Bernard M. Jaffe, MD Professor of Surgery, Emeritus APPENDICITIS Bernard M. Jaffe, MD Professor of Surgery, Emeritus

INCIDENCE Very Common, 1 in 10,000/year 12% of Men, 25% of Women Mean Age 31 Years Rare in Infancy M:F Ratio 1.2-1.3 to 1.0 Misdiagnosis 22% in Women, 9% in Men

CAUSES Appendiceal Obstruction Children- Lymphoid Hyperplasia Adults- Fecalith Carcinoid Mucinous Carcinoma Cecal Carcinoma Parasites

PATHOGENESIS Obstruction of Appendiceal Lumen ↓ Appendiceal Distention (Mucus) Venous Ischemia/Gangrene Perforation at Base (Widest Portion)

BACTERIOLOGY Aerobes Anaerobes E. coli Klebsiella Species Pseudomonas aeroginosa Staphylococcal Species Enterococcus Bacteroides fragilis Fusobacterium Species Peptostreptococcus Clostridium Species

SYMPTOMS Abdominal Pain Classically, Peri-Umbilical to Right Lower Quadrant Constant, Not Colicky Increased With Increased Intra- Abdominal Pressure Comes on Fairly Abruptly

SYMPTOMS Anorexia, Nausea, Vomiting Bowel Movements Unpredictable Pain on Walking and Moving Abdominal Muscles Fever, Chills, Sweating Shortness of Breath

PHYSICAL FINDINGS Right Lower Quadrant and Referred Tenderness Involuntary Guarding Psoas, Obturator Signs Decreased Diaphragmatic Excursion Direct and Referred Rebound Distention, Decreased Bowel Sounds Tachycardia, Tachypnea, Flushing

DIAGNOSIS Made on Clinical Findings Anorexia as First Symptom Fairly Suggestive White Blood Cell Count Unreliable Additional Studies Rarely Necessary Imaging Grossly Overused and Rarely Helpful

DIFFERENTIAL DIAGNOSIS Crohn’s Disease Meckel’s Diverticulitis Sigmoid/Cecal Diverticulitis Pelvic Inflammatory Disease Cholecystitis Mesenteric Adenitis Ruptured Ectopic Pregnancy, Ovarian Cyst, Torsion

ALVARADO SCALE Migration of Pain Value 1 Anorexia 1 Nausea, Vomiting 1 Right Lower Quadrant Tenderness 2 Rebound 1 Elevated Temperature 1 Leukocytosis 2 Left Shift 1

ALVARADO SCALE Often Used as Diagnostic Tool Add Up Values to Determine Likelihood 9-10 Positive 7-8 High Liklihood 5-6 Equivocal 0-4 Very Unlikely

IMAGING For Equivocal Presentations To Detect Complications CT Equal Results as Ultrasound Has Not Lowered Rates of False Pos/Neg Diagnosis Perforation

IMAGING Findings- Dilated Appendix (>7cm) Thick Walled Appendix Peri-Appendiceal Fluid/Edema Adjacent Mesenteric Fat Stranding Free Air Uncommon After Perforation Failure to Fill With Contrast Unreliable

APPENDICEAL RUPTURE Overall Rate 26% Higher Rates in Children <5- 45% Elderly >65- 51% Perforation Difficult to Diagnose Increases with Length of Symptoms Suspicion- T > 39 WBC >18,000

PROGNOSIS Mortality Rate Overall 0.2/100,000 Ruptured Appendix 3% Ruptured in Elderly 15% Death Usually from Uncontrolled Sepsis Morbidity Nonperforated 3% Perforated 47% Wound Infection Most Common

LAPAROSCOPIC APPENDECTOMY ? More Effective Than Open Compared to Open- More Expensive Longer Operation Fewer Wound Infections 3-X More Abcesses Same Mortality Rate

ABCESS More Common After Perforation Gangrene Sites- Interloop (Often Multiple) Appendiceal Fossa Subhepatic Space Pelvis (Pouch of Douglas)

PELVIC ABCESSES Common After Perforated Appendicitis Usually Recognized 5-8 Days After Operation Drainage- Surgical (Open or Lap) Percutaneous (Can Be Tough) Transrectal- Most Direct Most Effective Transvaginal in Women

PREGNANCY Incidence 1 in 2,000 Pregnancies More Common First, Second Trimesters Appendix Rises as Uterus Grows Leukocytosis Confusing- 15-20,000 Normally in Pregnancy Perforation Doubles Rate of Fetal Mortality Operation- 10-25% Premature Labor

RLQ MASS Imaging Determines Therapeutic Plan Abcess- Percutaneous Drainage Antibiotics Phlegmon- Operation More Dangerous Operate for Acute Abdomen For Both, Once Well- Perform Interval Appendectomy

INTERVAL APPENDECTOMY More Expensive Two Hospitalizations, Each 1-3 Days Morbidity 3% Can Be Done Laparoscopically Controversy If It Is Necessary???

INTERVAL APPENDECTOMY Pro- 40% Need Appendectomy Earlier Than Planned Late Failure, Persistent, Recurrent Appendicitis 35% At Operation, 80% Have Peri-Appendiceal Abcess or Adhesions Occasional Appendiceal Tumor

INTERVAL APPENDECTOMY Con- 50% Never Have Subsequent Clinical Appendicitis 25-50% Have Normal Histology Despite Minimal Procedure, It is Another Operation Requires Recuperation

CHRONIC APPENDICITIS Pain Same Location, Less Intense, Lasts Longer Anorexia, Nausea, Less Vomiting Normal WBC Counts, Imaging Surgeons Establish Diagnosis With 94% Specificity, 78% Sensitivity Good Correlation Symptoms With Findings Appendectomy Cures 94%

INCIDENTAL APPENDECTOMY Need 36 Appendectomies to Prevent One Appendicitis Spend $20 Million to Save $6 Million Special Circumstances- Disabled Patients Crohn’s Disease (at Other Operation) Children About to Start Chemotherapy Travel to Remote Places

APPENDICEAL TUMORS Rare, 0.9 to 1.4% Appendectomies 0.12 Per 1,000,000 People/Year Rarely Suspected Pre-Op Only 50% Diagnosed at Operation Mucocele (Benign or Malignant) More Common Than Carcinoid Also Lymphoma- Very Rare