Appendicitis

approach & management: current senario

1. Approach & management (11/09/2018)
Dr. Asif Mian Ansari
DNB resident
Max Superspeciality Hospital, Mohali
Punjab
Moderator: Dr. Gaurav
Kaushal

2. Inflammation of appendix
All layers of colon
Additionally B & T lymphocytes in mucosa &
submucosa IgA GALS
Main precipitating factor is obstruction of
lumen
Fecalith, lymphoid hyperplasia, calculi, infections,
benign or malignant tumors and paracites in
endemic regions

3. Obstruction  rise in intraluminal pressure
 obstruction of venous outflow & lymphatic
stasis engorgement of appendix 
appendicular walls ischemia & necrosis 
bacterial overgrowth  neutrophils
infiltration  invasion of walls  perforation
 localised peritonitis and abscess formation

4. Age : 2
nd
and 3
rd
decade most common
Migratory right lower quadrant abdominal
pain
Anorexia
Nausea & vomiting
Non specific symptoms like fever,
Indigestion, Flatulence, Bowel irregularity,
Diarrhea, Generalized malaise etc.
Symptmes may vary according to tip position

5. Inflamed anterior appendix:
Marked pain & tenderness
in RIF
Inflamed retrocaecal
appendix:
Dull aching pain
Inflamed pelvic appendix:
Tenderness at McBurney’s
point , increased urinary
frequency, dysuria and
rectal symptoms

6. Elevated temperature and tachycardia
Per abdomen findings:
Tenderness in RIF region
Rebound tenderness
Guarding & rigidity
Accessory signs:
▪Rovsing sign
▪Dunphy sign
▪Obturator sign
▪Psoas sign

7. Leukocytosis (80%) with shift to left
Mild hyperbilirubinemia
Raised C- reactive protein

8. Modified Alvarado score
Score </= 3 appendicitis unlikely
Score 4-6 needs further evaluation
Score >/= 7 appendicitis (78%)
1 point 2 points
Migratory right lower quadrant painTenderness in the right lower quadrant
Anorexia
Leukocytosis of white blood cell count
>10 x 10
9
/liter
Nausea or vomiting
Fever >37.5°C (>99.5°F)
Rebound tenderness in the right lower
quadrant

9. Imaging techniques for acute appendicitis:
CT scan:
Preferred imaging, imaging features are:
▪Enlarged appendiceal dilatation (>6 mm)
▪Appendiceal wall thickening (>2 mm)
▪Periappendiceal fat stranding
▪Appendiceal wall enhancement
▪Appendicolith

10. Normal appendix and appedicitis in CT scan

11. Ultrasonography : preferred in children and
pregnancy or if CT is not rapidly available
Findings are:
▪Noncompressible appendix with double-wall thickness
diameter of >6 mm
▪Probe tenderness with compression
▪Appendicolith
▪Increased echogenicity of inflamed periappendiceal fat
▪Fluid in the right lower quadrant

12. Normal appendix and acute appendicitis on
USG

13. Magnetic resonance imaging: preferred in
pregnancy.
Findings are comparable to CT

14. Imaging modalities for diagnosis of appendicitis
  Advantages Disadvantages
US
No ionizing radiation Lower diagnostic accuracy than CT or MRI
Widely available, including at the bedside
Operator-dependent variability in
diagnostic performance

High rates of indeterminate exams with
50 to 85% of normal appendices not
visualized
CT
High diagnostic accuracy Ionizing radiation
Lowest rates of indeterminate exams with
80 to 90% of normal appendix visualized
Intravenous iodinated contrast needed for
optimum diagnostic performance
MRI
No ionizing radiation Limited availability
High diagnostic accuracy
Requires patient lie still in an enclosed
scanner for 10 to 30 minutes
Moderates rates of nondiagnostic exams
with 20 to 30% normal appendices not
visualized

15. Test performance for diagnosis of appendicitis
Test performance for diagnosis of
appendicitis
Test Sensitivity Specificity
WBC 0.84 (0.73 to 0.92) 0.67 (0.50 to 0.81)
CRP 0.81 (0.74 to 0.87) 0.54 (0.42 to 0.64)
WBC & CRP 0.93 (0.86 to 1.00) 0.62 (0.37 to 0.86)
CT 0.96 (0.95 to 0.97) 0.96 (0.93 to 0.97)
US 0.85 (0.79 to 0.90) 0.90 (0.83 to 0.95)
MRI 0.95 (0.88 to 0.98) 0.92 (0.87 to 0.95)

17. Appendix without pathological evidence of
acute inflammation
Decreased in last 10 years

18. •Nonperforated appendicitis
•Perforated appendicitis

19. Appendicitis without clinical or radiographic
signs of perforation (eg, inflammatory mass,
phlegmon, or abscess)
Timely appendectomy is recommended by :
American College of Surgeons
Society for Surgery of the Alimentary Tract
Society of American Gastrointestinal and
Endoscopic Surgeons

20. European Association of Endoscopic Surgery
World Society of Emergency Surgery
Antibiotics are only for augmentation of
surgery

21. Nonoperative treatment: favourable evidences from 6 RCTs

22. Conclusions :
Patients treated with antibiotics have lower or
similar pain scores, require fewer doses of
narcotics, have a quicker return to work and do
not have a higher perforation rate
90 percent of patients treated successfully with
antibiotics, 10 % non responders require surgery
70% patients are able to avoid surgery during the
first year

23. Issues about non-operative treatment:
Preoperative abdominal CT cannot reliably
distinguish uncomplicated appendicitis from
complicated disease. False negative CT will cause
increased morbidity due to nonsurgical
management
Patient with fecaliths have higher complication
rates nonsurgical treatment is not
recommended

24. Nonoperative management poses a greater risk
for patients who are older, immunocompromised,
or have medical comorbidities
These groups of patients were excluded from
trials  efficacy of non operative treatment is
unknown

25. Standard treatment for appendicitis is
appendectomy; either open or laparoscopic
Timing of appendectomy:

26. Patients are acutely ill and have significant
dehydration and electrolyte abnormalities
Pain is localised to RLQ (if walled off by
omentum) or diffused (if generalized
peritonitis )
On imaging, contained perforation
(phlegmon), abscess or rarely free
perforation may be seen
12-20% of all acute appendicitis cases

27. Stable patients : immediate surgery versus
initial non operative treatment

28. Stable patients with abscess antibiotics
and image guided drainage of abscess
Responders  7-10 days antibiotic treatment
and to be followed up after 6-8 weeks

29. Stable patients with phlegmon (Lump)
Ochsner-Sherren regimen
Rescue appendectomy for non responders
Rising temperature/pulse
Increased size of lump
Abscess formation

30. Antibiotics choice:
carbepenems, piperacillin-tazobactum or
ticarcilline-clavulanate are single-agent regimen
Cefuroxime, ceftriaxone, cefazoline, cefotaxime
or ciprofloxacin is used with metronidazole
Amikacin or vancomycin may be added for
enterococcal coverage

31. Follow up after 6-8 weeks
Colonoscopy (if age >40 years)
Interval appendectomy
Prevents recurrent appendicitis
excludes appendiceal neoplasms