ACUTE APPENDICITIS :EASY TO DIAGNOSE

DR FADI JALLAD CONSULTANT GENERAL SURGERY

MD,FACS

DEFINITION

• ACUTE APPENDICITIS: A SURGICAL EMERGENCY CHARACTERISED BY SYMPTOMS DUE TO THE INFLAMMATION OF THE VERMIFORM APPENDIX.

HISTORY

• THE CLASSIC HISTORY OF ANOREXIA AND PERIUMBILICAL PAIN FOLLOWED BY NAUSEA, (RLQ) PAIN, AND VOMITING OCCURS IN ONLY 50% OF CASES.

• NAUSEA (61-92%) • ANOREXIA (74-78%) • VOMITING OCCURS, IT NEARLY ALWAYS FOLLOWS THE ONSET OF PAIN• MIGRATING PAIN (SENSITIVITY AND SPECIFICITY OF 80%).

EXAMINATION • USUALLY LIE DOWN, FLEX THEIR

HIPS, AND DRAW THEIR KNEES UP TO REDUCE MOVEMENTS AND TO AVOID WORSENING THEIR PAIN.

• LATER, A WORSENING PROGRESSIVE PAIN ALONG WITH VOMITING, NAUSEA, AND ANOREXIA ARE DESCRIBED BY THE PATIENT.

DURATION OF SYMPTOMS

• DURATION OF SYMPTOMS IS LESS THAN 48 HOURS IN APPROXIMATELY 80% OF ADULTS • LONGER IN ELDERLY PERSONS AND IN THOSE WITH

PERFORATION. • 2% OF PATIENTS REPORT DURATION OF PAIN IN

EXCESS OF 2 WEEKS

NON CLASSICAL PRESENTATION

• AN INFLAMED APPENDIX NEAR THE URINARY BLADDER OR URETER CAN CAUSE IRRITATIVE VOIDING SYMPTOMS AND HEMATURIA OR PYURIA.

• CONSIDER THE POSSIBILITY OF AN INFLAMED PELVIC APPENDIX IN MALE PATIENTS WITH APPARENT CYSTITIS.

• CONSIDER THE POSSIBILITY OF APPENDICITIS IN PEDIATRIC OR ADULT PATIENTS WHO PRESENT WITH ACUTE URINARY RETENTION.

EXAMINATION

• MCBURNEY POINT IN ONLY 4% OF PATIENTS 36% THE BASE WAS WITHIN 3 CM OF THE POINT; 28% IT WAS 3-5 CM FROM THAT POINT 36% THE BASE OF THE APPENDIX WAS MORE THAN 5 CM FROM THE

MCBURNEY POINT. *

• REBOUND TENDERNESS, PAIN ON PERCUSSION, RIGIDITY, AND GUARDING. • RLQ TENDERNESS IS PRESENT IN 96% OF PATIENTS, THIS IS A

NONSPECIFIC FINDING.• (LLQ) TENDERNESS HAS BEEN THE MAJOR MANIFESTATION IN PATIENTS

WITH SITUS INVERSUS OR IN PATIENTS WITH A LENGTHY APPENDIX THAT EXTENDS INTO THE LLQ.

• OTO A, ERNST RD, MILESKI WJ, NISHINO TK, LE O, WOLFE GC, ET AL. LOCALIZATION OF APPENDIX WITH MDCT AND INFLUENCE OF FINDINGS ON CHOICE OF APPENDECTOMY INCISION. AJR AM J ROENTGENOL. 2006 OCT. 187(4):987-90

ACCESSORY SIGNS• THE ROVSING SIGN• THE OBTURATOR SIGN (RLQ PAIN WITH

INTERNAL AND EXTERNAL ROTATION OF THE FLEXED RIGHT HIP) SUGGESTS THAT THE INFLAMED APPENDIX IS LOCATED DEEP IN THE RIGHT HEMIPELVIS.

• THE PSOAS SIGN • THE DUNPHY SIGN (SHARP PAIN IN THE

RLQ ELICITED BY A VOLUNTARY COUGH) • THE MARKLE SIGN, PAIN ELICITED IN A

CERTAIN AREA OF THE ABDOMEN WHEN THE STANDING PATIENT DROPS FROM STANDING ON TOES TO THE HEELS WITH A JARRING LANDING, SENSITIVITY OF 74%

ALVARADO SCORE• ACUTE APPENDICITIS: DIAGNOSTIC ACCURACY OF

ALVARADO SCORING SYSTEM• ASIAN J SURG. 2013 OCT;36(4):144-9. DOI: 10.1016/J.ASJSUR.2013.04.004. EPUB 2013 MAY 28.

MEMON ZA1, IRFAN S, FATIMA K, IQBAL MS, SAMI W.

• CONCLUSION: ALVARADO SCORE CAN BE USED EFFECTIVELY IN OUR SETUP TO REDUCE THE INCIDENCE OF NEGATIVE APPENDECTOMIES. HOWEVER, ITS ROLE IN FEMALES WAS NOT SATISFACTORY

• SCHNEIDER ET AL CONCLUDED THAT THE MANTRELS SCORE WAS NOT SUFFICIENTLY ACCURATE TO BE USED AS THE SOLE METHOD FOR DETERMINING THE NEED FOR APPENDECTOMY IN THE PEDIATRIC POPULATIONS

CHNEIDER C, KHARBANDA A, BACHUR R. EVALUATING APPENDICITIS SCORING SYSTEMS USING A PROSPECTIVE

PEDIATRIC COHORT. ANN EMERG MED. 2007 JUN. 49(6):778-84, 784.E1.

STAGES OF APPENDICITIS

• EARLY STAGE APPENDICITIS:OBSTRUCTION OF THE APPENDICEAL LUMEN LEADS TO MUCOSAL EDEMA, MUCOSAL ULCERATION, BACTERIAL DIAPEDESIS, APPENDICEAL DISTENTION DUE TO ACCUMULATED FLUID, AND INCREASING INTRALUMINAL PRESSURE. THE VISCERAL AFFERENT NERVE FIBERS ARE STIMULATED, AND THE PATIENT PERCEIVES MILD VISCERAL PERIUMBILICAL OR EPIGASTRIC PAIN, WHICH USUALLY LASTS 4-6 HOURS.• SUPPURATIVE APPENDICITIS: INCREASING INTRALUMINAL PRESSURES EVENTUALLY EXCEED

CAPILLARY PERFUSION PRESSURE, WHICH IS ASSOCIATED WITH OBSTRUCTED LYMPHATIC AND VENOUS DRAINAGE AND ALLOWS BACTERIAL AND INFLAMMATORY FLUID INVASION OF THE TENSE APPENDICEAL WALL.

TRANSMURAL SPREAD OF BACTERIA CAUSES ACUTE SUPPURATIVE APPENDICITIS. WHEN THE INFLAMED SEROSA OF THE APPENDIX COMES IN CONTACT WITH THE PARIETAL PERITONEUM, PATIENTS TYPICALLY EXPERIENCE THE CLASSIC SHIFT OF PAIN FROM THE PERIUMBILICUS TO THE RIGHT LOWER ABDOMINAL QUADRANT (RLQ), WHICH IS CONTINUOUS AND MORE SEVERE THAN THE EARLY VISCERAL PAIN.

• GANGRENOUS APPENDICITIS INTRAMURAL VENOUS AND ARTERIAL THROMBOSIS• PERFORATED APPENDICITIS.• PHLEGMONOUS APPENDICITIS OR ABSCESS• SPONTANEOUSLY RESOLVING APPENDICITIS IF THE

OBSTRUCTION OF THE APPENDICEAL LUMEN IS RELIEVED, ACUTE APPENDICITIS MAY RESOLVE SPONTANEOUSLY. 

( LYMPHOID HYPERPLASIA OR WHEN A FECALITH IS EXPELLED FROM THE LUMEN)• RECURRENT APPENDICITIS  10%. THE DIAGNOSIS IS ACCEPTED AS SUCH IF THE PATIENT

UNDERWENT SIMILAR OCCURRENCES OF RLQ PAIN AT DIFFERENT TIMES THAT, AFTER APPENDECTOMY, WERE HISTOPATHOLOGICALLY PROVEN TO BE THE RESULT OF AN INFLAMED APPENDIX.

CHRONIC APPENDICITIS • INCIDENCE OF 1% • DEFINED BY THE FOLLOWING: (1) THE PATIENT HAS A HISTORY OF RLQ PAIN OF AT LEAST 3 WEEKS’ DURATION WITHOUT AN ALTERNATIVE DIAGNOSIS. (2) AFTER APPENDECTOMY, THE PATIENT EXPERIENCES COMPLETE RELIEF OF SYMPTOMS.(3) HISTOPATHOLOGICALLY, THE SYMPTOMS WERE PROVEN TO BE THE RESULT OF CHRONIC ACTIVE INFLAMMATION OF THE APPENDICEAL WALL OR FIBROSIS OF THE APPENDIX.

DIAGNOSTIC CONSIDERATIONS

• THE OVERALL ACCURACY FOR DIAGNOSING ACUTE APPENDICITIS IS APPROXIMATELY 80%,

• MEAN NEGATIVE APPENDECTOMY RATE OF 20%. • DIAGNOSTIC ACCURACY VARIES BY SEX, WITH A RANGE OF 78-92% IN MALE PATIENTS 58-85% IN FEMALE PATIENTS• THE CLASSIC HISTORY OCCURS IN ONLY 50% OF CASES• APPENDICITIS IN PATIENTS OLDER THAN 60 YEARS ACCOUNTS FOR 10% OF ALL

APPENDECTOMIES.

WBC

• 80-85% : (WBC) COUNT GREATER THAN 10,500 CELLS. • NEUTROPHILIA GREATER THAN 75% OCCURS IN 78% OF

PATIENTS.• LESS THAN 4% OF PATIENTS WITH APPENDICITIS HAVE A WBC

COUNT LESS THAN 10,500 CELLS AND NEUTROPHILIA LESS THAN 75%.

C-REACTIVE PROTEIN• CRP LEVELS OF GREATER THAN 1 MG/DL ARE COMMONLY REPORTED IN

PATIENTS WITH APPENDICITIS, • VERY HIGH LEVELS OF CRP IN PATIENTS WITH APPENDICITIS INDICATE

GANGRENOUS EVOLUTION OF THE DISEASE, ESPECIALLY IF IT IS ASSOCIATED WITH LEUKOCYTOSIS AND NEUTROPHILIA.

• CRP NORMALIZATION OCCURS 12 HOURS AFTER ONSET OF SYMPTOMS. •  THIMSEN ET AL NOTED THAT A NORMAL CRP LEVEL AFTER 12 HOURS OF

SYMPTOMS WAS 100% PREDICTIVE OF BENIGN, SELF-LIMITED ILLNESSTHIMSEN DA, TONG GK, GRUENBERG JC. PROSPECTIVE EVALUATION OF C-REACTIVE PROTEIN IN PATIENTS SUSPECTED TO HAVE ACUTE APPENDICITIS. AM SURG. 1989 JUL. 55(7):466-8.

URINALYSIS AND URINARY 5-HIAA

• MILD PYURIA MAY OCCUR • SEVERE PYURIA IS A MORE COMMON FINDING IN URINARY TRACT INFECTIONS

(UTIS)• BOLANDPARVAZ ET AL, MEASUREMENT OF THE URINARY 5-

HYDROXYINDOLEACETIC ACID (U-5-HIAA) LEVELS COULD BE AN EARLY MARKER OF APPENDICITIS

BOLANDPARVAZ S, VASEI M, OWJI AA, ATA-EE N, AMIN A, DANESHBOD Y, ET AL. URINARY 5-HYDROXY INDOLE ACETIC ACID AS A TEST FOR EARLY DIAGNOSIS OF ACUTE APPENDICITIS. CLIN BIOCHEM. 2004 NOV. 37(11):985-9.

COMPUTED TOMOGRAPHY SCANNING• A LARGE, SINGLE CENTER STUDY FOUND THAT

CT HAS A HIGH RATE OF SENSITIVITY AND SPECIFICITY (98.5% AND 98%).

PICKHARDT PJ, LAWRENCE EM, POOLER BD, BRUCE RJ. DIAGNOSTIC PERFORMANCE OF MULTIDETECTOR COMPUTED TOMOGRAPHY FOR SUSPECTED ACUTE APPENDICITIS. ANN INTERN MED. 2011 JUN 21. 154(12):789-96

• LOW-DOSE ABDOMINAL CT ALLOWS FOR A 78% REDUCTION IN RADIATION EXPOSURE COMPARED TO TRADITIONAL ABDOMINOPELVIC CT AND MAY BE PREFERABLE FOR DIAGNOSING CHILDREN AND YOUNG ADULTS. 

KIM K, KIM YH, KIM SY, KIM S, LEE YJ, KIM KP, ET AL. LOW-DOSE ABDOMINAL CT FOR EVALUATING SUSPECTED APPENDICITIS. N ENGL J MED. 2012 APR 26. 366(17):1596-605

ULTRASONOGRAPHY

• TYPICALLY DEMONSTRATES A NO COMPRESSIBLE TUBULAR STRUCTURE OF 7-9 MM IN DIAMETER 

MAGNETIC RESONANCE IMAGING• THE LACK OF IONIZING RADIATION MAKES IT AN

ATTRACTIVE MODALITY IN PREGNANT PATIENTS.• COBBEN ET AL SHOWED THAT MRI IS FAR

SUPERIOR TO TRANSABDOMINAL ULTRASONOGRAPHY IN EVALUATING PREGNANT PATIENTS WITH SUSPECTED APPENDICITIS. 

• COBBEN LP, GROOT I, HAANS L, BLICKMAN JG, PUYLAERT J. MRI FOR CLINICALLY SUSPECTED APPENDICITIS DURING PREGNANCY. AJR AM J ROENTGENOL. 2004 SEP. 183(3):671-5.

• THE SENSITIVITY AND SPECIFICITY OF MRI FOR APPENDICITIS APPEARS TO BE SIMILAR TO THOSE OF COMPUTED TOMOGRAPHY (CT) SCANNING

REPPLINGER MD, LEVY JF, PEETHUMNONGSIN E, ET AL. SYSTEMATIC REVIEW AND META-ANALYSIS OF THE ACCURACY OF MRI TO DIAGNOSE APPENDICITIS IN THE GENERAL POPULATION. J MAGN RESON IMAGING. 2015 DEC 22

MANAGEMENT

• APPENDECTOMY REMAINS THE ONLY CURATIVE TREATMENT OF APPENDICITIS

• CONTROVERSIES EXIST OVER THE NONOPERATIVE MANAGEMENT OF ACUTE APPENDICITIS.

URGENT VERSUS EMERGENT APPENDECTOMY

• A RETROSPECTIVE STUDY SUGGESTED THAT THE RISK OF APPENDICEAL RUPTURE IS MINIMAL IN PATIENTS WITH LESS THAN 24-36 HOURS OF UNTREATED SYMPTOMS

BICKELL NA, AUFSES AH JR, ROJAS M, BODIAN C. HOW TIME AFFECTS THE RISK OF RUPTURE IN APPENDICITIS. J AM COLL SURG. 2006 MAR. 202(3):401-6

• RETROSPECTIVE STUDY SUGGESTED THAT APPENDECTOMY WITHIN 12-24 HOURS OF PRESENTATION IS NOT ASSOCIATED WITH AN INCREASE IN HOSPITAL LENGTH OF STAY, OPERATIVE TIME, ADVANCED STAGES OF APPENDICITIS, OR COMPLICATIONS COMPARED WITH APPENDECTOMY PERFORMED WITHIN 12 HOURS OF PRESENTATION. 

ABOU-NUKTA F, BAKHOS C, ARROYO K, KOO Y, MARTIN J, REINHOLD R, ET AL. EFFECTS OF DELAYING APPENDECTOMY FOR ACUTE APPENDICITIS FOR 12 TO 24 HOURS. ARCH SURG. 2006 MAY. 141(5):504-6; DISCUSSION 506-7

LAPAROSCOPIC APPENDECTOMY• ACCORDING TO THE 2010 SOCIETY OF AMERICAN GASTROINTESTINAL AND

ENDOSCOPIC SURGEONS (SAGES) GUIDELINE, THE INDICATIONS FOR LAPAROSCOPIC APPENDECTOMY ARE IDENTICAL TO THOSE FOR OPEN APPENDECTOMY. 

THE 2010 SAGES GUIDELINE LISTS THE FOLLOWING CONDITIONS AS SUITABLE FOR LAPAROSCOPIC APPENDECTOMY 

UNCOMPLICATED APPENDICITIS APPENDICITIS IN PEDIATRIC PATIENTS SUSPECTED APPENDICITIS IN PREGNANT WOMENACCORDING TO THE SAGES GUIDELINE, LAPAROSCOPIC APPENDECTOMY MAY BE THE PREFERRED APPROACH IN THE FOLLOWING CASES 

PERFORATED APPENDICITIS APPENDICITIS IN ELDERLY PATIENTS APPENDICITIS IN OBESE PATIENTS[GUIDELINE] KORNDORFFER JR JR, FELLINGER E, REED W. SAGES GUIDELINE FOR LAPAROSCOPIC APPENDECTOMY. SURG ENDOSC. 2010 APR. 24(4):757-61.