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Epidemiology

• 1^st described in the late 1400s and 1^st published in 1544 by Jean Fernal
• 1^st appendectomy was performed in 1736 on an 11yo boy
• 233/100,000 population
• May occur throughout life, but is most common age group is 10-19yo and slightly more common in men
• Badass of the Millennium goes to….Leonid Rogozov.  He was the only physician on a Soviet team in Antarctica in 1961 and performed an appendectomy…on himself…and survived (Article here)

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Anatomy of the Appendix

• Located where the taenia coli converge at the base of cecum
• Average length 6-9cm, outer diameter 3-8mm, and luminal diameter 1-3mm
• Arterial supply is from appendicular branch of the ileocolic artery
• The attachment of the base of the appendix is constant, but the tip may be positioned:
  • Retrocecal (most common)
  • Subcecal
  • Preileal
  • Postileal
  • Pelvic

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Pathogenesis

• Follows traditional predictable series of events for inflammation of a hollow visceral organ:
  • Inflammation
    • Most commonly by an obstruction
      • Fecalith, calculi, lymphoid hyperplasia, infection, mass
      • Causes a closed-loop obstruction
  • Distention
    • Normal secretion and bacterial overgrowth
      • Causes visceral nerve pain
    • Luminal pressure > perfusion
      • Involves the serosa
        • Causes parietal pain
  • Perforation
    • As areas of ischemia progress and pressures increase, perforation may occur
      • May be contained (localized) or cause peritonitis
    • Although this progression is predictable, the time frame may be variable
      • Perforation may occur anywhere from 24-48 hours after symptom onset

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History

• Abdominal pain occurs first
  • Starts as diffuse, periumbilical
  • Appendix position may alter pain location
• Nausea and vomiting then follows
• Anorexia (Negative Cheeseburger Sign)
• Last is migratory pain to RLQ (50-60%)

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Physical Examination

• Often non-specific as appendix position, time course of illness, and patient anatomy may obscure findings
• Classic physical exam findings include:
  • McBurney’s Point Tenderness
    • Maximal tenderness 3cm from ASIS, or 1/3^rd the distance from ASIS to umbilicus
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  • Rovsing’s Sign
    • Palpation or rebound pressure of LLQ causes RLQ pain
  • Psoas Sign (retrocecal)
    • Pain in RLQ when ipsilateral hip is extended or flexed against resistance
  • Obsturator Sign (pelvic)
    • Pain in RLQ with internal rotation of ipsilateral hip with flexed knee
• • Guarding and peritoneal signs may be seen with perforation

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Laboratory Studies

• CBC with differential and CRP are needed for the scoring systems, but are not very specific

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Pretest Probability Scoring Systems

• Alvarado Score
  • Developed in 1986 and modified in 1994
• Appendicitis Inflammatory Response (AIR) Score
  • Developed in 2008
• Pediatric Appendicitis Score
  • Developed in 2002

• Interpretation
  • Alvarado Score
    • 0-3 – low probability (discharge)
    • 4-6 – indeterminate (image or admit)
    • ≥ 7 – high probability (admit or surgery)
  • AIR Score
    • 0-4 – Low probability (discharge)
    • 5-8 – Indeterminate (image or admit)
    • ≥ 9 – high probability (admit or surgery)
  • PAS
    • < 3 – low probability (discharge)
    • 3-7 – indeterminate (image or admit)
    • ≥ 8 – high probability (admit and consult)

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Radiographic Imaging

• Imaging is generally reserved for indeterminate cases or special populations (children, women, elderly) as clinical examination is just as effective as imaging in ruling-out appendicitis
• Computed Tomography
  • IV contrast
  • Findings suggesting appendicitis:
    • ≥ 6mm diameter
    • Appendiceal wall thickening ≥ 2mm
    • Periappendiceal fat stranding
    • Appendicolith

• Ultrasound
  • Study of choice in children and pregnant women and becoming study of choice in adults
  • Findings suggestive of appendicitis:
    • Aperistaltic, noncompressible, dilated (> 6mm) appendix
    • Distinct appendiceal wall layers
    • Echogenic prominent pericecal fat
    • Periappendiceal fluid collection
    • Target appearance on axial section

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Management

• Nonoperative Management
  • Several studies have looked at antibiotic management of uncomplicated appendicitis and found:
    • Up to 53% of antibiotic-only management still required surgery within 48hr
    • Antibiotic-only patients had lower pain scores and quicker return to work
    • Up to 37% of antibiotic-only patients required surgery for recurrent appendicitis within 2 years
    • Most recent study (APPAC Trial, JAMA, 2015) did meet prespecified criterion for noninferiority
    • May be an options for special populations
      • Poor surgical candidates, patients who refuse surgery
  • As for now, there isn’t enough good data to support routine, nonoperative management for uncomplicated appendicitis
• Operative Management
  • Uncomplicated
    • Urgent (12-24hr) vs Emergent (< 12hr)
      • No difference in outcomes
      • 
  • Complicated (perforation with abscess)
    • Sick or with generalized peritonitis = emergent surgery
    • Limited peritonitis
      • Antibiotics, bowel rest, percutaneous drainage
      • Interval appendectomy after improvement in clinical course
  • Laparoscopic vs Open Appendectomy
    • Laparoscopic > open in regards to patient outcomes
  • Complications
    • Wound infections
    • Organ space infections
    • Stump appendicitis

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Cottage Physician

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References

1. Williams GR. Presidential Address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg. 1983;197(5):495-506.
2. Buckius MT, Mcgrath B, Monk J, Grim R, Bell T, Ahuja V. Changing epidemiology of acute appendicitis in the United States: study period 1993-2008. J Surg Res. 2012;175(2):185-90.
3. Liang MK, Andersson RE, Jaffe BM, Berger DH. The Appendix. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz’s Principles of Surgery, 10e. New York, NY: McGraw-Hill; 2014. http://accesssurgery.mhmedical.com/content.aspx?bookid=980&Sectionid=59610872. Accessed June 14, 2016.
4. Raahave D, Christensen E, Moeller H, Kirkeby LT, Loud FB, Knudsen LL. Origin of acute appendicitis: fecal retention in colonic reservoirs: a case control study. Surg Infect (Larchmt). 2007;8(1):55-62.
5. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology. 2000;215(2):337-48.
6. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg. 1995;221(3):278-81.
7. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91(1):28-37.
8. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix.  NY State Med J. 1889;50:676.
9. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-64.
10. Kalan M, Talbot D, Cunliffe WJ, Rich AJ. Evaluation of the modified Alvarado score in the diagnosis of acute appendicitis: a prospective study. Annals of the Royal College of Surgeons of England. 76(6):418-9. 1994.
11. Andersson M, Andersson RE. The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World journal of surgery. 32(8):1843-9. 2008.
12. De castro SM, Ünlü C, Steller EP, Van wagensveld BA, Vrouenraets BC. Evaluation of the appendicitis inflammatory response score for patients with acute appendicitis. World J Surg. 2012;36(7):1540-5.
13. Samuel M. Pediatric appendicitis score. Journal of pediatric surgery. 37(6):877-81. 2002.
14. Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Accuracies of diagnostic methods for acute appendicitis. The American surgeon. 2013;79(1):101-6.
15. Whitley S, Sookur P, McLean A, Power N. The appendix on CT. Clinical radiology. 2009;64(2):190-9.
16. Appendicitis. http://radiopaedia.org/articles/appendicitis. Accessed on June 14th, 2016.
17. Sallinen V, Akl EA, You JJ. Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis. Br J Surg. 2016;103(6):656-667.
18. Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ. 2012;344:e2156.
19. Salminen P, Paajanen H, Rautio T. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313(23):2340-8.
20. Society of American Gastrointestinal and Endoscopic Surgeons. Guidelines for Laparoscopic Appendectomy.  http://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-appendectomy/.  Accessed on June 15^th, 2016.
21. Blackborne LH. The Appendix. In: Surgical Recall. 6^th Philadelphia, PA. LWW.