651

28
Appendix

Elliot C. Pennington, MD
Peter A. Burke, MD

ANATOMY & PHYSIOLOGY the timing is highly variable. Gangrene implies microscopic
perforation, bacterial contamination of the peritoneum, and
In infants, the appendix is a conical diverticulum at the apex peritonitis. This process may be effectively localized by adhe-
of the cecum, but with differential growth and distention sions from nearby viscera.
of the cecum, the appendix ultimately arises on the left and
dorsally approximately 2.5 cm below the ileocecal valve. The ! Clinical Findings
taeniae of the colon converge at the base of the appendix, an
arrangement that helps in locating this structure at opera- Acute appendicitis may simulate almost any other acute
tion. The appendix is freely mobile in the majority and is abdominal illness, and in turn may be mimicked by a variety
fixed retrocecally in 16% of adults. of conditions. Progression of symptoms and signs is the
The appendix in children is characterized by a large rule—in contrast to the fluctuating course of some other
concentration of lymphoid follicles that appear 2 weeks diseases.
after birth and number about 200 or more at age 15 years.
Thereafter, progressive atrophy of lymphoid tissue proceeds A. Signs and Symptoms
with fibrosis of the wall and partial or total obliteration of the Typically, the illness begins with vague midabdominal or
lumen. If the appendix has a physiologic function, it is prob- periumbilical discomfort followed by nausea, anorexia, and
ably related to the presence of lymphoid follicles. indigestion. The pain is continuous but not severe, with
occasional mild cramping. The patient may feel constipated
ACUTE APPENDICITIS or may vomit. Importantly, within several hours of the onset
of symptoms the pain shifts to the right-lower quadrant,
! General Considerations becoming localized and causing discomfort on moving,
Approximately 7% of people in Western countries have walking, or coughing.
appendicitis at some time during their lives. With more than Physical examination shows localized tenderness to pal-
250,000 appendectomies for acute appendicitis performed pation and perhaps slight muscular guarding. Rebound or
annually in the United States, it is the most common sur- percussion tenderness (the latter provides the same infor-
gical emergency encountered by the general surgeon and mation more humanely) may be elicited in the right-lower
accounts for about 1% of all surgical operations. quadrant. Rectal and pelvic examinations are likely to be
Obstruction of the proximal lumen by fibrous bands, negative; if positive, these more often point to another etiol-
lymphoid hyperplasia, fecaliths, calculi, or parasites has long ogy. The temperature is only slightly elevated in the absence
been considered to be the major cause of acute appendi- of perforation. Administration of narcotic pain medications
citis. A fecalith or calculus is found in only 10% of acutely does not affect the accuracy of the physical examination.
inflamed appendices. Though evidence of temporal and A common misconception is that inflammation of a
geographic clustering of cases has suggested a primary infec- retrocecal appendix produces an atypical syndrome. This is
tious etiology this remains to be proven. incorrect; the clinical findings in this situation are the same
As appendicitis progresses, the blood supply is impaired as for ordinary (antececal) appendicitis. Acute appendicitis
by bacterial infection in the wall and distention of the lumen; may mimic other surgical diseases if the appendix is located
gangrene and perforation occur at about 24 hours, though outside the right-lower quadrant (ie, sigmoid diverticulitis,
 652
▲ CHAPTER 28

acute cholecystisis, or a perforated ulcer). Even when the approach. When appendicitis is accompanied by a right-
cecum is normally situated, however, a long appendix may lower quadrant mass, an ultrasound or CT scan should be
reach to other parts of the abdomen. obtained to differentiate between a periappendiceal phleg-
Three general points are worth remembering: (1) people mon and an abscess or tumor.
with early (nonperforated) appendicitis often do not appear
ill. Finding localized tenderness over the McBurney point D. Appendicitis During Pregnancy
is the cornerstone of diagnosis. (2) A rule that will help
Appendicitis is the most common nonobstetric surgical
considerably with atypical cases is never to place appendi-
disease of the abdomen during pregnancy affecting between
citis lower than second in the differential diagnosis of acute
1 in 1400 and 1 in 6600 live births, with cases equally dis-
abdominal pain in a previously healthy person. (3) Patients
tributed through all three trimesters. By far the most com-
with appendicitis most commonly have a history of general-
mon presentation is right-lower quadrant pain, tenderness,
ized abdominal that over time becomes focused in the right-
and leukocytosis—the classic syndrome—but the enlarged
lower quadrant.
uterus occasionally will have pushed the appendix into the
right-upper quadrant, which gives rise to pain in this loca-
B. Laboratory Findings
tion. Some symptoms, such as nausea and vomiting, occur in
The average leukocyte count is 15,000/μL, and 90% of normal pregnancy, which may obscure accurate diagnosis.
patients have counts over 10,000/μL. In three-fourths of Fever is less common than with appendicitis in the absence
patients, the differential white count shows more than 75% of pregnancy. The main problem is to recognize appendicitis
neutrophils. It must be emphasized, however, that 1 patient and perform appendectomy promptly. Both CT and MRI
in 10 with acute appendicitis has a normal leukocyte count, are highly sensitive and specific for the diagnosis of acute
and many have normal differential cell counts. Appendicitis appendicitis during pregnancy. Delay in operation runs a
in HIV-positive patients, while up to three times more com- higher than usual risk of perforation and diffuse peritonitis,
mon, produces the same syndrome as in healthy adults but because the omentum is less available to wall off the infec-
the white blood cell count is usually normal. tion. The mother is in greater jeopardy of serious abdominal
Urinalysis is typically normal, but a few leukocytes and infection, and the fetus is more vulnerable to premature
erythrocytes and occasionally even gross hematuria may be labor with complications. Laparoscopic appendectomy is
noted, particularly in retrocecal or pelvic appendicitis. well tolerated by the mother and fetus, but the frequency
of technical complications is higher than with the open
C. Imaging Studies approach. Appendectomy during pregnancy is often fol-
lowed by preterm labor but rarely by preterm delivery. Early
On plain radiographs localized air-fluid levels, localized
appendectomy in pregnancy has decreased the maternal
ileus, or increased soft tissue density in the right-lower
death rate to under 0.5% and the fetal death rate to less than
quadrant is present in 50% of patients with early acute
10%. Appendectomy in general does not increase a woman’s
appendicitis. Less common findings are a calculus, an altered
risk for infertility later in life.
right psoas shadow, an abnormal right flank stripe, or free
peritoneal air (from perforated appendicitis). In general, the
findings on plain films rarely aid in diagnosis.
! Diagnosis & Differential Diagnosis
A CT examination of the abdomen may be of help in The clinical diagnosis of appendicitis rests on a combina-
diagnosis. An enlarged appendix with wall thickening, tion of localized pain and tenderness accompanied by signs
enhancement, or periappendiceal fat stranding is the most of inflammation, such as fever, leukocytosis, and elevated
useful CT findings of acute appendicitis. Other findings may C-reactive protein levels. Migration of pain from the peri-
be present, including focal cecal thickening, appendicoliths, umbilical area to the right-lower quadrant is also diagnosti-
extraluminal or intramural air, and pericecal phlegmon, cally significant. In the absence of signs of inflammation the
but are less reliable. Oral contrast administration is not. CT diagnosis is less certain, and in this situation a CT scan may
scans are of greatest value in patients with less than typi- be of value. The best strategy in equivocal cases is to observe
cal clinical and laboratory findings, where a positive study the patient for a period of 6 hours or more. During this time,
would be an indication for appendectomy. In young adults, patients with appendicitis experience increasing pain and
low-dose CT is noninferior to standard-dose CT. In the signs of inflammation, while those without appendicitis gen-
face of typical time course of disease, right-lower quadrant erally improve. False-positive diagnoses often involve cases
pain and tenderness plus signs of inflammation (eg, fever, where the surgeon has accorded more significance to the
leukocytosis), a CT scan would be superfluous and, if nega- patient’s pain than to the presence or absence of inflamma-
tive, even misleading. Ultrasound imaging is generally less tory signs. Over the past 20 years, the overall false-positive
reliable than CT, though may become more reliable when rate for the diagnosis of appendicitis has dropped from
done using a combined transabdominal and transvaginal 15% to 10% without an accompanying rise in the number
 653
APPENDIX
▲
of perforations. Thus, diagnostic accuracy appears to be C. Appendiceal Abscess
improving. Some patients experience chronic appendicitis,
which involves pain lasting 3 weeks or more, and typically Localized perforation occurs when the periappendiceal
includes an acute illness in the recent past compatible with infection becomes walled off by omentum and adjacent vis-
acute appendicitis that was managed nonoperatively. cera. Clinical presentation consists of the usual findings in
The diagnosis of acute appendicitis may be difficult in appendicitis, and may include a right-lower quadrant mass.
patients at the extremities of age, and it is in these groups that An ultrasound or CT scan should be performed; if an abscess
diagnosis is most often delayed. Infants display only lethargy, is found, it is best treated by percutaneous imaging-guided
irritability, and anorexia in the early stages, but may develop aspiration. Opinion differs about how small abscesses and
vomiting, fever, and pain as the disease progresses. The phlegmons should be handled. Some surgeons prefer a
elderly may not display any classic symptoms, even though regimen consisting of antibiotics and expectant manage-
the course of appendicitis is more virulent in this age group. ment followed by elective appendectomy 6 weeks later, so
The highest incidence of false-positive diagnosis (20%) as to avoid spreading the localized infection and the need
is in women between ages 20 and 40 and is attributable to for a more extensive operation. This strategy is associated
gynecologic conditions such as pelvic inflammatory disease. with lower rates of overall complications, abscess forma-
Compared with appendicitis, pelvic inflammatory disease is tion, bowel obstruction, and reoperation. Other surgeons
more often associated with bilateral lower quadrant tender- recommend immediate appendectomy, which some believe
ness, left adnexal tenderness, onset of illness within 5 days of shortens the duration of illness.
the last menstrual period, and a history that does not include When an unsuspected abscess is encountered during
nausea and vomiting. appendectomy, it is usually best to proceed and remove the
Clinical scoring systems can be effective in the diagno- appendix. If the abscess is large and further dissection would
sis of acute appendicitis. For example, the Alvarado Score, be hazardous, drainage alone is appropriate.
which uses both physical examination (anorexia, migration Appendicitis recurs in only 10% of patients whose initial
of pain, nausea, right-lower quadrant tenderness, rebound treatment consisted of antibiotics with or without drainage
pain, and elevated temperature) and laboratory findings of an abscess. Therefore, when the presence of ancillary con-
(leukocytosis, shift of WBC count to the left) has excellent ditions increases the risks of surgery, interval appendectomy
negative predictive value, with a sensitivity of 99%. may be postponed unless symptoms recur.

D. Pylephlebitis
! Complications
Pylephlebitis is suppurative thrombophlebitis of the portal
The complications of acute appendicitis include perforation, venous system. Chills, high fever, low-grade jaundice, and,
peritonitis, abscess, and pylephlebitis. later, hepatic abscesses are the hallmarks of this grave but
fortunately rare condition, which affects less than 1% of
A. Perforation patients. Prompt surgery and antibiotic therapy is indicated.
Perforation follows the natural history of acute appendicitis,
and most likely appears because of delay in seeking treat- ! Prevention
ment. Perforation is accompanied by more severe pain and There is no effective prevention strategy for appendicitis. In
higher fever (average, 38.3°C) than in simple appendicitis. the past it was common to perform an incidental appendec-
It is unusual for the acutely inflamed appendix to perforate tomy in young people during the course of an abdominal
within the first 12 hours. Appendicitis has progressed to operation for another illness—as long as the exposure was
perforation by the time of appendectomy in about 50% of adequate and there were no specific contraindications. The
patients under age 10 or over age 50. Perforation in young declining lifetime risk of appendicitis now calls this practice
women increases the subsequent risk of tubal infertility into question. A related question concerns the appropriate
about fourfold. course when a laparoscopy is performed for presumptive
appendicitis and the appendix looks normal. There is no
B. Peritonitis consensus on these cases, with some surgeons preferring to
remove the appendix and some electing to leave it in place.
Localized peritonitis results from microscopic perforation of
In children, it is not necessary to remove the appendix after
a gangrenous appendix, while spreading or generalized peri-
an incidentally diagnosed appendicolith.
tonitis usually implies gross perforation into the free perito-
neal cavity. Increasing tenderness and rigidity, abdominal
! Treatment
distention, and adynamic ileus are obvious in these patients.
High fever and severe toxicity mark progression of this cata- With few exceptions, the treatment of appendicitis is surgi-
strophic illness. cal (ie, appendectomy). The operation can be done open
 654
▲ CHAPTER 28

A B C

Purse-string
suture

Tie on strings
with single knot

D Inversion E

▲ Figure 28–1. Technique of open appendectomy. A: Incision. B: After delivery of the tip of the cecum, the mesoap-
pendix is divided. C: The base is clamped and ligated with a simple throw of the knot. The next step—inversion of the
stump—is optional. D: A clamp is placed to hold the knot during inversion with a purse-string suture of fine silk. E: The
loosely tied inner knot on the stump assures that there is no closed space for the development of a stump abscess.

(Figure 28–1) or laparoscopically. A laparoscopic approach of stay. Generally, patients undergoing laparoscopic appen-
is desirable when the preoperative diagnosis is uncertain. In dectomy have less postoperative pain and a shorter length of
select patients, outpatient laparoscopic appendectomy may stay by 1 day. However, laparoscopic appendectomy may be
be possible. associated with increased overall hospital costs and longer
Prophylactic antibiotics are indicated preoperatively with operative times. Conversion rates from laparoscopic to open
a single-drug regimen, usually a cephalosporin. Culturing approach range from 0% to 27%, and should be based on
abdominal fluid is not indicated even when the appendix surgeon experience, judgment, and ability to safely perform
has perforated, as the organisms obtained are the typical the procedure. Currently most patients in the United States
fecal flora. Abdominal drains are called for only to treat undergo laparoscopic treatment, and this approach is safe
established abscesses. for both uncomplicated and complicated appendicitis. In
If a patient with appendicitis cannot be taken to a mod- select patients, the appendix can be removed using a single-
ern surgical facility for care, treatment should consist of port technique.
antibiotics alone. The complication-free success rate of this
approach is above 93%, though acute appendicitis may recur B. Outcomes
in this population. Success rates of greater than 60% have
Although a death rate of zero is theoretically attainable in
been reported at 1 year.
acute appendicitis, deaths still occur, some of which are
avoidable. The mortality rate in simple acute appendicitis
A. Laparoscopic Versus Open Appendectomy
is approximately 0.1% and has not changed significantly
The laparoscopic approach to appendectomy was first since 1930. Progress in preoperative and postoperative
described by Kurt Semm in 1983. There has been much care has reduced mortality from perforation to about 5%.
debate over the appropriate role of laparoscopy in the Nonetheless, postoperative infections still occur in 30% of
treatment of appendicitis since that initial report, with cases of gangrenous or perforated appendicitis. While the
an increasing majority of cases in this country performed cases may be more technically challenging, obese patients
laparoscopically. In one large study, patients treated laparo- have similar rates of complication, length of stay, and
scopically had lower overall morbidity (except organ space readmission. The substantial increase in tubal infertility
surgical site infections in patients with complicated appen- that follows perforation in young women is avoidable by
dicitis), but similar serious morbidity, mortality, and length early appendectomy. If the entirety of the appendix is not
 655
APPENDIX
▲
removed, stump appendicitis can occur in the residual
Ohle R et al. The Alvarado score for predicting acute appendicitis:
appendix. a systematic review. BMC Med 2011;9:139.
Parks NA, Schroeppel TJ. Update on imaging for acute appendici-
C. Controversies tis. Surg Clin North Am 2011;91(1):141-154.
Rollins MD et al. Prophylactic appendectomy: unnecessary in
Many controversies exist regarding the treatment of acute children with incidental appendicoliths detected by computed
appendicitis. Some surgeons routinely irrigate all four quad- tomographic scan. J Pediatr Surg 2010;45(12):2377-2380.
rants in all appendectomies, while others do not. Irrigation Sauerland S et al. Laparoscopic versus open surgery for suspected
has been shown to reduce postoperative abscess rates in appendicitis. Cochrane Database Syst Rev 2010;(10):CD001546.
perforated appendicitis only. There is emerging evidence Sieren LM et al. The incidence of benign and malignant neoplasia
presenting as acute appendicitis. Am Surg 2010;76(8):808-811.
that antibiotics alone may be a preferable initial treatment Simillis C et al. A meta-analysis comparing conservative treat-
of uncomplicated acute appendicitis. While it is clear that ment versus acute appendectomy for complicated appendicitis
postoperative antibiotics are not beneficial for nonperfo- (abscess or phlegmon). Surgery 2010;147(6):818-829.
rated appendicitis after appendectomy, no consensus exists St Peter SD et al. Single incision versus standard 3-port laparo-
on the drug regimen or duration of antibiotics for perforated scopic appendectomy: a prospective randomized trial. Ann Surg
disease. 2011;254(4):586-590.
Subramanian A, Liang MK. A 60-year literature review of
stump appendicitis: the need for a critical view. Am J Surg
Amoli HA et al. Morphine analgesia in patients with acute appen- 2012;203(4):503-507.
dicitis: a randomised double-blind clinical trial. Emerg Med J
Varadhan KK et al. Safety and efficacy of antibiotics compared
2008;25(9):586-589.
with appendicectomy for treatment of uncomplicated acute
Basaran A, Basaran M. Diagnosis of acute appendicitis dur- appendicitis: meta-analysis of randomised controlled trials.
ing pregnancy: a systematic review. Obstet Gynecol Surv BMJ 2012;344:e2156.
2009;64(7):481-488.
Bondi M et al. Improving the diagnostic accuracy of ultra-
sonography in suspected acute appendicitis by the com- TUMORS OF THE APPENDIX
bined transabdominal and transvaginal approach. Am Surg
2012;78(1):98-103. Benign tumors, including carcinoids, were found in 4.6% of
Cardenas-Salomon CM et al. Hospitalization costs of open 71,000 human appendix specimens examined microscopi-
vs. laparoscopic appendectomy: 5-year experience. Cir Cir cally, typically as incidental findings.
2011;79(6):534-539.
Cash CL et al. A prospective treatment protocol for outpatient
laparoscopic appendectomy for acute appendicitis. J Am Coll ! Malignant Tumors
Surg 2012;215(1):101-105. Primary malignant tumors were found in 1.4% of appen-
Coakley BA et al. Postoperative antibiotics correlate with worse
outcomes after appendectomy for nonperforated appendicitis.
dices in the same large series. Carcinoid and neuroendo-
J Am Coll Surg 2011;213(6):778-783. crine tumors comprise the majority of appendiceal cancers,
Deugarte DA et al. Obesity does not impact outcomes for appen- and the appendix is the commonest location of carcinoid
dicitis. Am Surg 2012;78(2):254-257. tumors of the gastrointestinal tract. Carcinoid tumors of the
Gilo NB et al. Appendicitis and cholecystitis in pregnancy. Clin appendix are most commonly found at the tip and are usu-
Obstet Gynecol 2009;52(4):586-596. ally benign, but tumors over 2 cm in diameter may exhibit
Hekimoglu K et al. Comparison of combined oral and i.v. contrast- malignant behavior. About half of these tumors are discov-
enhanced versus single i.v. contrast-enhanced mdct for the
detection of acute appendicitis. JBR-BTR 2011;94(5):278-282.
ered during an appendectomy for acute appendicitis, with
Hussain A et al. Prevention of intra-abdominal abscess following the remainder identified incidentally. Lesions less than 2 cm
laparoscopic appendicectomy for perforated appendicitis: a in diameter invade the appendiceal wall in 25% of cases, but
prospective study. Int J Surg 6(5):374-377. only 3% metastasize to lymph nodes. Hepatic metastases and
Ingraham AM et al. Comparison of outcomes after laparoscopic the carcinoid syndrome are truly rare. Appendectomy alone
versus open appendectomy for acute appendicitis at 222 is adequate treatment unless the lymph nodes are visibly
ACS NSQIP hospitals. Surgery 2010;148(4):625-635; discussion involved, the tumor is more than 2 cm in diameter, muci-
635-627.
Kim K et al. Low-dose abdominal CT for evaluating suspected
nous elements are present in the tumor (adenocarcinoid), or
appendicitis. N Engl J Med 2012;366(17):1596-1605. the mesoappendix or base of the cecum is invaded; in these
Klein DB et al. Increased rates of appendicitis in HIV-infected men: cases, right hemicolectomy is recommended. The recurrence
1991-2005. J Acquir Immune Defic Syndr 2009;52(1):139-140. rate after surgical treatment is near zero.
Korndorffer JR et al. SAGES guideline for laparoscopic appendec- Colonic adenocarcinoma can arise in the appendix and
tomy. Surg Endosc 2010;24(4):757-761. spread rapidly to regional lymph nodes or implant on other
Liu K, Fogg L. Use of antibiotics alone for treatment of uncompli- peritoneal surfaces. Most patients present with advanced
cated acute appendicitis: a systematic review and meta-analysis.
Surgery 2011;150(4):673-683.
disease. Adenocarcinoma is virtually never diagnosed pre-
operatively, and about half of cases present as acute
 656
▲ CHAPTER 28

appendicitis. Right hemicolectomy should be performed if MULTIPLE CHOICE QUESTIONS

disease is localized to the appendix and/or regional lymph
nodes. The 5-year survival rate is 60% after right hemico- 1. All of the following are true about the appendix, except
lectomy and only 20% after appendectomy alone, but the A. The appendix in children is characterized by a large
latter group includes patients with distant metastases at concentration of lymphoid follicles that appear
diagnosis. 2 weeks after birth and number about 200 or more
at age 15 years.
! Mucocele and Pseudomyxoma Peritonei B. The taeniae of the colon converge at the base of the
An appendiceal mucocele is a cystic, dilated appendix filled appendix.
with mucin. Simple mucocele is not a neoplasm and results C. A fecalith or calculus is found in only 10% of acutely
from chronic obstruction of the proximal lumen, usually by inflamed appendices.
fibrous tissue. Rarely, mucocele is caused by a neoplasm— D. The appendix is fixed retrocecally in 65% of adults.
cystadenoma, or adenocarcinoma grade 1 in the older E. Acute appendicitis may simulate almost any other
terminology, now often called a mucinous appendix neo- acute abdominal illness.
plasm (MAN). This lesion may arise de novo or (perhaps)
in a preceding simple mucocele. Appendectomy is adequate 2. Helpful tests in the diagnosis of acute appendicitis
treatment in either case. If a MAN ruptures, it can lead to a include
condition known as pseudomyxoma peritonei, character- A. Abdominal CT
ized by diffuse mucin production throughout the peritoneal B. Transvaginal ultrasound
cavity, with variable amounts of tumor cellularity. Patients C. Encephalopathy
can be treated with either simple appendectomy or right D. A, B, and C
hemicolectomy. E. A and C

Foster JM et al. Right hemicolectomy is not routinely indicated in 3. Primary malignant tumors of the appendix
pseudomyxoma peritonei. Am Surg 2012;78(2):171-177.
Guraya SY, Almaramhy HH. Clinicopathological features and the A. Should prompt right colectomy in nearly all patients
outcome of surgical management for adenocarcinoma of the B. Are most commonly neuroendocrine (carcinoid)
appendix. World J Gastrointest Surg 2011;3(1):7-12. tumors
Shapiro R et al. Appendiceal carcinoid at a large tertiary center: C. Is the most common etiology of appendicitis
pathologic findings and long-term follow-up evaluation. Am J D. Usually presents due to liver metastases
Surg 2011;201(6):805-808. E. Are usually found at the base of the appendix