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Appendicitis

Last Updated: September 12, 2006


Synonyms and related keywords: typhlitis, vermiform appendix, appendectomy, acute abdominal pain, appendiceal lumen, lymphoid hyperplasia, irritable bowel disease, IBD, fecal stasis, fecaliths, lymphoid hyperplasia of the appendix, obstruction of the appendiceal lumen, periappendicular abscess, peritonitis

Author: Luigi Santacroce, MD, Assistant Professor, Department of Dentistry and Surgery, Section of General Surgery, Medical and Dentistry School, State University at Bari, Italy Coauthor(s): Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh; Tommaso Losacco, MD, Residency Director of Digestive Surgery, Associate Professor, Department of Dentistry and Surgery, Section of General Surgery, Medical and Dentistry School, State University at Bari, Italy Editor(s): Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD , Senior Pharmacy Editor, eMedicine; Michael A Grosso, MD, Department of Cardiothoracic Surgery, St Francis Hospital; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; and John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital INTRODUCTION

The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. Its average length is 8-10 cm (ranging from 2-20 cm). This organ appears during the fifth month of gestation, and several lymphoid follicles are scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20 years. Appendicitis is inflammation of the inner lining of the vermiform appendix that spreads to its other parts. Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important step is the obstruction of the appendiceal lumen. This illness is one of the more common surgical emergencies, and it is one of the most common causes of abdominal pain. In the last few years, though, the incidence and mortality rate of this illness has markedly decreased. For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Appendicitis and Abdominal Pain in Adults. History of the Procedure: The first report of an appendectomy came from Amyan, a surgeon of the English army. Amyan performed an appendectomy in 1735 without anesthesia to remove a perforated appendix. Reginald H. Fitz, an anatomopathologist at Harvard who advocated early surgical intervention, first described appendicitis in 1886. Because he was not a surgeon, his

advice was ignored for a time. Then, at the end of the 19th century, the English surgeon H. Hancock successfully performed the first appendectomy in a patient with acute appendicitis. Some years after this, the American C. McBurney published a series of reports that constituted the basis of the subsequent diagnostic and therapeutic management of acute appendicitis. Currently, appendectomy, either open or laparoscopic, remains the treatment for noncomplicated appendicitis. Problem: Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency. In fact, this illness is one of the more common causes of acute abdominal pain. Left untreated, appendicitis has the potential for severe complications, including perforation or sepsis, and may even cause death. The diagnosis of appendicitis is clinical and essentially is based on history and clinical examination findings. The classic form of appendicitis may be promptly diagnosed and treated. When appendicitis appears with atypical presentations, it remains a clinical challenge. In such cases, laboratory and imaging investigation may be useful in establishing a correct diagnosis. Statistics report that 1 of 5 cases of appendicitis is misdiagnosed; however, a normal appendix is found in 15-40% of patients who have an emergency appendectomy. Although many antibiotics to control infections are available, appendicitis remains a surgical disease. In fact, appendectomy is the only rational therapy for acute appendicitis. It avoids clinical deterioration and may avoid chronic or recurrent appendicitis. Although difficult, prompt recognition and immediate treatment of the disease prevent complications. Frequency: The incidence of acute appendicitis is around 7% of the population in the United States and in European countries. In Asian and African countries, the incidence is probably lower because of the dietary habits of the inhabitants of these geographic areas. In the last few years, a decrease in frequency of appendicitis in Western countries has been reported, which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is believed to be related to poor fiber intake in such countries. Persons of any age may be affected, with highest incidence occurring during the second and third decades of life. Rare cases of neonatal and prenatal appendicitis have been reported. Appendicitis occurs more frequently in males than in females, with a male-to-female ratio of 1.7:1. Etiology: Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the obstruction include lymphoid hyperplasia secondary to irritable bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies

and neoplasms. Lymphoid hyperplasia of the appendix may be related to Crohn disease, mononucleosis, amebiasis, measles, and GI and respiratory infections. Fecaliths are solid bodies within the appendix that form after precipitation of calcium salts and undigested fiber in a matrix of dehydrated fecal material. Pathophysiology: Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes. Independent of the etiology, obstruction is believed to cause an increase in pressure within the lumen. Such an increase is related to continuous secretion of fluids and mucus from the mucosa and the stagnation of this material. At the same time, intestinal bacteria within the appendix multiply, leading to the recruitment of white cells and the formation of pus and subsequent higher intraluminal pressure. If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall. Various specific bacteria, viruses, fungi, and parasites can be responsible agents of infection that affect the appendix, including Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species, Schistosoma species, pinworms, and Strongyloides stercoralis. Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a periappendicular abscess or peritonitis may occur. Clinical: The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of the abdomen. Later, a worsening progressive pain along with vomiting, nausea, and anorexia are described by the patient. Usually, a fever is not present at this stage. In addition to recording the history of the abdominal pain, obtain a complete summary of the recent personal history surrounding gastroenterologic, genitourinary, and pneumologic conditions. Also consider gynecologic history in female patients. The differential diagnosis of appendicitis is often a clinical challenge because appendicitis can mimic several abdominal conditions. The differential diagnosis must include cholecystitis and biliary colic, gastroenteritis, enterocolitis, diverticulitis, pancreatitis, perforated duodenal ulcer, renal colic, and urinary tract infection (UTI). In pediatric patients, consider mesenteric lymphadenitis and intussusception. In women of childbearing age who are not pregnant, the differential diagnosis must also include ovarian cyst torsion, mittelschmerz, ectopic pregnancy, and pelvic inflammatory disease (PID). Small bowel obstruction, Crohn disease, Meckel diverticulitis, tumors, Henoch-Schnlein purpura, and rectus sheath hematoma are more rare

conditions that mimic appendicitis. Usually, patients are lying down, flexing their hips, and drawing their knees up to reduce movements and to avoid worsening the pain. A careful physical examination, not limited to the abdomen, must be performed in any patient with suspected appendicitis. GI, genitourinary, and pulmonary systems must be studied. Perform a rectal examination in any patient with an unclear clinical picture, and perform a pelvic examination in all women with abdominal pain. Tenderness on palpation in the RLQ over the McBurney point is the most important sign in these patients. Additional signs such as increasing pain with cough (ie, Dunphy sign), rebound tenderness related to peritoneal irritation elicited by deep palpation with quick release (ie, Blumberg sign), and guarding may or may not be present. Patients with appendicitis may not have the reported classic clinical picture 37-45% of the time, especially when the appendix is located in an unusual place (see Relevant Anatomy). In such cases, imaging studies may be important but not always available. Patients with this condition usually have accessory signs that may be helpful for diagnosis. For example, the obturator sign is present when the internal rotation of the thigh elicits pain (ie, pelvic appendicitis), and the psoas sign is present when the extension of the right thigh elicits pain (ie, retroperitoneal or retrocecal appendicitis). INDICATIONS

Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present. If the clinical picture is unclear, a short period (4-6 h) of watchful waiting and a CT scan may improve diagnostic accuracy and help to hasten diagnosis. However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, instruct the patient to return for continued or recurrent symptoms, and the patient may benefit from a follow-up examination in 24 hours. RELEVANT ANATOMY AND CONTRAINDICATIONS

Relevant Anatomy: The appendix is a wormlike extension of the cecum, and its average length is 8-10 cm (ranging from 2-20 cm). This organ appears during the fifth month of gestation, and its wall has an inner mucosal layer, 2 muscular layers, and a serosa. Several lymphoid follicles are scattered in its mucosa. The number of follicles increases when individuals are aged 8-20

years. The inner muscular layer is circular, and the outer layer is longitudinal and derives from the taenia coli. Taenia coli converge on the posteromedial area of the cecum. This site is the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix. Within the mesoappendix courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found. The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The course of the appendix and the position of its tip may vary widely, accounting for the nonspecific signs and symptoms of appendicitis. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Contraindications: Patients with appendicitis always need urgent referral and prompt treatment. No contraindications to appendectomy are known for patients with suspected appendicitis except in the case of a patient with a long history of symptoms and signs of a large phlegmon. If a periappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some physicians may choose a conservative approach with broadspectrum antibiotics and percutaneous drainage followed by appendectomy later. Certain contraindications exist for laparoscopic appendectomy. These contraindications are extensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, and coagulopathies. Laparoscopic appendectomy is contraindicated in the first trimester of pregnancy. Rarely, an appendiceal mucocele may occur. It is a collection of mucus within the appendiceal lumen. Occasionally, patients may present with a low-grade carcinoma of the appendix or cecum. In such cases, the surgeon must avoid perforation during dissection because it may cause seeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei. WORKUP

Lab Studies:

Laboratory tests are not specific for appendicitis but may be helpful to confirm diagnosis in patients with an atypical presentation. Complete blood cell count
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A mild elevation of WBCs (ie, >12,000/ L) is a common finding in patients with acute appendicitis. In these patients, leukocytosis occurs. Otherwise, the WBC count has

low specificity for appendicitis, and a number of bacterial and viral diseases may also lead to leukocytosis.
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In infants and elderly patients, a WBC count is especially unreliable because these patients may not mount a normal response to infection. In pregnant women, the physiologic leukocytosis renders the CBC count useless for the diagnosis of appendicitis.

Urinalysis
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Urinalysis may be useful in differentiating appendicitis from urinary tract conditions. Mild pyuria may occur in patients with appendicitis because of the relationship of the appendix with the right ureter. Severe pyuria is a more common finding in UTI. Proteinuria and hematuria suggest genitourinary diseases or hemocoagulative disorders.

C-reactive protein
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C-reactive protein (CRP) has been reported to be useful in the diagnosis of appendicitis. This protein is physiologically produced by the liver when bacterial infections occur and rapidly increases within the first 12 hours. CRP lacks specificity and cannot be used to distinguish between sites of infection. CRP levels greater than 1 mg/dL commonly are reported in patients with appendicitis. Very high levels of CRP in these patients indicate gangrenous evolution of the disease, especially if it is associated with leukocytosis and neutrophilia. However, CRP normalization occurs 12 hours after onset of symptoms.

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Liver and pancreatic function tests (eg, transaminases, bilirubin, alkaline phosphatase, serum lipase, amylase) may be helpful to determine the diagnosis in patients with an unclear presentation. For women of childbearing age, the level of urinary betahuman chorionic gonadotropic (beta-hCG) is useful in differentiating appendicitis from early ectopic pregnancy. Urinary 5-hydroxyindoleacetic acid
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According to a recent report, measurement of the urinary 5-5-hydroxyindoleacetic acid (U-5-HIAA) could be an early marker of appendicitis. The rationale of such measurement is related to the large amount of serotonin-secreting cells in the appendix. In the cited report, U-5-HIAA levels increase significantly in acute appendicitis,

decreasing when the inflammation shifts to necrosis of the appendix. Therefore, such decrease could be an early warning sign of perforation of the appendix. Imaging Studies:

Abdomen plain film: Occasionally, a plain film of the abdomen may demonstrate fecalith within the appendix, but this study is rarely indicated. Barium enema
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Although barium enema is currently performed only rarely, in the past this examination was used to diagnose appendicitis. When barium enema is performed, the typical radiologic sign of appendicitis is the "reverse 3. This sign typically manifests as an indentation of the cecum. In addition, the appendix does not fill with barium. The appendix cannot be visualized in 50% of healthy individuals; therefore, barium enema lacks reliability.

Ultrasound
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A healthy appendix usually cannot be viewed with ultrasound (US). When appendicitis occurs, the US typically demonstrates a noncompressible tubular structure of 7-9 mm in diameter. Vaginal ultrasound alone or in combination with transabdominal scan may be useful to determine the diagnosis in women of childbearing age. False-positive results may occur in patients with Crohn disease. False-negative results are frequent in patients with retrocecal appendix. The main limitation of US scan is that its reliability is completely user-dependent.

Computed tomography scan


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CT scan with oral contrast medium or rectal Gastrografin enema may help in diagnosis. Intravenous contrast is not usually necessary. It may help differentiate between appendicitis and other pelvic pathologies. The typical findings are a nonfilling appendix with distention and thickened walls of both the appendix and the cecum, enlarged mesenteric nodes, and periappendiceal inflammation or fluid. Because of its cost, CT scans are generally reserved for patients with uncertain diagnosis or severe obesity.

Recently, helical CT scan has demonstrated high sensitivity and specificity in differentiating appendicitis from other conditions, and it may be cost efficient with regards to limiting the number of unnecessary operations.

A recently reported diagnostic tool for acute appendicitis is radionuclide scanning using WBCs labeled with technetium Tc-99 (99Tc). Despite its reported high specificity and sensitivity, the procedure is time consuming and not useful in emergency situations. It is cost effective; however, it is not widely available.

Diagnostic Procedures:

Diagnostic laparoscopy may be useful in selected cases (eg, infants, elderly patients, female patients) to confirm the diagnosis. If findings are positive, such procedures should be followed by definitive surgical treatment at the time of laparoscopy.

Histologic Findings: In the early stages of the disease, the appendix grossly appears edematous with dilation of the serosal vessels. Microscopy demonstrates neutrophil infiltrate of the mucosal and muscularis layers extending into the lumen. As time passes, the appendiceal wall grossly appears thickened, the lumen appears dilated, and a serosal exudate (fibrinous or fibrinopurulent) may be observed as granular roughening. At this stage, mucosal necrosis may be observed microscopically. At later stages, the appendix grossly shows marked signs of mucosal necrosis extending into the external layers of the appendiceal wall that can become gangrenous. Sometimes the appendix may be found in a collection of pus. At this stage, microscopy may demonstrate multiple microabscesses of the appendiceal wall and severe necrosis of all layers. Staging: Appendicitis usually has 3 stages.

Edematous stage
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Appendicitis may have spontaneous regression or may evolve to the second stage. The mesoappendix is commonly involved with inflammation.

Purulent (phlegmonous) stage


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Spontaneous regression rarely occurs. Appendicitis usually evolves beyond perforation and rupture. Peritonitis may be possible.

Gangrenous stage
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Spontaneous regression never occurs.

Peritonitis is present.

TREATMENT

Medical therapy: Appendectomy remains the only curative treatment for appendicitis. Although many controversies exist over the nonoperative management of acute appendicitis, antibiotics have an important role in the treatment of patients with this condition. Antibiotics considered for patients with appendicitis must offer full aerobic and anaerobic coverage. Duration of the administration is closely related to the stage of appendicitis at the time of the diagnosis, considering either intraoperative findings or postoperative evolution. According to several studies, antibiotic prophylaxis should be administered before every appendectomy. When the patient becomes afebrile and the WBC count normalizes, antibiotic treatment may be stopped. Cefotetan and cefoxitin seem to be the best choices of antibiotics. Surgical therapy: Thousands of classic appendectomies (open procedure) have been performed in the last 2 centuries. Mortality and morbidity have gradually decreased, especially in the last few decades because of antibiotics, early diagnosis, and improvements in anesthesiologic and surgical techniques. Since 1987, many surgeons have begun to treat appendicitis laparoscopically. This procedure has now been improved and standardized. The reported results of both laparoscopic and open-procedure appendectomies seem to be overlapping. In fact, the average rate of abdominal abscesses, negative appendectomies, and hospital stays are very similar according to a recent overview of 17 retrospective studies. Laparoscopy has some advantages, including decreased postoperative pain, better aesthetic result, a shorter time to return to usual activities, and lower incidence of wound infections or dehiscence. This procedure is cost effective but may require more operative time compared with open appendectomy. Preoperative details: Preparation of patients undergoing appendectomy is similar for both open and laparoscopic procedures. Because they may mask the underlying disease, do not administer analgesics and antipyretics to patients with suspected appendicitis who have not been evaluated by the surgeon. Perform complete routine laboratory and radiologic studies before intervention. Venous access must be obtained in all patients diagnosed with appendicitis. Venous access allows administration of isotonic fluids and broad-spectrum intravenous antibiotics prior to the operation. Prior to the start of the surgical procedure, the anesthesiologist performs endotracheal intubation to

administer volatile anesthetics and to assist respiration. The abdomen is washed, antiseptically prepared, and then draped. Intraoperative details: Open appendectomy Prior to incision, the surgeon should carefully perform a physical examination of the abdomen to detect any mass and to determine the site of the incision. Open appendectomy requires a transverse incision in the RLQ over the McBurney point (ie, two thirds of the way between the umbilicus and the anterior superior iliac spine). The vertical incisions (ie, the Battle pararectal) are rarely performed because of the tendency for dehiscence and herniation. The abdominal wall fascia (ie, Scarpa fascia) and the underlying muscular layers are sharply dissected or split in the direction of their fibers to gain access to the peritoneum. If necessary (eg, because of concomitant pelvic pathologies), the incision may be extended medially, dissecting some fibers of the oblique muscle and retracting the lateral part of the rectus abdominis. The peritoneum is opened transversely and entered. Note the character of any peritoneal fluid to help confirm the diagnosis and then suction it from the field; if purulent, collect and culture the fluid. Retractors are gently placed into the peritoneum. The cecum is identified and medially retracted. It is then exteriorized by a moist gauze sponge or Babcock clamp, and the taenia coli are followed to their convergence. The convergence of teniae coli is detected at the base of the appendix, beneath the Bauhin valve (ie, the ileocecal valve), and the appendix is then viewed. If the appendix is hidden, it can be detected medially by retracting the cecum and laterally by extending the peritoneal incision. After exteriorization of the appendix, the mesoappendix is held between clamps, divided, and ligated. The appendix is clamped proximally about 5 mm above the cecum to avoid contamination of the peritoneal cavity and is cut above the clamp by a scalpel. Fecaliths within the lumen of the appendix may be detected. The appendix must be ligated to prevent bleeding and leakage from the lumen. The residual mucosa of the appendix is gently cauterized to avoid future mucocele. The appendix may be inverted into the cecum with the use of a pursestring suture or z-stitch. Although performed by several surgeons, the appendiceal stump inversion is not mandatory. The cecum is placed back into the abdomen. The abdomen is irrigated. When evidence of free perforation exists, peritoneal lavage with several liters of warm saline is recommended. After the lavage, the irrigation fluid must be completely aspirated to avoid the possibility of spreading infection to other areas of the peritoneal cavity. The use of a drain is not commonly required in patients with acute appendicitis, but obvious abscess with gross contamination requires drainage. The wound closure begins by closing the peritoneum with a running suture. Then, the fibers of the

muscular and fascial layers are reapproximated and closed with a continuous or interrupted absorbable suture. Lastly, the skin is closed with subcutaneous sutures or staples. In cases of perforated appendicitis, some surgeons leave the wound open, allowing for secondary closure or a delayed primary closure until the fourth or fifth day after operation. Other surgeons prefer immediate closure in these cases. Laparoscopic appendectomy The surgeon typically stands on the left of the patient, and the assistant stands on the right. The anesthesiologist and the anesthesia equipment are placed at the patient's head, and the video monitor and instrument table are placed at the feet. Although some variations are possible, 3 cannulae are placed during the procedure. Two of them have a fixed position (ie, umbilical and suprapubic). The third is placed in the right periumbilical region, and its position may vary greatly depending on the patient's anatomy. According to the preferences of the surgeon, a short umbilical incision is made to allow the placement of a Hasson cannula or Veress needle that is secured with 2 absorbable sutures. Pneumoperitoneum (10-14 mm Hg) is established and maintained by insufflating carbon dioxide. Through the access, a laparoscope is inserted to view the entire abdomen cavity. A 12-mm trocar is inserted above the pubic symphysis to allow the introduction of instruments (eg, incisors, forceps, stapler). Another 5-mm trocar is placed in the right periumbilical region, usually between the right costal margin and the umbilicus, to allow the insertion of an atraumatic grasper to expose the appendix. The appendix is grasped and retracted upward to expose the mesoappendix. The mesoappendix is divided using a dissector inserted through the suprapubic trocar. Then, a linear Endostapler, Endoclip, or suture ligature is passed through the suprapubic cannula to ligate the mesoappendix. The mesoappendix is transected using a scissor or electrocautery. To avoid perforation of the appendix and iatrogenic peritonitis, the tip of the appendix should not be grasped. The appendix may now be transected with a linear Endostapler, or, alternately, the base of the appendix may be suture ligated in a similar manner to that in an open procedure. The appendix is now free and may be removed through the umbilical or the suprapubic cannula using a laparoscopic pouch to prevent wound contamination. Peritoneal irrigation is performed with antibiotic or saline solution. Completely aspirate the irrigant. The cannulae are then removed and the pneumoperitoneum is reduced. The fascial layers at the cannula sites are closed with absorbable suture, while the cutaneous incisions are closed with interrupted subcuticular sutures or sterile adhesive strips. Postoperative details: Administer intravenous antibiotics postoperatively. The length of administration is based on the operative findings and the recovery of the patient. In complicated appendicitis, antibiotics may be required for many days or weeks.

Antiemetics and analgesics are administered to patients experiencing nausea and wound pain. The patient is encouraged to ambulate early. When appendicitis is not complicated, the diet may be advanced quickly postoperatively and the patient is discharged from the hospital once a diet is tolerated. In patients with complicated appendicitis, a clear liquid diet may be started when bowel function returns. These patients may be discharged after complete restitution of infection. Follow-up care: After hospital discharge, patients must have a light diet and limit their physical activity for a period of 2-6 weeks based on the surgical approach (ie, laparoscopic or open appendectomy). The patient should be evaluated by the surgeon in the clinic to determine improvement and to detect any possible complications. COMPLICATIONS

Complications may occur in patents with appendicitis, accounting for an average morbidity near 10%. Death is rare but can occur in patients who have profound peritonitis and sepsis. Severe infection may result in adynamic ileus. Postoperatively, wound infection or dehiscence may occur, especially in patients with gangrenous or perforated appendicitis, persistent ileus, cecal fistulas, and pelvic or abdominal abscess. Patients with these conditions present with wound tenderness or soreness, drainage of fluid from the incision, or swelling and redness at the incision site. Cardiovascular (eg, myocardial infarction, pulmonary embolism) and pulmonary (eg, pneumonia) complications have been reported. Patients with postoperative infections usually present with a mild fever, abdominal pain, and disorders of bowel transit (ie, diarrhea or constipation). Persistent nausea, vomiting, difficulty with micturition, and persistent pain in the lower limbs may also occur. If a complication occurs, further diagnostic and therapeutic procedures could be required, leading to additional cost and prolonged hospitalization. OUTCOME AND PROGNOSIS

The outcome of appendicitis, whether it is complicated or simple, is good. Patients may return to their activities soon after the operation, and, once the patient has recovered, no changes in lifestyle (eg, diet, exercise) are required after appendectomy. Prognosis is excellent. In fact, no mortality has been reported in patients with a nonperforated

appendix. The mortality rate is less than 1% if appendiceal perforation exists. An exception is elderly patients, who have a mortality rate that approaches 5%. An intermediate mortality rate (1-4%) is reported in infants because of the high frequency of perforation caused by delayed diagnosis related to the difficulties in distinguishing appendicitis from other conditions in the differential diagnosis. FUTURE AND CONTROVERSIES

Appendicitis remains an emergency. Physicians should always suspect this disease, especially in patients with unclear symptoms. The typical findings on history and physical examination are the mainstays of diagnosis. However, a patient suspected of having appendicitis may be further evaluated with laboratory tests and imaging studies. Some of these diagnostic tools are not widely available (eg, helical CT scan) or are time consuming, although some are cost effective (eg, scintigraphy with labeled WBCs). When advanced imaging systems are not available, ultrasound and plain film of the abdomen may be considered to confirm the diagnosis, especially in patients with atypical symptoms. However, avoiding time-consuming studies appears to be mandatory in patients with symptoms lasting more than 24 hours because of the risk of delayed diagnosis. Patients with evidence of IBD at the time of exploration around the appendix but without evidence of appendicitis should not undergo appendectomy. If an appendectomy is performed, it results in fistula formation postoperatively. Another controversy continues over the operative approach to appendectomy. Open appendectomy is still the most common approach because it is quick and cost effective. However, an increasing number of surgeons prefer laparoscopic appendectomy because of the diagnostic ability of laparoscopy, especially in female patients. The aesthetic results and an earlier return to normal activities may also be advantageous. Some authors have criticized the cost of a laparoscopic procedure, but evidence indicates that in the future it will be the standard for the treatment of patients with appendicitis and undiagnosed abdominal pain. If the surgeon finds a normal appendix, he or she is faced with a dilemma. At this point, other causes of the patient's condition should be ruled out, including ovarian pathology, Meckel diverticulum, sigmoid disease, and cholecystitis. Regardless of the findings, the authors believe that appendectomy should be performed. The patient will have a RLQ incision, and, in the future, physicians who examine the patient may assume that an appendectomy has been performed and they will not include appendicitis in the differential diagnosis. In the past, appendicitis sometimes was so severe that the cecum appeared necrotic. Today, this finding is very rare, fortunately. In such cases, perform an ileocecectomy or right hemicolectomy with a primary anastomosis.

The nonoperative management of appendicitis with high doses of antibiotics is reported in some studies, but it seems to be effective in only 60% of patients. It may be useful (and should be considered) in rural areas or if a surgical facility is not in close proximity to the patient. BIBLIOGRAPHY

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