etiology and Pathophysiology Appendicitis, diverticular disease, and colorectal carcinoma have been shown to be diseases of developed civilizations. Burkitt14 found an increased incidence of appendicitis in Western countries compared to Africa, as well as in wealthy, urban communities compared to rural areas. He attributed this to the Western diet, which is low in dietary fiber and high in refined sugars and fat, and postulated that low-fiber diets lead to less bulky bowel contents, prolonged intestinal transit time, and increased intraluminal pressure. Burkitt theorized that the combination of firm stool leading to appendiceal obstruction and increased intraluminal pressure causing bacterial translocation across the bowel wall resulted in appendicitis. In examining appendixes removed for reasons other than appendicitis, he found fecaliths to be more prevalent in Canadian (32%) than in South African (4%) adults. In a group of patients with appendicitis, fecaliths were more common in Canadians (52%) than in South Africans (23%).15 He felt this was confirmation that appendiceal obstruction resulted in appendicitis. Of note, however, the majority of patients with appendicitis in his study did not have evidence of a fecalith. Wangensteen extensively studied the structure and function of the appendix and the role of obstruction in appendicitis.16,17 Based on anatomic studies, he postulated that mucosal folds and a sphincterlike orientation of muscle fibers at the appendiceal orifice make the appendix susceptible to obstruction. He proposed the following sequence of events to explain appendicitis: (1) closed loop obstruction is caused by a fecalith and swelling of the mucosal and submucosal lymphoid tissue at the base of the appendix; (2) intraluminal pressure rises as the appendiceal mucosa secretes fluid against the fixed obstruction; (3) increased pressure in the appendiceal wall exceeds capillary pressure and causes mucosal ischemia; and (4) luminal bacterial overgrowth and translocation of bacteria across the appendiceal wall result in inflammation, edema, and ultimately necrosis. If the appendix is not removed, perforation can ensue.

Although appendiceal obstruction is widely accepted as the primary cause of appendicitis, evidence suggests that this may be only one of many possible etiologies. First, some patients with a fecalith have a histologically normal appendix.15,18,19 Moreover, the majority of patients with appendicitis show no evidence for a fecalith.15,18,19 Arnbjornsson and Bengmark20 studied at laparotomy the appendixes of patients with suspected appendicitis. They found the intraluminal pressure of the appendix prior to removal to be elevated in only 8 of 27 patients with nonperforated appendicitis. They found no signs of obstruction in the remaining patients with nonperforated appendicitis, as well as all patients with a normal appendix. Taken together, these studies imply that obstruction is but one of the possible etiologies of acute appendicitis. Presentation Perhaps the most common surgically correctable cause of abdominal pain, the diagnosis of acute appendicitis remains difficult in many instances. Some of the signs and symptoms can be subtle to both the clinician and the patient and may not be present in all instances. Arriving at the correct diagnosis is essential, however, as a delay in diagnosis may allow progression to perforation and significantly increased morbidity and mortality. Incorrectly diagnosing a patient with appendicitis, although not catastrophic, often subjects the patient to an unnecessary operation. The classic presentation of acute appendicitis begins with crampy, intermittent abdominal pain, thought to be due to obstruction of the appendiceal lumen. The pain may be either periumbilical or diffuse and difficult to localize. This is typically followed shortly thereafter with nausea; vomiting may or may not be present. If nausea and vomiting precede the pain, patients are likely to have another cause for their abdominal pain, such as gastroenteritis. Classically, the pain migrates to the right lower quadrant as transmural inflammation of the appendix leads to inflammation of the peritoneal lining of the right lower abdomen. This usually occurs within 1224 hours of the onset of symptoms. The character of the pain also changes from dull and colicky to sharp and constant. Movement or Valsalva maneuver often worsens this pain, so that the patient typically desires to lie still; some patients describe pain with every bump in the car or ambulance ride to the hospital. Patients may report low-grade fever up to 101F (38.3C). Higher temperatures and shaking chills should again alert the surgeon to other diagnoses, including appendiceal perforation or nonappendiceal sources. When questioned, patients who have appendicitis commonly report anorexia; appendicitis is unlikely in those with a normal appetite. The surgeon is constantly reminded that in practice, the classic presentation of acute appendicitis is not present in all patients. Patients may have none or only a few of the symptoms just described. For instance, they may not notice or recall the initial colicky pain. When the pain becomes constant, it may localize to other quadrants of the abdomen due to an alteration in appendiceal anatomy as in late pregnancy or malrotation. In patients with a retrocecal appendix, the pain may never localize until generalized peritonitis from perforated appendicitis occurs. Urinary or bowel

frequency may be present due to appendiceal inflammation irritating the adjacent bladder or rectum. Because appendicitis is so common, a high index of suspicion for appendicitis is warranted in all patients with abdominal pain. Perforated Appendicitis It is a commonly held belief that if left untreated, appendiceal inflammation will progress inevitably to necrosis, and ultimately to perforation. The time course of this progression varies among patients. In one study of the natural history of appendicitis, the authors questioned patients undergoing appendectomy for suspected appendicitis about their duration of symptoms.21 Patients with nonperforated appendicitis reported an average of 22 hours of symptoms prior to presentation to the hospital, while patients with perforated appendicitis reported an average of 57 hours. However, 20% of cases of perforated appendicitis presented within 24 hours of the onset of symptoms; one of those patients had symptoms for only 11 hours. Although concern for perforation should be present when evaluating a patient with more than 24 hours of symptoms, the clinician must remember that perforation can develop more rapidly. Some authors have questioned whether some perforations in acute appendicitis are attributable to delay in diagnosis after a patient seeks medical attention. Velanovich and Satava postulated a surgeon's misdiagnosis rate (the percentage of normal appendixes found at appendectomy) to be inversely related to the perforation rate (the percentage of perforated appendixes found at laparotomy).22 They believed that surgeons are obliged to operate quickly when appendicitis is suspected, thus minimizing the likelihood of perforation in exchange for a higher rate of misdiagnosis. More recent studies suggest that this reasoning is flawed. Temple and colleagues showed that patients with perforated appendicitis were operated on more quickly than those with nonperforated appendicitis (6.5 hours versus 9 hours), but perforated patients had significantly longer prehospital symptoms (57 hours versus 22 hours).21 These findings are confirmed by two other studies, both showing that longer duration of prehospital delay is the major contributor to perforation.23,24 Perforation after presenting to surgical attention appears to be uncommon. When acute appendicitis has progressed to appendiceal perforation, other symptoms may be present. Patients will often complain of two or more days of abdominal pain, but their duration of symptoms may be shorter, as previously discussed. The pain usually localizes to the right lower quadrant if the perforation has been walled off by surrounding intra-abdominal structures including the omentum, but it may be diffuse if generalized peritonitis ensues. The pain may be so severe that patients do not remember the antecedent colicky pain. Patients with perforation often have rigors and high fevers to 102F (38.9C) or above. A history of poor oral intake and dehydration may also be present. Most patients with perforated appendicitis present with symptoms related to the inflamed appendix itself or to a localized intraperitoneal abscess from perforation. Other more rare presentations do occur, however. These are most likely to occur in the very young and very old, who cannot express their symptoms and often present late in

the course of their disease. For instance, abscesses can also form in the retroperitoneum due to perforation of a retrocecal appendix, or in the liver from hematogenous spread of infection through the portal venous system. An intraperitoneal abscess could fistulize to the skin, resulting in an enterocutaneous fistula. Pylephlebitis (septic portal vein thrombosis) presents with high fevers and jaundice and can be confused with cholangitis; it is a dreaded complication of acute appendicitis and carries a high mortality.25 Occasionally, patients will have bilious vomiting and obstipation due to a small bowel obstruction resulting from appendiceal perforation. Because appendicitis is so common, these rare presentations should alert the surgeon to the possibility of appendicitis. Diagnosis History and Physical Examination As always, the diagnosis begins with a thorough history and physical examination. The patient should be asked about the classic symptoms of appendicitis, but the surgeon should not be dissuaded by the absence of many of the symptoms. Many patients with acute appendicitis do not have a classic history. Because the differential diagnosis of appendicitis is extensive, patients should be queried about certain symptoms that may suggest an alternative diagnosis. Surgeons must also remember that a previous appendectomy does not definitively exclude the diagnosis of appendicitis, as "stump appendicitis" (appendicitis in the remaining appendiceal stump after appendectomy), although rare, has been described.26 On inspection, patients look mildly ill and may have slightly elevated temperature and pulse. They often lie still to avoid the peritoneal irritation caused by movement. The surgeon should systematically examine the entire abdomen, starting in the left upper quadrant away from the patient's described pain. Maximal tenderness is typically in the right lower quadrant, at or near McBurney's point, located one-third of the way from the anterior superior iliac spine to the umbilicus. This tenderness is often associated with localized muscle rigidity and signs of peritoneal inflammation, including rebound, shake, or tap tenderness. Right lower quadrant tenderness is the most consistent of all signs of acute appendicitis;27,28 its presence should always raise the specter of appendicitis, even in the absence of other signs and symptoms. Because of the various anatomic locations of the appendix, however, it is possible for the tenderness to be in the right flank or right upper quadrant, the suprapubic region, or the left lower quadrant. Patients with a retrocecal or pelvic appendix may have no abdominal tenderness whatsoever. In such cases, rectal examination can be helpful to elicit right-sided pelvic tenderness. Multiple signs can be detected on physical examination to contribute to the diagnosis of appendicitis. Rovsing's sign, pain in the right lower quadrant on palpation of the left lower quadrant, is further evidence of localized peritoneal inflammation in the right lower quadrant. Psoas sign, pain with flexion of the leg at the right hip, can be seen with a retrocecal appendix due to inflammation adjacent to the psoas muscle. The

obdurator sign, pain with rotating the flexed right thigh internally, indicates inflammation adjacent to the obdurator muscle in the pelvis. In cases of perforated appendicitis, patients can look gravely ill, appearing flushed with dry mucous membranes and considerable elevations in temperature or pulse. If sepsis has developed, blood pressure can be depressed. If the perforation has been walled off by surrounding structures to create an abscess or phlegmon, a mass may be palpable in the right lower quadrant. If free intraperitoneal rupture has occurred, the patient can have signs of generalized peritonitis with diffuse rebound tenderness.

Perforated Appendicitis When appendicitis progresses to perforation, management depends on the nature of the perforation. If the perforation is contained, a solid or semisolid periappendiceal mass of inflammatory tissue can form, referred to as a phlegmon. In other cases, contained perforation may result in a pus-filled abscess cavity. Finally, free perforation can occur, causing intraperitoneal dissemination of pus and fecal material. In the case of free perforation, the patient is typically quite ill and perhaps septic. Urgent laparotomy is necessary for appendectomy and irrigation and drainage of the peritoneal cavity. If the diagnosis of perforated appendicitis is known, the appendectomy can be performed through a right lower quadrant incision, and the technique follows that previously described for open appendectomy. Sometimes patients with free perforation present with an acute abdomen and generalized peritonitis, and the decision to perform a laparotomy is made without a definitive diagnosis. In such instances, a midline incision is prudent. Once perforated appendicitis is discovered, appendectomy again proceeds as described above. Peritoneal drains are not necessary, as they do not reduce the incidence of wound infection or abscess after appendectomy for perforated appendicitis.84,85 The final operative decision is whether or not to close the incision. Because of wound infection rates ranging from 3050% with primary closure of grossly contaminated wounds, many advocate delayed primary or secondary closure.82,86 However, a cost-utility analysis of contaminated appendectomy wounds showed primary closure to be the most cost-effective method of wound management.87 Our technique of skin closure is interrupted permanent sutures or staples every 2 cm with loose wound packing in between. Removal of the packing in 48 hours often leaves an excellent cosmetic result with an acceptable incidence of wound infection. Patients are often continued on broad-spectrum antibiotics for 57 days and should remain in the hospital until afebrile and tolerating a regular diet. If the patient does not have signs of generalized peritonitis, but an abscess or phlegmon is suspected by history and physical exam, a CT scan can be particularly helpful to solidify the diagnosis. A solid, inflammatory mass in the right lower quadrant without evidence of a fluid-filled abscess cavity suggests a phlegmon. In such instances, appendectomy can be difficult due to dense adhesions and

inflammation. Ileocecectomy may be necessary if the inflammation extends to the wall of the cecum. Complications such as inadvertent enterotomy, postoperative abscess, or enterocutaneous fistula may ensue. Because of these potential complications, many support an initially nonoperative approach.8890 Such an approach is only advisable if the patient is not ill-appearing. Nonoperative management includes intravenous antibiotics and fluids as well as bowel rest. Patients should be closely monitored in the hospital during this time. Treatment failure, as evidenced by bowel obstruction, sepsis, or persistent pain, fever, or leukocytosis, requires immediate appendectomy. If fever, tenderness, and leukocytosis improve, diet can be slowly advanced, usually within 35 days. Patients are discharged home when clinical parameters have normalized. Using this approach, more than 80% of patients can be spared an appendectomy at the time of initial presentation.88,89 If imaging studies demonstrate an abscess cavity, CT- or ultrasound-guided drainage can often be performed percutaneously or transrectally.91,92 Studies suggest that this approach to appendiceal abscesses results in fewer complications and shorter overall length of stay.90,93 Again, following drainage the patient is closely monitored in the hospital and is placed on bowel rest with intravenous antibiotics and fluids. Advancement of diet and hospital discharge progress as clinically indicated. Interval Appendectomy Treatment following initial nonoperative management of an appendiceal phlegmon or abscess is controversial. Some recommend interval appendectomy93,94 (appendectomy performed approximately 6 weeks after inflammation has subsided), while others consider subsequent appendectomy unnecessary.89,95 Authors who advise against interval appendectomy cite a relatively low incidence of future appendicitis (20% or less)95 and complication rates from interval appendectomy as high as 16%.90 Proponents of interval appendectomy point to the low morbidity relative to appendectomy for acute appendicitis, the likelihood of recurrence, and the possibility of ongoing appendiceal pathology,94 including cancer. Because it can now be performed laparoscopically on an outpatient basis with low morbidity,96 interval appendectomy should be considered for most patients who were initially treated with nonoperative management.