Moshe Schein
We all know: “Whatever the clinical presentation, whatever the abdominal findings, always keep acute appendicitis at the back of your mind”.
Acute appendicitis (AA) is discussed in any surgical text dating from the turn of the nineteenth century. Looking at the lengthy chapters devoted to this subject we often wonder what there is to chat so much about. Knowing that you have been fed on AA ad nauseum since the early days of medical school we do not intend to repeat here the whole “spiel” again. Instead, we promise to be brief and not to bore, and perhaps teach a few things, which have escaped you until now.
Diagnosis
AA is an inflammation – turning into infection – of the appendix. This rudi- mentary structure varies in length and position, making matters complicated. Even a dentist (but not a gynecologist) can diagnose a case of “classical” AA (> Fig. 28.1);
the history of mid-abdominal visceral discomfort, shifting to the right lower quadrant (RLQ) and becoming a somatic, localized pain speaks for itself. Add to it the clinical and laboratory evidence of systemic inflammation/infection and, most important, the localized physical findings of peritoneal irritation. Unfortunately (or fortunately, otherwise dentists would be treating AA), for each classical case you will see two atypical cases. Sure, you know by now that AA is missed at the extremes of age, that in menstruating females it is often confused with gynecological con- ditions (> Chap. 31), that retrocecal and pelvic appendices are more problematic, and that it should be “always on your mind” – at least number two on your list of differential diagnosis. So what can we add that you do not know? Perhaps nothing – but let us emphasize a few points:
Never confirm or exclude the diagnosis of AA on the presence or absence of one or other symptom, sign or finding “that must be there” because such an obliga- tory variable does not exist. Instead, suspect AA from a synthesis of the whole clinical picture and the various laboratory tests.
Every budding surgeon feels compelled to design his own screening test for AA. The “cough test”, the “jump sign” the “please bring your tummy to my finger
test” and many others. They are all fun, but none approaches a sensitivity or specifi- city of 90% (oops, sorry, we promised not to use percentages). The truth is that it is impossible to be completely accurate in the clinical diagnosis of AA. Should your policy to operate be based only on clinical assessment and basic laboratory values then one or two out of ten extracted organs will be a normal, “white” appendix (in fertile females this proportion will be much higher…). More than that implies that you are a “cowboy”; less suggests that you are dangerously prudent.
So you seriously suspect AA after having excluded, or at least you believe so, a gynecological complaint, urological pathology, gastroenteritis, the nebulous
“mesenteric lymphadenitis”, or the trash bin called “non-specific abdominal pain”.
Should you now proceed directly to the operating theatre or order fancy imaging?
Caveat
The management of patients with suspected appendicitis has traditionally focused on the prevention of perforation by early operation, but at the expense of a high proportion of unnecessary operations. But despite an increase in use of modern diagnostic modalities the rate of perforation has not declined. In addition, population-based studies document that diagnostic accuracy decreases as the rate of appendectomy increases, but the rate of perforation does not change. This teaches
Fig. 28.1. Even a dentist can diagnose classic appendicitis
us that perforation is a different disease:patients come to hospital with perforation – they do not perforate while we investigate them or observe them. Sure, sometimes we miss a “masked” perforation but that’s another story.
Abdominal Imaging in Acute Appendicitis
While it is clear that we cannot modify the rate of perforated appendicitis (one in four will be perforated) we can decrease the number of unnecessary,negative appendectomies. It has been said, “a fool with a tool is still a fool”. Indiscriminate and non-selective usage of modern diagnostic technology is not going to change this observation.What is needed is common sense and rational deployment of available investigations. Frankly, managing at least one case of adult (i.e. >13 years old) acute appendicitis per week, I do not recall when last I removed a normal one (during a non-therapeutic laparotomy) or missed an abnormal one (but then again, don’t ALL my patients do well??).
And this is how I do it:
1. Male patients with “typical” presentation. Operate immediately or the next morning.
2. Male patients with “atypical” presentation. Serial re-examinations – if not
“better” or still “atypical” I do a CT (see > Chap. 5).
3. Females in the reproductive age with “typical”presentation.I always start with a trans-vaginal ultrasound (US), which frequently detects ovarian pathology and fluid in the pouch of Douglas to explain the clinical picture. If US is not helpful they are sent for a CT.
4. Females with “atypical” presentation – see items 2 and 3 above.
5. As the above approach differentiates between those who need an operation and those who do not I see no sense in using laparoscopy as a purely diagnos- tic tool.Diagnostic laparoscopy per se is a costly and invasive operation (some call it “controlled penetrating abdominal trauma”) and, despite assertions that normal appendices discovered during laparoscopy should be left alone, many surgeons still feel uncomfortable with this approach. Thus, commonly,
“negative laparoscopy” means “negative appendectomy”. And in fact, studies of laparoscopic appendectomy report a much higher rate of these negative appendectomies.
Ultrasoundin “good hands” has been reported to be accurate in the diagnosis of AA and is useful in excluding other diagnoses, which may require a different therapy (e.g., hydronephrosis), or incision (e.g., acute cholecystitis), or indeed no therapy at all (e.g., ovarian cyst). Most of us do not work in an institution where we
can be so confident of the radiologist’s diagnosis of appenidicitis on the basis of ultrasound.
Periodic Re-evaluation
Many of you, however – in Russia or in the “bush” for example – don’t have a CT scanner readily available, and thus can’t follow the advice given above. But this does not mean that you should have a high rate of negative appendectomies.Periodic re-evaluation is a time-honored and proven diagnostic modality in the doubtful case. Unfortunately, the art of periodic re-examination and the virtue of patience are disappearing from the scene of modern practice where the emphasis is on obsessive activity, when in order to prove oneself one has always to “do something”.
In the absence of clear peritonitis and toxicity, very rarely are attacks of AA a true emergency requiring an immediate operation. If undecided, admit the patient and periodically re-examine him or her over the day or night. In most instances,AA will declare itself and, if it is not AA, the “attack” will resolve. Patients do not perforate under surgical observation – they lie with neglected perforations in the emergency room or pediatric wards.
[Note: if you decide to observe the patient, do not administer antibiotics as they may mask the findings,“partially treat”, or even cure the AA.]
So we order imaging selectively. Unfortunately on our side of the Atlantic the diagnostic algorithm is increasingly driven by dogmatic emergency room personnel who perform CT scans in lieu of clinical evaluation. Such indiscriminate use of CT scanning leads to a new syndrome we call “CT appendicitis”: you admit for ob- servation a patient with right lower quadrant pain and ambiguous clinical findings.
Meanwhile the emergency room doctor orders a CT, which is reported by the radiologist the following morning. At this stage, the patient feels much better, his abdomen is benign, and he wants to go home but the radiologist claims that the appendix is grossly inflamed. Should we treat the CT digital image or the patient?
Classification
Let us bring here a simple classification of AA to facilitate the discussion of management. In essence, AA is either “simple” or “complicated”. “Simple” AA implies inflammation of the appendix of any extent in the absence of appendiceal gangrene, perforation or peri-appendicular pus formation. Define AA as “compli- cated” whenever any of these changes is present.
Another entity you should be familiar with is the appendiceal mass, develop- ing late in the natural history of AA. The “mass”is an inflammatory phlegmon made
of omentum or/and adjacent viscera,walling off a “complicated”appendix.A “mass”’
containing a variable amount of pus is an appendiceal abscess.
Management Antibiotics
Judicious administration of antibiotics,to cover Gram-negative and anaerobic bacteria, will minimize the incidence of postoperative wound (common) and intra- abdominal (rare) infective complications. In “simple” AA the antibiotics are con- sidered prophylactic,while in “complicated”AA they are therapeutic.We encourage you to administer the first dose of antibiotics pre-operatively just before you scrub.
If at surgery the AA proves to be “simple”, no postoperative administration is nec- essary. Should you, on the other hand, discover “complicated” AA, additional post- operative doses are indicated. We suggest that you tailor the duration of adminis- tration to the operative findings. Gangrenous AA, without any pus formation, rep- resents a “resectable infection”, which does not require more than 24 hours of postoperative administration. Perforated AA with or without intra-peritoneal pus should be treated longer – but for no more than 5 days (> Chaps. 7, 12 and 42).
Perhaps you are not aware that most attacks of simple AA would respond to non-operative management with antibiotics. Also complicated AA may respond to antibiotics or at least could mature into an abscess. So why don’t we treat most cases of AA initially conservatively, along the same lines as acute diverticulitis (> Chap. 6) of the sigmoid colon? Because the surgical management of AA is simpler and less morbid than that of diverticulitis. However, when faced with AA away from surgical facilities (e.g., in mid ocean) you should treat the patient with antibiotics (which should be available on any ship).Also the preferred management of an appendiceal mass is conservative as discussed below.
The Operation
“The appendix is generally attached to the cecum.” (Mark M. Ravitch, 1910–1989)
“The point of greatest tenderness is, in the average adult, almost exactly 2 inches from the anterior iliac spine, on a line drawn from this process through the umbilicus.” (Charles McBurney, 1845–1913)
When to Operate?
You don’t have to rush to the operating room as soon as possible with each patient diagnosed as AA! Obviously, if your patient is systemically “sick” and his abdominal findings are impressive (denoting a perforation), operate immediately.
Otherwise, a few hours of delay while the patient receives antibiotics are acceptable.
You do not rush to the operating room with acute diverticulitis (> Chap. 26), so what’s the difference?
Open versus Laparoscopic Approach?
As pointed out above, liberal use of diagnostic laparoscopy for suspected AA leads to a high incidence of unnecessary removal of normal appendices – proce- dures that are not free of complications.But what about laparoscopic appendectomy (LA) if the diagnosis has been established? Evidence suggests that, compared to the open procedure, LA is associated with some reduction in postoperative pain, earlier discharge (a day) and lower incidence of wound infection. However, it is associated with a higher risk of intra-abdominal infective complications when performed for complicated AA. Concerning costs, the money saved by an earlier discharge after LA is spent on a more expensive and longer procedure. It appears, thus, that surgeons who prefer open appendectomy – we are among them – have the support of the literature but it does not mean that they should avoid LA altogether;
it surely has a place in very obese patients (avoiding a large incision) or in those with non-perforated appendicitis who specifically demand the laparoscopic ap- proach.
Technical Points
Only the open procedure will be discussed here. Should you like, however, to play with gas, sticks and staplers help yourself!
We presume that you have done your share of appendectomies already as an intern.However,having seen many surgeons transform a customary appendectomy to an elaborate operation resembling a Whipple’s procedure, we remind you of the KISS principle (keep it simple, stupid! – ):
Incision: you do not need the long unsightly oblique incision. Use the trans- verse one. A common error is to place it too medially over the rectus sheath; stay lateral to it. Start with a mini-incision; it can be always enlarged.
Appendectomy: you can remove the appendix in an antegrade or retrograde fashion but there is no need to invert the stump- unless you are hooked on useless
rituals. So just ligate or suture-transfix the appendix at its base and chop the rest off.
The commonly performed rituals of painting the stump with Betadine or burning it with diathermy are simply ridiculous.
Peritoneal toilet: just suck out the fluid and mop up whatever pus is present with a dry gauze-stick (do not forget the pelvis). Peritoneal lavage through this keyhole incision is useless. Don’t do it.
Drains: almost never necessary but may perhaps be indicated after the drain- age of a large appendicular abscess.
Closure: separate closure of the peritoneum is not necessary. Instillation of an antibiotic in the fat protects against wound infection (in addition to systemic administration). Do not insert subcutaneous sutures (foreign bodies). Our bias is for primary closure of the skin in all cases. A few will develop wound infection managed by removal of (a few) stitches. Isn’t this better than secondary closure, which condemns all patients to further manipulations and an ugly scar? (> Chaps.38 and 49).
The “White” Appendix
What should you do when the appendix proves to be normal-white? Well, you can rub it to allow the pathologist to diagnose mild acute inflammation (just kidding). The classical dictum is that whenever an abdominal appendectomy incision exists the appendix should be removed in order not to confuse matters in the future. What about a normal appendix visualized at laparoscopy? Should it be also removed? The emerging consensus is to leave it alone, informing the patient or his parents that the appendix has been left in situ. However, most laparoscopists do not feel comfortable with this recommendation, always worrying that what appears normal through the video camera may prove diseased at histology. Thus, for most surgeons,diagnostic laparoscopy for suspected appendicitis leads to appendectomy regardless of whether the appendix is normal or diseased.
Obviously, when the appendix appears normal you should search for alter- native diagnoses such as Meckel’s diverticulitis, adnexal pathology, perforated cecal diverticulitis (> Chap. 26), or mesenteric lymphadenitis (whatever that is). In most instances, however, you’ll find nothing.What should you do if foul smelling, murky, or bile-stained peritoneal fluid is encountered, suggesting serious alternate patho- logy elsewhere? Bile should guide you into the upper abdomen. Close the incision and place a new one where “the action is”. Feces or its odor direct you towards the sigmoid; just extend the incision across the midline and you are there.
The “Valentino” Appendix
Intra-peritoneal inflammation from any cause can inflame-inject the appendix from the outside,mimicking AA.This was the case with the famous movie actor and womanizer Rudolph Valentino who underwent an appendectomy for suspected acute appendicitis in New York (1926). He became gravely ill after the operation and died; autopsy revealed a perforated peptic ulcer. The findings of peritoneal fluid and suppuration, together with a mildly inflamed and non-gangrenous and non- perforated appendix should raise your suspicions that the pathology is elsewhere- look for it!
The Post-appendectomy Appendiceal Stump Phlegmon
Your patient had an uneventful appendectomy for acute appendicitis follow- ing which he happily went home. Seven days later he presents with right lower quadrant pain, a temperature and high white cell count. The wound looks OK.
This is a typical presentation of an appendix stump phlegmon. Nowadays the diagnosis is simple: a CT will demonstrate a phlegmon, which involves the cecum – as opposed to a drainable abscess. A few days of antibiotic therapy will cure this relatively rare complication, which for some reason is not mentioned by standard texts.
Stump appendicitis: be aware that patients can develop classical acute appen- dicitis at any time after appendectomy. This is becoming more common in the era of laparoscopic appendectomy, where during the procedure surgeons may misiden- tify the cecal base of the appendix and consequently leave a long appendiceal stump – prone to stump appendicitis and requiring a re-appendectomy.
Appendiceal Mass
Typically, patients with an appendiceal mass present late in the course of the disease,with abdominal symptoms lasting a week or more.Occasionally,they report a spontaneous improvement in their symptoms, reflecting the localization of the inflammatory process. On clinical examination you will find a right iliac fossa mass.
Overlying tenderness or obesity may obscure the presence of the mass. Therefore, suspect an appendiceal mass in the “late presenters” or those with an atypical smoldering picture. When palpation is not rewarding, obtain a CT scan, which is the best way to document an appendiceal mass. Another indication for CT is associated evidence of undrained pus such a spiking fever and toxicity, signifying an appendiceal abscess.
Why should you distinguish between AA and appendiceal mass (or abscess) if the management of these conditions is the same (e.g. operation and antibiotics)?
Because the appendiceal mass (and abscess) can be managed non-operatively.
You could operate on both, as you operate on AA, but removal of the appendix involved in an inflammatory mass may be more hazardous than usual, occasional- ly necessitating a right hemicolectomy. On the other hand, conservative treatment with antibiotics leads to the resolution of the mass in the vast majority of cases.
As no more than one out of five patients will suffer a recurrence of AA (usually within 1 year and not a severe attack) the dogma of routine “interval appendectomy”
within 6 weeks has become obsolete. Interestingly, in many of these patients at interval appendectomy the appendix is found to be rudimentary and scarred. In patients over the age of 40 years we suggest an elective colonoscopy and CT scan (after 3 months) to exclude the rare situation in which cecal carcinoma was the cause of the mass.
Failure of the mass to respond to antibiotics signifies an abscess. CT or ultra- sound guided percutaneous drainage is the most rational approach (> Chap. 44).
Failure to improve clinically within 48 hours means that an operation is needed.
At operation, drain the pus and remove the appendix if it is not too difficult.
With a high index of suspicion you can obviate an operation in the majority of patients with an appendiceal mass. And remember – appendiceal mass represents an unfavorable situation for your laparoscopic skills.
Appendicitis Epiploica
We mention this condition here because of its name, because you probably have not heard much about it, and because it is not so rare and often imitates AA.
Appendicitis epiploica follows a spontaneous torsion of the appendix epiploica – the peritoneum-covered tabs of fat attached along the tenia coli. It is more common in obese individuals and in the cecum and sigmoid. Since the sigmoid colon often crosses the midline the most common manifestation is localized tenderness and peritoneal signs in the right iliac fossa. Typically, patients do not feel or appear sick despite these findings. Thus, “AA on examination” in an afebrile and healthy looking patient should raise your suspicions. The natural history is spontaneous remission as the appendix epiploica sloughs off, transforming into that loose calci- fied peritoneal body that you occasionally find during unrelated abdominal proce- dures. CT scan may identify the localized area of peri-colonic inflammation. If you are misled into an operation just remove the necrotic piece of fat.
Conclusions
Acute appendicitis, like any other surgical condition, has a spectrum. To reach the diagnosis, consider historical, physical and laboratory variables together. No isolated variable can confirm or exclude AA, while the more typical variables are present, the higher the chance that you are dealing with AA. Whether you operate immediately or tomorrow, whether you observe or obtain additional tests is deter- mined selectively based on your individual patient.
Never become blasé about AA; it can kill even today, and may humble even the most experienced surgeon.
There are two things in life that I will never understand: women and acute appendicitis.
“The surgeon who can describe the extent of an appendiceal peritonitis has convicted himself of performing an improper operation.” (Mark M. Ravitch, 1910–1989)
