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

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

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

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

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

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

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

8. 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

9. 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

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

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

12. 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

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

14. 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

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

16. 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

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

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

19. 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

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

21. 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

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

23. 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

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

25. 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%

26. 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

27. 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