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TOPIC: Acute appendicitis: etiology, pathogenesis, classification,

clinical signs, diagnosis, differential diagnosis, treatment, atypical
clinical picture of acute appendicitis, complications.

Anatomy and Physiology

The appendix is a derivative of the midgut along with the ileum and ascending colon. In the
adult, the average length of the appendix is 6-9 cm. Its outside diameter varies between 3 and 8 mm
and the luminal diameter is between 1 and 3 mm. The tip of the appendix can be located anywhere
in the right lower quadrant of the abdomen or pelvis. There are six locations of appendix regarding
cecum: medial - the tip of the appendix is located medial to the cecum between the loops of the
small intestine, lateral - appendix adjacent to the peritoneum covering the anterior abdominal wall
laterally to the cecum, ascending (subhepatic) - the tip of the appendix is located under the liver,
descending (pelvic) - appendix falls down to the small pelvis, retrocecal - appendix is located
behind the cecum, retroperitoneal – is located retroperitonealy. In case of retrocecal location
appendix has mesentery. It is pelvic in location in 30% and retroperitoneal in 2% of the population.
The base of the appendix can be located by following the longitudinally oriented tenia coli to their
confluence at the cecum.
The appendix receives its arterial supply from the appendicular branch of the ileocolic artery.
This artery originates posterior to the terminal ileum, entering the mesoappendix close to the base of
the appendix. A small arterial branch arises at this point that runs to the cecal artery. The lymphatic
drainage of the appendix flows into lymph nodes that lie along the ileocolic artery. Innervation of
the appendix is derived from sympathetic elements contributed by the superior mesenteric plexus
(T10–L1) and solar plexus, afferents from parasympathetic elements brought in via the vagus nerve.
In women from the base of the appendix to the right broad ligament of the uterus goes fold of
peritoneum, known as ligament Clado (lig. appendico-ovaricum), in which the blood and lymph
vessels go. This explains the spread of infection from the appendix on the female internal genitalia
and vice versa.
The histological features of the appendix include the following: first, the muscularis layers are
not well defined and may be deficient in some locations; second, in the submucosa and mucosa,
lymphoid aggregates occur with or without the typical structure of a germinal center. Lymph
vessels are prominent in regions underlying these lymphoid aggregates. Third, the mucosa is like
that of the large intestine, except for the density of the lymphoid follicles. The crypts are irregularly
sized and shaped, in contrast to the more uniform appearance of the crypts in the colon.
Neuroendocrine complexes composed of ganglion cells, Schwann cells, neural fibers, and
neurosecretory cells are positioned just below the crypts. Serotonin is a prominent secretory product
and has been implicated in mediating pain arising from the noninflamed appendix. These complexes
may be the source of carcinoid tumors, for which the appendix is known to be the most common
site of origin.
With regard to function, the widely held notion that the appendix is a vestigial organ is not
consistent with the facts. Curiously, the appendix seems more highly developed in the higher
primates, and it is possible that the appendix may play a role in immune surveillance. In addition,
although the unique function of the appendix remains unclear, the mucosa of the appendix, like any
mucosal layer, is capable of secreting fluid, mucin, and proteolytic enzymes.

BACKGROUND
Appendicitis is an inflammation of the inner lining of the vermiform appendix that spreads to its
other parts. This condition is a common and urgent surgical illness with protean manifestations,
generous overlap with other clinical syndromes, and significant morbidity, which increases with
diagnostic delay. Despite diagnostic and therapeutic advancement in medicine, appendicitis remains
a clinical emergency and is one of the more common causes of acute abdominal pain.
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HISTORY
Although appendicitis has been a common problem for century years it was not until the early
19th century that the appendix recognized as an organ capable of causing disease. There was
continued debate through the mid 1800s about the cause of right lower quadrant inflammation with
terms such as perityphlitis and paratyphlitis commonly used. In 1827, Melier described several
autopsy cases of appendicitis and clearly stated the opinion that the appendix was the likely cause,
including the presumed patho-physiology that is accepted today. However, a strongly opposing
position by Dupuytren, the most eminent surgeon of the time, caused Melier's views to not gain
widespread acceptance. Continued work in Britain and Germany pointed to the appendix as a potential
source of disease, and indeed, the number of publications on diseases of the appendix began to
increase significantly by 1860. By 1880, both Matterstock in Germany and With in Norway published
papers that clearly point to the appendix as a significant cause of iliac fossa inflammation. In 1886,
Reginald Fitz of Boston made a landmark contribution by discussing the appendix as the primary
cause of right lower quadrant inflammation. He coined the term appendicitis and, importantly,
recommended early surgical treatment of the disease. By 1886, the widespread availability of
anesthesia and the growing acceptance of antisepsis set the stage for the rapid application of these
recommendations, with several U.S. surgeons making important contributions.
Before 1886, a number of cases of intervention for appendicitis had been reported. However, most
of these patients underwent surgery well after the disease was established, with the primary goal
to drain the infection. Several papers of note were published in the ensuing years. In 1889, Chester
McBurney described the migratory pain as well as the finger point localization of pain between
1,5 and 2 inches from the anterior iliac spine on an oblique line to the umbilicus. He incorrectly
stated that this was an almost constant finding in patients with appendicitis. McBurney in New York
and McArthur in Chicago described a right lower quadrant muscle splitting incision for surgical
treatment in 1894. It is interesting to note that McBurney kept his patients on bed rest for at least 4
weeks after surgery! In 1905, Murphy clearly described the appropriate sequence of symptoms of pain
followed by nausea and vomiting with fever and exaggerated local tenderness in the position
occupied by the appendix. There continued to be significant improvements in survival, so by the time
penicillin became routinely available in the late 1940s, the mortality rate for appendicitis was less
than 2%. Further advances in the management of appendicitis have included the recognition of
the polymicrobial flora, improved diagnostic studies, and interventional radiologic procedures for
treatment of abscesses. The mortality rate for appendicitis is 0,2-0,8%. Appendicitis occurs
infrequently in very young children and elderly persons. The disease has a maximal incidence in
patients in their late teens and 20s. There is a slight increased prevalence in males versus females.

ETIOLOGY AND PATHOGENESIS

ROLE OF ENVIRONMENT: DIET AND HYGIENE. Given the relatively lower frequency of
appendicitis and other bowel disorders among peoples with high fiber diets, it has been proposed
that low-fiber diets contribute to changes in motility, flora, or luminal conditions that predispose to
development of fecaliths. Striking, however, is the observation that most patients with acute
appendicitis do not have obvious fecalith or stone in either population group.
ROLE OF OBSTRUCTION. Early descriptions conceptualized acute appendicitis as a closed-loop
obstruction with the obstruction usually being caused by a fecalith. More recently, it has become
dogma that, in the absence of a fecalith, many cases of obstruction are caused by hyperplasia of
lymphoid tissue in the mucosa and submucosa. In a very small percentage of cases, perhaps 2%,
obstruction is caused by neoplasm (carcinoma or carcinoid tumor) or, very rarely, a foreign body. In
the evolution of acute appendicitis, the following sequence of events is envisioned: first, luminal
obstruction leads to secretion of mucus and fluid, with a consequent rise in luminal pressure;
second, when the rise in luminal pressure exceeds pressure within the submucosal venules and
lymphatics, outflow of blood and lymph is obstructed, leading to increases in pressure within the
appendiceal wall; and third, when capillary pressure is exceeded, mucosal ischemia, inflammation,
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and ulceration are the result. Eventually, bacterial overgrowth within the lumen and bacterial
invasion into the mucosa and submucosa lead to transmural inflammation, edema, vascular stasis,
and necrosis of the muscularis. Perforation ensues. Accompanying the local changes within the
appendix is a regional inflammatory response mediated by the mesothelium and blood vessels in the
parietal peritoneum and serosa of nearby visceral structures. This leads to formation of a walled-off,
periappendiceal abscess. Alternatively, if surrounding structures fail to wall off the evolving
phlegmon, perforation of the appendix would cause spillage into the peritoneal cavity, leading to
spreading peritonitis, massive thirdspacing of fluid, shock, prostration, and then death. Although it
is widely accepted that obstruction is the inciting event in most cases of acute appendicitis, it is
worth pointing out some observations that are not consistent with this hypothesis. The first
observation is that impacted fecaliths have been observed with no accompanying local
inflammation or syndrome of appendicitis. In addition, fecalith impaction or functional evidence of
obstruction cannot be demonstrated in a substantial number, up to half, of cases. Thus obstruction
may be just one of many factors involved in the etiology and pathogenesis of acute appendicitis.
ROLE OF NORMAL COLONIC FLORA. The flora of the inflamed appendix differs from that of the
normal appendix. About 60% of aspirates of inflamed appendices have anaerobes, compared to
25% of aspirates from normal appendices. Presumably, the lumen is the source of organisms that
invade the mucosa when mucosal integrity is compromised by increased luminal pressure or
intramural ischemia. Tissue specimens from the inflamed appendix wall (not luminal aspirates)
virtually all culture out E. coli and Bacteroides species. In fact, studies indicate that invasion of
tissue by Bacteroides elicits specific humoral responses. Moreover, as is discussed next, in many
cases in which acute appendicitis is highly likely, antibiotic therapy alone can reverse the evolving
clinical syndrome and permit individuals to get well without an operation. Thus, the normal colonic
flora play a key role in the evolution of acute appendicitis to gangrene and perforation.

CLASSIFICATION
Best of all reflects the clinical course of disease classification proposed by V.I. Kolesov (1972):
1. Appendicular colic;
2. Simple appendicitis (superficial, catarrhal);
3. Destructive appendicitis: phlegmonous, gangrenous, perforating;
4. Complications of acute appendicitis: appendicular infiltrate, appendicular abscess, diffuse
peritonitis, abdominal abscesses, pylephlebitis, liver abscesses, sepsis.

CLINICAL PICTURE
NATURAL HISTORY AND COMPLICATIONS
As classically conceptualized, acute appendicitis progresses inexorably, from obstruction to
mucosal and then transmural inflammation, necrosis, and then gangrene with local inflammatory
responses from the visceral and parietal peritoneum, to perforation with local abscess formation or
spreading peritonitis. One time-honored observation has been that perforation is not common if
symptoms have been present for less than 24 h. In one recent study, 1895 consecutive adult patients
with symptoms and signs of acute appendicitis were monitored prospectively. Fifteen patients
ultimately were shown to have a perforation. Of these, 3 (20%) developed perforation earlier than
24 h after onset of symptoms; in 1 patient, perforation occurred as early as 10 h after the onset of
symptoms. Average time from onset of symptoms to perforation was 64 h. Once necrotic or
perforated, other complications can result. What should be emphasized about such complications is
that they are observed generally in the very young and the very old. In other words, these
complications occur in patients who cannot speak for themselves or infirm patients who do not
experience the acute lower abdominal symptoms that would ordinarily motivate the patient to see a
physician more quickly.
CLINICAL PRESENTATION
SYMPTOMS
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At the onset of the episode, the patient typically reports crampy (colicky) abdominal pain. This
quality of the pain is attributable to the initial response of the muscularis of the appendix (or any
hollow-lumen organ) to obstruction. The pain is described as diffuse or perhaps centered about the
umbilicus or epigastric region; this is because the appendix arises from the midgut, an embryonic
midline structure that derives its innervation from autonomic afferents related to the spinal cord
centered around T10 (solar plexus). Typically, this pain does not radiate, nor do the patients
describe it as being exacerbated by changes in body position, meals, urination, or defecation. As the
response to luminal obstruction evolves to include luminal distension, intramural edema, and
ischemia, the pain becomes constant and is located in rught lower quadrant (sign of pain migration
Kocher-Volkovych). Single vomiting is often reported by younger patients but is not a prominent
symptom in mature adult and aged patients. In general, patients with appendicitis report nausea and
loss of appetite; a patient reporting a normal appetite is very uncommon.
SIGNS
The invasion of bacteria with ensuing inflammatory response within the appendiceal wall and the
surrounding visceral structures leads to appearance of pain and tenderness localized to the area of
parietal peritoneum overlying the inflamed tissue (“phlegmon”). Fever above 38.2°C rarely occurs
early in the appendicitis syndrome and usually appears after the time when localizing tenderness
appears. In many cases, the localized pain and tenderness are accompanied by peritoneal findings
that are localized to the right lower quadrant of the abdomen. These symptoms include rebound
tenderness (Blumberg’s sign – the abdominal wall is compressed slowly and then rapidly released,
presence of pain makes the sign positive), referred tenderness, and involuntary guarding in the area
overlying the phlegmon. Although its predictive power is disputed, McBurney’s point is supposed
to be the place where the appendix lies and therefore the place of maximum tenderness. When the
inflamed portion of the appendix (usually the tip) is not located near the parietal peritoneum, the
place of maximal tenderness is not necessarily in the right lower quadrant. In fact, there may be no
localizing area of tenderness when the appendix is located in a retroperitoneal or retroileal position
or in the true pelvis. Theoretically, an acutely inflamed appendix in the true pelvis can be suspected
by means of rectal examination when the examiner elicits localized tenderness or palpates a mass.
Classic texts also recognize three diagnostic maneuvers: Rovsing’s sign left hand presses on the
anterior abdominal wall in the left iliac area in the projection of the descending colon, right hand
presses on the anterior abdominal wall above the left hand. Increased pain in the right iliac region
indicates the presence of inflammation of the appendix; the mechanism of symptom is associated
with the movement of gases through colon towards the cecum and stretching of appendix. The
psoas sign is elicited by positioning the patient on the left side and extending the right hip. Pain
produced with this maneuver reflects irritation of the right psoas muscle and indicates retrocecal
and retroperitoneal irritation from a phlegmon or an abscess. The obturator sign is produced by
positioning the patient supine and then rotating the flexed right thigh internally, from lateral to
medial. Pain produced with this maneuver indicates inflammation near the obturator muscle in the
true pelvis. It should be recognized that each of these “signs” is sought as a way of establishing the
location of the inflamed or perforated appendix. It is only in the context of a characteristic history
and examination that the diagnosis of appendicitis itself is made. These considerations emphasize
that no one symptom or finding, observed at any single point in time, reliably establishes or
excludes the diagnosis of acute appendicitis: It is the overall clinical picture that counts.
Other signs:
Voskresenski’s sign - the doctor sits down to the right near the patient, with his left hand stretches
patients shirt, fingertips of his right and slips from the right costal arch to the right iliac area. If the
patient feels a sharp pain at the end of slide, the sign is positive;
Rozdolsky’s sign – pain at percussion in the right iliac region, resulting from shaking the parietal
peritoneum in the area of nflammation.
Perforation of the appendix is caused by purulent destruction of the wall in phlegmonous
appendicitis or gangrenous necrosis, and accompanied by a sharpintensification of pain in the right
iliac area and spread it around the abdomen. This increased pain is especially noticeable on the
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background of calming down in the case of his gangrenous appendicitis. The patient develops
diffuse peritonitis, anterior abdominal wall is not involved in the act of breathing, positive
Blumberg's sign in all parts of the abdomen. Oftenly develops high hectic fever.
Acute appendicitis with pelvic location of the appendix is characterized by poor clinical picture and
atypical course. The pain is localized and expressed slightly in the lower abdomen above the pubis.
Often the patients have diarrhea and frequent urge to painful defecation (tenesmus), if the appendix
tip is adjacent to the front wall of the rectum, or dysuria if the appendixs is adjacent to the bladder.
Symptoms of peritoneal irritation are not expressed. A rectal or vaginal study (in women) define
pain, hanging right wall of the rectum or vagina.

LABORATORY FINDINGS
Routine laboratory studies are helpful in diagnosing acute appendicitis, largely through exclusion of
other conditions. Perhaps the only truly routine study is the leukocyte count. It is well recognized
that the white blood cell (WBC) count is usually elevated in bona fide cases of appendicitis.
However, a substantial number of patients have the diagnosis and a normal WBC count. Depending
on the clinical circumstances, three other types of studies should be performed routinely. First, urine
analysis with microscopic examination should be performed in all patients with suspected
appendicitis. The goal of performing the test is to exclude ureteral stones (hematuria) and to
evaluate the possibility of urinary tract infection (pyuria, bacteruria) as a cause of lower abdominal
pain, particularly in elderly diabetic patients. The presence of UTI thus does not exclude acute
appendicitis, but does need to be identified. The newer “dipsticks” that contain indicators for
bacterial infection can be used to supplant the microscopic examination. Second, measurement of
serum liver enzymes and amylase levels can be very helpful in diagnosing liver, gallbladder, or
pancreatic inflammation if the pain is described as being more in the midabdomen or even right
upper quandrant. Serum amylase levels are reported elevated in 3% to 10% of patients with acute
appendicitis or acute lower abdominal pain not attributable to pancreatitis. If pancreatitis is the
cause, the pattern of amylase elevation is usually higher and is accompanied by elevations of serum
lipase. Measurements of serum amylase are not recommended for all patients with abdominal pain,
but should be considered in patients with atypical clinical features. Third, serum HCG (human
chorionic gonadotropin) levels should be measured in women of childbearing years if there is any
possibility of pregnancy.

IMAGING STUDIES
Four types of imaging studies may assist in the diagnosis of acute appendicitis. Plain abdominal
films have been used regularly in evaluation of patients with acute abdominal pain. The finding
most commonly associated with acute appendicitis is the fecalith. However, although fecaliths are
found in 10%–40% of patients with appendicitis, it is difficult to formulate estimates of the
sensitivity and specificity of the finding of a fecalith. It would appear, however, that in the setting of
acute abdominal pain, the presence of fecalith is likely to be associated with acute appendicitis
about 90% of the time. It may thus be regarded as a sensitive sign of acute appendicitis and
predictive of a high likelihood of progression to perforation.
In older patients, where perforated viscus is a major part of the differential diagnosis, it is difficult
to argue against the plain film as the initial imaging study. In younger patients, the low likelihood of
finding a fecalith suggests that obtaining plain films is not cost-effective. If such films are done, it is
best to obtain a complete series of plain films, including flat and upright views.
A follow-up barium enema can be helpful but is not more helpful than other modalites.
Ultrasound examination of the abdomen has become increasingly popular in recent years. Key
findings of this study include (1) thickening of the wall and loss of the normal layers (“target” sign);
(2) loss of wall compressibility; (3) increased echogenicity of the surrounding fat; and (4) loculated
pericecal fluid. Although this test has a relatively low sensitivity level (80%), it has a relatively high
specificity (90%). This imaging modality is very helpful in excluding other causes of abdominal
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pain in women, particularly those in their childbearing years. When gynecological causes of pain
are difficult to exclude, vaginal ultrasound may be a useful adjunct in these patients.
Computerized tomography (CT) may be considered the gold standard for noninvasive imaging of
acute appendicitis. The CT scan can detect and localize inflammatory mass and abscess; if orally
administered contrast fills the appendiceal lumen and no inflammatory changes are present, the
diagnosis is essentially excluded. In addition, other abdominal pathology can be detected, including
lesions in the pelvis. Although technological innovation has produced highresolution images with
standard or helical imaging protocols, a technique for focused helical CT of the appendix has
recently been introduced as a means of saving time and cost without reducing accuracy. However, it
is not clear that such cost savings can be realized in institutions that do not have access to this
technology.

A number of clinical and laboratory based scoring systems have been devised to assist diagnosis.
The most widely used is Alvarado score:
Symptoms
Migratory right iliac fossa pain 1 point
Anorexia 1 point
Nausea and vomiting 1 point
Signs
Right iliac fossa tenderness 2 points
Rebound tenderness 1 point
Fever 1 point
Laboratory
Leucocytosis 2 points
Shift to left (segmented neutrophils) 1 point
Total score 10 points
A score below 5 is strongly against a diagnosis of appendicitis – patient should be observed during
24-48 h with WBC control, while a score of 7 or more is strongly predictive of acute appendicitis –
patient is indicated appendectomy. In patients with an equivocal score of 5-6, CT scan should be
performed to make correct diagnosis and reduce the rate of negative appendicectomy.

EVALUATION AND MANAGEMENT OF THE PATIENT WITH SUSPECTED

APPENDICITIS
STRUCTURED AND HISTORY EXAMINATION
A structured approach to the patient with acute abdominal pain improves diagnostic accuracy and
accelerates the initiation of the correct management plan. Three points deserve repeat emphasis:
first, the evolution of symptoms and signs is the key to correct diagnosis and one examination alone
is not usually sufficient to render a diagnosis; second, the examination is incomplete unless digital
rectal and (in women) speculum/ bimanual examinations of the pelvis are performed; third, urine
analysis and pregnancy test should be performed to avoid missing a diagnosis of urinary tract
processes and pregnancy, as well as to prevent unknowing exposure of an unborn fetus to X-ray
radiation.
INDICATIONS FOR OPERATION
When the diagnosis of appendicitis has been made with a reasonable degree of certainty (more then
7 point of Alvarado score), operation is indicated except in unusual circumstances. One such
circumstance involves the patient in whom the acute illness has passed but is now complicated by
formation of a well-circumscribed infiltration or abscess.
Appendicular infiltrate – is an inflammatory conglomerate formed by greater omentum, small
bowel loops, cecum and ascending colon, which adhere each other to separate the inflammed
destructed appendix and exudate from the free abdominal cavity. Infiltrate formed in case of high
protection ability of macroorganism and low virulence of microorganisms that caused acute
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appendicitis. The frequency of different authors ranges from 0.2% to 5%. Infiltrate is being formed
on 3-5 days from the disease beginning. During questioning the patient can establish that the disease
began typically for acute appendicitis, but gradually abdominal pain decreased, became dull, and at
the time of addressing in the hospital more often pain occurs during movement and does not bother
the patient at rest. Decreased patient's body temperature to normal or low-grade. On the background
of deceasing clinical symptoms of acuteappendicitis in the right iliac area is palpated  dense,
initially painful mass. Infiltratemay dissolve or suppurate. If infiltration resolves, then the patient
has normal body temperature, pain persists in the area of infiltration, which decreases in size,
normal complete blood count. Resorption lasts approximately 8-16 days. If a patient diagnosed with
appendicular infiltrate, he must be hospitalized and assign anti-inflammatory drugs and antibiotics
to prevent suppuration of infiltrate. After resolution of infiltrates should perform routine
appendectomy at least 3 months from the onset of the disease.
Appendicular abscess. The most common reason for the formation of appendicular abscess is
suppuration of appendicular infiltrate, sometimes it is caused by the formation of purulent exudate
due to  perforation of the appendix. Early sign of suppuration of infiltrate are the appearance of pain
in the region of abdominal mass. In addition there are clinical signs of intoxication (fatigue,
headache, hectic fever, tachycardia). In CBC, increases the blood leukocytosis and leukocyte shift
to the left. CT is excellent at delineating such lesions. In cases of abscess the use of CT directs a
percutaneous approach to drainage. In this situation, the base of the cecum and appendix are not
recognizable in the inflammatory mass. A secure operative closure is not feasible and operative
intervention is not likely to accomplish much more than percutaneous drainage of the abscess. CT-
directed drainage avoids laparotomy until definitive (so-called interval) appendectomy is performed
3 month later. This approach is particularly suited to the elderly, infirm patient who is at risk for
more morbidity in the acutely ill and debilitated state. It should be emphasized that a nonoperative
approach is employed most successfully when the acute illness is passed or when the abscess is
circumscribed. Most patients are better served by early operation once the diagnosis is made.
It should be pointed out that a number of clinicians have also evaluated the possibility of treating
acute appendicitis, in its early phases, using intravenous antibiotics alone. However, limited data
suggest that it would be difficult to argue that this nonoperative approach is a cost-effective
approach in most clinical situations.
PREOPERATIVE PREPARATION
Once the diagnosis is made and operative management is chosen, the patient should be made
comfortable with pain medication. Fluid status should be monitored closely, using clinical
indicators (pulse, blood pressure, urine output). Electrolyte balance is not usually a problem, unless
the illness has been prolonged and other complications (i.e., bowel obstruction) have supervened. If
such imbalances are detected in the admitting serum chemistry evaluation, they should also be
addressed.
When the decision to operate has been made, antibiotic therapy is started, usually consisting of a
second-generation cephalosporin alone or a combination regimen that includes broad-spectrum
coverage of gram-negative aerobes (principally E. coli) and anaerobes (Bacteroides spp.).38 It
should be emphasized that ordinarily, the goal of antibiotic therapy is not to treat the appendicitis
itself. In uncomplicated cases antibiotics are used to reduce the incidence of wound and deep
peritoneal infections that may occur after the operation and to protect against the consequences of
bacteremia. In cases complicated by abscess formation or bacteremia, antibiotics are used to treat
the complications. The literature regarding antibiotic prophylaxis is complicated, but there does
seem to be consensus about the following: (1) in uncomplicated cases, a second-generation
cephalosporin is as effective in reducing wound complications as multiple drug regimens; (2)
antibiotics are most effective when given just before or at the time of surgery, to obtain good tissue
levels as the incision is being made; and (3) in uncomplicated cases, one dose is enough and
additional doses after the operation do not further reduce infection rates.

OPERATIVE DECISIONS
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The first decision to be made is whether the procedure will be performed through a traditional
“open” approach or with the assistance of laparoscopy. Numerous trials comparing open and
laparoscopically assisted approaches have been performed since the technique was popularized in
the early 1990s. A number of outcome–cost and meta-analyses have been published in the last few
years as well.39–42 Based on the most recent information available, it seems clear that, in
uncomplicated cases where the diagnosis is secure, the laparoscopic approaches may offer a small
reduction in pain scores, a mild reduction in hospital stay, and possibly a reduction in wound
infection rates. Return to work may also occur earlier. In these cases, however, the operating time
and overall hospital costs of the laparoscopic approach are higher. Thus, in a cost analysis, the
benefit of laparoscopically assisted appendectomy can only be realized if the patients routinely
return to work and productive activity sooner than patients undergoing open procedures. This
advantage has not yet been shown. Patients with complications of appendicitis have not yet been
included in large enough numbers to reach conclusions about the relative advantages of either
approach. In the meantime, the optimal choice for operative approach should be based on likelihood
of diagnosis, complexity of the appendicitis, and severity of illness. The one circumstance in which
laparoscopic approach may offer a definite advantage is when the diagnosis is in doubt. The
diagnosis is particularly difficult to make in young women. In this group, as many as 25% to 50%
of patients explored for the diagnosis of acute appendicitis will actually have another disorder.43,44
Although the rate of “negative exploration” is expected to decrease with increasing use of imaging
modalities such as ultrasound and appendix-directed CT, it seems likely that this group of patients
will continue to pose a challenge. Thus, it will probably turn out that patients in this subgroup will
benefit from a laparoscopic approach. At the time of the operation, the appendix is removed if it
appears inflamed. A key point in the operation includes dissection of appendix to its true base at the
confluence of the tenia on the cecal wall. Failure to fully dissect the appendix may lead to retention
of an appendiceal stump that is sufficiently large to harbor recurring appendicitis. A number of such
cases have been reported, occurring even many years later. Such cases should serve as a warning to
the wary clinician: even when a patient reports a prior appendectomy and has a scar to prove it,
there may yet be a recurrent appendicitis. Once identified, the appendix is amputated close to the
base. When the operation is performed open, it is customary to invert the appendiceal stump into the
cecal lumen. However, there is no evidence that this reduces postoperative leak or fistula formation,
either being exceedingly rare events in uncomplicated cases. When surgery is performed
laparoscopically, the appendix is usually amputated at its base using a stapling device, and no
inversion is performed. When the base of the appendix cannot be identified because inflammation
or abscess formation precludes safe dissection, a closed suction drain may be placed into the cavity.
If the lumen of the appendix has not been obliterated, the drain allows fecal contents to drain to the
outside, thereby preventing accumulation of pus and fecal material inside the peritoneal cavity. If
the exploration or laparoscopy fails to reveal acute appendicitis, a search for the cause of the acute
abdominal pain must be undertaken. If no other source of pain can be identified, it is reasonable to
remove the appendix. There are three reasons for removing the appendix, even if it appears grossly
normal: first, the presence of a scar and history of exploration for the diagnosis may lead future care
providers to assume the appendix has been removed; second, if the pain recurs, removal of the
appendix eliminates this diagnosis from the differential (with the caveat just noted); and third, even
in grossly normal appendices, early intramural or serosal inflammatory changes (so-called
periappendicitis) have been noted with regularity (25%–50%) in microscopic evaluation or with
special stains for inflammatory cytokines.45,46
The last intraoperative decision is whether the wounds should be left open, with the risk of wound
infection, or whether they can be closed primarily. Although most authors recommend leaving the
incisions open when there is gross contamination by pus and fecal material, there is increasing
evidence that this may be no more unsafe and less costeffective than closing all wounds (where it is
feasible) and later treating any wound infections that result.47 This decision should be
individualized to each patient.\
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POSTOPERATIVE CARE
In uncomplicated cases, patients may take liquids and then solid food as soon as they feel able, and
discharge should be anticipated within 24 to 48 h. Postoperative antibiotics and nasogastric
decompression are not indicated routinely in such patients. Patients with perforation, abscess, or
other complications have a variable course. With established peritonitis or abscess formation, a
longer course of antibiotics may be needed, from 5 to 7 days after surgery.

SPECIAL CONSIDERATIONS
CHILDREN
Incomplete formation of the immune system and the underdevelopment of greater omentum that
does not reach the right iliac area, promote the rapid spread of destructive changes in the appendix,
reduce the possibility of separating the inflammatory process and create conditions for increased
frequency of complications of disease or generalization of infection. The peculiarity of the disease
is the predominance of local over general symptoms. Clinical equivalent of pain in young children
is to change behavior and refusal of food. The first objective clinical symptom is often fever (39-
39,5 ° C to), and repeated vomiting (in 40-45%). Examination when the child is asleep can detect
pain that provokes bending leg in the hip joint and attempt to push the surgeon's hand, you can also
differentiate protective tension of muscles of anterior abdominal wall and active muscular
protection.

ADVANCED AGE
It is widely recognized that elderly patients with appendicitis present with less acute symptoms, less
impressive clinical signs, and leukocytosis. Up to 30% of elderly patients present more than 48 h
into the illness, and between 50% and 70% have a perforation at the time of surgery. In addition, the
elderly are susceptible to malignancy and other processes that are in the differential diagnosis,
making correct preoperative diagnosis of acute appendicitis more difficult. Perioperative
complications and mortality of delayed intervention increase with age as well. However, timely
intervention can result in very acceptable complication rates, even in the most elderly patients.
Therefore, in this age group, it is reasonable to be diagnostically aggressive (i.e., use CT scan) to
establish the diagnosis or to identify other pathology and to move as quickly as possible to the
appropriate intervention.

PREGNANCY
The diagnosis of acute appendicitis during pregnancy is one of the most challenging of all clinical
problems. Pregnancy itself, especially in the early stages, is associated with nausea, vomiting,
abdominal pain and physiological leucocytosis. In the first and early second trimester, the evolution
of symptoms and signs is not different from that in nonpregnant women. After the fifth month, the
cecum and appendix are shifted upward by the expanding uterus. In the last trimester, localized
tenderness from the appendix may be found in the upper flank and right upper quadrant of the
abdomen. Ultrasound is very helpful in this setting, as it may provide images of the appendix,
gallbladder, uterus, and other pelvic organs. X-rays should be avoided if at all possible. When the
diagnosis of appendicitis is considerred likely, the patient should be explored. The following
considerations should be borne in mind if the diagnosis is not certain: (1) appendicitis is not more
common in any of the three trimesters; (2) progression to perforation seems to be more common in
the last trimester, presumably because of delays in seeking treatment and delays in recognition of
the need for surgery; (3) fetal mortality is probably less than 5% if the appendix is removed before
rupture and as high as 20% if the appendix is removed after rupture; and (4) maternal mortality is
small (less than 1%) but has been reported almost exclusively in patients who had a ruptured
appendix. On the other hand, patients and relatives need to be counseled about the risks of negative
laparotomy to the fetus. Overall, however, it would seem that, while the risk of preterm labor in
increased, the actual harm to the fetus is not associated with increased perinatal mortality. These
considerations strongly argue for a proactive approach to exploration in doubtful cases and probably
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justify the higher negative laparotomy rates of 25% to 40% that have been reported. One additional
consideration is whether it is safe and appropriate to submit the pregnant patient to laparoscopic
exploration and appendectomy. In the last trimester of pregnancy, it is technically too difficult for
laparoscopic instruments to reach the appendix, which lies above or behind the uterus, and the
procedure is most expeditiously performed using an open incision. In the first and early second
trimester, however, it is feasible to perform laparoscopy and, if needed, appendectomy with
laparoscopic assistance. The safety of laparoscopic surgery in pregnancy remains a controversial
subject, with some groups reporting no adverse events and some groups reporting higher than
expected incidents of adverse fetal outcomes. When the diagnosis of appendicitis seems likely, an
open procedure is probably the most expeditious approach.

INCIDENTAL APPENDECTOMY
This term refers to the removal of the appendix when the laparotomy or laparoscopy is being
performed to address an unrelated clinical problem. The stated goal of this practice is to prevent an
episode of acute appendicitis later on. It may be reasonable to perform incidental appendectomy in
children and young adults, but it is difficult to justify the practice in patients over the age of 30
years. Incidental appendectomy should not be performed if, in the surgeon’s judgment, there is a
possibility that it would incur any additional morbidity.