current surgical diagnosis and treatment textbook

1. Appendix
Anatomy and physiology
Shuo Huang
Specialist surgeon
Associate professor
Jiamusi University Hospital, China
154 002 Jiamusi
Telephone: +86-454-862-3466
Email: shuo.huang@hotmail.com
In infants, the appendix is a conical diverticulum at the apex of the cecum, but with
differential growth and distention of the cecum, the appendix ultimately arises on the
left and dorsally approximately 2.5 cm below the ileocecal valve.
The taeniae of the colon converge at the base of the appendix, an arrangement that
helps in locating this structure at operation.
The appendix is fixed retrocecally in 16% of adults and is freely mobile in the
remainder.
The appendix in youth is characterized by a large concentration of lymphoid follicles
that appear 2 weeks after birth and number about 200 or more at age 15.
Thereafter, progressive atrophy of lymphoid tissue proceeds concomitantly with
fibrosis of the wall and partial or total obliteration of the lumen.
If the appendix has a physiologic function, it is probably related to the presence of
lymphoid follicles.
Reports of a statistical relationship between appendecotomy and subsequent
carcinoma of the colon and other neoplasms in humans are not supported by
controlled studies.
Acute appendicitis
Essentials of diagnosis
Abdominal pain
Aborexia, nausea and vomiting
Localized right lower quadrant abdominal tenderness
Low-graded fewer
Leukocytosis
General considerations

2. Approximately 7% of people in Western countries have appendicitis at some time
during their lives, and about 200,000 appendectomies for acute appendicitis are
performed annually in the United States.
The incidence has been steadily dropping over the past 25 years, however, while the
incidence in developing countries which in the past has been quite low has been rising
in proportion to economic gains and changes in lifestyle.
Obstruction of the proximal lumen by fibrous bands, lymphoid hyperplasia, fecaliths,
calculi, or parasites has long been considered to be the major cause of acute
appendicitis, though that theory is doubted by many experts.
Evidence of temporal and geographic clustering of cased has suggested a primary
infectious etiology.
A fecalith or calculus is found in only 10% of acutely inflamed appendicices.
As appendicitis progresses, the blood supply is impaired by bacterial infection in the
wall and distention of the lumen by pus; gangrene and perforation occur at about 24
hours, though the timing is highly variable.
Gangrene implies microscopic perforation and bacterial peritonitis (which may be
localized by adhesions from nearby viscera).
Clinical findings
Acute appendicitis has protean manifestations.
It may simulate almost any other acute abdominal illness and in turn may be
mimicked by a variety of conditions.
Progression of symptoms and signs is the rule in contrast to the fluctuating course of
some other disease.
A. Symptoms and Signs
Typically, the illness begins with vague mid-abdominal discomfort followed by
nausea, anorexia, and indigestion.
The pain is persistent and continuous but not severe, with occasional mild cramps.
These may be an episode of vomiting, and within several hours the pain shifts to the
right lower quadrant, becoming localized and causing discomfort on moving, walking,
or coughing.
The patient may feel constipated.
Examination at this point shows localized tenderness to one finger palpation and
perhaps slight muscular guarding.
Rebound or percussion tenderness (the latter provides the same information more

3. humanely) may be elicited in the same area.
Peristalsis is normal or slightly reduced.
Rectal and pelvic examinations are likely to be negative.
The temperature is only slightly elevated (eg, 37.8° C) in the absence of perforation.
Contrary to traditional teaching, tenderness on rectal examination is not a sign of
acute appendicitis.
If present, it more often points to another cause of the symptoms.
Another common misconception is that inflammation in a retrocecal appendix
produces an atypical syndrome.
This too is incorrect; the clinical findings in this situation are the same as for ordinary
(antececal) appendicitis.
Rarely, the cecum may lie on the left side of the abdomen, and appendicitis may be
mistaken for sigmoid diverticulitis.
An inflamed appendix in the right upper quadrant may mimic acute cholecystitis or
performed ulcer.
Even when the cecum is normally situated, a long appendix may reach to other parts
of the abdomen, and acute appendicitis in these circumstances may be very confusing
indeed.
A couple of general points are worth remembering:
(1) People with early (non-perforated) appendicitis often do not appear ill and may
even apologize for taking your time.
Finding localized tenderness over McBurney’s point is the cornerstone of diagnosis.
(2) A rule that will help considerably with atypical cases is never to place appendicitis
lower than second in the differential diagnosis of acute abdominal pain in a previously
healthy person.
B. Laboratory Findings
The average leukocyte count is 15 ×109/L, and 90% of patients have counts over 10
×109/L.
In three-fourths of patients, the differential white count shows more than 75%
neutrophils.
It must be emphasized, however, that one patient in ten with acute appendicitis has a
leukocyte count indistinguishable from normal, and many have normal differential
cell counts.
Appendicitis in patients infected whit HIV produces the same syndrome as in other
people, but the white blood cell count is usually normal.
The urine is usually normal, but a few leukocytes and erythrocytes and occasionally
even gross hematuria may be noted, particularly in retrocecal or pelvic appendicitis.

4. C. Imaging Studies
Localized hair- fluid levels, localized ileus, or increased soft tissue density in the right
lower quadrant is present in 50% of patients with early acute appendicitis.
Less common findings are a calculus, an altered right psoas shadow, or an abnormal
right flank stripe.
The finding on plain films of a calculus in the right lower quadrant coupled with pain
in this area strong supports a diagnosis of appendicitis.
Although perforated peptic ulcer is by far the most common cause of free
intraperitoneal air, free air is also a rare manifestation of performed appendicitis.
In general, however, the findings on plain films are nonspecific and rarely of help in
diagnosis.
A suggestion that barium enema may contribute to the diagnosis has not been
supported by experience.
A spiral CT examination of the appendix may be of help in diagnosis.
An enlarged appendix with peri-appendiceal fat stranding, found in 90% of cases, is
the most common CT finding of acute appendicitis.
Other criteria are less reliable.
CT scans are of greatest value in patients with less than typical clinical and laboratory
findings, where a positive study would be an indication for appendectomy.
In the face of typical right lower4 quadrant pain and tenderness plus signs of
inflammation (eg, fever, leukocytosis), a CT scan would be superfluous and, if
negative, even misleading.
Ultrasound imaging is much less reliable that CT.
When appendicitis is accompanied by a right lower quadrant mass, an ultrasound or
CT scan should be obtained to differentiate between a periappendiceal phlegmon and
an abscess.
D. Appendicitis during pregnancy
Appendicitis is the most common non-obstetric surgical disease of the abdomen
during pregnancy.
Pregnant women develop appendicitis with the same frequency as do non-pregnant
women of the same age, and the cases are equally distributed through the three
trimesters of pregnancy.
By far the most common presentation is right lower quadrant pain and tenderness- the
classic syndrome- but the enlarged uterus occasionally will have pushed the appendix
into the right upper quadrant, which gives rise to pain in this location.
Fever is less common than with appendicitis in the absence of pregnancy.
Leukocytosis is typical, but it too may be absent.
The main problem is to recognize the possibility of appendicitis and perform
appendectomy promptly.

5. Delay in operation runs a higher than usual risk of perforation and diffuse peritonitis,
because omentum is less available to wall off the infection.
The mother is in greater jeopardy of serious abdominal infection, and the fetus is
more vulnerable to premature labor with complications.
Laparoscopic appendectomy (specifically the penumoperitoneum) is well tolerated by
the mother and the fetus, but the frequency of technical complications is higher than
with the open approach.
Appendectomy during pregnancy is often followed by preterm labor but rarely by
preterm delivery.
Early appendectomy has decreased the maternal death rate to under 0.5% and the fetal
death rate to fewer than 10%.
Diagnosis and differential diagnosis
The clinical diagnosis of appendicitis rests on a combination of localized pain and
tenderness accompanied by signs of inflammation, such as fever, leukocytosis, and
elevated C-reactive protein levels.
Migration of pain from the periumbilical area to the right lower quadrant is also
diagnostically significant.
In the absence of signs of inflammation, the diagnosis is less certain (ie, falsely
positive), and in this situation a CT scan might be of value.
The best strategy in equivocal cases is to observe the patient for a period of 6 hours or
more.
During this time, patients with appendicitis experience increasing pain and signs of
inflammation and those without appendicitis generally improve.
False-positive diagnoses often involve cases where the surgeon has accorded more
significance to the patient’s sign than to the presence or absence of inflammatory
signs.
Anorexia, nausea, and rectal of inflammatory are not indicative signs of appendicitis.
During the past 15 years, the overall false- positive rate for the diagnosis of
appendicitis has dropped from 15% to 10% without an accompanying rise in the
number of perforations.
Thus, diagnostic accuracy appears to be improving.
The diagnosis of acute appendicitis is particularly difficult in the vary young and in
the elderly.
These are the groups where diagnosis is most often delayed and perforation most
common.
Infants manifest only lethargy, irritability, and anorexia in the early stages, but
vomiting, fever, and pain are apparent as the disease progresses.
Classic symptoms may not be elicited in aged patients, and the diagnosis is often not
considered by the examining physician.
The course of appendicitis is more virulent in the elderly, and suppurative
complications occur earlier.

6. The highest incidence of false-positive diagnosis (20%) is in women between ages 20
and 40 and is attributable to pelvic inflammatory disease and other gynecologic
conditions.
Compared with appendicitis, pelvic inflammatory disease is more often associated
with bilateral lower quadrant tenderness, left adnexal tenderness, onset of illness
within 5 days of the last menstrual period, and a history that does not include nausea
and vomiting.
Cervical motion tenderness is common in both diseases.
Complications
The complications of acute appendicitis include perforation, peritonitis, abscess, and
pylephlebitis.
A. Perforation
Delay in seeking medical care appears to be the principal reason for perforations; the
disease has just been allowed to progress according to its natural history.
Perforation is accompanied by more severe pain and higher fever (averge, 38.3 ºC)
than in appendicitis.
It is unusual for the acutely inflamed appendix to perforate within the first 12 hours.
The appendicitis has progressed to perforation by the time of appendectomy in about
50% of patients under age 10 or over age 50.
Nearly all deaths occur in the latter group.
The acute consequences of perforation vary from generalized peritonitis to formation
of a tiny abscess that may not appreciably alter the symptoms and signs of
appendicitis.
Perforation in young women increases the subsequent risk of tubal infertility about
four-fold.
B. Peritonitis
Localized peritonitis results from microscopic perforation of a gangrenous appendix,
while spreading or generalized peritonitis usually implies gross perforation into the
free peritoneal cavity.
Increasing tenderness and rigidity, abdominal distention, and adynamic ilus are
obvious in patients with peritonitis.
High fever and severe toxicity mark progression of this catastrophic illness in
untreated patients.
C. Appendiceal Abscess (Appendicealmass)
Localized perforation occurs when the periappendiceal infection becomes walled off

7. by omentum and adjacent viscera.
The clinical presentation consists of the usual findings in appendicitis plus a right
lower quadrant mass.
An ultrasound or CT scan should be performed; if an abscess in found, it is best
treated by percutaneous ultrasound-guided aspiration.
Opinion differs about how every small abscesses and phlegmons should be handled.
Some surgeons prefer a regimen consisting of antibiotics and expectant management
followed by elective appendectomy 6 weeks later.
The purpose is to avoid spreading the localized infection, which usually resolves in
response to the antibiotics.
Other surgeons recommended immediate appendectomy, which considerably shortens
the duration of the illness.
The trend is in favor of the latter approach, since it is more expeditious and appears to
be just as safe.
When the surgeon encounters as unsuspected abscess during appendectomy, it is
usually best to proceed and remove the appendix.
If the abscess is large and further dissection would be hazardous, drainage alone is
appropriate.
Appendicitis recurs in only 10% of patients whose initial treatment consisted of
antibiotics or antibiotics plus drainage of an abscess.
Therefore, when the presence of ancillary conditions increases the risks of surgery,
interval appendectomy may be postponed unless symptoms recur.
D. Phylephlebitis
Pylephlebitis is suppurative thrombophlebitis of the portal venous system.
Chills, high fever, low grade janundice, and, later, hepatic abscess are the hallmarks of
this grave condition.
The appearance of shaking chills in a patient with acute appendicitis demands
vigorous antibiotic therapy to prevent the development of pylephlebitis.
CT scanning is the best means of detecting thrombosis and gas in the portal vein.
In addition to antibiotics, prompt surgery is indicated to treat appendicitis or other
primary sources of infection (eg, diverticulitis).
Prevention
In the past it was common to perform an incidental appendectomy in people under age
50 during the course of an abdominal operation for another illness- as long as the
exposure was adequate and there were no specific contraindications.
The declining lifetime risk of appendicitis now calls this practice into question.
A related question concerns the appropriate course when a laparoscopy is performed

8. for presumptive appendicitis and the appendix looks normal.
The trend in this case is to leave the appendix intact- not to remove it prophylactically
or on the assumption that the visual assessment may be inaccurate.
Treatment
With few exceptions, the treatment of appendicitis is surgical (ie, appendectomy).
The operation can be done open or laparoscopically.
The results of clinical trails comparing the two methods show no clear-cut advantage
of one method over the other, though patients treated laparoscopically return to work
a few days earlier.
A laparoscopic approach is desirable when the preoperative diagnosis is uncertain
because the morbidity is less if the appendix is found to be uninflamed and an
appendectomy is not done.
Prophylactic antibiotics are indicated preoperatively.
A single-drug regimen, usually a cephalosporin, is as effective as more aggressive
multiple-drug combinations.
The practice of routinely culturing abdominal fluid is of no practical value even when
the appendix has perforated.
The organisms obtained are the usual fecal flora.
Abdominal drains are called for only to treat established abscesses, not for diffuse
inflammation or abdominal fluid.
If a patient with appendicitis cannot be taken to a modern surgical facility for care,
treatment should consist of antibiotics alone.
The complication-free success rate of this approach is high.
Prognosis
Although a death rate of zero is theoretically attainable in acute appendicitis, deaths
still occur, some of which are avoidable.
The death rate in simple acute appendicitis is approximately 0.1% and has not
changed significantly since 1930.
Progress in pre- and postoperative care- particularly the emphasis on fluid
replacement before operation- has reduced the death rate from perforation to about
5%.
Nonetheless, postoperative infections still occur in 30% of cases of gangrenous or
perforated appendix.
Although most of these patients survive, many near fatalities increase in tubal
infertility that follows perforation in young women is also avoidable by early
appendectomy.

9. Chronic appendicitis
Chronic abdominal pain is a common problem, and when the complaints are confined
to the right lower quadrant, the question of chronic appendicitis is usually raised.
Patients with genuine chronic appendicitis experience pain that lasts for 3 weeks or
more.
The history usually includes an acute illness at some time in the past, compatible with
acute appendicitis, the appendix is chronically inflamed or fibrotic.
The symptoms resolve with appendectomy.
Chronic intermittent pain in the right lower quadrant is most often caused by
something other than appendicitis, such as Crohn’s disease or renal disease.
Barium X-rays are sometimes helpful, particularly in children.
In many patients, the diagnosis is not obvious.
Appendectomy relieves symptoms occasionally, but laparotomy for chronic
abdominal pain is generally unproductive in the absence of objective findings (eg,
localized tenderness, palpable mass, leukocytosis).
Tumors of the appendix
Benign tumors, including carcinoids, were found in 4.6% of 71,000 human appendix
specimens examined microscopically.
Benign neoplasms may arise from any cellular and are usually incidental findings.
Occasionally, a neoplasm obstructs the appendiceal lumen and produces acute
appendicitis.
No treatment other than appendectomy is indicated.
Malignant tumors
Primary malignant tumors were found in 1.4% of appendices in the same large series.
Carcinoid and argentaffin tumors comprise the majority of appendiceal cancers, and
the appendix is the commonest location of carcinoid tumors of the gastrointestinal
tract.
Carcinoid tumors of the appendix are usually benign, but the uncommon tumor that is
over 2 cm in diameter may exhibit malignant behavior.
Most appendiceal carcinoids are found in the tip of the organ, while a few are at the
base.
About half of these tumors are discovered during an appendectomy for acute
appendicitis, and the remainders are incidental findings.
Lesions less than 2 cm in diameter invade the appendiceal wall in 25% of cases, but
only 3% metastasize to lymph nodes, and hepatic metastases and the carcinoid
syndrtome are truly rare.

10. Appendectomy alone is adequate treatment unless the lymph nodes are visibly
involved, the tumor is more than 2 cm diameter, mucinous elements are present in the
tumor (adeno-carcinoid), or the mesoappendix or base of the cecum is invaded.
Right hemicolectomy is recommended for these more aggressive lesions.
Adeno-carcinoma of the colonic type can arise in the appendix and spread rapidly to
regional lymph nodes or implant on ovaries or other peritoneal surfaces.
Ten percent of patients have widespread metastases when first seen.
Adeno-carcinoma is virtually never diagnosed preoperatively; about half of cases
present as acute appendicitis, and 15% have formed apepndiceal abscesses.
Right hemicolectomy should be performed if disease is localized to the appendix and
regional lymph nodes.
The 5-year survival rate is 60% after right hemicolectomy and only 20% after
appendectomy alone, but the later group includes patients with distant meatstases at
the time of diagnosis.
Mucocele
Mucocele of the appendix is a cystic, dilated appendix filled with mucin.
Simple mucocele is not a neoplasm and results from chronic obstruction of the
proximal lumen, usually by fibrous tissue.
If the appendiceal contents distally are sterile, mucous cells continue to secrete until
distention of the lumen thins the wall and interferes with nutrition of the lining cells;
histologically, simple mucocele is lined by flattened cuboidal epithelium or no
epithelium at all.
Simple mucocele is cured by appendectomy.
Less commonly, mucocele is caused by a neoplasm- cystadenoma, or adenocarcinoma
grade 1 in the older terminology.
This lesion may arise de novo or (perhaps) in a preceding simple mucocele.
In cystadenoma, the lumen is filled with mucin but the wall is lined by columnar
epithelium with papillary projections.
Tumor does not infiltrate the appendiceal wall and does not metastasize, although it
may recur locally after appendectomy.
Cystadenoma is believed to undergo malignant change in some instances.
Appendectomy is adequate treatment.