Appendicitis

Mark W. Jones; Hassam Zulfiqar; Jeffrey G. Deppen.

Last Update: June 26, 2019.

Introduction
Appendicitis is inflammation of the vermiform appendix. This is a hollow organ located at
the tip of the cecum, usually in the right lower quadrant of the abdomen. However, it can be
located in almost any area of the abdomen depending on if there were any abnormal
developmental issues or if there are any other concomitant conditions such as pregnancy or
prior surgeries. The appendix develops embryonically at the fifth week. During this time
there is a movement of the midgut to the external umbilical cord with the eventual return to
the abdomen and rotation of the cecum. This results in the usual retrocecal location of the
appendix. It is most often a disease of acute presentation, usually within 24 hours, but it can
also present as a more chronic condition. If there has been a perforation with a contained
abscess, then the presenting symptoms can be more indolent. The exact function of the
appendix has been a debated topic. Today it is accepted that this organ may have an
immunoprotective function and acts as a lymphoid organ especially in the younger person.
Other theories contend that the appendix acts as a storage vessel for "good" colonic bacteria.
Still, others argue that it is a mear developmental remnant and has no real function.[1][2][3]

Etiology
The cause of appendicitis is usually from an obstruction of the appendiceal lumen. This can
be from an appendicolith (stone of the appendix), or from some other mechanical etiologies.
Appendiceal tumors such as carcinoid tumors, intestinal parasites, and hypertrophied
lymphatic tissue are all known causes of appendiceal obstruction and appendicitis. Often, the
exact etiology of acute appendicitis is unknown. When the appendiceal lumen gets
obstructed, bacteria will build up in the appendix and cause acute inflammation with
perforation and abscess formation. One of the most popular misconceptions is the story of the
death of Harry Houdini. After being unexpectedly punched in the abdomen, the rumor goes,
his appendix ruptures causing immediate sepsis and death. The facts are that Houdini did die
from sepsis and peritonitis from a ruptured appendix, but it had no connection to him being
struck in the abdomen. It was more related to widespread peritonitis and the limited
availability of effective antibiotics at the time.[4][5]

Epidemiology
Appendicitis occurs most often between the ages of 5 and 45 with a mean age of 28. The
incidence is approximately 233/100,000 people. Males have a slightly higher predisposition
of developing acute appendicitis compared to females, with a lifetime incidence of 8.6% for
men and 6.7 % for women. There are approximately 300,000 hospital visits yearly in the
United States for appendicitis-related issues.

Pathophysiology
The pathophysiology of appendicitis likely stems from obstruction of the appendiceal orifice.
This results in inflammation, localized ischemia, perforation, and the development of a
contained abscess or frank perforation with resultant peritonitis. This obstruction may be
caused by lymphoid hyperplasia, infections (parasitic), fecaliths, or benign or malignant
tumors. When an obstruction is the cause of appendicitis, it leads to an increase in
intraluminal and intramural pressure, resulting in small vessel occlusion and lymphatic stasis.
Once obstructed, the appendix fills with mucus and becomes distended, and as lymphatic and
vascular compromise advances, the wall of the appendix becomes ischemic and necrotic.
Bacterial overgrowth then occurs in the obstructed appendix, with aerobic organisms
predominating in early appendicitis and mixed aerobes and anaerobes later in the course.
Common organisms include Escherichia coli, Peptostreptococcus, Bacteroides,
and Pseudomonas. Once significant inflammation and necrosis occur, the appendix is at risk
of perforation leading to a localized abscess and sometimes frank peritonitis.[6]
The most common position of the appendix is retrocecal. While the anatomical position of
the root of the appendix is mostly constant, tail positions can vary. Possible positions include
retrocecal, subcecal, pre- and post-ileal, and pelvic.

Histopathology
Microscopic findings in acute appendicitis include the proliferation of neutrophils of the
muscularis propria. The degree and extent of inflammation are directly proportionate to the
severity of the infection and duration of the disease. As this condition progresses, extra
appendiceal fat and surrounding tissues become involved in the inflammatory process. In
severe situations, the cecum may be involved and may require resection at the time of
surgery.

History and Physical

Classically, appendicitis presents as an initial generalized or periumbilical abdominal pain
that then localizes to the right lower quadrant. Initially, as the visceral afferent nerve fibers at
T8 through T10 are stimulated, and this leads to vague centralized pain. As the appendix
becomes more inflamed and the adjacent parietal peritoneum is irritated, the pain becomes
more localized to the right lower quadrant. Pain may or may not be accompanied by any of
the following symptoms:
 Anorexia
 Nausea/vomiting
 Fever (40% of patients)
 Diarrhea
 Generalize malaise
 Urinary frequency or urgency

Uncommon presentation
Some patients may present with uncommon features such as pain localized to the right lower
quadant. In these patients, the pain may have woken the patient up from sleep. In addition,
the rare patient may complain of pain while walking or coughing.
Pain upon passive extension of the right leg with the patient in the left lateral decubitus
position is known as psoas sign. This maneuver stretches the psoas major muscle, which can
be irritated by an inflamed retrocecal appendix. Patients often flex the hip to shorten the
psoas major muscle and relieve pain.
Physical exam findings are often subtle, especially in early appendicitis.
As inflammation progresses, signs of peritoneal inflammation develop. Signs include:
 Right lower quadrant guarding and rebound tenderness over McBurney's point (1.5 to 2
inches from the anterior superior iliac spine on a straight line from the ASIS to the umbilicus)
 Rovsing's sign (right lower quadrant pain elicited by palpation of the left lower quadrant)
 Dunphy's sign (increased abdominal pain with coughing)

Other associated signs such as psoas sign (pain on external rotation or passive extension of
the right hip suggesting retrocecal appendicitis) or obturator sign (pain on internal rotation of
the right hip suggesting pelvic appendicitis) are rare.
The time course of symptoms is variable but typically progresses from early appendicitis at
12 to 24 hours to perforation at greater than 48 hours. Seventy-five percent of patients present
within 24 hours of the onset of symptoms.
The risk of rupture is variable but is about 2% at 36 hours and increases about 5% every 12
hours after that.

Evaluation
The emergency department physician must refrain from giving the patient any pain
medication until the patient has been seen by the surgeon. The analgesics can mask the
peritoneal signs and lead to a delay in diagnosis or even a ruptured appendix.
Lab Testing
Elevated white blood cells (WBC) with or without a left shift or bandemia is classically
present, but up to one-third of patients with acute appendicitis will present with a normal
WBC count. There are usually ketones found in the urine and the CRP may be elevated.
Imaging
Appendicitis is traditionally a clinical diagnosis. However, CT scan has greater than 95%
accuracy for the diagnosis of appendicitis and is used with increasing frequency.[7][8][9]
CT criteria for appendicitis include an enlarged appendix (greater than 6 mm in diameter),
appendiceal wall thickening (greater than 2 mm), peri-appendiceal fat stranding, appendiceal
wall enhancement, the presence of appendicolith (approximately 25% of patients). It is
unusual to see air or contrast in the lumen with appendicitis due to luminal distention and
possible blockage in most cases of appendicitis. Nonvisualization of the appendix does not
rule out appendicitis.
Ultrasound is less sensitive and specific than CT but may be useful to avoid ionizing
radiation in children and pregnant women. MRI may also be useful for the pregnant patient
with suspected appendicitis and an indeterminate ultrasound.
Classically the best way to diagnose acute appendicitis is with a good history and detailed
physical exam performed by an experienced surgeon. Today, however, it is very easy to get a
CT scan done in the emergency department. It has become common practice to rely mostly
on the CT report to make the diagnosis of acute appendicitis. Occasionally appendicoliths are
incidentally found on routine x-rays or CT scans. These patients are at a higher risk to
develop appendicitis than the general population.
These patients should be considered for prophylactic appendectomies. Studies have also
shown a 10% to 30% incidence of appendicoliths present in appendectomy specimens done
for acute appendicitis.

Treatment / Management
While in the emergency department, the patient must be kept NPO and hydrated
intravenously with crystalloid. Antibiotics should be administered intravenously as per the
surgeon. The responsibility for the consent falls on the surgeon.
The gold-standard treatment for acute appendicitis is to perform an appendectomy. Today the
laparoscopic appendectomy is preferred over the open approach. Most uncomplicated
appendectomies are performed laparoscopically. In cases where there is an abscess or
advanced infection, the open approach may be needed. The laparoscopic approach affords
less pain, quicker recovery, and the ability to explore most of the abdomen through small
incisions. Situations, where there is a known abscess from a perforated appendix, may require
a percutaneous drainage procedure usually done by an interventional radiologist. This
stabilizes the patient and allows the inflammation to subside over time enabling a less
difficult laparoscopic appendectomy to be performed at a later date. Practitioners also start
patients on broad-spectrum antibiotics. There is some disagreement regarding preoperative
antibiotic administration for uncomplicated appendicitis. Some surgeons feel routine
antibiotics in these cases are not warranted, while others give them routinely. There have also
been several studies promoting the treatment of uncomplicated appendicitis solely with
antibiotics and avoiding surgery altogether.[1][10]
In patients with an appendiceal abscess, some surgeons continue antibiotics for several weeks
and then perform an elective appendectomy. When the appendix has ruptured, the procedure
can still be done laparoscopically but extensive irrigation of the abdomen and pelvis is
necessary. In addition, the trocar sites may have to be left open.

Differential Diagnosis
The differential diagnosis includes Crohn ileitis, mesenteric adenitis, mittelschmerz,
salpingitis, ruptured ovarian cyst, ectopic pregnancy, tubal-ovarian
abscess, musculoskeletal disorders, endometriosis, pelvic inflammatory disease,
gastroenteritis, right-sided colitis, renal colic, kidney stones, irritable bowel disease, testicular
torsion, ovarian torsion, round ligament syndrome, epididymitis, and other
nondescript gastroenterological issues.

Prognosis
If diagnosed and treated early, within 24 to 48 hours, the recovery and prognosis should be
very good. Cases that present with advanced abscesses, sepsis, and peritonitis may have a
more prolonged and complicated course, possibly requiring additional surgery or other
interventions.

Complications
Postoperative abscesses, hematomas, and wound complications are all complications that can
be seen after appendectomies. If the wound does get infected, one may grow bacteroides.
"Recurrent" appendicitis can occur if too much of the appendiceal stump is left after an
appendectomy. This acts just like an appendix and can become occluded and infected just as
with the initial episode. Therefore, it is important to ensure that there be very minimal and
preferably no residual appendiceal stump after an appendectomy. If left untreated,
appendicitis can lead to abscess formation with the development of an enterocutaneous
fistula. Diffuse peritonitis and sepsis can also develop which may progress to significant
morbidity and possible death.

Pearls and Other Issues

Special consideration should be given to the treatment of patients with perforated appendicitis
with an abscess. Those who present with an abscess and do not exhibit peritonitis may benefit
from CT or ultrasound-guided percutaneous drain placement as well as antibiotics. Interval
appendectomy is classically performed 6 to 10 weeks after recovery. Historically, 20% to
40 % of patients treated medically for perforated appendicitis with abscess had recurrent
appendicitis in historical literature. More recent studies suggest these rates be much lower.
Complications of appendicitis and appendectomy include surgical site infections, intra-
abdominal abscess formation (3% to 4% in open appendectomy and 9% to 24% in
laparoscopic appendectomy), prolonged ileus, enterocutaneous fistula, and small bowel
obstruction.
Occasionally the incorrect diagnosis of acute appendicitis is made when in reality the correct
diagnosis is Crohn's disease of the cecum or terminal ileum. It is important to know that is
this occurs that the appendix should be left in place if there is involvement at its base.
Removal of the appendix in this situation has a high leak and fistula rate formation. On the
other hand, if the base of the appendix is spared, then the appendix should be removed, even
if it appears normal. This eliminates the future confusion of diagnosing acute Crohn's versus
acute appendicitis.
In the past, it was commonplace to routinely remove the appendix at the time of other
nonrelated surgeries to avoid developing appendicitis in the future. Today, however, most
surgeons do not routinely remove a normal appendix at the time of other scheduled
procedures. If a patient does go into surgery for an incorrect diagnosis of acute appendicitis,
then it is advised to remove the appendix to avoid any future diagnostic issues.

Enhancing Healthcare Team Outcomes

Several guidelines exist that can help healthcare workers make a diagnosis of appendicitis.
While most physicians, nurse practitioners, and physician assistants rely on the physical
exam, others may obtain an ultrasound. For questionable cases, a CT scan of the abdomen
may be helpful. The American College of Radiology recommends an ultrasound in pregnant
women and an MRI in inconclusive cases in the same patient population.[11][12]
Controversy also exists on how to best manage an appendiceal mass or phlegmon and when
to undertake surgery. There is no longer any question that laparoscopic appendectomy is
associated with minimal pain and faster recovery, but it is costly. Other studies indicate that a
single small incision provides comparable results to a laparoscopic appendectomy and is cost
effective. In view of these controversies, a multidisciplinary approach to diagnosis and
management of appendicitis needs to be established in each institution to ensure that the
patient has no morbidity and the management is cost-effective. [13](level III)
Outcomes
Many large series show that simple appendicitis treated either with an open or laparoscopic
procedure has excellent outcomes. (Level III) However, more severe and complicated
appendicitis is known to be associated with worse outcomes and greater utilization of
resources. Further, the atypical presentation of appendicitis in pregnancy and the elderly may
also make diagnosis difficult and lead to a higher incidence of complications. [14][15](Level
III) In an era of managed care where quality care indices are monitored, it behooves
healthcare workers to know the current standards of diagnosis and management of
appendicitis or face denial of reimbursement.

References
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