Must know facts on Acute Appendicitis for Medical Students

1. PEDIATRIC GASTROENTEROLOGY
JOHN PAUL AMATA TADAY, MD-MPA LEVEL 3
BICOL UNIVERSITY – COLLEGE OF MEDICINE
 ACUTE APPENDICITIS

2. REFERENCES
1 – Harrison's Internal Medicine - 19th Edition 2015, pp 1985-1988
2 – Hawkey's Gastroenterology and Hepatology - 2nd Edition 2012, pp 505-506
3 – Schwartz's Principles of Surgery - 10th Edition 2015, pp 1243-1256
4 – Rosai and Ackerman’s Surgical Pathology - 10th Edition 2012, pp 715
5 – Nelson's Pediatrics - 20th Edition 2016, pp 1887-1894
1 2 3 4 5

3. DEFINITION
 INFLAMMATION of the APPENDIX
 First described in 1886 by DR. REGINALD FITZ1
 Most common surgical condition requiring
emergency surgery in adults2
 Remains the most common acute surgical
condition in children & major cause of childhood
morbidity5

4. DEFINITION
SIMPLE APPENDICITIS  inflamed appendix, in
the absence of gangrene, perforation, or
abscess around the appendix2
COMPLICATED APPENDICITIS  perforated or
gangrenous appendicitis or the presence of
peri-appendicular abscess2

5. EPIDEMIOLOGY
 INCIDENCE RATE  1/1,000 (West)1, 2.5/1,000 (Philippines)
 ~100,000 children treated in children’s hospitals for AP each year5
 MORTALITY RATE  <1% (low)
 GENDER  male-to-female ratio is 1.4:1
 AGE  most common age group ––– 10–19 y/o1
 1-2/10,000 children ––– BIRTH TO 4 y/o5
 19-28/10,000 children ––– <14 y/o
 RACE  WHITES>BLACKS; more frequently in WESTernized societies, but
increasing in African Americans, Asians, and Native Americans
 SEASON  peak incidence in AUTUMN and SPRING
LIFETIME RISKS:
MALE3
8.6%
FEMALE3
6.7%
CHILDREN5
~7%

6. ETIOLOGY
 EXACT CAUSE  not completely understood1
 ASSOCIATED FACTORS1,5:
• FECALITHS or APPENDICOLITHS  common
in developed countries with refined, low-
fiber diets
• INCOMPLETELY DIGESTED FOOD RESIDUE
 to include foreign body ingestion
• LYMPHOID HYPERPLASIA  SUBMUCOSAL
LYMPHOID FOLLICLES few at birth but
multiply steadily during childhood

7. ETIOLOGY
 ASSOCIATED FACTORS (con’t)1,5:
• INTRALUMINAL SCARRING  blunt trauma
• TUMORS OR MALIGNANCIES  carcinoid tumors
• MICROORGANISMS:
a. BACTERIA  Yersinia, Salmonella, & Shigella spp.,
b. VIRUSES  Mumps, Coxsackievirus B & Adenovirus,
Infectious mononucleosis
c. OTHERS  Ascaris lumbricoides
• OTHER DISEASES:
a. IBD1  for adults)
b. CYSTIC FIBROSIS5  for children

8. PATHOPHYSIOLOGY
 Luminal Distention Bacterial Overgrowth
INFLAMMATION Loss of Function, Pain, Swelling, Heat, Redness  Intraluminal Pressure
Cont’d
OBSTRUCTION OFTHE APPENDICEAL LUMEN
FECALITHS /
APPENDICOLITHS
LYMPHOID
HYPERPLASIA
INCOMPLETELY
DIGESTED FOOD
RESIDUE
INTRALUMINAL
SCARRING TUMORS
PATHOGENS
(VIRUSES,
BACTERIA)
OTHER
DISEASES
FECALITHS /
APPENDICOLITHS
LYMPHOID
HYPERPLASIA

9. PATHOPHYSIOLOGY
Vascular
Thrombosis
Ischemic
Necrosis
PERFORATION
GANGRENOUS APPENDICITIS
*50% of patients with fecaliths
*Patients with S/S for >48 hrs more likely to perforate
Leak of Contents into the Omentum
and SurroundingTissues
INHIBITION OF LYMPHATIC
AND BLOOD FLOW
Abscess
Formation Peritonitis
Supportive
Thrombosis
COMPLICATIONS
*Children with  perforation rate
(82% for <5yo & 100% for infants)
*Impaired arterial perfusion, ischemia
of the wall of the appendix
*Escalating diffuse abdominal pain
with rapid development of toxicity
evidenced by dehydration and signs
of sepsis including hypotension,
oliguria, acidosis, & high-grade fever
Small Bowel
Obstruction

10. CLINICAL MANIFESTATIONS
 LOCATION1:
• Right Lower Quadrant
• Right Upper Quadrant
• Left Side of the Abdomen
• Pelvis and Right flank
 PRESENTATION2:
• Retrocecal/retrocolic (64%)
• Subcaecal (32%)
• Pre-ileal (1%)
• Post-ileal (2%)
• Pelvic appendix
POSITION of the appendix is a critical factor affecting presentations of signs & symptoms

11. CLINICAL MANIFESTATIONS
 PAIN (depends on the location) 1:
• IF UNUSUALLY POSITIONED – challenge in
diagnosis regarding the pain
• IF BEHIND THE CECUM OR BELOW THE
PELVIC BRIM – may prompt very little
tenderness
• IF RETROCECAL/RETROCOLIC – psoas
stretch sign
FOR ELDERLY  can be subtle, nausea, anorexia, and
emesis may be the predominant complaints1
FOR VERY YOUNG  atypical presentation, pain
patterns –– common1

12. CLINICAL MANIFESTATIONS
 EMESIS  only mild and scant1
 NAUSEA & VOMITING  occur in more than half the patients, usually follow the
onset of abdominal pain by several hours
 ANOREXIA  so common that the diagnosis of appendicitis SHOULD BE
QUESTIONED IN ITS ABSENCE1
 PELVIC APPENDICITIS  more likely to present with dysuria, urinary frequency,
diarrhea, or tenesmus1
 DIARRHEA & URINARY SYMPTOMS  also common, particularly in cases of
perforated appendicitis when there is likely inflammation near the rectum and
possible abscess in the pelvis
 FEVER  common, typically low-grade unless perforation has occurred

13. CLINICAL MANIFESTATIONS
 NONSPECIFIC COMPLAINTS occur first1
 Changes in bowel habits, malaise & vague,
perhaps intermittent, crampy, abdominal
pain in the EPIGASTRIC or PERIUMBILICAL
REGION1
 Pain migrates to RLQ in 12–24 hours,
(sharper & localized at MCBURNEY’S POINT)1
1 = Anterior superior iliac spine
2 = Umbilicus
x = McBurney’s point
ADULTS

14. CLINICAL MANIFESTATIONS
 SAME CLASSIC PRESENTATION  <50% of cases,
therefore, majority of cases of appendicitis have an
“atypical” presentation5
 BEGINS INSIDIOUSLY with brief period of
generalized malaise & anorexia  family is not likely
to seek consultation – assumption of “STOMACH FLU”
 ESCALATES RAPIDLY with progressive abdominal pain
followed by vomiting  perforation likely to occur
within 48° of the onset
PEDIA

15. CLINICAL MANIFESTATIONS
SYMPTOMS
MANIFESTATION PERCENTAGE
Abdominal pain >95%
Anorexia >70%
Constipation 4–16%
Diarrhea 4–16%
Fever 10–20%
Migration of pain to RLQ 50–60%
Nausea >65%
Vomiting 50–75%
MANIFESTATION PERCENTAGE
Abdominal tenderness >95%
RLQ tenderness >90%
Rebound tenderness 30–70%
Rectal tenderness 30–40%
Cervical motion tenderness 30%
Rigidity ~10%
Psoas sign 3–5%
Obturator sign 5–10%
Rovsing’s sign 5%
Palpable mass <5%
SIGNS

16. MORPHOLOGY
OUTER ASPECT OF APPENDIX INVOLVED BY ACUTE
INFLAMMATION. A THICK PURULENT COATING IS SEEN TOGETHER
WITH MARKED HYPEREMIA OF THE SEROSA.
Gross Findings4
ACUTE APPENDICITIS WITH MASSIVE INFLAMMATORY INFILTRATE,
EXTENSIVE ULCERATION, AND HEMORRHAGE. AN ISLAND OF
HEAVILY INFLAMED RESIDUAL MUCOSA IS SEEN IN THE CENTER.
Histologic Findings4

17. MORPHOLOGY
Gross Findings4
RUPTURE OF APPENDIX SECONDARY TO TRANSMURAL ACUTE APPENDICITIS

18. PHYSICAL EXAMINATION
 HALLMARK of diagnosing acute
appendicitis remains a careful and
thorough Hx & PE
 Presence of LOCALIZED ABDOMINAL
TENDERNESS  the SINGLE MOST
reliable finding in the diagnosis of
acute appendicitis

19. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
REBOUND TENDERNESS
 Elicited by deep palpation of the
abdomen followed by the sudden
release of the examining hand5

20. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
ROVSING’S SIGN
 Palpating in the left lower
quadrant causes pain in the
right lower quadrant1

21. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
OBTURATOR SIGN
 Internal rotation of the hip
causes pain, suggesting the
possibility of an inflamed
appendix located in the pelvis1

22. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
ILIOPSOAS SIGN
 Extending the right hip causes
pain along posterolateral
back and hip, suggesting
retrocecal appendicitis1

23. PHYSICAL EXAMINATION
CLASSIC SIGNS OF APPENDICITIS IN PATIENTS WITH ABDOMINAL PAIN
DUNPHY SIGN  Coughing may elicit pain
d/t abdominal wall movement5

24. PHYSICAL EXAMINATION
OTHER SIGNS OF APPENDICITIS:
 BASSLER SIGN  Sharp pain created by
compressing the inflamed appendix between
abdominal wall and Iliacus
 TEN HORN SIGN  Pain in the RLQ or
McBurney’s Point caused by gentle traction of
right testicle or the spermatic cord for males

25. DIFFERENTIAL DIAGNOSIS

26. DIFFERENTIAL DIAGNOSIS

27. DIAGNOSTIC FACTORS
 CBC (with DIFFERENTIAL COUNT)
• WBC  10,000–18,000/mm3 in 70% cases1
 11,000–16,000/mm3 for pediatric patients5
 >20,000/mm3 –––– indicates PERFORATED CASES
• “LEFT SHIFT” toward immature PMN leukocytes in >95% of cases
 URINALYSIS
• Indicated to help EXCLUDE genitourinary conditions1
• Often with WBC and RBC d/t result of the proximity of the
inflamed appendix to the ureter or bladder, but it should be free
of bacteria5
LABORATORY TESTS

28. DIAGNOSTIC FACTORS
 OTHER TESTS
• ELECTROLYTES & LIVER PANEL  most helpful only in
assessing the level of illness and direct fluid
resuscitation, but RARELY aid accurate diagnosis5
• C-REACTIVE PROTEIN  increases in proportion to the
degree of inflammation, but non-specific as well5
• AMYLOID A PROTEIN  consistently elevated in
patients with acute appendicitis (SENSITIVITY –– 86%;
SPECIFICITY –– 83%)

29. DIAGNOSTIC FACTORS
 PLAIN RADIOGRAPHS
• Most helpful in evaluating complicated cases in which
small bowel obstruction or free air is suspected5
• FINDINGS:
1. Sentinel loops of bowel & localized ileus
2. Scoliosis from psoas muscle spasm
3. Colon “CUT-OFF” Sign  colonic air–fluid level above
the right iliac fossa
4. RLQ soft-tissue mass
5. Calcified appendicolith (5-10% of cases)
IMAGING TESTS

30. DIAGNOSTIC FACTORS
 ULTRASOUND
• Highly operator dependent
• SENSITIVITY – 0.86
• SPECIFICITY – 0.81
• FINDINGS5:
1. Wall thickness ≥6 mm
2. Appendicolith
3. Luminal distention
4. Lack of compressibility
5. Complex mass in the RLQ
WALL-C
MAIN LIMITATION  an inability to visualize the appendix in up to 20% cases

31. DIAGNOSTIC FACTORS
• GOLD STANDARD for pediatric evaluation
• BUT carries negative effects of radiation &
increased costs
• SENSITIVITY – 0.94
• SPECIFICITY – 0.95
• FINDINGS5:
1. Distended (>7 mm) thick-walled appendix
2. Inflammatory streaking of surrounding mesenteric fat
3. Pericecal phlegmon or abscess
4. Appendicoliths more readily seen (40-50%) than
plain radiographs (5-15%
 COMPUTED TOMOGRAPHY Also helpful in demonstrating NON-APPENDICEAL
CAUSES of abdominal pain

32. DIAGNOSTIC FACTORS
 COMPUTED TOMOGRAPHY

33. DIAGNOSTIC FACTORS
 MAGNETIC RESONANCE IMAGING
• EQUIVALENT to CT in diagnostic
accuracy for appendicitis
• LIMITED because it is less available,
more costly, often requires sedation
• DOES NOT involve ionizing radiation
• Most useful in adolescent girls when
advanced imaging is needed

34. DIAGNOSTIC FACTORS
 WHITE BLOOD CELL SCAN
• RADIONUCLIDE-LABELED WBC SCANS
• Also been used in some centers in
evaluating atypical cases of possible
appendicitis in children
• SENSITIVITY – 0.97
• SPECIFICITY – 0.80

35. DIAGNOSTIC FACTORS
CLINICAL SCORING SYSTEMS3 • <3  low likelihood
• 4–6  needs further evaluation
• ≥7  high likelihood
SCORES
INTERPRETATION

36. DIAGNOSTIC FACTORS
CLINICAL SCORING SYSTEMS5
• ≤2  low likelihood
• 3-7  needs further evaluation
• ≥8  high likelihood
SCORES
INTERPRETATION

37. DIAGNOSTIC FACTORS
• Dx of ACUTE APPENDICITIS made in only 50-70% of children at the
time of initial assessment
• NEGATIVE APPENDECTOMY rates (10-20%)
• PERFORATION rates (30-40%) REMAINS HIGH!!
MEDICAL ALERT!!

38. MANAGEMENT
MEDICAL MANAGEMENT
 ANTIBIOTIC THERAPY
• Lowers the incidence of POSTOPERATIVE WOUND INFECTIONS
& INTRAPERITONEAL ABSCESSES in perforated appendicitis,
but their role is less well defined in simple appendicitis5
• Antibiotic coverage is continued postoperatively for 3-5 days
• For SIMPLE NON-PERFORATED AP  one pre-op dose of a single broad-spectrum
agent (CEFOXITIN) or equivalent is sufficient
• For PERFORATED OR GANGRENOUS APPENDICITIS  combination regimens such as
Zosyn (piperacillin/tazobactam), ticarcillin/clavulanate, or ceftriaxone/metronidazole

39. MANAGEMENT
 For UNCOMPLICATED APPENDICITIS:
NON-OPERATIVE vs OPERATIVE
• NON-OPERATIVE:
a. Used in an environment where Sx not available & antibiotics alone not effective
b. Pt’s who did not pursue medical treatment occasionally have spontaneous resolution
• OPERATIVE  remains the standard of care
URGENT vs EMERGENT
• Dependent on each institution & surgeon
• URGENT  best done within hours
• EMERGENT  done as soon as possible because minutes can make a difference
SURGICAL MANAGEMENT

40. MANAGEMENT
 For COMPLICATED APPENDICITIS:
• Refers to PERFORATED APPENDICITIS commonly associated with an ABSCESS
or PHLEGMON
NON-OPERATIVE vs OPERATIVE
• NON-OPERATIVE  patients with complicated appendicits & a contained
abscess or phlegmon but limited peritonitis ––– conservative management
only (antibiotics, bowel rest, fluids, and possible percutaneous drainage) d/t
 risk for POSTOPERATIVE INTRA-ABDOMINAL ABSCESS FORMATION
• OPERATIVE  sepsis & generalized peritonitis would prompt immediate
management at the OR with concurrent resuscitation

41. MANAGEMENT
 OPERATIVE INTERVENTIONS:
1. INTERVAL APPENDECTOMY3,5
• Performing appendectomy following initial successful non-operative management
in patients with no further symptoms
• GOAL –– To prevent future attacks or to identify other disease (e.g. malignancies)
• Role following successful management of conservative treatment of complicated
appendicitis –– UNCLEAR
• Majority of pediatric surgeons perform this routinely (4-6 wk interval) after initial
non-operative management of perforated appendicitis5

42. MANAGEMENT
 IF WITHOUT CONTRAINDICATIONS –
if suggestive of medical Hx & PE with
supportive Labs should undergo
APPENDECTOMY urgently1
2. OPEN APPENDECTOMY3
• Under GA, placed in supine position
• RLQ MCBURNEY’S INCISION (oblique) or
ROCKY-DAVIS INCISION (transverse)3

43. MANAGEMENT
2. OPEN APPENDECTOMY (con’t)
• If appendix not easily identified, the CECUM
and MESENTERY should be located3
• Appendiceal stump managed by SIMPLE
LIGATION or by LIGATION AND INVERSION3
• If appendicitis not found, a methodical search
must be made for an alternative diagnosis3
• NEGATIVE APPENDECTOMY  term used for
an operation performed for suspected
appendicitis, in which the appendix is found
to be normal on histological evaluation2

44. MANAGEMENT
3. LAPAROSCOPIC APPENDECTOMY3
• First reported laparoscopic appendectomy
was performed in 1983 by Semm
• Under GA, an OGT and NGT are used
• Surgeon and assistant stands on the pt’s left
FACING THE APPENDIX
• Screens should be positioned on the pt’s
right or at the foot of the bed
• Stump should be carefully examined to
ensure hemostasis, complete transection,
and ensure that no stump is left behind

45. MANAGEMENT
3. LAPAROSCOPIC APPENDECTOMY (con’t)
ADVANTAGES:
• Fewer incisional surgical site infections
• Less pain, shorter length of stay
• Quicker return to normal activity
DISADVANTAGES:
• Increased risk of intra-abdominal abscess LAPAROSCOPIC APPENDICECTOMY. ARROW
SHOWS THE INFLAMED APPENDIX.

46. MANAGEMENT
4. LAPAROSCOPIC SINGLE-INCISION APPENDECTOMY
• “GROWING INTEREST”3 –– Instead of two or three incisions, a SINGLE INCISION
made, typically periumbilical
• Almost similar with the typical laparoscopic appendectomy
• NO DIFFERENCE in the ff:
a. Return to bowel function
b. Post-operative pain
c. Return to normal activity
d. Overall cost
e. Incidence of hernia formation
• Late outcomes & patient quality-of-life outcomes REMAIN TO BE INVESTIGATED

47. MANAGEMENT
5. NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY
• New surgical procedure using FLEXIBLE ENDOSCOPES in the abdominal cavity
• Access gained by way of organs that are reached through a NATURAL, ALREADY-
EXISTING external orifice (e.g. transvaginal approach)

48. Positivismum et Excellentiam!