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Year : 2014  |  Volume : 7  |  Issue : 6  |  Page : 749-752  

Acute appendicitis: Common surgical emergency


Department of Surgery, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, Maharashtra, India

Date of Web Publication18-Nov-2014

Correspondence Address:
Bharat Bhushan Dogra
Department of Surgery, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.144866

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How to cite this article:
Dogra BB. Acute appendicitis: Common surgical emergency. Med J DY Patil Univ 2014;7:749-52

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Dogra BB. Acute appendicitis: Common surgical emergency. Med J DY Patil Univ [serial online] 2014 [cited 2024 Mar 28];7:749-52. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2014/7/6/749/144866


  Introduction Top


Acute appendicitis is one of the most common acute surgical conditions of the abdomen reporting to a general surgeon. The worldwide incidence of appendicitis is estimated to be 86 cases annually/100,000 population. [1] Diagnosis of appendicitis is generally straightforward, made on clinical history, examination, supported by a routine blood investigation and urine test. However, in Infants and young children, the diagnosis is difficult because 33-50% will present atypically. [1] The mortality rate of nonperforated appendicitis is <1%; however, perforated appendicitis carries a higher mortality rate of around 5%. [2] The incidence of complicated acute appendicitis like perforated or gangrenous appendicitis also remains high despite the availability of modern imaging. [2] Hence, although appendectomy for acute appendicitis is one of the most common intra-abdominal surgical procedures performed by general surgeons, morbidity rates in the postoperative period remain between 9% and 18%, respectively. [3]


  Pathophysiology Top


Classically, appendicitis is described as a dynamic disease process that comprises five stages occurring over a 24-36 h period. [4] The inciting event is the obstruction of the appendiceal lumen, which is unable to drain and, as a result, distends. The etiology is multifactorial, but fecoliths, lymphoid hyperplasia, foreign bodies, malignancy, and parasites have all been described. During the second stage, stimulation of the 8 th -10 th visceral afferent thoracic nerves causes a mild to moderate peri-umbilical pain that typically lasts from 4 h to 6 h. [5] As intraluminal pressure increases, appendiceal wall perfusion decreases due to arterial insufficiency. This third stage results in tissue ischemia and mucosal compromise. Bacteria are then able to invade the luminal wall, leading to transmural inflammation-the fourth stage. As transmural inflammation extends beyond the appendix, the parietal peritoneum and adjacent structures also become inflamed. This final stage causes a shift in pain perception from the periumbilical region to the right lower quadrant of the abdomen. At this stage, the pain is typically more severe, continuous, and often associated with constitutional symptoms, such as anorexia, fever, nausea, and vomiting. [6] If untreated, appendicitis rarely resolves spontaneously, and usually progresses to perforation. Studies have suggested that a delay of >48 h in the diagnosis or in the treatment of appendicitis results in perforation and complication rates >60%. [6] Bacterial peritonitis can subsequently arise, which may result in overwhelming sepsis and death.

Appendicitis due to foreign bodies is rare. Foreign bodies leading to appendicitis or perforation are usually sharp, pointed objects. It occurs in 0.0005% of cases of appendicitis. Various objects have been reported in the literature, including bird shot, air gun pellets, bullets, pins, needles, teeth, dental drill bits, toothpicks, bone fragments, fish-bone, fruit seeds and pits, chewing gum, gallstones, fishhooks, coins, and earrings. [7]

Rare cause of pain right lower abdomen may be diverticulitis of the vermiform appendix, the incidence of which is greater than that generally appreciated. Due to the thinned wall, these diverticula are prone to perforate early in the presence of acute inflammation. [8] Although appendiceal diverticulitis is rare, clinicians should be aware of its occurrence, because it can lead to early perforation due to the thin wall of the diverticulum.

Appendicitis within an inguinal hernia (Amyand's hernia) is another rare presentation, incidence being <1% and when it occurs, it is usually misdiagnosed as strangulated inguinal hernia, another surgical emergency. The proper treatment in such a case involves appendectomy through the herniotomy with primary hernia repair without the use of any synthetic mesh. [9] A rarer presentation of appendicitis can be pain in the left lower quadrant if the patient happens to be the case of situs inversus totalis. In such a case, chest radiograph will reveal dextrocardia, and left-sided appendicitis should be suspected. A strong suspicion of appendicitis and an emergency laparoscopic operation after confirmation of the diagnosis by imaging modalities including abdominal computed tomography (CT) can reduce the likelihood of misdiagnosis and complications including perforation and abscess. [10] Tawk et al. have reported a case of acute appendicitis presenting with a left upper quadrant pain due to intestinal malrotation. Such cases require abdominal CT, which will help in clinching the correct diagnosis. [11]


  Role of Alvarado Score Top


In 1986, Alvarado constructed a 10-point clinical scoring system, for the diagnosis of acute appendicitis as based on symptoms, signs, and diagnostic tests in patients presenting with suspected acute appendicitis [12] [Table 1].
Table 1: Probability of appendicitis by Alvarado score

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  • Alvarado score 1-4: Discharge.
  • Alvarado score 5-6: Observations/admission.
  • Alvarado score 7-10: Surgery.


The Alvarado score enables risk identification in patients presenting with abdominal pain, linking observation or surgical intervention and further investigations, such as ultrasound and CT.


  Relevance of C-Reactive Protein (CRP) Top


C-reactive protein levels >1 mg/dL are common in patients with appendicitis. Very high levels of CRP in patients with appendicitis indicate gangrenous appendicitis, especially if it is associated with leukocytosis and neutrophilia.

In adults who have had symptoms for longer than 24 h, a normal CRP level has a negative predictive value of 97-100% for appendicitis. [13]


  Urinary 5-Hydroxy Indole Acetic Acid (5-HIAA) Top


Urinary 5-hydroxy indole acetic acid levels increase significantly in acute appendicitis and decrease when the inflammation shifts to necrosis of the appendix. Therefore, such decrease could be an early warning sign of perforation of the appendix. [14]


  Role of Imaging Studies Top


• Abdominal radiographs taken for the evaluation of patients with acute abdominal pain, include the abdominal radiograph in a standing position, as well as a chest radiograph may be useful in patients with atypical presentation. Perforated appendix may present with pneumoperitoneum in only 1-2% of cases. Abdominal radiographs may show a fecolith and localized ileus.

• Ultrasonography is often used as the initial diagnostic imaging study in the majority of patients in whom the clinical diagnosis of appendicitis is equivocal. It has sensitivity of around 85% and specificity of more than 90%. In acute appendicitis, the appendix can be seen as a fluid filled, noncompressible tubular structure with a diameter of more than 6 mm. [15] Other signs of appendicitis include the presence of a fecolith, peri-cecal or periappendiceal fluid, secondary to inflammation. However, ultrasound examination is operator dependent and there may be difficulty in visualizing in obese individual.

• Computed tomography changes observed in a case of appendicitis are an appendiceal diameter >6 mm, thickening or enhancement of the appendix, and periappendiceal fat stranding. [16] Moreover, CT is not operator dependent, and is also very useful for evaluating the complications of appendicitis, identifying alternative diagnoses, and is reported to be able to identify a normal appendix in 67-100% of patients evaluated. [1] CT is especially useful in distinguishing those patients presenting late in their clinical course and who may have developed an appendicular lump or abscess.


  Appendicitis During Pregnancy Top


Acute appendicitis during pregnancy presents diagnostic problems, because during the third trimester, the uterus is rapidly enlarging and causes displacement of the cecum and appendix into the right upper abdomen. Thus, acute appendicitis in these patients causes symptoms and signs higher and more lateral during the third trimester. Diagnostic imaging techniques facilitate in clinching the diagnosis in such cases. Graded compression ultrasound has shown to be highly sensitive and specific although to a lesser degree after a gestational age of 35 weeks due to technical difficulties. [14] The ultrasound examination should be considered first in working up suspected acute appendicitis during pregnancy. CT has recently shown to be a safe and potentially reliable tool to accurately identify appendiceal changes in appendicitis. Magnetic resonance imaging is useful in pregnant patients if graded compression ultrasonography is nondiagnostic. [17]


  Management Top


Traditional management of acute appendicitis has been emergent appendectomy based on the theory that, if left untreated simple appendicitis will progress to perforation, with a resultant increase in morbidity and mortality. However, management of patients with an appendiceal mass can usually be divided into the following three categories:

a. Patients with an appendicular mass or a small abscess: After intravenous antibiotic therapy, an interval appendectomy can be performed 4-6 weeks later.

b. Patients with a larger well-defined abscess: Under broad-spectrum antibiotic cover, percutaneous drainage is performed. The patient can be discharged with the catheter in place. Interval appendectomy can be performed after the fistula is closed.

c. Patients with a multi-compartmental abscess: These patients require early surgical drainage.

Preoperative antibiotics have been very effective in decreasing postoperative wound infection rates in numerous prospective controlled studies. Broad-spectrum Gram-negative and anaerobic coverage is indicated. A retrospective study suggested that the risk of appendiceal rupture is minimal in patients with <24-36 h of untreated symptoms. [18]

Historically, emergent appendectomy was recommended for all patients with appendicitis, whether perforated or unperforated. First appendectomy was performed in 1735 by Amyan, a surgeon of the English army to remove a perforated appendix.

Since1987, however, an increasing number of surgeons prefer laparoscopic appendectomy. Laparoscopic appendectomy has some advantages, including decreased postoperative pain, better esthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. In their study Kouhia et al. they found that by 2008, operative time with laparoscopic appendectomy was only 10 min longer than with the open approach. In addition, patients who underwent open appendectomy returned to work later and had more complications. [19] Laparoscopic appendectomy is successful in approximately 90% of cases of perforated appendicitis. However, this procedure is contraindicated in patients with significant intra-abdominal adhesions. According to the 2010 Society of American Gastrointestinal and Endoscopic Surgeons guideline, laparoscopic appendectomy may be the preferred approach in perforated appendicitis, appendicitis in elderly patients and appendicitis in obese patients. [20]

Single incision laparoscopic surgery (SILS) is a new technique that has now been utilized in many centers for appendicectomy. This technique is a novel way of minimally invasive surgery using a single incision. The use of SILS has the potential of further reducing postoperative port site complications as well as improving cosmesis and patient satisfaction. [21]


  Conclusion Top


Patients with appendicitis reporting with persistent right lower abdominal pain, fever and having leukocytosis, need urgent admission and prompt treatment in the form of appendectomy. If the clinical picture is unclear, a short period of 4-6 h of watchful waiting and a CT scan may help arrive at the correct diagnosis.

 
  References Top

1.
Brennan GD. Pediatric appendicitis: Pathophysiology and appropriate use of diagnostic imaging. CJEM 2006;8:425-32.  Back to cited text no. 1
[PUBMED]    
2.
Wong CS, Naqvi SA. Appendicular perforation at the base of the caecum, a rare operative challenge in acute appendicitis, a literature review. World J Emerg Surg 2011;6:36.  Back to cited text no. 2
    
3.
Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: A contemporary appraisal. Ann Surg 1997;225:252-61.  Back to cited text no. 3
    
4.
Gandy RC, Truskett PG, Wong SW, Smith S, Bennett MH, Parasyn AD. Outcomes of appendicectomy in an acute care surgery model. Med J Aust 2010;193:281-4.  Back to cited text no. 4
    
5.
Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000;215:337-48.  Back to cited text no. 5
    
6.
Wilson EB. Surgical evaluation of appendicitis in the new era of radiographic imaging. Semin Ultrasound CT MR 2003;24:65-8.  Back to cited text no. 6
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7.
Klingler PJ, Seelig MH, DeVault KR, Wetscher GJ, Floch NR, Branton SA, et al. Ingested foreign bodies within the appendix: A 100-year review of the literature. Dig Dis 1998;16:308-14.  Back to cited text no. 7
    
8.
Rabinovitch J, Arlen M, Barnett T, Cuello R, Rabinovitch P. Diverticulosis and diverticulitis of the vermiform appendix. Ann Surg 1962;155:434-40.  Back to cited text no. 8
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9.
The Internet Journal of Surgery 2004;6:1 available at http://ispub.com/IJS//6/1/10631 [Last accessed on 2014 Nov 10].  Back to cited text no. 9
    
10.
Oh JS, Kim KW, Cho HJ. Left-sided appendicitis in a patient with situs inversus totalis. J Korean Surg Soc 2012;83:175-8.  Back to cited text no. 10
    
11.
Tawk CM, Zgheib RR, Mehanna S. Unusual case of acute appendicitis with left upper quadrant abdominal pain. Int J Surg Case Rep 2012;3:399-401.  Back to cited text no. 11
    
12.
Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64.  Back to cited text no. 12
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13.
Albu E, Miller BM, Choi Y, Lakhanpal S, Murthy RN, Gerst PH. Diagnostic value of C-reactive protein in acute appendicitis. Dis Colon Rectum 1994;37:49-51.  Back to cited text no. 13
    
14.
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;37:985-9.  Back to cited text no. 14
    
15.
Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986;158:355-60.  Back to cited text no. 15
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16.
Choi D, Park H, Lee YR, Kook SH, Kim SK, Kwag HJ, et al. The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT. Acta Radiol 2003;44:574-82.  Back to cited text no. 16
    
17.
Pastore PA, Loomis DM, Sauret J. Appendicitis in pregnancy. J Am Board Fam Med 2006;19:621-6.  Back to cited text no. 17
    
18.
Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006;202:401-6.  Back to cited text no. 18
    
19.
Kouhia ST, Heiskanen JT, Huttunen R, Ahtola HI, Kiviniemi VV, Hakala T. Long-term follow-up of a randomized clinical trial of open versus laparoscopic appendicectomy. Br J Surg 2010;97:1395-400.  Back to cited text no. 19
    
20.
Korndorffer JR Jr, Fellinger E, Reed W. SAGES guideline for laparoscopic appendectomy. Surg Endosc 2010;24:757-61.  Back to cited text no. 20
    
21.
Oltmann SC, Garcia NM, Ventura B, Mitchell I, Fischer AC. Single-incision laparoscopic surgery: Feasibility for pediatric appendectomies. J Pediatr Surg 2010;45:1208-12.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1]


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  In this article
Introduction
Pathophysiology
Role of Alvarado...
Relevance of C-R...
Urinary 5-Hydrox...
Role of Imaging ...
Appendicitis Dur...
Management
Conclusion
References
Article Tables

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