Appendicitis

60,000 appendectomies/yr

20,000 ruptured

100 deaths/year

History

Paseo Iliaca

Reginald Fitz - 1886

“Perforating Inflammation of the Vermiform Appendix: with special

reference to its early diagnosis and treatment” Am J Med Sci 1:321-46, 1886.

Reginald Heber Fitz

B. 5/5/1843 D. 9/30/1913

MD Harvard 1868 - Prof. Pathology

25 appendectomies

Charles McBurney

B. 2/17/1845, D. 11/7/1913

BA Harvard 1866

MD 1870 College of Physicians and Surgeons

Charles McBurney

McBurney had a point

T.G. Morton - 1887

Pathophysiology

Obstruction

Increased intraluminal pressure

Stages

Simple

Suppurative

Gangrenous

Ruptured

Abscessed

Microbiology

Intraoperative cultures are useless !

Bacteroides Fragilis: #1

Diagnosis

> 90% accurac

y

Pain

Shift

ANV

Physical Exam

Gestalt

Posture

Point tenderness

Laboratory Results

Signs of Perforation

AXR

BE

US

CT

MGH AJR 2005 Jun;184(6):1802-8.

40% scanned had appendicitis

Sens 99%, Specif 95%

• 88% suspected appy

• n = 753: had CT

• False neg rate dropped: 20% to 3%

Differential diagnosis

GastroenteritisConstipation

GUGYN

Mesenteric Adenitis

Pneumonia

Antibiotics

Treatment

Operation

Irrigation

Drainage (rarely)

Wound closure

Medical management

Interval appendectomy

Complications

Appendiceal stump blow-out

Abscess

Phlegmon

Dehiscence

Infertility

SBO

Wound problems

Abscess

Wound infection

Obstruction

Mortality

CMH Research Appendicitis - recent

1. St Peter SD, Sharp SW, Ostlie DJ. Influence of histamine receptor antagonists on the outcome of perforated appendicitis: analysis from a prospective trial. Arch Surg. 2010 Feb;145(2):143-6.

2. St Peter SD, Aguayo P, Fraser JD, Keckler SJ, Sharp SW, Leys CM, Murphy JP, Snyder CL, Sharp RJ, Andrews WS, Holcomb GW 3rd, Ostlie DJ. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. J Pediatr Surg. 2010 Jan;45(1):236-40.

3. Fraser JD, Aguayo P, Sharp SW, Snyder CL, Rivard DC, Cully BE, Sharp RJ, Ostlie DJ, St Peter SD. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg. 2010 Jan;45(1):231-4; discussion 234-4.

4. Fraser JD, Aguayo P, Sharp SW, Snyder CL, Holcomb GW 3rd, Ostlie DJ, St Peter SD. Physiologic predictors of postoperative abscess in children with perforated appendicitis: Subset analysis from a prospective randomized trial. Surgery. [Epub ahead of print]

5. St Peter SD, Sharp SW, Holcomb GW 3rd, Ostlie DJ. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg. 2008 Dec;43(12):2242-5.

6. St Peter SD, Tsao K, Spilde TL, Holcomb GW 3rd, Sharp SW, Murphy JP, Snyder CL, Sharp RJ, Andrews WS, Ostlie DJ. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008 Jun;43(6):981-5.

1913: LaddBismuth enema

1927 Barium

1948: Ravitch & McCune

32% Op Mortality

1953: Gross opposed Nonoperative reduction

1959 - air enema China

intuss = "within" (Lat.)

suscipere = "to receive" (Lat.)

1 in 2,000

2:1 m:f

3 mo < 50% < 9 mo

May - July

? Viral

1 in 5 + prior illness

Pathogenesis

*ceptum goes into the *cipiens ="recipient"

*ceptum swells, bleeds (currant jelly)

ASx /incidental Intussusception:

Watch

[PP are on antimesenteric border*]

*Except @ Ti

95% of Intussusception:

Ileocolic area

No PLP

20% + PLP > 2 yr old

Ileoileocolic:

4% all casesHard to reduce (25% success)

40% PLP

Pathologic Leadpoints

Meckel’s diverticulum # 1

Intestinal polyps & duplications # 2

Appendix

Ectopic gastric or pancreatic mucosa

Henoch-Schonlein purpura

Suture line

Neoplasms: leukemia, lymphoma

Hemangioma

Neurofibromas

Foreign body / Ascaris

Cystic fibrosis

Abdominal trauma

> 5yr old = > 50% chance of PLP

4% PLP 1st recurrence

14% PLP if > 1 recurrence

1200 Canadian Kids:11 Lymphomas / intussusception

Postoperative Intussusception:

1% all Int.

5 - 10% of all ped SBO

Intrauterine Intussusception

Clinical Presentation

Classic Symptoms:Intermittent colicky abdominal pain (85%)

Vomiting (50%)

Classic Signs:Abdominal Mass (25 - 50%)Rectal bleeding (25 - 50%)*

* late sign, currant jelly

Plain films 50% accuracy

Ultrasound >98% accuracy

US: ? irreducibility

Thick outer rimFree peritoneal fluid

Trapped fluid in *septumBig mesenteric LN

No flow in in*septum (Doppler) # 1

Medical Mgmt - HSP

Steroids?

Radiologic reduction (90% success)

CI’s...

Pneumatic reduction with US or Fluoroscopic guidance

Start with 50 mm Hg - > up to 110 - 120 mm Hg

Pneumatic Reduction

? sedation? glucagon? abdominal manipulation? delayed repeat enema

? home after successful reduction

Perforation < 1%

Success of air enema > 90%

Gou 19866,396 air reductions

0.14% perf rate

Gu 19939,000 pts

0.16% perf rate

Increased perf risk

< 6 mo oldSx > 36 hrs

Operation

Open or Lap

Recurrence - 5% overall

p BE 5 - 10% (AE ?)p Op reduct 3 - 5%

p Op resect 1%

Mean t (recur) = 8 months

CMH Research Intussusception

• Fraser JD, Aguayo P, Ho B, Sharp SW, Ostlie DJ, Holcomb GW 3rd, St Peter SD. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. 2009 Aug;19(4):563-5.