1. APPENDICITIS - WHAT WE ALL FORGOT (or never knew in the first place!)

2. APPENDICITIS History Berengario DaCarpi, a physician-anatomist,
made the first description of the appendix in 1521
Leonardo DaVinci demonstrated the appendix in drawings made in 1492 but not published until the 18th century.
Lorenz Heister gave the first unequivocal account of appendicitis in 1711
The appendix is clearly illustrated in De Humani Corporis Febrica Liber V by Andreas Vesalius published in 1543
Vesalius A. De Humani Corporis Fabrica Liber V. Basel: Iohannis Oporini; 1543.

3. APPENDICITIS
History
Heister, a student of Boerhaave, described a perforation of the appendix with a small abscess adjacent to a gangrenous appendix
Heister speculated that the appendix might be the site of acute inflammation. He described the autopsy on the body of a criminal
Francois Melier, a Parisian physician, described 6 cases of appendicitis at autopsy and first suggested the possibility of removing the appendix in 1827

4. APPENDICITIS
History
Claudius Amyand, Sergeant Surgeon to George II, performed the first known appendectomy in He operated on an 11-year-old boy with a right scrotal hernia and a fistula. He identified the appendix, perforated by a pin, within the scrotum. He ligated the appendix and removed it.
Shepherd JA. Acute appendicitis: a historical survey. Lancet 1954;2:

5. APPENDICITIS History Fitz – 1886
Proposed that the appendix is the cause of most inflammatory disease of the right lower quadrant. He went on to describe the clinical features of appendicitis and, importantly, proposed early surgical removal of the appendix
Fitz RH. Perforating inflammation of the vermiform appendix: with special
reference to its early diagnosis and treatment. Am J Med Sci 1886;92:

6. APPENDICITIS
History
In 1889, McBurney of New York published the first of several important papers regarding the appendix. He suggested early operative intervention and developed the muscle-splitting incision that bears his name and is commonly used today
McBurney C. Experience with early operative interference in cases of disease of the
vermiform appendix. NY Med J 1889;50:
McBurney C. The incision made in the abdominal wall in cases of appendicitis,
with a description of a new method of operation. Ann Surg 1894;20:38-43.

7. APPENDICITIS Introduction Lifetime risk – 6% to 7%
Peak age – Adolescents and young adults
Uncommon <5 and >50 yrs
1 in 35 men
1 in 50 women
Male:Female 1.3:1

8. APPENDICITIS Introduction
More common in industrialised nations (refined, low fibre diet)
Presumably, this diet leads to hard stool, higher intracolic pressure and faecolith formation
Familial association is simply due to similar environment and dietary habits

9. APPENDICITIS Pathophysiology Small lumen to length ratio
Predisposed to closed loop obstruction, especially with proximal swelling or faecolith
Ongoing mucosal secretion leads to elevated intraluminal pressure
Venous pressure is exceeded and
ischaemia develops
Hypoxic mucosa begins to ulcerate
Bacterial translocation

11. APPENDICITIS Clinical Features
Begins as peri-umbilical discomfort – poorly localised and unrelieved by stools.
Loss of Appetite (80%)
Nausea (+- vomiting)
Diarrhoea (uncommon)
6-12 hours later localised to RIF (localised peritonism)
Less tenderness in retrocaecal or pelvic appendix
Pyrexia (37.5 to 38) – 25% to 50% have temp <37.5

12. APPENDICITIS Clinical Features Leukocytosis…
Cardall and colleagues showed that fever and leukocytosis were not always present and cannot be wholly relied upon in the diagnosis
Pieper and colleagues reported 493 patients in which only 67% had a leukocyte count greater than 11.0
CRP
Cardall T, Glasser J, Guss DA. Clinical value of the total white blood cell count and
termperature in the evaluation of patients with suspected appendicitis. Acad Emerg
Med 2004;11:1021-7
Pieper R, Kager L, Nasman P. Acute appendicitis: a clinical study of 1018 cases of
emergency appendectomy. Acta Chir Scand 1982;48:51-62.

13. APPENDICITIS
Clinical Features

14. APPENDICITIS Clinical Features PSOAS SIGN
The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip.
Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this manoeuvre.

15. APPENDICITIS OBTURATOR SIGN
Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee resulting in internal rotation of the femur.
Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this manoeuvre.

16. Perforation - Clinical Features
APPENDICITIS
Perforation - Clinical Features
Occurs in 20%-30%
Longer duration of symptoms before presentation
Age <3yrs and >50yrs
Increasing abdominal pain (severity and sight)
Temperature > 38
The morbidity of a negative appendectomy is preferable to the morbidity of perforated appendicitis

17. Peri-appendiceal Abscess - Clinical Features
APPENDICITIS
Peri-appendiceal Abscess - Clinical Features
Occurs in 10%
Scenario – Develops RIF pain and fever for 1-2 days then resolves, then recurs 7-10 days later
Palpable mass
Ultrasound or CT to confirm diagnosis
Avoid surgery if possible, especially if appendix is difficult to find (discussed later)

18. Recurrent Appendicitis
Debatable existence
Sinanan has shown it to be a real entity
Recurrent attacks of RIF pain
If interval appendectomy not done after medical Rx, 10-80% recurrence
Histology in recurrent pain pts- chronic AND acute inflammation
Sinanan M. Acute Abdomen and Appendix. In: Greenfield LJ, Mulholland MW,
Oldham KT, Zelenock GB, editors. Surgery: Scientific Principles and Practice.
Philadelphia: JB Lippincott; 1993, pp

19. APPENDICITIS Chronic Appendicitis Chronic RIF pain
If appendectomy relieves pain, and histology shows chronic inflammation – Diagnosis is made retrospectively

20. Atypical Presentations
APPENDICITIS
Atypical Presentations
3 factors…
1) Extremes of age
2) Variable appendiceal position
3) Associated conditions (e.g. pregnancy, Crohn’s, antibiotics, steroids, recent abdominal surgery)

21. Atypical Presentations
APPENDICITIS
Atypical Presentations
3 factors…
1) Extremes of age
Age 1-5 has 70% perforation rate
Age < 1yr has almost 100% perforation rate
REASONS…
Communication
Shorter, incompletely formed omentum

22. Atypical Presentations
APPENDICITIS
Atypical Presentations
3 factors…
3) Associated conditions (e.g. pregnancy, Crohn’s, antibiotics, steroids, recent abdominal surgery)
Pregnancy causes delays in diagnosis
Abdominal pain, nausea, vomiting, leukocytosis all ‘normal’ for pregnancy
Appendix moves to RUQ in 3rd trimester

23. Differential Diagnosis
APPENDICITIS
Differential Diagnosis
CHILDREN…
Extra-abdominal – (Otitis, pneumonia, meningitis, URTI – can all present with abdominal pain, nausea, vomiting.
Diarrhoea – usually suggestive of gastroenteritis
Mesenteric Lymphadenitis
Meckel’s diverticulitis
Intussusception (Tender mass and red-currant stools)
Typhlitis (neutropaenic child)

24. APPENDICITIS Imaging A SHORT NOTE…
If the diagnosis is apparent from the history, examination and lab findings – then surgery is indicated without imaging.
Imaging is reserved for doubtful diagnosis

25. APPENDICITIS Imaging PLAIN RADIOGRAPHS… Faecolith (5-8%)
Gas in the appendix
Localised paralytic ileus
Loss of caecal shadow
Blurring of R Psoas
R scoliosis of lumbar spine
Free air (rare)

26. APPENDICITIS Imaging PLAIN RADIOGRAPHS…
Study of 821 patients… no x-ray was sensitive or specific
Use to rule out other condition (obstruction, renal calculus, perforation)
Overall – not cost effective
Rao PM, Rhea JT, Rao JA, Conn AK. Plain abdominal radiography in clinically
suspected appendicitis: diagnostic yield, resource use, and comparison with CT.
Am J Emerg Med 1999;17:325-8.

27. APPENDICITIS Imaging ULTRASOUND
Deutsch and Leopold visualised appendix in 1981
Graded pressure technique (compresses the bowel overlying the appendix)
Immobile, non-compressible, blind-ending structure consisting of an anechoic lumen surrounded by an echogenic mucosa and hypoechoic thickened wall adjacent to the caecum.
Deutsch A, Leopold GR. Ultrasonic demonstration of the inflamed appendix: case
report. Radiology 1981;140:163-4.

28. APPENDICITIS Imaging ULTRASOUND
The diagnostic accuracy of graded compression ultrasound has been reported to range from 71% to 97%, with sensitivities and specificities in the 76% to 96% and 47% to 94% ranges, respectively
Operator dependent
Normal appendix must be visualised to rule out appendicitis (60-82%)
Retrocaecal appendix difficult to visualise

29. APPENDICITIS Imaging ULTRASOUND Appendicitis features –
Appendiceal diameter > 6-7mm (sensitivity 100%, specificity 64%)
Target sign
Loculated peri-caecal fluid (rupture)
Appendicolith
Absence of gas in appendix lumen

31. APPENDICITIS Imaging ULTRASOUND - summary Disadvantages…
Low specificity
Discomfort for patient with probe pressure
Advantages…
Inexpensive
Non-invasive
No radiation
Can find other abdominal pathology

32. APPENDICITIS Imaging CT SCAN… Accuracy of 93-98% Sensitivity 87-100%
Specificity 95-99%
Enlarged appendix
Appendiceal wall thickening
Peri-appendiceal fat stranding
Appendiceal wall enhancement
Rao PM, Rhea JT, Novelline RA. Sensitivity and specificity of the individual CT
signs of appendicitis: experience with 200 helical appendiceal CT examinations.
J Comput Assist Tomogr 1997;21:

33. APPENDICITIS Imaging CT SCAN… Study of 908 patients…
Drop in perforation rate (22% to 14%)
Drop in negative appendectomy rate (20% to 7%)
Rao P, Rhea JT, Rattner DW, Wenus LG, Novelline RA. Introduction of
appendiceal CT: impact on negative appendectomy and appendiceal perforation
rates. Ann Surg 1999;229:344-9. .

34. APPENDICITIS Imaging CT vs. ULTRASOUND… CT advantages…
Higher diagnostic accuracy
Operator independence
CT Disadvantages
Contrast problems
Radiation
Cost

36. APPENDICITIS Antibiotics Large meta-analysis of 9576 patients
Proven to prevent wound infection and intra-abdominal abscess
Cover Gram negative and anaerobic organisms
Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for
prevention of postoperative infection after appendicectomy. Cochrane Database
Syst Rev 2004;4:1-64

37. APPENDICITIS Surgery Generally indicated unless…
Symptoms resolved when patient presents
Peri-appendiceal abscess without peritonitis – percutaneous drainage
Interval appendectomy
Optimise patient before surgery

38. APPENDICITIS Open Appendectomy Normal appendix?
Check Caecum, ileum (and sigmoid) for diverticular disease.
Check for Meckel’s
Gall Bladder
Iiflammatory Bowel Disease
Perforated Duodenal Ulcer
GUT (females – PID, follicular cysts, ectopic)
Mesenteric lymphadenpathy
NB – if ++ pus, full exploration required

39. APPENDICITIS Open Appendectomy Normal appendix?
Do appendectomy anyway (presence of the scar, etc.)
Exception is diseased caecum (e.g. Crohn’s) where a fecal fistula may form

40. Peri-appendiceal Abscess
APPENDICITIS
Peri-appendiceal Abscess
CT or Sonar guided percutaneous catheter
7-10 days of drainage
Interval appendectomy at 6-8 weeks
If laparotomy done…
Open abscess
Appendectomy only if safe
If caecum friable, leave it and do interval appendectomy (10% to 80% risk of recurrence)

41. Laparoscopic Appendectomy
APPENDICITIS
Laparoscopic Appendectomy
Kurt Semm 1983
Major meta-analysis, still major controversy
Dependent on expertise and equipment
Allows for better visualisation of the abdomen

42. Laparoscopic Appendectomy
APPENDICITIS
Laparoscopic Appendectomy
CONTRA-INDICATIONS…
Lack of surgeon’s experience
Inability to tolerate GA
Refractory coagulopathy
Diffuse peritonitis with haemodynamic compromise
Previous abdominal surgery (relative)
Portal Hypertension (relative)
Advanced pregnancy (relative)
Severe cardiac failure (relative)

43. Selected randomized trials of laparoscopic versus open appendectomy
Reference
number
OR Time Conversion rate(%) LOS <days> L O
Long et al (2002) 93
105
107 91 16
2.6
3.4
Pedersen et al (2001)
282
301 60 40 23 2
Ozmen et al (1999) 35 28 38 —
1.6
3.7
Hellberg et al (1999)
244
256 12
Heikkinen et al (1998) 19 21 31 41
5.3
Klinger et al. (1998) 87 82 3 4
Reiertsen et al (1997) 42 51 25
3.5
3.2
Minne et al (1997) 27 67
7.4
1.1
1.2
Macarulla et al (1997)
106
104 55 45
8.3
4.8
Ortega et al (1995)
167 86 68 58
6.5
2.8

44. Laparoscopic Appendectomy
APPENDICITIS
Laparoscopic Appendectomy
Laparoscopic longer by minutes
5% - 25% conversion
Hospital stay same or 1 day in favour of laparoscopic
Return to normal activity 5-7 days earlier
Results of complication rates mixed
No difference in cost
(equipment/length vs. hospital stay)
‘Jury is still out