By Gregory E. Jeansonne
All information condensed from Schwartz: Principles of Surgery & Companion Handbook.
Background Information: The appendix originates on the posteromedial aspect of the cecum at the confluence of the three teniae coli. Position and length of the free end are variable. Lymphoid tissue enters 2wks after birth">
By Gregory E. Jeansonne
All information condensed from Schwartz: Principles of Surgery & Companion Handbook.
Background Information: The appendix originates on the posteromedial aspect of the cecum at the confluence of the three teniae coli. Position and length of the free end are variable. Lymphoid tissue enters 2wks after birth, increases through puberty, plateaus for 10yrs, and steadily resorbs until absent in the 7th decade.
Incidence: The most common acute surgical condition of the abdomen. Peaking in the 2nd and 3rd decades with 1.3:1 male predominance. 84% true pathology, 16% nonpathologic (68% female). 15-25% ruptured at presentation.
Pathophysiology: Proximal obstruction leading to distal distention from continued mucus production and bacterial multiplication. Periumbilical pain is transmitted via visceral afferent pain fibers. Increased luminal pressure leads to venous occlusion, mucosal breakdown (possible sepsis), serosal inflammation (parietal peritoneum irritation producing right lower quadrant pain), and eventual gangrene (rupture producing peritonitis of variable extent).
Clinical Findings:
Symptoms: Anorexia => Periumbilical Pain => Right Lower Quadrant Pain (McBurney's Point = 1/3 distance from ASIS to umbilicus) but variable due to position of appendix. Emesis, obstipation, and diarrhea (especially w/ children).
Signs: Mild tachycardia, mild fever (<1ºC unless ruptured). Comfort in fetal or supine with hips and knees flexed. Cutaneous hyperesthesia (right T10,11&12 dermatomes), Rovsing's sign (right lower quadrant pain with left palpation), Psoas sign (pain on extension of right leg), Obturator sign (pain on passive internal rotation of right hip), Flank pain, Cul-de-sac of Douglas pain on palpation.
Labs: Inconclusive. Mild leukocytosis (10-18k) with moderate PMN shift. Rule out UTI.
Imaging: Plain films rarely useful. Graded compression sonography most useful (positive = noncompressible appendix >6mm AP diameter). CT useful but $$$. Barium enema useful but risk rupture & peritoneal leakage. CXR rules out right lower lung problems. Laparoscopy may be diagnostic and therapeutic.
DDX: Acute Mesenteric Adenitis, Acute Gastroenteritis (salmonella), Testicular/Ovarian Torsion, Epididymitis/Seminal Vesiculitis/PID/Mittelschmerz/Endometriosis/Ectopic Pregnancy, Meckel's/Other Diverticulitis, Intussusception, Acute Ileitis/Regional Enteritis, Peptic Ulcer, Epiploic Appendagitis, UTI, Ureteral Stone, Peritonitis, Henoch-Schonlein Purpura, Yersiniosis, Bowel Perforation, Mesenteric Vascular Occlusion, Right Lower Pleuritis, Acute Pancreatitis, Abdominal Wall Hematoma.
Special Concern Groups:
Young = fast progression, high fever, increased emesis, 15-50% rupture at presentation.
Old = Clinically Mild, increased morbidity, concomitant disease, high perforation
rate.
Pregnant = Diagnosis more difficult, Fetal risk (simple => 2-8.5% mortality, ruptured
=> 20% mortality, OR => 10-15% premature labor).
HIV/AIDS = Variable Leukocytosis, CMV enteritis, Tuberculosis, Ileal Lymphoma.
Tx: Always Operate. If simple acute, operate immediately. If ruptured with local peritonitis, operate after fluid & electrolyte stability (within 4hrs). If symptoms resolving, treat medically followed by operation 6wks to 3mo later. Pre-Op antibiotics reduce infection rates but are controversial. Should be discontinued at 24hrs or after resolution of fever and leukocytosis.
Procedure: See Operation Procedure.
Px: Simple = 0.1% mortality. Ruptured = 3% mortality (15% if elderly). Morbidity is related to rupture and patient age. Early complications involve infection. Wound Infection/dehiscence, Intraabdominal abscesses, Fecal fistula. Late complications relate to adhesion formation. Barring complications, complete recovery can be expected.
Revised: August 05, 2002.