CASE REPORT

“ACUTE APPENDICITIS”

Created by:

Annisa Ratya
Bela Riski Dinanti
Intan Rehana
M. Mahardhika Malik
Nycho Alva Chindo
Pratiwi Aminah
Selvia Farahdina
Zuryati Toiyiba Qurbany

Supervisor:

dr H. Yusmaidi, Sp.B

KEPANITERAAN KLINIK SMF BEDAH

RUMAH SAKIT UMUM DAERAH H ABDUL MOELOEK

FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNG

2015
 CHAPTER I

CASE REPORT

I. PATIENT’S IDENTITY

Name : Hajerli

Age : 15 years old

Sex : Male

Occupation : Student

Address : Durian Payung, Bandar Lampung

Admitted to hospital : November 3, 2015

II. ANAMNESIS

Main complaint

Right lower quadrant pain

Case History
A boy, 16 years old presents with, a severe pain at her abdomen which
started at the area around his periumbilical area shift to right lower
quadrant region perceivedsince 7daysbefore admitted to hospital, pain is
getting worse than ever 2 days before admitted to
hospital.Hereportsthathevomit1x/dayof food,feelsnauseaand lostappetite.
The fever can go up and dawn, watery stools more than 5 times a day in
week. Painless urination, no sand, the colour is clear yellow. The pain was
getting worse when he’s cough.
III. PHYSICAL EXAMINATION

General condition

 General status :mild

 GCS : E4M5V6 (GCS: 15)

 Blood pressure : 120/80 mmHg

 Pulse : 80 x/minute, regular

 Respiratory rate: 20 x/minute

 Temperature : 36,70C

Head – neck

 Head : normochepaly, symmetric, deformity (-)

 Eye : anemic (-/-), icteric (-/-), reflex of pupil

(+/+)

 Neck : enlarge lymph node (-), enlarge tyroid (-)

 Ear, nose, throat : deformity (-)

Thorax

 Inspection : simmetric (+), retraction (-), mass (-)

 Palpation : movement of chest wall simmetric (+), pressure

pain (-), mass (-), ictus cordis (+) ICS V

 Percussion

Pulmo : sonor (+)

Cor : dull (+)

 Auscultasion
Pulmo : vesicular +/+, rhonki -/-, wheezing -/-
Cor : S1-S2 single, reguler, murmur (-), gallop (-)
Abdomen
 Inspection : distention (+), mass (-), scar (-)
 Auscultation : bowel sound (+),
 Palpation : pressure pain (+) Mc Burney’s point, defans
muscular (+), hepar/spleennot palpable, mass (-),rovsing’s sign (+),
blumberg’s sign (+), psoas’s sign (+), obturator’s sign (+)
 Percussion : timpani (+)

Uro-genital
 regio flank and CVA : bulging -/-, inflammation sign (-), pressure
pain -/-, ballottement (-/-), CVA tenderness (-/-)
 regio supra pubic : distention of bladder (-), mass (-), pressure pain
(-)
 regio genitalia externa : signs of inflammation (-)

Anal-perianal
 Inspection : fistle (-), hemmorhoid (-), abscess (-).
 Rectal Touche: thestrength of anal sphincter is good, slippery
mucosa, a mass (-), pain at 11 o’clock direction ,faeces (-),
blood (-).

Extremities
 Warm acral +/+, oedeme -/-

Local Condition

Abdomen
 Inspection : distention (+), mass (+), scar (-)
 Auscultation : bowel sound (+)
 Palpation : pressure pain (+) Mc Burneys’s point,
defansmuscular (-), hepar/lien not palpable
 Percussion : timpani (+)
IV. SUPPORTING EXAMINATION

Laboratory result

Hb : 12,4 g/dL

Leucocytes : 18.100/μl

Erytrocytes : 4,5 x 106 /μl

Haematocryte : 35%

Trombocytes : 350.000 /μl

Diff count : 0/1/1/73/9/16

SGOT : 43 U/L

SGPT : 65 U/L

Glucose : 141 mg/dL

Ureum : 23 mg/dL

Creatinine : 0,7 mg/dL

Sodium : 125 mmol/L

Calium : 3,2 mmol/L

Calsium : 8,6 mg/dL

Chlorida : 93 mmol/L

V. DIAGNOSIS

Susp. Acute Appendicitis

VI. THERAPY

NPO

IVFD RL XX gtt/minute
 Ceftriaxone 1gr/12 hours

Ranitidin 50mg/12hours

Paracetamol 3 x 500 mg tab

FOLLOW UP

Date Follow Up Therapy

November, 3rd 2015 S/ abdominal pain and NPO
distension, nausea, vomitus IVFD RL XX gtt/minute
O/ BP 120/80 Ceftriaxone 1gr/12 hours
HR 80x/m Ranitidin 50mg/12hours
RR 20x/m Paracetamol 3 x 500 mg tab
T 36,70C Thorax x-ray
A/ susp. Acute Plain abdominal X-ray
Appendicitis Laboratory test (Urine,
Blood, SGOT/SGPT, CT,
BT)
November, 4th 2015 S/ abdominal pain NPO
O/ BP 110/70 Loading RL 500 cc -> IVFD
HR 72x/m NaCl 30 gtt/minute
RR 20x/m Ceftriaxone 1gr/12 hours
T 380C Ranitidin 50mg/12hours
A/ susp. Acute Paracetamol infus 1 flc
Appendicitis Gentamicin 80 mg/12 hours

Advice from dr.Pirma,Sp.B

:
-observation in Emergency
room
- Antibiotic + Gentamicin
80mg/12 hours
-Laparotomy planning

November, 5th 2015 S/ febris (-) pain at surgical IVFD RL XX gtt/minute

wound (+) flatus (+) Ceftriaxone 1gr/12 hours
O/ BP 120/80 Ranitidin 50mg/12hours
HR 80x/m Ketorolac 2x1 amp drip
RR 20x/m Mobilization
T 37oC
A/ Post appendectomy
November, 6th 2015 S/ febris (-) pain at surgical IVFD RL XX gtt/minute
wound (-) Ceftriaxone 1gr/12 hours
O/ BP 120/80 Ranitidin 50mg/12hours
HR 84x/m Mobilization
RR 20x/m
T 37oC
A/ Post appendectomy
November, 6th 2015 S/ febris (-) pain at surgical Active mobilization
wound (-) Ciprofloxacin 2x500 mg
O/ BP 120/80 Ranitidin 2x50 mg
HR 80x/m Asam mefenamat 3x500 mg
RR 16x/m
T 37oC
A/ Post appendectomy
 CHAPTER II
ACUTE APPENDICITIS

Historical Background

Although ancient texts have scattered descriptions of surgery being undertaken for
ailments sounding like appendicitis, credit for performing the first appendectomy
goes to 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
hernial 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 the condition. 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.5 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. In 1839, a
textbook authored by Bright and Addison entitled Elements of Practical Medicine
described the symptoms of appendicitis and identified the primary cause of
inflammatory processes of the right lower quadrant.6 Reginald Fitz, a professor of
pathologic anatomy at Harvard, is credited with coining the term appendicitis. His
landmark paper definitively identified the appendix as the primary cause of right
lower quadrant inflammation.

Initial surgical therapy for appendicitis was primarily designed to drain right
lower quadrant abscesses that occurred secondary to appendiceal perforation. It
appears that the first surgical treatment for appendicitis or perityphlitis without
abscess was carried out by Hancock in 1848. He incised the peritoneum and
drained the right lower quadrant without removing the appendix. The first
published account of appendectomy for appendicitis was by Krönlein in 1886.
However, this patient died 2 days after operation. Fergus, in Canada, performed
the first elective appendectomy in 1883.

The greatest contributor to the advancement in the treatment of appendicitis was

Charles McBurney. In 1889, he published his landmark paper in the New York
State Medical Journal describing the indications for early laparotomy for the
treatment of appendicitis. It is in this paper that he described the McBurney point
as follows: "maximum tenderness, when one examines with the fingertips is, in
adults, one half to two inches inside the right anterior spinous process of the ilium
on a line drawn to the umbilicus." McBurney subsequently published a paper in
1894 describing the incision that bears his name. However, McBurney later
credited McArthur with first describing this incision. Semm is widely credited
with performing the first successful laparoscopic appendectomy in 1982.

The surgical treatment of appendicitis is one of the great public health advances of
the last 150 years. Appendectomy for appendicitis is the most commonly
performed emergency operation in the world. Appendicitis is a disease of the
young, with 40% of cases occurring in patients between the ages of 10 and 29
years. In 1886, Fitz reported the associated mortality rate of appendicitis to be at
least 67% without surgical therapy. Currently, the mortality rate for acute
appendicitis with treatment is reported to be <1%.

Anatomy and Function

The appendix first becomes visible in the eighth week of embryologic

development as a protuberance off the terminal portion of the cecum. During both
antenatal and postnatal development, the growth rate of the cecum exceeds that of
the appendix, so that the appendix is displaced medially toward the ileocecal
valve. The relationship of the base of the appendix to the cecum remains constant,
whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right
pericolic position (Fig 1). These anatomic considerations have significant clinical
importance in the context of acute appendicitis. The three taeniae coli converge at
the junction of the cecum with the appendix and can be a useful landmark to
identify the appendix. The appendix can vary in length from <1 cm to >30 cm;
most appendices are 6 to 9 cm long. Appendiceal absence, duplication, and
diverticula have all been described.

Fig 1. Various anatomic positions of the vermiform appendix.

For many years, the appendix was erroneously viewed as a vestigial organ with no
known function. It is now well recognized that the appendix is an immunologic
organ that actively participates in the secretion of immunoglobulins, particularly
immunoglobulin A. Although there is no clear role for the appendix in the
development of human disease, recent studies demonstrate a potential correlation
between appendectomy and the development of inflammatory bowel disease.
There appears to be a negative age-related association between prior
appendectomy and subsequent development of ulcerative colitis. In addition,
comparative analysis clearly shows that prior appendectomy is associated with a
more benign phenotype in ulcerative colitis and a delay in onset of disease. The
association between Crohn's disease and appendectomy is less clear. Although
earlier studies suggested that appendectomy increases the risk of developing
Crohn's disease, more recent studies that carefully assessed the timing of
appendectomy in relation to the onset of Crohn's disease demonstrated a negative
correlation. These data suggest that appendectomy may protect against the
subsequent development of inflammatory bowel disease; however, the mechanism
is unclear.

Lymphoid tissue first appears in the appendix approximately 2 weeks after birth.
The 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.

Incidence

The lifetime rate of appendectomy is 12% for men and 25% for women, with
approximately 7% of all people undergoing appendectomy for acute appendicitis
during their lifetime. Over the 10-year period from 1987 to 1997, the overall
appendectomy rate decreased in parallel with a decrease in incidental
appendectomy. However, the 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:female predominance
(1.2 to 1.3:1).

Despite the increased use of ultrasonography, computed tomography (CT), and

laparoscopy, the rate of misdiagnosis of appendicitis has remained constant
(15.3%), as has the rate of appendiceal rupture. The percentage of misdiagnosed
cases of appendicitis is significantly higher among women than among men (22.2
vs. 9.3%). The negative appendectomy rate for women of reproductive age is
23.2%, with the highest rates in women aged 40 to 49 years. The highest negative
appendectomy rate is reported for women >80 years of age
Etiology and Pathogenesis

Obstruction of the lumen is the dominant etiologic factor in acute appendicitis.

Fecaliths are the most common 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, in 65% of cases
of gangrenous appendicitis without rupture, and in nearly 90% of cases of
gangrenous appendicitis with rupture.

Traditionally the belief has been that there is a predictable sequence of events
leading to eventual appendiceal rupture. The proximal obstruction of the
appendiceal lumen produces a closed-loop obstruction, and continuing normal
secretion by the appendiceal mucosa rapidly produces distention. The luminal
capacity of the normal appendix is only 0.1 mL. Secretion of as little as 0.5 mL of
fluid distal to an obstruction raises the intraluminal pressure to 60 cm H2O.
Distention of the appendix stimulates the nerve endings of visceral afferent stretch
fibers, producing vague, dull, diffuse pain in the midabdomen or lower
epigastrium. Peristalsis also is stimulated by the rather sudden distention, so that
some cramping may be superimposed on the visceral pain early in the course of
appendicitis. Distention increases from continued mucosal secretion and from
rapid multiplication of the resident bacteria of the appendix. Distention of this
magnitude usually causes reflex nausea and vomiting, and the diffuse visceral
pain becomes more severe. As pressure in the organ increases, venous pressure is
exceeded. Capillaries and venules are occluded, but arteriolar inflow continues,
resulting in engorgement and vascular congestion. The inflammatory process soon
involves the serosa of the appendix and in turn parietal peritoneum in the region,
which produces the characteristic shift in pain to the right lower quadrant.

The mucosa of the GI tract, including the appendix, is susceptible to impairment

of blood supply; thus its integrity is compromised early in the process, which
allows bacterial invasion. As progressive distention encroaches on first the venous
return and subsequently the arteriolar inflow, the area with the poorest blood
supply suffers most: ellipsoidal infarcts develop in the antimesenteric border. As
distention, bacterial invasion, compromise of vascular supply, and infarction
progress, perforation occurs, usually through one of the infarcted areas on the
antimesenteric border. Perforation generally occurs just beyond the point of
obstruction rather than at the tip because of the effect of diameter on intraluminal
tension.

This sequence is not inevitable, however, and some episodes of acute appendicitis
apparently subside spontaneously. Many patients who are found at operation to
have acute appendicitis give a history of previous similar, but less severe, attacks
of right lower quadrant pain. Pathologic examination of the appendices removed
from these patients often reveals thickening and scarring, suggesting old, healed
acute inflammation.15,16 The strong association between delay in presentation and
appendiceal perforation supported the proposition that appendiceal perforation is
the advanced stage of acute appendicitis; however, recent epidemiologic studies
have suggested that nonperforated and perforated appendicitis may, in fact, be
different diseases.

Bacteriology

The bacterial population of the normal appendix is similar to that of the normal
colon. The appendiceal flora remains constant throughout life with the exception
of Porphyromonas gingivalis. This bacterium is seen only in adults. The bacteria
cultured in cases of appendicitis are therefore similar to those seen in other
colonic infections such as diverticulitis. The principal organisms seen in the
normal appendix, in acute appendicitis, and in perforated appendicitis are
Escherichia coli and Bacteroides fragilis. However, a wide variety of both
facultative and anaerobic bacteria and mycobacteria may be present (Table 1).
Appendicitis is a polymicrobial infection, with some series reporting the culture of
up to 14 different organisms in patients with perforation
 Table 1. Common Organisms Seen in Patients with Acute Appendicitis

Aerobic and Facultative Anaerobic

Gram-negative bacilli Gram-negative bacilli

Escherichia coli Bacteroides fragilis

Pseudomonas aeruginosa Other Bacteroides species

Klebsiella species Fusobacterium species

Gram-positive cocci Gram-positive cocci

Streptococcus anginosus Peptostreptococcus species

Other Streptococcus species Gram-positive bacilli

Enterococcus species Clostridium species

The routine culture of intraperitoneal samples in patients with either perforated or

nonperforated appendicitis is questionable. As discussed earlier, the flora is
known, and therefore broad-spectrum antibiotics are indicated. By the time culture
results are available, the patient often has recovered from the illness. In addition,
the number of organisms cultured and the ability of a specific laboratory to culture
anaerobic organisms vary greatly. 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 prophylaxis is effective in the prevention of postoperative wound
infection and intra-abdominal abscess. Antibiotic coverage is limited to 24 to 48
hours in cases of nonperforated appendicitis. For perforated appendicitis, 7 to 10
days of therapy is recommended. IV antibiotics are usually given until the white
blood cell count is normal and the patient is afebrile for 24 hours. Antibiotic
irrigation of the peritoneal cavity and the use of transperitoneal drainage through
the wound are controversial.
Clinical Manifestations

Symptoms

Abdominal pain is the prime symptom of acute appendicitis. Classically, pain is

initially diffusely centered in the lower epigastrium or umbilical area, is
moderately severe, and is steady, sometimes with intermittent cramping
superimposed. After a period varying from 1 to 12 hours, but usually within 4 to 6
hours, the pain localizes to the right lower quadrant. This classic pain sequence,
although usual, is not invariable. In some patients, the pain of appendicitis begins
in the right lower quadrant and remains there. Variations in the anatomic location
of the appendix account for many of the variations in the principal locus of the
somatic phase of the pain. For example, a long appendix with the inflamed tip in
the left lower quadrant causes pain in that area. A retrocecal appendix may cause
principally flank or back pain; a pelvic appendix, principally suprapubic pain; and
a retroileal appendix, testicular pain, presumably from irritation of the spermatic
artery and ureter. Intestinal malrotation also is responsible for puzzling pain
patterns. The visceral component is in the normal location, but the somatic
component is felt in that part of the abdomen where the cecum has been arrested
in rotation.

Anorexia nearly always accompanies appendicitis. It is so constant that the

diagnosis should be questioned if the patient is not anorectic. Although vomiting
occurs in nearly 75% of patients, it is neither prominent nor prolonged, and most
patients vomit only once or twice. Vomiting is caused by both neural stimulation
and the presence of ileus.

Most patients give a history of obstipation beginning before the onset of

abdominal pain, and many feel that defecation would relieve their abdominal pain.
Diarrhea occurs in some patients, however, particularly children, so that the
pattern of bowel function is of little differential diagnostic value.

The sequence of symptom appearance has great significance for the differential
diagnosis. In >95% of patients with acute appendicitis, anorexia is the first
symptom, followed by abdominal pain, which is followed, in turn, by vomiting (if
vomiting occurs). If vomiting precedes the onset of pain, the diagnosis of
appendicitis should be questioned.

Signs

Physical findings are determined principally by what the anatomic position of the
inflamed appendix is, as well as by whether the organ has already ruptured when
the patient is first examined.

Vital signs are minimally changed by uncomplicated appendicitis. Temperature

elevation is rarely >1°C (1.8°F) and the pulse rate is normal or slightly elevated.
Changes of greater magnitude usually indicate that a complication has occurred or
that another diagnosis should be considered.

Patients with appendicitis 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.

The classic right lower quadrant physical signs are present when the inflamed
appendix lies in the anterior position. Tenderness often is maximal at or near the
McBurney point. Direct rebound tenderness usually is present. In addition,
referred or indirect rebound tenderness is present. This referred tenderness is felt
maximally in the right lower quadrant, which indicates localized peritoneal
irritation. The Rovsing sign—pain in the right lower quadrant when palpatory
pressure is exerted in the left lower quadrant—also indicates the site of peritoneal
irritation. Cutaneous hyperesthesia in the area supplied by the spinal nerves on the
right at T10, T11, and T12 frequently accompanies acute appendicitis. In patients
with obvious appendicitis, this sign is superfluous, but in some early cases, it may
be the first positive sign. Hyperesthesia is elicited either by needle prick or by
gently picking up the skin between the forefinger and thumb.

Muscular resistance to palpation of the abdominal wall roughly parallels the

severity of the inflammatory process. Early in the disease, resistance, if present,
consists mainly of voluntary guarding. As peritoneal irritation progresses, muscle
spasm increases and becomes largely involuntary, that is, true reflex rigidity due
to contraction of muscles directly beneath the inflamed parietal peritoneum.

Anatomic variations in the position of the inflamed appendix lead to deviations in

the usual physical findings. With a retrocecal appendix, the anterior abdominal
findings are less striking, and tenderness may be most marked in the flank. When
the inflamed appendix hangs into the pelvis, abdominal findings may be entirely
absent, and the diagnosis may be missed unless the rectum is examined. As the
examining finger exerts pressure on the peritoneum of Douglas' cul-de-sac, pain is
felt in the suprapubic area as well as locally within the rectum. Signs of localized
muscle irritation also may be present. The psoas sign indicates an irritative focus
in proximity to that muscle. The test is performed by having the patient lie on the
left side as the examiner slowly extends the patient's right thigh, thus stretching
the iliopsoas muscle. The test result is positive if extension produces pain.
Similarly, a 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.

Laboratory Findings

Mild leukocytosis, ranging from 10,000 to 18,000 cells/mm3, usually is present in

patients with acute, uncomplicated appendicitis and often is accompanied by a
moderate polymorphonuclear predominance. White blood cell counts are variable,
however. It is unusual for the white blood cell count to be >18,000 cells/mm3 in
uncomplicated appendicitis. White blood cell counts above this level raise the
possibility of a perforated appendix with or without an abscess. Urinalysis can be
useful to rule out the urinary tract as the source of infection. Although several
white or red blood cells can be present from ureteral or bladder irritation as a
result of an inflamed appendix, bacteriuria in a urine specimen obtained via
catheter generally is not seen in acute appendicitis.

Imaging Studies
Plain films of the abdomen, although frequently obtained as part of the general
evaluation of a patient with an acute abdomen, rarely are helpful in diagnosing
acute appendicitis. However, plain radiographs can be of significant benefit in
ruling out other pathology. In patients with acute appendicitis, one often sees an
abnormal bowel gas pattern, which is a nonspecific finding. The presence of a
fecalith is rarely noted on plain films but, if present, is highly suggestive of the
diagnosis. A chest radiograph is sometimes indicated to rule out referred pain
from a right lower lobe pneumonic process.

Additional radiographic studies include barium enema examination and

radioactively labeled leukocyte scans. If the appendix fills on barium enema,
appendicitis is excluded. On the other hand, if the appendix does not fill, no
determination can be made. To date, there has not been enough experience with
radionuclide scans to assess their utility.

Graded compression sonography has been suggested as an accurate way to

establish the diagnosis of appendicitis. The technique is inexpensive, can be
performed rapidly, does not require a contrast medium, and can be used even in
pregnant patients. Sonographically, the appendix is identified as a blind-ending,
nonperistaltic bowel loop originating from the cecum. With maximal
compression, the diameter of the appendix is measured in the anteroposterior
dimension. Scan results are considered positive if a noncompressible appendix ≥6
mm in the anteroposterior direction is demonstrated. The presence of an
appendicolith establishes the diagnosis. Thickening of the appendiceal wall and
the presence of periappendiceal fluid is highly suggestive. Sonographic
demonstration of a normal appendix, which is an easily compressible, blind-
ending tubular structure measuring ≤5 mm in diameter, excludes the diagnosis of
acute appendicitis. The study results are considered inconclusive if the appendix is
not visualized and there is no pericecal fluid or mass. When the diagnosis of acute
appendicitis is excluded by sonography, a brief survey of the remainder of the
abdominal cavity should be performed to establish an alternative diagnosis. In
females of childbearing age, the pelvic organs must be adequately visualized
either by transabdominal or endovaginal ultrasonography to exclude gynecologic
pathology as a cause of acute abdominal pain. The sonographic diagnosis of acute
appendicitis has a reported sensitivity of 55 to 96% and a specificity of 85 to
98%.Sonography is similarly effective in children and pregnant women, although
its application is somewhat limited in late pregnancy

Although sonography can easily identify abscesses in cases of perforation, the

technique has limitations and results are user dependent. A false-positive scan
result can occur in the presence of periappendicitis from surrounding
inflammation, a dilated fallopian tube can be mistaken for an inflamed appendix,
inspissated stool can mimic an appendicolith, and, in obese patients, the appendix
may not be compressible because of overlying fat. False-negative sonogram
results can occur if appendicitis is confined to the appendiceal tip, the appendix is
retrocecal, the appendix is markedly enlarged and mistaken for small bowel, or
the appendix is perforated and therefore compressible.

Some studies have reported that graded compression sonography improved the
diagnosis of appendicitis over clinical examination, specifically decreasing the
percentage of negative explorations for appendectomies from 37 to
13%.Sonography also decreases the time before operation. Sonography identified
appendicitis in 10% of patients who were believed to have a low likelihood of the
disease on physical examination. The positive and negative predictive values of
ultrasonography have impressively been reported as 91 and 92%, respectively.
However, in a recent prospective multicenter study, routine ultrasonography did
not improve diagnostic accuracy or rates of negative appendectomy or perforation
compared with clinical assessment.

High-resolution helical CT also has been used to diagnose appendicitis. On CT

scan, the inflamed appendix appears dilated (>5 cm) and the wall is thickened.
There is usually evidence of inflammation, with "dirty fat," thickened
mesoappendix, and even an obvious phlegmon. Fecaliths can be easily visualized,
but their presence is not necessarily pathognomonic of appendicitis. An important
suggestive abnormality is the arrowhead sign. This is caused by thickening of the
cecum, which funnels contrast agent toward the orifice of the inflamed appendix.
CT scanning is also an excellent technique for identifying other inflammatory
processes masquerading as appendicitis.

Several CT techniques have been used, including focused and nonfocused CT

scans and enhanced and nonenhanced helical CT scanning. Nonenhanced helical
CT scanning is important, because one of the disadvantages of using CT scanning
in the evaluation of right lower quadrant pain is dye allergy. Surprisingly, all of
these techniques have yielded essentially identical rates of diagnostic accuracy: 92
to 97% sensitivity, 85 to 94% specificity, 90 to 98% accuracy, and 75 to 95%
positive and 95 to 99% negative predictive values. The additional use of a rectally
administered contrast agent did not improve the results of CT scanning.

A number of studies have documented improvement in diagnostic accuracy with

the liberal use of CT scanning in the work-up of suspected appendicitis. CT
lowered the rate of negative appendectomies from 19 to 12% in one study, and the
incidence of negative appendectomies in women from 24 to 5% in another. The
use of this imaging study altered the care of 24% of patients studied and provided
alternative diagnoses in half of the patients with normal appendices on CT scan.

Despite the potential usefulness of this technique, there are significant

disadvantages. CT scanning is expensive, exposes the patient to significant
radiation, and cannot be used during pregnancy. Allergy contraindicates the
administration of IV contrast agents in some patients, and others cannot tolerate
the oral ingestion of luminal dye, particularly in the presence of nausea and
vomiting. Finally, not all studies have documented the utility of CT scanning in
all patients with right lower quadrant pain.

A number of studies have compared the effectiveness of graded compression

sonography and helical CT in establishing the diagnosis of appendicitis. Although
the differences are rather small, CT scanning has consistently proven superior. For
example, in one study, 600 ultrasounds and 317 CT scans demonstrated sensitivity
of 80 and 97%, specificity of 93 and 94%, diagnostic accuracy of 89 and 95%,
positive predictive value of 91 and 92%, and negative predictive value of 88 and
98%, respectively. In another study, ultrasound positively impacted the
management of 19% of patients, compared with 73% of patients for CT. Finally,
in a third study, the negative appendix rate was 17% for patients studied by
ultrasonography compared with a negative appendix rate of 2% for patients who
underwent helical CT scanning. One concern about ultrasonography is the high
intraobserver variability.

One issue that has not been resolved is which patients are candidates for imaging
studies. This question may be moot, because CT scanning routinely is ordered by
emergency physicians before surgeons are even consulted. The concept that all
patients with right lower quadrant pain should undergo CT scanning has been
strongly supported by two reports by Rao and his colleagues at the Massachusetts
General Hospital. In one, this group documented that CT scanning led to a fall in
the negative appendectomy rate from 20 to 7% and a decline in the perforation
rate from 22 to 14%, as well as establishment of an alternative diagnosis in 50%
of patients. In the second study, published in the New England Journal of
Medicine, Rao and associates documented that CT scanning prevented 13
unnecessary appendectomies, saved 50 inpatient hospital days, and lowered the
per-patient cost by $447. In contrast, several other studies failed to prove an
advantage of routine CT scanning, documenting that surgeon accuracy
approached that of the imaging study and expressing concern that the imaging
studies could adversely delay appendectomy in affected patients.

The rational approach is the selective use of CT scanning. This has been
documented by several studies in which imaging was performed based on an
algorithm or protocol. The likelihood of appendicitis can be ascertained using the
Alvarado scale (Table 2). This scoring system was designed to improve the
diagnosis of appendicitis and was devised by giving relative weight to specific
clinical manifestation. Table 2 lists the eight specific indicators identified. Patients
with scores of 9 or 10 are almost certain to have appendicitis; there is little
advantage in further work-up, and they should go to the operating room. Patients
with scores of 7 or 8 have a high likelihood of appendicitis, whereas scores of 5 or
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 for those with scores of 7 and 8. On the other hand, it is difficult to
justify the expense, radiation exposure, and possible complications of CT
scanning in patients whose scores of 0 to 4 make it extremely unlikely (but not
impossible) that they have appendicitis.

Table 2. Alvarado Scale for the Diagnosis of Appendicitis

Manifestations Value

Symptoms Migration of pain 1

Anorexia 1

Nausea and/or vomiting 1

Signs Right lower quadrant tenderness 2

Rebound 1

Elevated temperature 1

Laboratory values Leukocytosis 2

Left shift in leukocyte count 1

Total points 10

Selective CT scanning based on the likelihood of appendicitis takes advantage of

the clinical skill of the experienced surgeon and, when indicated, adds the
expertise of the radiologist and his or her imaging study. Figure 2 proposes a
treatment algorithm addressing the rational use of diagnostic testing.
Fig.2 Clinical algorithm for suspected cases of acute appendicitis. If gynecologic
disease is suspected, a pelvic and endovaginal ultrasound examination is
indicated.

Laparoscopy can serve as both a diagnostic and therapeutic maneuver for patients
with acute abdominal pain and suspected acute appendicitis. Laparoscopy is
probably most useful in the evaluation of females with lower abdominal
complaints, because appendectomy is performed on a normal appendix in as many
as 30 to 40% of these patients. Differentiating acute gynecologic pathology from
acute appendicitis can be effectively accomplished using the laparoscope.

Appendiceal Rupture

Immediate appendectomy has long been the recommended treatment for acute
appendicitis because of the presumed risk of progression to rupture. The overall
rate of perforated appendicitis is 25.8%. Children <5 years of age and patients >65
years of age have the highest rates of perforation (45 and 51%, respectively) (Fig.
30-6). It has been suggested that delays in presentation are responsible for the
majority of perforated appendices. There is no accurate way of determining when
and if an appendix will rupture before resolution of the inflammatory process.
Recent studies suggest that, in selected patients, observation and antibiotic therapy
alone may be an appropriate treatment for acute appendicitis.
Appendiceal rupture occurs most frequently distal to the point of luminal
obstruction along the antimesenteric border of the appendix. Rupture should be
suspected in the presence of fever with a temperature of >39°C (102°F) and a
white blood cell count of >18,000 cells/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 is detected on physical examination. This

could represent a phlegmon, which consists of matted loops of bowel adherent to
the adjacent inflamed appendix, or a periappendiceal abscess. Patients who
present with a mass have experienced symptoms for a longer duration, usually at
least 5 to 7 days. Distinguishing acute, uncomplicated appendicitis from acute
appendicitis with perforation on the basis of clinical findings is often difficult, but
it is important to make the distinction because their treatment differs. CT scan
may be beneficial in guiding therapy. Phlegmons and small abscesses can be
treated conservatively with IV 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 using
an extraperitoneal approach, with appendectomy reserved for cases in which the
appendix is easily accessible. Interval appendectomy performed at least 6 weeks
after the acute event has classically been recommended for all patients treated
either nonoperatively or with simple drainage of an abscess.

Differential Diagnosis

The differential diagnosis of acute appendicitis is essentially the diagnosis of the

acute abdomen. This is because clinical manifestations are not specific for a given
disease but are specific for disturbance of a given physiologic function or
functions. Thus, an essentially identical clinical picture can result from a wide
variety of acute processes within the peritoneal cavity that produce the same
alterations of function as does acute appendicitis.
The accuracy of preoperative diagnosis should be approximately 85%. If it is
consistently less, it is likely that some unnecessary operations are being
performed, and a more rigorous preoperative differential diagnosis is in order. A
diagnostic accuracy rate that is consistently >90% should also cause concern,
because this may mean that some patients with atypical, but bona fide, cases of
acute appendicitis are being "observed" when they should receive prompt surgical
intervention. The Haller group, however, has shown that this is not invariably
true.Before that group's study, the perforation rate at the hospital at which the
study took place was 26.7%, and acute appendicitis was found in 80% of the
patients undergoing operation. By implementing a policy of intensive inhospital
observation when the diagnosis of appendicitis was unclear, the group raised the
rate of acute appendicitis found at operation to 94%, but the perforation rate
remained unchanged at 27.5%. The rate of false-negative appendectomies is
highest in young adult females. A normal appendix is found in 32 to 45% of
appendectomies performed in women 15 to 45 years of age.

A common error is to make a preoperative diagnosis of acute appendicitis only to

find some other condition (or nothing) at operation. Much less frequently, acute
appendicitis is found after a preoperative diagnosis of another condition. The most
common erroneous preoperative diagnoses—together accounting for >75% of
cases—are, in descending order of frequency, acute mesenteric lymphadenitis, no
organic pathologic condition, acute pelvic inflammatory disease, twisted ovarian
cyst or ruptured graafian follicle, and acute gastroenteritis.

The differential diagnosis of acute appendicitis depends on 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.

Acute Mesenteric Adenitis

Acute mesenteric adenitis is the disease most often confused with acute
appendicitis in children. Almost invariably, an upper respiratory tract infection is
present or has recently subsided. The pain usually is diffuse, and tenderness is not
as sharply localized as in appendicitis. Voluntary guarding is sometimes present,
but true rigidity is rare. Generalized lymphadenopathy may be noted. Laboratory
procedures are of little help in arriving at the correct diagnosis, although a relative
lymphocytosis, when present, suggests mesenteric adenitis. Observation for
several hours is in order if the diagnosis of mesenteric adenitis seems likely,
because it is a self-limited disease. However, if the differentiation remains in
doubt, immediate exploration is the safest course of action.

Human infection with Yersinia enterocolitica or Yersinia pseudotuberculosis,

transmitted through food contaminated by feces or urine, causes mesenteric
adenitis as well as ileitis, colitis, and acute appendicitis. Many of the infections
are mild and self limited, but they may lead to systemic disease with a high
fatality rate if untreated. The organisms are usually sensitive to tetracyclines,
streptomycin, ampicillin, and kanamycin. A preoperative suspicion of the
diagnosis should not delay operative intervention, because appendicitis caused by
Yersinia cannot be clinically distinguished from appendicitis due to other causes.
Approximately 6% of cases of mesenteric adenitis are caused by Yersinia
infection.

Salmonella typhimurium infection causes mesenteric adenitis and paralytic ileus

with symptoms similar to those of appendicitis. The diagnosis can be established
by serologic testing. Campylobacter jejuni causes diarrhea and pain that mimics
that of appendicitis. The organism can be cultured from stool.

Gynecologic Disorders

Diseases of the female internal reproductive organs that may erroneously be

diagnosed as appendicitis are, in approximate descending order of frequency,
pelvic inflammatory disease, ruptured graafian follicle, twisted ovarian cyst or
tumor, endometriosis, and ruptured ectopic pregnancy.

Pelvic Inflammatory Disease

In pelvic inflammatory disease the infection usually is bilateral but, if confined to

the right tube, may mimic acute appendicitis. Nausea and vomiting are present in
patients with appendicitis, but in only approximately 50% of those with pelvic
inflammatory disease. Pain and tenderness are usually lower, and motion of the
cervix is exquisitely painful. Intracellular diplococci may be demonstrable on
smear of the purulent vaginal discharge. The ratio of cases of appendicitis to cases
of pelvic inflammatory disease is low in females in the early phase of the
menstrual cycle and high during the luteal phase. The careful clinical use of these
features has reduced the incidence of negative findings on laparoscopy in young
women to 15%.

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 are rather diffuse. Leukocytosis and fever are minimal or
absent. Because this pain occurs at the midpoint of the menstrual cycle, it is often
called mittelschmerz.

Twisted Ovarian Cyst

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. If the mass is palpable on physical examination, the
diagnosis can be made easily. Both transvaginal ultrasonography and CT scanning
can be diagnostic if a mass is not palpable.

Torsion requires emergent operative treatment. If the torsion is complete or

longstanding, the pedicle undergoes thrombosis, and the ovary and tube become
gangrenous and require resection. Leakage of ovarian cysts resolves
spontaneously, however, and is best treated nonoperatively.

Ruptured Ectopic Pregnancy

Blastocysts may implant in the fallopian tube (usually the ampullary portion) and
in the ovary. 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. Unfortunately, patients do
not always realize they are pregnant. 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 chorionic gonadotropin are characteristic. Although the leukocyte count
rises slightly (to approximately 14,000 cells/mm3), the hematocrit level falls as a
consequence of the intra-abdominal hemorrhage. 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.

Acute Gastroenteritis

Acute gastroenteritis is common but usually can be easily distinguished from

acute appendicitis. Gastroenteritis is characterized by profuse diarrhea, nausea,
and vomiting. Hyperperistaltic abdominal cramps precede the watery stools. The
abdomen is relaxed between cramps, and there are no localizing signs. Laboratory
values vary with the specific cause.

Other Intestinal Disorders

Meckel's Diverticulitis

Meckel's diverticulitis gives rise to a clinical picture similar to that of acute

appendicitis. Meckel's diverticulum is located within the distal 2 ft of the ileum.
Meckel's diverticulitis is associated with the same complications as appendicitis
and requires the same treatment—prompt surgical intervention. Resection of the
segment of ileum bearing the diverticulum with end-to-end anastomosis can
nearly always be done through a McBurney incision, extended if necessary, or
laparoscopically.
Crohn's Enteritis

The manifestations of acute regional enteritis—fever, right lower quadrant pain

and tenderness, and leukocytosis—often simulate acute appendicitis. The presence
of diarrhea and the absence of anorexia, nausea, and vomiting favor a diagnosis of
enteritis, but this is not sufficient to exclude acute appendicitis. In an appreciable
percentage of patients with chronic regional enteritis, the diagnosis is first made at
the time of operation for presumed acute appendicitis. In cases of an acutely
inflamed distal ileum with no cecal involvement and a normal appendix,
appendectomy is indicated. Progression to chronic Crohn's ileitis is uncommon.

Colonic Lesions

Diverticulitis or perforating carcinoma of the cecum, or of that portion of the

sigmoid that lies in the right side, may be impossible to distinguish from
appendicitis. These entities should be considered in older patients. CT scanning is
often helpful in making a diagnosis in older patients with right lower quadrant
pain and atypical clinical presentations.

Epiploic appendagitis probably results from infarction of the colonic appendage(s)

secondary to torsion. Symptoms may be minimal, or there may be continuous
abdominal pain in an area corresponding to the contour of the colon, lasting
several days. Pain shift is unusual, and there is no diagnostic sequence of
symptoms. The patient does not look ill, nausea and vomiting are unusual, and
appetite generally is unaffected. Localized tenderness over the site is usual and
often is associated with rebound without rigidity. In 25% of reported cases, pain
persists or recurs until the infarcted epiploic appendage is removed.

Other Diseases

Diseases or conditions not mentioned in the preceding sections that must be

considered in the differential diagnosis include foreign body perforations of the
bowel, closed-loop intestinal obstruction, mesenteric vascular infarction, pleuritis
of the right lower chest, acute cholecystitis, acute pancreatitis, hematoma of the
abdominal wall, epididymitis, testicular torsion, urinary tract infection, ureteral
stone, primary peritonitis, and Henoch-Schönlein purpura.

Acute Appendicitis in the Young

The establishment of a diagnosis of acute appendicitis is more difficult in young

children than in the adult. The inability of young children to give an accurate
history, diagnostic delays by both parents and physicians, and the frequency of GI
upset in children are all contributing factors. In children the physical examination
findings of maximal tenderness in the right lower quadrant, the inability to walk
or walking with a limp, and pain with percussion, coughing, and hopping were
found to have the highest sensitivity for appendicitis.

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. Children <5 years of age have a negative appendectomy rate of 25% and
an appendiceal perforation rate of 45%. These rates may be compared with a
negative appendectomy rate of <10% and a perforated appendix rate of 20% for
children 5 to 12 years of age. The incidence of major complications after
appendectomy in children is correlated with appendiceal rupture. The wound
infection rate after the treatment of nonperforated appendicitis in children is 2.8%
compared with a rate of 11% after the treatment of perforated appendicitis. The
incidence of intra-abdominal abscess also is higher after the treatment of
perforated appendicitis than after nonperforated appendicitis (6% vs. 3%). The
treatment regimen for perforated appendicitis generally includes immediate
appendectomy and irrigation of the peritoneal cavity. Antibiotic coverage is
limited to 24 to 48 hours in cases of nonperforated appendicitis. For perforated
appendicitis IV antibiotics usually are 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.
Acute Appendicitis in the Elderly

Compared with younger patients, elderly patients with appendicitis often pose a
more difficult diagnostic problem because of the atypical presentation, expanded
differential diagnosis, and communication difficulty. These factors may be
responsible for the disproportionately high perforation rate seen in the elderly. In
the general population, perforation rates range from 20 to 30%, compared with 50
to 70% in the elderly. In addition, the perforation rate appears to increase with age
>80 years.

Elderly patients usually present with lower abdominal pain, but on clinical
examination, localized right lower quadrant tenderness is present in only 80 to
90% of patients. A history of periumbilical pain migrating to the right lower
quadrant is reported infrequently. The usefulness of the Alvarado score appears to
decline in the elderly. Fewer then 50% of the elderly with appendicitis have an
Alvarado score of ≥7. Although currently there are no criteria that definitively
identify elderly patients with acute appendicitis who are at risk of rupture,
prioritization should be given to patients with a temperature of >38°C (100.4°F)
and a shift to the left in leukocyte count of >76%, especially if they are male, are
anorectic, or have had pain of long duration before admission.

As a result of increased comorbidities and an increased rate of perforation,

postoperative morbidity, mortality, and hospital length of stay are increased in the
elderly compared with younger populations with appendicitis. Although no
randomized trials have been conducted, it appears that elderly patients benefit
from a laparoscopic approach to treatment of appendicitis. The use of laparoscopy
in the elderly has significantly increased in recent years. In general, laparoscopic
appendectomy offers elderly patients with appendicitis a shorter length of hospital
stay, a reduction in complication and mortality rates, and a greater chance of
discharge to home (independent of further nursing care or rehabilitation).
Acute Appendicitis during Pregnancy

Appendectomy for presumed appendicitis is the most common surgical

emergency during pregnancy. The incidence is approximately 1 in 766 births.
Acute appendicitis can occur at any time during pregnancy. The overall negative
appendectomy rate during pregnancy is approximately 25% and appears to be
higher than the rate seen in nonpregnant women.A higher rate of negative
appendectomy is seen in the second trimester, and the lowest rate is in the third
trimester. The diversity of clinical presentations and the difficulty in making the
diagnosis of acute appendicitis in pregnant women is well established. This is
particularly true in the late second trimester and the third trimester, when many
abdominal symptoms may be considered pregnancy related. In addition, during
pregnancy there are anatomic changes in the appendix and increased abdominal
laxity that may further complicate clinical evaluation. There is no association
between appendectomy and subsequent fertility.

Appendicitis in pregnancy should be suspected when a pregnant woman

complains of abdominal pain of new onset. The most consistent sign encountered
in acute appendicitis during pregnancy is pain in the right side of the abdomen.
Seventy-four percent of patients report pain located in the right lower abdominal
quadrant, with no difference between early and late pregnancy. Only 57% of
patients present with the classic history of diffuse periumbilical pain migrating to
the right lower quadrant. Laboratory evaluation is not helpful in establishing the
diagnosis of acute appendicitis during pregnancy. The physiologic leukocytosis of
pregnancy has been defined as high as 16,000 cells/mm3. In one series only 38%
of patients with appendicitis had a white blood cell count of >16,000
cells/mm3.Recent data suggest that the incidence of perforated or complex
appendicitis is not increased in pregnant patients.

When the diagnosis is in doubt, abdominal ultrasound may be beneficial. Another

option is magnetic resonance imaging, which has no known deleterious effects on
the fetus. The American College of Radiology recommends the use of nonionizing
radiation techniques for front-line imaging in pregnant women. Laparoscopy has
been advocated in equivocal cases, especially early in pregnancy; however
laparoscopic appendectomy may be associated with an increase in pregnancy-
related complications. In an analysis of outcomes in California using
administrative databases, laparoscopy was found to be associated with a 2.31
increased odds of fetal loss over open surgery.

The overall incidence of fetal loss after appendectomy is 4% and the risk of early
delivery is 7%. Rates of fetal loss are considerably higher in women with complex
appendicitis than in those with a negative appendectomy and with simple
appendicitis. It is important to note that a negative appendectomy is not a benign
procedure. Removing a normal appendix is associated with a 4% risk of fetal loss
and 10% risk of early delivery. Maternal mortality after appendectomy is
extremely rare (0.03%). Because the incidence of ruptured appendix is similar in
pregnant and nonpregnant women and because maternal mortality is so low, it
appears that the greatest opportunity to improve fetal outcomes is by improving
diagnostic accuracy and reducing the rate of negative appendectomy.

Appendicitis in Patients with AIDS or HIV Infection

The incidence of acute appendicitis in HIV-infected patients is reported to be

0.5%. This is higher than the 0.1 to 0.2% incidence reported for the general
population.The presentation of acute appendicitis in HIV-infected patients is
similar to that in noninfected patients. 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%).
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

The risk of appendiceal rupture appears to be increased in HIV-infected patients.

In one large series of HIV-infected patients who underwent appendectomy for
presumed appendicitis, 43% of patients were found to have perforated
appendicitis at laparotomy. The increased risk of appendiceal rupture may be
related to the delay in presentation seen in this patient population.The mean
duration of symptoms before arrival in the emergency department has been
reported to be increased in HIV-infected patients, with >60% of patients reporting
the duration of symptoms to be longer than 24 hours. In early series, significant
hospital delay also may have contributed to high rates of rupture. However, with
increased understanding of abdominal pain in HIV-infected patients, hospital
delay has become less prevalent. A low CD4 count is also associated with an
increased incidence of appendiceal rupture. In one large series, patients with
nonruptured appendices had CD4 counts of 158.75 ± 47 cells/mm3 compared with
94.5 ± 32 cells/mm3 in patients with appendiceal rupture.

The differential diagnosis of right lower quadrant pain is expanded in HIV-

infected patients compared with the general population. In addition to the
conditions discussed elsewhere in this chapter, opportunistic infections should be
considered as a possible cause of right lower quadrant pain. Such opportunistic
infections include cytomegalovirus (CMV) infection, Kaposi's sarcoma,
tuberculosis, lymphoma, and other causes of infectious colitis. CMV infection
may be seen anywhere in the GI tract. CMV infection causes a vasculitis of blood
vessels in the submucosa of the gut, which leads 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 avium-intracellulare complex, Mycobacterium
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 HIV-infected patients
than in the general population. 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 in HIV-infected patients.

A thorough history and physical examination is important 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. The
majority of pathologic findings identified in HIV-infected patients who undergo
appendectomy for presumed appendicitis are typical. The negative appendectomy
rate is 5 to 10%. However, in up to 25% of patients AIDS-related entities are
found in the operative specimens, including CMV, Kaposi's sarcoma, and M.
avium-intracellulare complex.

In a retrospective study of 77 HIV-infected patients from 1988 to 1995, the 30-

day mortality rate for patients undergoing appendectomy was reported to be 9.1%.
More recent series report 0% mortality in this group of patients.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. In addition, the length of
hospital stay for HIV-infected patients undergoing appendectomy is twice that for
the general population. No series has been reported to date that addresses the role
of laparoscopic appendectomy in the HIV-infected population.

Treatment

Despite the advent of more sophisticated diagnostic modalities, the importance of

early operative intervention should not be minimized. Once the decision to
operate for presumed acute appendicitis has been made, the patient should be
prepared for the operating room. Adequate hydration should be ensured,
electrolyte abnormalities should be corrected, and pre-existing cardiac,
pulmonary, and renal conditions should be addressed. A large meta-analysis has
demonstrated the efficacy of preoperative antibiotics in lowering the infectious
complications in appendicitis. Most surgeons routinely administer antibiotics to
all patients with suspected appendicitis. 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 GI tract origin that are 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. The recommendations are similar for
children.

Open Appendectomy

For open appendectomy most surgeons use either a McBurney (oblique) or

Rocky-Davis (transverse) right lower quadrant muscle-splitting incision in
patients with suspected appendicitis. The incision should be 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. This is especially relevant in older patients
with possible malignancy or diverticulitis.

Several techniques can be used to locate the appendix. Because the cecum usually
is 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, with care
taken to ligate the appendiceal artery securely.

The appendiceal stump can be managed by simple ligation or by ligation and

inversion with either a purse-string or Z stitch. As long as the stump is clearly
viable and the base of the cecum is not involved with the inflammatory process,
the stump can be safely ligated with a nonabsorbable suture. The mucosa is
frequently obliterated to avoid the development of mucocele. The 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.
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 must be made for an alternative

diagnosis. The cecum and mesentery should first be inspected. Next, the small
bowel should be examined in a retrograde fashion beginning at the ileocecal valve
and extending at least 2 ft. In females, special attention should be paid to the
pelvic organs. An attempt also should be made to examine the upper abdominal
contents. Peritoneal fluid should be sent for Gram's staining and culture. If
purulent fluid is encountered, it is imperative that the source be identified. A
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 is made.

Laparoscopic Appendectomy

Semm first reported successful laparoscopic appendectomy several years before

the first laparoscopic cholecystectomy.10 However, the laparoscopic approach to
appendectomy did not come into widespread use until after the success of
laparoscopic cholecystectomy. This may be due to the fact that appendectomy, by
virtue of its small incision, is already a form of minimal-access surgery.

Laparoscopic appendectomy is performed under general anesthesia. A nasogastric

tube and a urinary catheter are placed before obtaining a pneumoperitoneum.
Laparoscopic appendectomy usually requires the use of three ports. Four ports
may occasionally be necessary to mobilize a retrocecal appendix. The surgeon
usually stands to the patient's left. One assistant is required to operate the camera.
One trocar is placed in the umbilicus (10 mm), and a second trocar is placed in the
suprapubic position. Some surgeons place this second port in the left lower
quadrant. The suprapubic trocar is either 10 or 12 mm, depending on whether or
not a linear stapler will be used. The placement of the third trocar (5 mm) is
variable and usually is either in the left lower quadrant, epigastrium, or right
upper quadrant. Placement is based on location of the appendix and surgeon
preference. Initially, the abdomen is thoroughly explored to exclude other
pathology. The appendix is identified by following the anterior taeniae to its base.
Dissection at the base of the appendix enables the surgeon to create a window
between the mesentery and the base of the appendix. The mesentery and base of
the appendix are then secured and divided separately. When the mesoappendix is
involved with the inflammatory process, it is often best to divide the appendix
first with a linear stapler and then to divide the mesoappendix immediately
adjacent to the appendix with clips, electrocautery, Harmonic Scalpel, or staples.
The base of the appendix is not inverted. The appendix is removed from the
abdominal cavity through a trocar site or within a retrieval bag. The base of the
appendix and the mesoappendix should be evaluated for hemostasis. The right
lower quadrant should be irrigated. Trocars are removed under direct vision.

Fig 3. Laparoscopic resection of the appendix. Occasionally, if the appendix and

mesoappendix are extremely inflamed, it is easier to divide the appendix at its
base before division of the mesoappendix. A. A window is created in the
mesoappendix close to the base of the appendix. B. The linear stapler is then used
to divide the appendix at its base. C. Finally the mesoappendix can be easily
divided using the linear stapler.

The utility of laparoscopic appendectomy in the management of acute appendicitis

remains controversial. Surgeons may be hesitant to implement a new technique
because the conventional open approach already has proved to be simple and
effective. A number of articles in peer-reviewed journals have compared
laparoscopic and open appendectomy, including >20 randomized, controlled trials
and 6 meta-analyses. The overall quality of these randomized, controlled trials has
been limited by the failure to blind patients and providers as to the treatment
modality used. Furthermore, investigators have failed to perform prestudy sample
size analysis for the outcomes studied. The largest meta-analysis comparing open
to laparoscopic appendectomy included 47 studies, 39 of which were studies of
adult patients. This analysis demonstrated that the duration of surgery and costs of
operation were higher for laparoscopic appendectomy than for open
appendectomy. Wound infections were approximately half as likely after
laparoscopic appendectomy as after open appendectomy. However, the rate of
intra-abdominal abscess was three times higher after laparoscopic appendectomy
than after open appendectomy.

A principal proposed benefit of laparoscopic appendectomy has been decreased

postoperative pain. Patient-reported pain on the first postoperative day is
significantly less after laparoscopic appendectomy. However, the difference has
been calculated to be only 8 points on a 100-point visual analogue scale. This
difference is below the level of pain that an average patient is able to
perceive.Hospital length of stay also is statistically significantly less after
laparoscopic appendectomy. However, in most studies this difference is <1 day. It
appears that a more important determinant of length of stay after appendectomy is
the pathology found at operation—specifically, whether a patient has perforated
or nonperforated appendicitis. In nearly all studies, laparoscopic appendectomy is
associated with a shorter period before return to normal activity, return to work,
and return to sports. However, treatment and subject bias may have a significant
impact on the data. Although the majority of studies have been performed in
adults, similar data have been obtained in children.

There appears to be little benefit to laparoscopic appendectomy over open

appendectomy in thin males between the ages of 15 and 45 years. In these
patients, the diagnosis usually is straightforward. Open appendectomy has been
associated with outstanding results for several decades. 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. In a retrospective study of 116 patients with a mean body
mass index of 35, postoperative length of stay was significantly shorter in the
group undergoing laparoscopic appendectomy, and there were fewer open
wounds. In all obese patients in whom the procedure was completed
laparoscopically the incisions closed primarily, whereas the wounds closed
primarily in only 58% of obese patients who underwent open appendectomy.
There was no difference in rates of wound infection; intra-abdominal abscess rates
were not reported.

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 treatment using
laparoscopic techniques. The question of leaving a normal appendix in situ is a
controversial one. Seventeen to 26% of appendices that appear normal at
exploration are found to have pathologic features on histologic analysis. The
availability of diagnostic laparoscopy may actually lower the threshold for
exploration and thus adversely impact the negative appendectomy rate. Fertile
women with presumed appendicitis constitute the group of patients most likely to
benefit from diagnostic laparoscopy. Up to one third of these patients do not have
appendicitis at exploration. In most of the patients without appendicitis,
gynecologic pathology is identified. A large meta-analysis demonstrated that in
fertile women in whom appendectomy was deemed necessary, diagnostic
laparoscopy reduced the number of unnecessary appendectomies. In addition, the
number of women without a final diagnosis was smaller. It appears that leaving a
normal-appearing appendix in fertile women with identifiable gynecologic
pathology is safe.

In summary, it has not been resolved whether laparoscopic appendectomy is more

effective in treating acute appendicitis than the time-proven method of open
appendectomy. It does appear that laparoscopic appendectomy is effective in the
management of acute appendicitis. Laparoscopic appendectomy should be
considered part of the surgical armamentarium available to treat acute
appendicitis. The decision on how to treat a specific patient with appendicitis
should be based on surgical skill, patient characteristics, clinical scenario, and
patient preference. Additional well-controlled, prospective, blinded studies are
needed to determine which subsets of patients may benefit from any given
approach to the treatment of appendicitis.

Natural Orifice Transluminal Endoscopic Surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a new surgical

procedure using flexible endoscopes in the abdominal cavity. In this procedure,
access is gained by way of organs that are reached through a natural, already-
existing external orifice. The hoped-for advantages associated with this method
include the reduction of postoperative wound pain, shorter convalescence,
avoidance of wound infection and abdominal-wall hernias, and the absence of
scars. The first case of transvaginal removal of a normal appendix has recently
been reported. Much work remains to determine if NOTES provides any
additional advantages over the laparoscopic approach to appendectomy.

Antibiotics as Definitive Therapy

Traditional management of acute appendicitis has emphasized emergent surgical

management. This approach has been based on the theory that, over time, simple
appendicitis will progress to perforation, with resulting increases in morbidity and
mortality. As a result, a relatively high negative appendectomy rate has been
accepted to avoid the possibility of progression to perforation. Recent data suggest
that acute appendicitis and acute appendicitis with perforation may be separate
disease entities with distinct pathophysiology. A time series analysis performed
on a 25-year data set did not find a significant negative relationship between the
rates of negative appendectomy and perforation. A study analyzing time to
surgery and perforation demonstrated that risk of rupture is minimal within 36
hours of symptom onset. Beyond this point, there is about a 5% risk of rupture in
each ensuing 12-hour period. However, in many patients the disease will have an
indolent course. In one study 10 of the 18 patients who did not undergo operation
for ≥6 days after their symptoms began did not experience rupture.

Many acute abdominal conditions such as acute diverticulitis and acute

cholecystitis are managed with urgent but not emergent surgery. Moreover,
evidence from submarine personnel who develop appendicitis suggests that
nonoperative management of appendicitis may be a viable treatment option.
Sailors who develop appendicitis while stationed on submarines do not have
access to prompt surgical care. They are successfully treated with antibiotics and
fluids days to weeks after the initial attack until the ship can surface and they can
be transferred to a hospital for care.

A randomized study comparing antibiotic treatment with immediate

appendectomy has been completed. Two hundred and fifty-two men 18 to 50
years of age with the presumptive diagnosis of appendicitis were enrolled in the
study between March 1996 and June 1999. For patients randomly assigned to
antibiotic therapy, if symptoms did not improve within the first 24 hours, an
appendectomy was performed. Participants were evaluated after 1 week, 6 weeks,
and 1 year. Acute appendicitis was found in 97% of the 124 patients randomly
assigned to surgery. Six patients (5%) had perforated appendices. The
complication rate in the surgery group was 14% (17 of 124). Of the 128 patients
enrolled in the antibiotic group, 15 patients (12%) underwent operation within the
first 24 hours due to lack of improvement in symptoms and apparent local
peritonitis. At operation seven patients (5%) had perforation. The rate of
recurrence within 1 year was 15% (16 patients) in the group treated with
antibiotics. In five of these patients a perforated appendix was found at operation.
Although it initially appears from these data that the use of antibiotics alone may
be reasonable therapy for acute appendicitis, there are several issues to take into
account. First, this study included only men between the ages of 18 and 50 and
may not have broad applicability to all patients with appendicitis, especially those
populations known to have higher perforation rates. Second, the incidence of
perforation was 9% in the antibiotic group when patients requiring operation in
both the acute and delayed settings are considered. This compares unfavorably
with the perforation rate of 5% for those patients operated on immediately. In
addition, the study follow-up was only 1 year, which suggests that patients
receiving only antibiotic therapy may still be at risk for the development of
appendicitis. Finally, when patients are treated with antibiotics alone it is possible
that diagnoses of significant pathology such as carcinoid or carcinoma may be
delayed. Because no laboratory test or clinical investigation can reliably
distinguish patients whose appendicitis is potentially amenable to conservative
treatment, surgery still remains the gold standard of care for patients with acute
appendicitis.

Interval Appendectomy

The accepted approach 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. This technique has been
quite successful and produces much lower morbidity and mortality rates than
immediate appendectomy. Unfortunately, this treatment is associated with greater
expense and longer hospitalization time (8 to 13 days vs. 3 to 5 days).

The initial treatment consists of IV antibiotics and bowel rest. Although this
therapy is generally effective, there is a 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.
Although the second stage of this treatment plan, interval appendectomy, has
usually been carried out, the need for subsequent operation has been questioned.
The major argument against interval appendectomy is that approximately 50% of
patients treated conservatively never develop manifestations of appendicitis, and
those who do generally can be treated nonoperatively. In addition, pathologic
examination of the resected appendix shows normal findings in 20 to 50% of
cases.

On the other hand, the data clearly support the need for interval appendectomy. In
a prospective series, 19 of 48 patients (40%) who were successfully treated
conservatively needed appendectomy at an earlier time (mean of 4.3 weeks) than
the 10 weeks planned because of bouts of appendicitis.91 Overall, the rate of late
failure as a consequence of acute disease averages 20%. An additional 14% of
patients either continue to have, or redevelop, right lower quadrant pain. Although
the appendix may occasionally be pathologically normal, persistent
periappendiceal abscesses and adhesions are found in 80% of patients. In addition,
almost 50% have histologic evidence of inflammation in the organ itself. Several
neoplasms also have been detected in the resected appendices, even in those of
children.

The timing of interval appendectomy is somewhat controversial. Appendectomy

may be required as early as 3 weeks after conservative therapy. Two thirds of the
cases of recurrent appendicitis occur within 2 years, and this is the outside limit.
Interval appendectomy is associated with a morbidity rate of ≤3% and a
hospitalization time of 1 to 3 days. The laparoscopic approach has been used and
has been successful in 68% of procedures. In a more recent study in children,
interval appendectomy was performed successfully using the laparoscopic
approach in all 35 patients.

Prognosis

The mortality from appendicitis in the United States has steadily decreased from a
rate of 9.9 per 100,000 in 1939 to 0.2 per 100,000 today. Among the factors
responsible are advances in anesthesia, antibiotics, IV fluids, and blood products.
Principal factors influencing mortality are whether rupture occurs before surgical
treatment and the age of the patient. The overall mortality rate in acute
appendicitis with rupture is approximately 1%. The mortality rate of appendicitis
with rupture in the elderly is approximately 5%—a fivefold increase from the
overall rate. Death is usually attributable to uncontrolled sepsis—peritonitis, intra-
abdominal abscesses, or gram-negative septicemia. Pulmonary embolism
continues to account for some deaths.

Morbidity rates parallel mortality rates and are significantly increased by rupture
of the appendix and, to a lesser extent, by old age. In one report, complications
occurred in 3% of patients with nonperforated appendicitis and in 47% of patients
with perforations. Most of the serious early complications are septic and include
abscess and wound infection. Wound infection is common but is nearly always
confined to the subcutaneous tissues and responds promptly to wound drainage,
which is accomplished by reopening the skin incision. Wound infection
predisposes the patient to wound dehiscence. The type of incision is relevant;
complete dehiscence rarely occurs in a McBurney incision.

The incidence of intra-abdominal abscess secondary to peritoneal contamination

from gangrenous or perforated appendicitis has decreased markedly since the
introduction of potent antibiotics. The sites of predilection for abscesses are the
appendiceal fossa, pouch of Douglas, the subhepatic space, and between loops of
intestine. In the latter site abscesses are usually multiple. Transrectal drainage is
preferred for an abscess that bulges into the rectum.

Fecal fistula is an annoying, but not particularly dangerous, complication of

appendectomy that may be caused by sloughing of the portion of the cecum inside
a constricting purse-string suture; by slipping of the ligature off a tied, but not
inverted, appendiceal stump; or by necrosis from an abscess encroaching on the
cecum.

Intestinal obstruction, initially paralytic but sometimes progressing to mechanical

obstruction, may occur with slowly resolving peritonitis with loculated abscesses
and exuberant adhesion formation. Late complications are quite uncommon.
Adhesive band intestinal obstruction after appendectomy does occur, but much
less frequently than after pelvic surgical therapy. The incidence of inguinal hernia
is three times higher in patients who have had an appendectomy. Incisional hernia
is like wound dehiscence in that infection predisposes to it, it rarely occurs in a
McBurney incision, and it is not uncommon in a lower right paramedian incision.

Chronic Appendicitis

Whether chronic appendicitis is a true clinical entity has been questioned for
many years. However, clinical data document the existence of this uncommon
disease.95 Histologic criteria have been established. Characteristically, the pain
lasts longer and is less intense than that of acute appendicitis but is in the same
location. There is a much 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.

At operation, surgeons can establish the diagnosis with 94% specificity and 78%
sensitivity. There is an excellent correlation between clinical symptomatology,
intraoperative findings, and histologic abnormalities. Laparoscopy can be used
effectively in the management of this clinical entity. 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

A number of intestinal parasites cause appendicitis. Although Ascaris

lumbricoides is the most common, a wide spectrum of helminths have been
implicated, including Enterobius vermicularis, Strongyloides stercoralis, and
Echinococcus granulosis. The live parasites occlude the appendiceal lumen,
causing obstruction. The presence of parasites in the appendix at operation makes
ligation and stapling of the appendix technically difficult. Once appendectomy has
been performed and the patient has recovered, therapy with helminthicide is
necessary to clear the remainder of the GI tract.

Amebiasis also can 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 antiamebic therapy
(metronidazole).

Incidental Appendectomy

Decisions regarding the efficacy of incidental appendectomy should be based on

the epidemiology of appendicitis. The best data were published by the Centers for
Disease Control and Prevention based on the period from 1979 to 1984. During
this period, an average of 250,000 cases of appendicitis occurred annually in the
United States. The highest annual incidence of appendicitis was in patients 9 to 19
years of age (23.3 per 10,000 population). Males were more likely to develop
appendicitis than females. Accordingly, the incidence during teenage years was
27.6 in males and 20.5 in females per 10,000 population per year. Beyond age 19
years, the annual incidence fell. Among those >45 years of age, the annual
incidence was 6 in 10,000 males and 4 in 10,000 females. When the life table
technique was used, the data identified a lifetime risk of appendicitis of 8.6% in
men and 6.7% in women. Although men were more likely to develop appendicitis,
the preoperative diagnosis was correct in 91.2% of men and 78.6% of women.
Similarly, perforation occurred more commonly in men than in women (19.2 vs.
17.8%). In contrast to the number of cases of appendicitis, 310,000 incidental
appendectomies were performed between 1979 and 1984, 62% of the total
appendectomies in men and 17.7% of those in women. Based on these data, 36
incidental appendectomies had to be performed to prevent one patient from
developing appendicitis.

The financial aspects of the decision to perform incidental appendectomy were

assessed. For open appendectomy, there was a financial disincentive to perform
incidental appendectomy. On an annual basis, $20,000,000 had to be spent to save
the $6,000,000 cost of appendicitis. With the laparoscopic approach, it was cost
effective to perform incidental appendectomy only in patients <25 years of age
and only if the reimbursement for surgeons was 10% of the usual and customary
charges. At a higher rate of reimbursement, incidental appendectomy was not cost
effective in any age group.

Although incidental appendectomy is 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.
 CHAPTER III

ANALYSES

A boy, 16 years old presents with, a severe pain at her abdomen which started at
the area around his periumbilical area shift to right lower quadrant region
perceivedsince 7daysbefore admitted to hospital, pain is getting worse than ever 2
days before admitted to hospital. Here ports that he vomits 1x/dayof food, feels
nausea and lost appetite. The fever can go up and dawn, watery stools more than 5
times a day in week. Painless urination, no sand, the colour is clear yellow. The
pain was getting worse when he’s cough.

From the physical examination, patient’s general condition is compos mentis,

blood pressure is 120/80 mmHg, pulse is 80 x/minute, regular; respiratory rate is
abour 20 x/minute and the temperature is 36,70 C. In abdominal examination from
the inspection there’s distention, bowel sound from auscultation, pressure pain
from palpation, rovsing’s sign, defans muscular, and blumberg’s sign. From the
rectal touche, the strength of anal sphincter is good, slippery mucosa, pain at 11
o’clock direction, faeces and blood are not traces. There is no abnormality based
on laboratory examination. Other supporting examination are needed and still on
going through this time. The Alvarado score is about 9.

Clinical features commonly found in acute appendicitis are:

a. Early signs of pain in the epigastric or umbilical region accompanied by
nausea and anorexia. Fever is usually mild, with a temperature of about
37.5 - 38,5C. When the temperaturehigher, may have occurred perforation.
b. Pain shifts to the lower right and showed signs of stimulation
Local peritoneum in point Mc Burney, tenderness, rebound tenderness and
thedefans muscular.
c. Pain stimuli indirect peritoneum lower right pain on pressure
left (Rovsing's Sign) lower right pain when pressure on the left
released (Blumberg's Sign) coughing or straining
Supporting investigation
Lab
a. Blood tests
- Leukocytosis in most cases of acute appendicitis, especially in cases with
complications
Radiological
a. Plain abdominal
Acute appendicitis occurs at a slow and there has been a complication(eg
peritonitis) appears:
 Scoliosis to the right
 Psoas shadow invisible
 Right lower intestinal gas shadow invisible
 A line of retroperitoneal fat right side of the body invisible
 5% of patients demonstrated a radio-opaque fecalith
b. USG
When the results of a physical examination doubt, be examined
Ultrasound, especially in women, also when a suspected abscess. With
Ultrasound can be used to get rid of diagnosis such as
ectopic pregnancy, adnecitis and so on.

Management of Acute Appendicitis

Emergency Care

a. Give crystalloid therapy for patients with clinical signs of dehydration or

epticemia.
b. Patients with suspected appendicitis should not be given anything by
mouth.
c. Give parenteral analgesics and antiemetics for patient comfort.
d. Give intravenous antibiotics in patients with signs of septicemia and
patients will continue to laparotomy.
Pre-operative antibiotics

a. Pre-operative antibiotics have demonstrated success in

lower levels of postoperative wound infection.
b. Broad-spectrum antibiotics for gram-negative and anaerobic
indicated.
c. Preoperative antibiotics should be administered in conjunction surgery.

Operating action

a. Appendectomy, cutting the appendix.

b. If the appendix is perforated, then the abdomen was washed with salt
physiological and antibiotics.
c. In the event of the first appendix abscess treated with antibiotics
IV, its mass may shrink, or abscess may require drainage
within a few days
 REFERENCES

Brunicardi FC, et all. 2010. Schwartz's Principles of Surgery, Ninth Edition. The
McGraw-Hill Companies, Inc.
Sjamsuhidajat, R. andDeJong, Wim. 2010. Buku ajar ilmu bedah. Jakarta : EGC.