ACUTE APPENDICITIS

MITCHELL P. CREED, M3
 1522: Jacopo 1561: Gabriele
30 AD: Aretaeus of
Berengario da Capri Fallopio first compares
Cappadocia first
first describes structure to worm 
describes appendicitis
appendix structure “appendix veriform”

1812: John Parkinson

1579: Caspar Bauhin 1735: Claudius describes fatal
theorizes role  Amyand performs first appendicitis 

BRIEF intrauterine feces successful surgeons begin

receptacle appendectomy draining localized
abscesses

HISTORY 1880: Robert Lawson

1886: Reginald Heber
Tait first diagnoses 1889: Tait drains
Fitz publishes study on
appendicitis & treats inflamed appendix
appendicitis; names
w/ removal of w/o removal
“appendectomy”
appendix

1893: Charles
McBurney proposes 1981: Kurt Semm
1900: Robert Fulton
muscle splitting performs first
Weir modifies muscle
operation; laproscopic
splitting procedure
“McBurney’s Point” appendectomy
namesake

Meljnikov I, Radojcić B, Grebeldinger S, Radojcić N. [History of surgical treatment of appendicitis]. Med Pregl. 2009 Sep-Oct;62(9-10):489-92.
Serbian. PubMed PMID: 20391748.
EPIDEMIOLOGY

• MCC abdominal surgical emergency

• Incidence: 233/100,000
• Lifetime: ♂ = 8.6% | ♀ = 6.7%
• M:F = 1.4:1
PATHOPHYSIOLOGY

• Obstruction d/t bezoars | foreign body | trauma | worms | lymphadenitis | fecaliths

• Continued filling w/ mucus  swelling & increased luminal/wall pressure
• Small vessel occlusion | lymphatic flow stasis  ischemia | necrosis
• Floral bacteria growth  suppuration
• Rupture  ‘burst appendix’  peritonitis  sepsis  death
SIGNS/SYMPTOMS

• Acute anorexia (80% specific for appendicitis)

• Begins with anorexia  vague periumbilical pain  several hours later: localized sharp, severe &
constant RLQ pain w/ RLQ tenderness, guarding & rebound (McBurney’s point) | n/v
Note: migratory pain occurs in only 50-60% pts
• Additional S/Sx include indigestion | flatulence | diarrhea | generalized malaise | low-grade fever
reaching 101.0°F (38.3°C) | leukocytosis
• Variations in position of appendix leads to variations in pain localization (see pic on handout)
• Retrocecal appendix  dull abdominal pain
• Pelvic appendix tip  tenderness below McBurney’s
• LLQ pain???
• Situs inversus totalis
CLINICAL SIGNS
• McBurney’s sign  Deep tenderness at McBurney’s Point indicating peritoneal irritation
• Kocher’s sign  from PMH, shifting of initial periumbilical pain to right iliac region
• Obturator sign  flexion of hip and knee w/ subsequent internal rotation of hip elicits RLQ pain
• Psoas sign (Obraztsova’s sign)  passive right hip extension or active flexion while supine elicits
RLQ pain; d/t inflammation of peritoneum overlying iliopsoas & inflammation of psoas (stretched
w/ movements)
• Heel-tap/Heel-jar sign  RLQ pain when R heel elevated 10-20ᵒ & hit firmly w/ palm; equivalent
to pain when ambulance hits bumps & potholes
• Shchetkin-Bloomberg’s sign  rebound tenderness in peritonitis
• Bartomier-Micelson’s sign  increased pain w/ palpation w/ lying on left side
• Dunphy’s sign  increased RLQ pain w/ cough
• Hamburger sign  pt refuses to eat
• Masssouh sign  pt grimace when examiner performs firm swish w/ finger across abdomen from
xiphoid process to right iliac fossa
• Rovsing’s sign  RLQ pain w/ continues deep counterclockwise palpation starting from left iliac
fossa pushing air/feces toward ileocecal valve
• Sitkovskiy (Rosenstein)’s sign  increased RLQ pain w/ lying on left side
DIAGNOSIS

• Alvarado/MANTRELS Score:
• Pediatric Appendicitis Score:
LABS

• CBC
• Elevated WBC in 70-90% pts
• Not a good indicator
• CRP
• ANC
• Urinalysis
• r/o UTIs
• Hcg to r/o ectopic pregnancy
IMAGING:
• X-ray:
• Not useful
• Fecalith may be visualized
• Ultrasound:
• Sensitivity = 86% | Specificity = 81%
• Children, pregnant women
• CT:
• Sensitivity = 94% | Specificity = 95%
• MRI:
• 2nd & 3rd trimesters
• Difficult to visualize on US d/t uterus displacing
appendix
DIFFERENTIAL DIAGNOSIS
• Children:
• Gastroenteritis | Mesenteric adenitis | Meckel’s diverticulitis | Intussusception | Henoch-Schönlein purpura | lobar pneumonia
| UTI | abdominal trauma 2/2 abuse | distal intestinal obstruction syndrome (CF pts) | typhlitis/neutropenic enterocolitis
(leukemia pts) | Sickle-cell Dz
• Adults:
• Perforated appendix | Cecal diverticulitis | Meckel’s diverticulitis |Acute ileitis | Crohn’s Dz | Renal colic | pseudoappendicitis
(e.g. Yersinia enterocolitica)
• Women:
• Tubo-ovarian abscess | PID | Ovarian cyst rupture | Mittelschmerz | torsion | endometriosis | ectopic pregnancy
• Men:
• Testicular torsion | epididymitis | appendix testis torsion
• Elderly:
• Diverticulitis | intestinal obstruction | colonic carcinoma | mesenteric ischemia | leaking aortic aneurysm
• Appendiceal neoplasms:
• Neuroendocrine (carcinoid) | adenocarcinoma | mucocele
TREATMENT:
• Appendectomy (open vs. laparoscopic
recommended over antibiotic treatment or
nonsurgical approach
• The laparoscopic approach was superior for:
• A lower rate of wound infections (all nine meta-
analyses; OR 0.3 to 0.52)
• Less pain on postoperative day 1 (two out of
three meta-analyses; by 0.7 to 0.8 points on a
10-point visual analog scale [VAS])
• Shorter duration of hospital stay (seven out of
eight meta-analyses; by 0.16 to 1.13 days)
‡
• The open approach was superior for: Appendectomy
Δ
• A lower rate of intra-abdominal abscesses Cefoxitin 2 g IV q 2 hours
(three out of six meta-analyses; OR 1.56 to
2.29) Enteric gram- OR cefotetan
Δ
2 g IV q 6 hours
• A shorter operative time (eight meta-analyses;
negative
by 7.6 to 18.3 minutes) bacilli, Δ <120 kg: 2 g IV
OR cefazolin q 4 hours
anaerobes, ≥120 kg: 3 g IV
enterococci PLUS
500 mg IV N/A
metronidazole
OPEN SPLIT-MUSCLE SURGICAL APPROACH:

• Transverse or oblique incision through oblique muscles over palpated appendix or centered over McBurney’s
point
• Too medial  anterior rectus sheath
• Too lateral  miss abdominal cavity
• Free appendix of adhesions
• Grasp mesoappendix w/ Babcock clamp
• Divide appendiceal artery w/ hemostats & tie w/ 3-0 absorbable sutures
• Non-absorbable purse-string suture placed in cecal wall around appendix
• Appendiceal base crushed w/ Kelly clamp, appendix doubly tied w/ 2-0 absorbable sutures
• Appendix excised w/ scalpel
• Stump cauterized & inverted into cecum while purse-string is tightened
• Abdomen irrigated w/ saline
• Closure
 Nonperforated:

• Antibiotic treatment not

necessary
POSTOPERATIVE
Perforated:
MANAGEMENT
• Increased risk for ileus
• Diet advanced as clinically
warranted
• Antibiotic treatment for 3-5 days