THE APPENDIX •

•
May function as a reservoir to recolonize the colon
with the healthy bacteria
Previously considered a vestigial organ, but now linked
to development and preservation of gut-associated
HISTORY lymphoid tissue (GALT) and to the maintenance of
• Vesalius and Leonardo Da Vinci had written about the intestinal flora
appendix • Currently unproven: appendectomy is asso. with
• 18th century: Claudius Amyand becomes the 1st increased C. difficile infections and increased
surgeon to describe a successful appendectomy subsequent cancer (colon, esophageal) as a result of
• 1889: Chester McBurney advocates for early microbial alteration
appendectomy • An early appendectomy is said to protect against
• 1926: Harry Houdini dies of a ruptured appendix after development of ulcerative colitis via release of dimeric
suffering a blow to his abdomen forms of IgA from plasma B cells and Th2 response
• 1940s: Introduction and widespread use of antibiotics mediated by IL-13–producing NK T cells
improves mortality rates
• 1982: Kurt Semm, a gynecologist, reports on the first
laparoscopic appendectomy, which is now the most
ACUTE APPENDICITIS
EPIDEMIOLOGY
widely adopted technique
Lifetime risk:
EMBRYOLOGY
• Male 8.6%
• 6th wks AOG: appendix and cecum appear as
• Female 6.7%
outpouchings from the caudal limb of midgut
Highest incidence: 2nd-3rd decade of life
• Midgut derivative (also ileum and colon) and first
Appendectomy is one of the most frequent emergent
appears at 8 wks of gestation
abdominal operations
• As the gut rotates medially, the cecum becomes fixed
in the RLQ
ETIOLOGY
• Subsequent unequal growth of the cecum causes the
• In pediatric populations: luminal obstruction that
appendix to find its adult position on the posterior
occurs as a result of lymphoid hyperplasia
medial wall, just below the ileocecal valve
• Adults:
ANATOMY
o Obstructing fecalith (MCC)
• A true diverticulum of the cecum, with differences in
o Fibrosis
the irregularity of crypts
o Foreign (food, parasites, calculi)
• Location: intraperitoneal and retrocecal, but it can be
o Neoplasia
pelvic (30%) and retroperitoneal (7%)
• Its base is identified by the convergence of cecal PATHOPHYSIOLOGY
taeneia
Proximal luminal obstruction
• Length: 6-9 cm
⇩
• Outer diameter 3-8 mm
• Luminal diameter 1-3 mm Normal mucosal secretions continue to increase luminal
pressure --> distension of the appendix
• Blood supply: appendicular branch of the ileocolic
artery ⇩
• Lymphatics: nodes that lie along ileocolic artery Stimulates the visceral stretch fibers (vague dull, diffuse pain
• Nerve supply: superior mesenteric plexus (T10-L1), CN referred to the periumbilical region)
X ⇩
• Its antimesenteric border is the area with the poorest Distension increases multiplication of resident bacteria of the
blood supply the MC area of rupture and where appendix subsequently leading to mixed flora
ellipsoidal infarcts develop ⇩
HISTOLOGY Impaired venous drainage; mucosal ischemia leading to
• Layers, outer to inner: serosa, muscularis, submucosa bacterial translocation, and subsequent gangrene and
(where lymphoid aggregates occur), mucosa intraperitoneal infection
⇩
Engorgement and vascular congestion

PHYSIOLOGY • Escherichia coli and Bacteroides fragilis are the MC

• Immunological organ aerobic and anaerobic bacteria isolated in perforated
• Actively participates in the secretion of appendicitis
immunoglobulins, particularly IgA

Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
Flora of the inflamed appendix differ from that of the normal • Diagnosed if px underwent similar occurrences of RLQ
appendix pain at different times that, after appendectomy, were
• E.coli, Bacteroides, F. necrophorum, histopathologically proven to be the result of an
Peptostreptococcus, Pseudomonas, Lactobacillus inflamed appendix
• ∼60% of aspirates of inflamed appendices have Chronic appendicitis (1%) is defined by the ff:
anaerobes compared to 25% from normal appendices 1. History of RLQ of at least 3 wks duration w/o an
• More tissue invasion by Bacteroides alternative diagnosis
2. After appendectomy, px experiences complete relief of
symptoms
3. Histopathologically, the symptoms were proven to be
the result of chronic active inflammation of the
appendiceal wall or fibrosis of the appendix

CLINICAL DIAGNOSIS
• Dx is essentially clinical
• Clinical diagnosis alone—15-30% negative
appendectomy

STAGES OF APPENDICITIS
Early
• Obstruction of the lumen → mucosal edema and
ulceration, bacterial diapedesis, appendiceal distention
due to accumulated fluid, and increasing intraluminal
pressure
Suppurative
• Increasing intraluminal pressure eventually exceed
capillary perfusion pressure, which is asso. with
obstructed lymphatic and venous drainage
• Bacterial and inflammatory fluid invasion of the tense
appendiceal wall
• Migratory pain is a classic sign of appendicitis, a result
• Transmural spread of bacteria causes acute
of inflammation of the visceral peritoneum that usually
suppurative appendicitis
progresses to the parietal peritoneum
• Inflamed serosa comes in contact with the parietal
• Regional inflammation → ileus, diarrhea, small bowel
peritoneum → classic shift of pain from periumbilicus
obstruction, hematuria
to RLQ
• Continuous and more severe than the early visceral
Clinical Presentation
pain
• Pain (diffuse visceral type or localized)
• Nausea
Gangrenous
• Vomiting
• Intramural venous and arterial thrombosis ensue
• Anorexia
Perforated
• Obstipation
• Persisting tissue ischemia results in appendiceal
• Diarrhea
infarction and perforation → localized or generalized
peritonitis • Elevated temp
Phlegmonous appendicitis or abscess • Murphy's triad (pain, vomiting, fever)
• Results from inflamed or perforated appendix walled
off by the adjacent greater omentum or small-bowel Physical Examination
loops • Most lay quite still due to parietal peritonitis
Spontaneous resolving appendicitis • Generally warm to the touch (low-grade fever, ~38.0°C
• May occur if luminal obstruction is relieved [100.4°F])
• Occurs if the cause is lymphoid hyperplasia or when a • Deep palpation: guarding more evident in the right iliac
fecalith is expelled from the lumen fossa vs. the left side
Recurrent • McBurney’s point, which is found 1/3 of the distance
• 10% incidence between the ASIS and the umbilicus, is often the point

Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
 of maximal tenderness in a patient with an o Urinalysis to rule out nephrolithiasis or
anatomically normal location of appendix pyelonephritis
Investigations
• Use of:
o Clinical scoring systems
o Imaging modalities
o Diagnostic laparoscopy
o Routine labs

Physical Signs of Appendicitis

Rebound Sharp, sudden pain felt when pressure of the
tenderness* examining hand is quickly released
<3: low likelihood of appendicitis
Rovsing's sign* Indirect tenderness; pain in the RLQ after 4-6: consider further imaging
release of gentle pressure on LLQ (appendix in ≥7: high likelihood
normal position)
Dunphy’s sign Pain with coughing (retrocecal appendix) Imaging
• Often utilized to confirm a diagnosis of appendicitis
Markle sign RLQ pain when standing patient drops from because a negative operation rate is acceptable in
standing on toes to the heels with a jarring aka <10% of male patients and <20% of female patients
jarring or ajar sign • Use of cross-sectional imaging somewhat reduces the
Iliopsoas sign Pain with flexion of the hip (retrocecal rate of negative laparotomies
appendix) • Appropriate for patients in whom a diagnosis of
appendicitis is unclear or who are at high risk from
Obturator sign Pain on internal rotation of a flexed thigh due
operative intervention and general anesthesia such as
inflammation near the obturator internus
pregnant patients or patients with multiple
muscle (pelvic appendix)
comorbidities
Hamburger “Px will not eat even if you give them a • CT, US, MRI
sign hamburger”
Rectal exam Tenderness in the rectovesical pouch Plain Abdominal X-Rays
(retrocecal) • Low sensitivity
• Appendicoliths picked up in only 10-15% of cases
Deep palpation Muscular resistance (guarding) in the right iliac
• Can be combined with barium enema
fossa, which may be more evident than the left
• Appendicitis: failure of appendix to “fill up”
side
• Low specificity: 20% of normal appendices don’t fill up
*strong indicators of peritoneal irritation ^ small shadow representing intraluminal entity

Laboratory findings
• Leukocytosis (10,000 cells/mm3; gangrenous and
perforated appendicitis: ∼17,000 cells/mm3)
• CRP, bilirubin, Il-6, and procalcitonin for predicting
perforated appendicitis
• CRP—a strong indicator of appendicitis (>10 g/L)
• Initial work-up
o WBC count and a C-reactive protein
o Pregnancy test

Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
CT scan • Expensive and requires significant expertise to perform
• 96% sensitivity and 96% specificity in diagnosing acute and interpret
appendicitis • Recommended for those whom the risk of ionizing
• Findings suggestive of appendicitis: radiation outweighs the relative ease of obtaining a CT
o Enlarged lumen and double wall thickness (>6 scan (pregnant, pediatric)
mm) • Doc: 2nd line imaging for pedia px
o Wall thickening (>2 mm)
o Periappendiceal fat stranding DIFFERENTIAL DIAGNOSIS
o Appendiceal wall thickening Frequently, no organic pathology is involved
o Appendicoliths, fecaliths Depends on:
• Typical low-dose CT scans result in exposure of 2 to 4 • Anatomic location of the inflamed appendix
mSv, which is not significantly higher than background • Stage of the process (uncomplicated or complicated)
radiation (3.1 mSv) • Age
• Low-dose CT scans of 2 mSv do not generate high- • Gender
resolution images, but using these lower resolution Differential Diagnosis
images does not affect clinical outcomes • Mittelschemerz (German for "middle pain"; no fever or
• IV contrast generally preferred, but can be avoided in leukocytosis, mid-menstrual cycle pain)
those w/ allergies to iodine or contrast, or low • Ectopic pregnancy
estimated GFR (<30 mL/min for 1.73 m2) • Acute mesenteric adenitis
• Limited use in pregnancy; abdominal shield is needed • Cecal diverticulitis
• Meckel’s diverticulitis
Ultrasound (US) • Acute ileitis
• 85% sensitivity, 90% specificity • Crohn’s disease
• Inexpensive, accessible • Acute PID (exquisite tenderness with motion)
• Graded compression ultrasonography is used to • Torsion of ovarian cyst or graafian follicle
identify the AP diameter of the appendix • Acute gastroenteritis
• Appendix ID'd as blind ending, nonperistaltic bowel
loops MANAGEMENT OF APPENDICITIS
• Appendicitis generally ruled out if appendix is easily Nonoperative → antibiotics
compressible and <5 mm in diameter • If surg trt is unavailable
• Findings suggestive of appendicitis Operative → open or laparoscopic appendectomy
o Thickened periappendiceal wall
o Diameter >6 mm Uncomplicated Appendicitis
o Pain with compression • Appendectomy is the preferred treatment to prevent
o Presence of an appendicolith the complications of appendicitis
o Increased echogenicity of the fat
• Study: non-operative management (antibiotics)
o (+) periappendiceal fluid
resulted in higher rates of adverse events, recurrence
• PROS: cheaper and more readily available than CT with complicated appendicitis, and eventual need for
scan, does not expose patients to ionizing radiation an appendectomy
• CONS: user-dependent, limited utility in obese • Conservative management can be offered, but it is not
patients, graded compression painful for patients with the standard modality of management of appendicitis,
peritonitis except in patients with significant phobia of surgery

Timing of Surgery
• Emergent surgery is often performed
• Delaying surgery <12 hours is acceptable in patients
with
o Short duration of symptoms (<48 hours)
o Nonperforated, nongangrenous appendicitis
• A slightly longer hospital stay was observed in patient
who underwent urgent surgery than those given
antibiotics upon admission
Encircled: appendicolith inside the lumen
Approach of Surgery
MRI • Open appendectomy vs laparoscopic appendectomy
• Sensitivity of 0.95 and specificity of 0.92 • Costs of the two techniques are relatively similar
• Laparoscopic increasing utilized in the US
Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
 Laparoscopic Open Incidence of recurrent High incidence of no
appendicitis (7.4%–8.8%) future events after a
• Shorter length of stay • Shorter operative times
Presence of appendiceal median follow-up of 34
(LOS) • Lower intra-abdominal
neoplasms detected on the months in 91% of patients
• Faster return to work infection rate
appendectomy
• Fewer SSIs • Higher risk of SSIs
(relevant benign lesions 0.7%,
• Lower superficial wound • Decreased risk of intra-
malignant lesions 1.3%)
infection rates, esp. in abdominal abscess
obese patients • More pain
• Increased risk of intra- • Bigger incision OPERATIVE INTERVENTION
abdominal abscess Preoperative Preparation
• Less pain, smaller incision • Place the px NPO
• Given pain reliever and/or anti-pyretics (if fever
present)
Complicated Appendicitis
• Antibiotic prophylaxis to prevent SSIs
• i.e. perforated and gangrenous appendicitis, and
o 60% of aspirates of inflamed appendix have
appendicitis with abscess or phlegmon formation
anaerobes
• Patients with perforated appendicitis…
• Majority of patients can be taken to the operating
o Usually present after 24 hrs of onset (20%
room within a short interval
present within 24 hrs)
• Placement of a Foley catheter is optional but not
o Are often acutely ill and dehydrated and
necessary
require resuscitation
• Preoperative antibiotics must be administered at least
• The perforated abscess is usually walled off in the RLQ
30-60 minutes prior to skin incision; post-op antibiotics
• Retroperitoneal abscesses including psoas abscess,
are usually not necessary
liver abscesses, fistulas, and pylephlebitis (portal vein
inflammation) can also occur when left untreated
Choice of pre-op antibiotics
Management Uncomplicated Cefoxitin (40mg/kg IV single dose),
• Perforated appendicitis → operatively or appendicitis ampicillin/sulbactam, or cefazolin +
nonoperatively metronidazole
• Immediate surgery is necessary in patients that appear Amoxicillin Clavulanate 45 mg/kg IV single
septic, but this is usually asso. with higher dose (alternative)
complications, including abscesses and Post-op antibiotics are usually not
enterocutaneous fistulae due to dense adhesions and necessary
inflammation ß-lactam allergies Clindamycin + a fluoroquinolone,
• Management of long-duration, complicated gentamicin, or aztreonam
appendicitis is often staged
Complicated Monotherapy with piperacillin/tazobactam
• Resuscitation and IV antibiotics appendicitis or cephalosporin + metronidazole
• Percutaneous image-guided drainage for px Duration of postoperative antibiotics is
with longstanding perforation generally <4 days once complete source
• Successful in 79% of patients who control has been achieved (STOP-IT trial)
achieve complete resolution, which
occurs more often in lower-grade • Patients w/ incomplete drainage, persistent catheters,
abscesses, transgluteal drainage, and complications from surgery, and uncertain resolution
with CT- (vs. ultrasound-) guided of inflammation might need a longer duration of
drainage antibiotics
• Operative intervention performed for those
OPERATIVE TECHNIQUE
who fail conservative management and in px
Open Appendectomy
with free intraperitoneal perforation
• Usually performed under general anesthesia; regional
• 80% of px w/ perforated appendicitis have resolution
anesthesia can be used
of their symptoms with drainage and antibiotics
• Px positon: supine Trendelenburg’s with the left side
Interval Appendectomy down
• Performed 6-8 weeks after the original inflammatory • Incision is usually made on McBurney’s point either in
episode an oblique fashion (McBurney’s incision) or transverse
incision (Rocky-Davis incision)
• Shared-decision making is necessary before proceeding
with an interval appendectomy • Perforated appendicitis with a phlegmon: a
lower midline laparotomy incision is more
Proponents of interval appen. Opponents appropriate
Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
 • NOTES (natural orifice transluminal endoscopic
surgery)
o Better cosmetic outcome and less postop pain
o Risk of contamination
o Suboptimal closure of enteral or vaginal
mucosa
• Robotic appendectomy
o Allows flexible motion of intraperitoneal
instruments
o Extremely expensive and requires larger ports

Negative Exploration
• If no evidence of appendicitis → thorough exploration
of the peritoneum must be performed to rule out
• Muscle-splitting approach can be utilized to access the contributing pathology
peritoneum in paralyzed patients • A normal appendix is often removed to reduce future
• Appendix readily identified; tracing the anterior taenia diagnostic dilemma
(taenia Liberia) of the cecum distally can help
• The mesentery is ligated to allow better exposure
• If the base of the appendix is viable, ligating the appendix is
acceptable
o Z-stitch or purse string configuration
o Alternative, the mucosa can be fulgurated
(=burn/destroyed using electric current)
• A Fowler extension (medial extension of the incision) is
performed in cases of retraction of the appendiceal artery
or unexpected bleeding
• Skin closure usually performed in a layered fashion
o Closure by secondary intention or delayed primary
closure has been considered in cases with
significant abscess or contamination
o No difference in SSI rates between above two
• Placement of surgical drains not proven beneficial for either
complicated or uncomplicated appendicitis

Laparoscopic Appendectomy Incidental Appendectomy

• Position: supine with the left arm tucked for better access; • Currently not advocated*, but routinely performed in:
Trendelenburg, with the left side down to sweep the bowel o Children undergoing chemotherapy
away o Compromised hosts with an unclear physical
• Access to the peritoneum exam
o Hasson technique in a periumbilical fashion, or o Patients with Crohn’s disease with a normal
o A Verees or optical trocar in the LUQ 3 cm below cecum
the costal margin in the MCL o Patients traveling to remote places with no
• 5 mm ports are usually placed in the suprapubic and LLQ urgent care
areas o Those undergoing cytoreductive operations
o The 3rd port can be placed in the RUQ for ovarian malignancies
• Appendix is grasped and elevated upwards to identify the • *because of higher risk of adhesions and future
window between the mesoappendix and the cecum complications after an appendectomy
• Base of the appendix is divided either with an endoscopic
stapler or after placing an endoloop SPECIAL CIRCUMSTANCES
• The appendix is retrieved through the midline port in a Appendicitis in Children
specimen bag • ~1 in 8 children
• Conversion to open surgery should be considered for • Of these, infants and young children most likely
failure to progress present with perforated disease (51%–100%)
• Neonates can also present with abdominal distension
Novel Techniques and lethargy or irritability
• Single incision appendectomy • School-age children have lower rates of perforation
• DDX (charateristic features)
Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
 o Intussusception (currant jelly stools, • Solid food
abdominal mass) • IV line should be removed
o Gastroenteritis (often no leucocytosis) • Pain reliever
o Malrotation (pain out of proportion) • Broad spectrum antibiotics for 4-7 days
o Pregnancy (ectopic) (perforated/complicated)
o Mesenteric adenitis o If afebrile w/o sepsis, shift from IV to oral
o Torsion of the omentum antibiotics
o Ovarian or testicular torsion • Check the incision site for any sign of infection
• Early appendicitis → laparoscopic appendectomy, • Check for fever
which has better outcomes than open appendectomy • Full recovery within 4-6 weeks after surgery
• Complicated appendicitis → urgent laparoscopic
appendectomy, if no abscess or mass COMPLICATIONS OF APPENDECTOMY
• Perforation → antibiotics are continued after surgery Surgical Site Infection
for at least 3 days, and preferably 5 days • Mgmt: open the incision and obtain a culture
• Nonoperative management may be safe for children • The extraction port site is the MC site of SSI following a
with early presentation (<48 hours), limited laparoscopic appendectomy
inflammation (WBC <18,000/cu.ml), appendicoliths, • Patients with cellulitis can be started on antibiotics
and no evidence of rupture on imaging • Determine to resuture the site or let it heal by
o Administered IV, then transitioned to oral secondary healing
antibiotics once inflammation reduces
o Usually effective in reducing inflammation Stump appendicitis
(88%–92%), but recurs in 22% • Uncommon
• Appendicitis in an incompletely excised appendiceal
Appendicitis in Older Adults stump (>0.5 cm stump length)
• Diminished inflammation and thus present with • Managed by reexcision of the appendiceal base, which
perforation or abscess more frequently is identified by:
• Have higher risk for complications because of their o "Appendiceal critical view" (below pic)
premorbid conditions, so obtain definitive diagnostic • Appendix placed at 10 o’clock
imaging prior to taking patients to the operating room
• Taenia coli/libera at 3 o’clock
• Laparoscopic appendectomy is safe and might allow
• Terminal ileum at 6 o’clock
patients to reduce pain and their hospital stay
o Identifying where taeniae coli merge and
disappear
Appendicitis in Pregnancy
• 1 in 800 to 1 in 1000 pregnancies, mostly in the 1st and
2nd trimesters
• Rare in the antepartum state
• Can occur in the postpartum state in geriatric
pregnancies (maternal age >35 years)
• Heartburn, bowel irregularity, flatulence, or a change
in bowel habits.
• The point of maximum tenderness is usually displaced
on physical exam.
• Ultrasound is the preferred imaging modality
(sensitivity 67-100%; specificity 93-96%) • A low index of suspicion is important to prevent delay
o MRI sensitivity 94%, specificity 97% diagnosis and complication in patients w/ prior
o CT carries risk of fetal irradiation appendectomy
• Risk of fetal loss is up to 36% if appendiceal perforation • A prior appendectomy therefore should not be an
occurs absolute criterion in ruling out acute appendicitis

Chronic or Recurrent Appendicitis Appendiceal Neoplasms

• Recurrent RLQ pain not asso. w/ febrile illness + • 1% of all appendectomy specimens
appendicolith or dilated appendix on imaging o Gastroenteropancreatic neuroendocrine
• Symptoms often resolve with appendectomy tumors (GEP-NETs; previously "carcinoids”)
• W/o imaging abnormalities, prophylactic o Mucinous neoplasms
appendectomy is not encouraged o Adenocarcinomas
• 1/3 present with acute appendicitis, other incidentally
POSTOPERATIVE TREATMENT detected or detected after regional spread of disease
• Give clear liquid
Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
GEP-NETS (hyperplasia, cysts, cystadenomas, mucinous
• Submucosal rubbery masses detected incidentally on cystadenocarcinoma)
the appendix • MC form of presentation is incidental, with
• Relatively indolent but can develop nodal or hepatic appendicitis occurring in 1/3 of cases
metastases • Findings on cross-sectional imaging:
• 2.9% with hepatic metastasis are asso. w/ a carcinoid o Low attenuation, round, well encapsulated
syndrome cystic mass in the right or quadrant
• If a carcinoid is found → evaluate nodal basin along the o Wall irregularity
ileocolic pedicle and examine for liver metastases o Soft tissue thickening
• 95% of all lesions are <1 cm → negative margin • Assess for the presence of ascites, peritoneal disease,
appendectomy and scalloping of the liver surface on initial evaluation
• 1-2 cm → no consensus on a completion colectomy • For a reliable diagnosis, imaging + surgical excision
• ≥2 cm → right hemicolectomy without capsular disruption is done
• Colectomy is performed when there are o Examine the peritoneum and determine
o Mesenteric invasion peritoneal cancer if mucin is present
o Enlarged nodes o Biopsy to examine content of epithelial and
o Positive or unclear margins neoplastic cells and mucin
• Serum chromogranin A measurement is recommended • Careful handling of a mucocele and the avoidance of
rupture is a must to intraperitoneal spread of
Goblet Cell Carcinomas neoplastic cells and subsequent development of
• Mistakenly called goblet cell carcinoids pseudomyxoma peritonei
• Adenocarcinoid with both adenocarcinoma and
neuroendocrine features Management
• AdenoCA > goblet cell CAs > carcinoids, in terms of • Homogeneous cyst without nodularity or signs of
worse prognosis dissemination → laparoscopic excision
• High risk peritoneal recurrence o Stapler is fired across the base of the cecum
• If lesions are detected → systematic surveillance of the to avoid a positive margin
peritoneum and a peritoneal cancer index score o Specimen should be placed in a plastic bag
• Surgical mgmt: right hemicolectomy if metastatic and carefully removed
disease is absent • Absence of mesenteric or peritoneal involvement →
o Some advocate this prodecure only for appendectomy with concurrent appendiceal
tumors ≥2 cm lymphadenectomy
Lymphomas • If patient has acute appendicitis → appendectomy
• Rare (1%–3% of lymphomas), usually NHL (suboptimal debulking is discouraged)
• Appendiceal diameter can be ≥2.5 cm • Also examine other intra-abdominal structures as
• Managed by appendectomy in most cases colorectal, ovarian, and endometrial cancers can
coexist in this condition
Adenocarcinoma • If primary lesion histology ≠ peritoneum → get
• Rare; has three major histologic subtypes: mucinous peritoneal histology
adenoCA, colonic adenoCA, and adenocarcinoid o e.g. if there is neoplasm in the appendix but
adenoCA in the peritoneum, considered as
• Most commonly presents as acute appendicitis. Other
having adenocarcinoma (AJCC M1b) disease
s/sx include:
o Ascites or a palpable mass
o Discovered as incidentaloma during an
operative procedure
• Treatment: formal right hemicolectomy
• Have a propensity for early perforation
• 5-yr survival: 55%
• At significant risk for both synchronous and
metachronous neoplasms, ∼1/2 of which will originate
from the GIT

Appendiceal Mucocele and Mucinous Neoplasms of the

Appendix
• "Appendiceal mucocle"—a mucus-filled appendix that
could be 2° to neoplastic or nonneoplastic pathologies

Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
 EXECUTIVE SUMMARY
When should one suspect acute appendicitis?
• When a patient presents with RLQ abdominal pain
• Level III Evidence Category A Recommendation

What clinical findings are most helpful in diagnosing acute

appendicitis?
• Acute appendicitis should be suspected in any patient
(esp. male) who presents with a high intensity of
perceived abdominal pain of at least 7-12 hrs duration,
with migration to the RLQ, followed by vomiting
o If vomiting occurred first, consider acute
gastroenteritis
o Appendicitis less likely if mov’t or cough did
not provoke pain, pain of low intensity, or
when symptom duration >48 hrs
• Although symptoms alone have a low discriminating
power, the dx becomes more certain when PE findings
include:
o RLQ tenderness, guarding, rebound
Pseudomyxoma Peritonei (PMP) Syndrome tenderness
• Results from peritoneal dissemination from an o Other sign of peritoneal irritations (the
appendiceal mucinous neoplasm, but can occur in physical signs)
gastric, ovarian, pancreatic, and colorectal primary • Level I Evidence Category A Recommendation
tumors
• Prognosis ranges from curative to palliative What diagnostic test are helpful in the diagnosis of acute
• Early detection and management of limited peritoneal appendicitis?
disease is favorable and preferred as opposed to Diagnosis of acute appendicitis is primarily based on clinical
extensive intraperitoneal mucin development findings. The ff. may be helpful:
• PMP with appendiceal primary → cytoreductive A. All cases
surgery and hyperthermic intraperitoneal o WBC with differential count
chemotherapy (HIPEC) are the standard of care, which o Level I Evidence Category A Recommendation
involves: B. Equivocal Appendicitis in Adults
o Parietal and visceral peritonectomies o CT scan
o Intraperitoneal administration of heated (42°C o Ultrasound
[108°F]) chemotherapy (usually mitomycin) o CT scan should be preferred over ultrasound
o Can be performed laparoscopically if detected because of its superior accuracy
early and is low volume o Level I Evidence Category A Recommendation
C. Equivocal appendicitis in the Pediatric Age Group
o Ultrasound (graded compression)
o CT scan
o While both are comparable in accuracy in this
Evidence-Based Clinical Practice Guidelines age group, ultrasound is preferred because of
(EBCPG): ACUTE APPENDICITIS its lack of radiation, cost-effectiveness and
Operational definition availability compared to CT scan
o Level II Evidence Category A Recommendation
Uncomplicated Includes the acutely inflamed, phlegmonous,
D. Selected cases
appendicitis suppurative, or mildly inflamed appendix with
o Diagnostic laparoscopy
or without peritonitis
o Despite its statistically significant favorable
Complicated Includes gangrenous appendicitis, perforated effects, diagnostic laparoscopy should be
appendicitis appendicitis, localized, purulent collection at viewed as an invasive procedure requiring
operation, generalized peritonitis and anesthesia and having risks similar to
periappendiceal abscess appendectomy.
Equivocal A patient with RLQ abdominal pain + atypical o Level III Evidence Category A
appendicitis history and PE + surgeon cannot decide Recommendation
whether to discharge or to operate on the E. The ff. are generally not useful in diagnosing acute
patient appendicitis:
o Plain abdominal x-ray
Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de
 o Barium enema gentamicin 5 mg/kg IV every 24 hours plus
o Scintigraphy clindamycin 7.5-10 mg/kg every 6 hours
o Level II Evidence Category A Recommendation
All above are Level I Evidence Category A Recommendations

What is the appropriate treatment for acute appendicitis? Gangrenous appendicitis → treat in the same manner as
• Appendectomy (Level II Evidence Category A uncomplicated appendicitis
Recommendation) o Level II Evidence Category A Recommendation
Duration of therapy may vary depending on the clinician's
What is the recommended approach to the surgical assessment. It may be maintained for 5-7 days. Sequential
management of acute appendicitis? therapy to oral antibiotics may be considered when GI function
• Open appendectomy. Therapeutic laparoscopic has returned
appendectomy is an alternative for selected cases o Level I Evidence Category A Recommendation
• Level I Evidence Category A Recommendation
Useful parameters for discontinuation of antibiotic therapy
What is the role of laparoscopic appendectomy in the (Level II Evidence Category A Recommendation):
management of acute appendicitis in children? o Absence of fever for 24 hours (<38 °C)
• It may be recommended as an alternative to open o Ability to tolerate oral intake
appendectomy in the pediatric age group o Normal WBC count with ≤3% band forms
• Level I Evidence Category A Recommendation
Should gram stain and culture and sensitivity be routinely done?
What is the role of antibiotics in the management of acute • No, except in high-risk and immunocompromised
appendicitis? patients. Intra-op specimens for sensitivity testing are
A. Is antibiotic prophylaxis effective in the prevention of purulent peritoneal fluid or tissue
SSIs? • Level II Evidence Category A Recommendation
o Yes, because it is effective in the prevention
of SSI for patients who undergo How should localized peritonitis be managed?
appendectomy and should be considered for • No necrotic tissue or purulent material should be left
routine use behind as much as possible
B. Recommended prophylaxis, its dose, and route of • General peritoneal lavage is not recommended
administration for uncomplicated appendicitis? • Intra-peritoneal drains, while most useful in patients
Recommended Cefoxitin 2g IV single dose (adults), 40 mg/kg with a well-dissected and localized abscess cavity,
IV single dose (children) should be selectively utilized
Alternative Ampicillin-sulbactam 1.5-3g IV single dose • Level II Evidence Category A Recommendation
(adults), 75 mg/kg IV single dose (children)
amoxicillin-clavulanate 1.2-2.4g IV single dose What is the appropriate method of wound closure in patients
(adults), 45 mg/kg IV single dose (children) with complicated appendicitis?
• Primary wound closure
If allergic to β- Gentamicin 80-120 mg IV single dose +
lactams clindamycin 600 mg IV single dose (adults)
What is the optimal timing of surgery for patients with
Gentamicin 2.5 mg/kg IV single dose +
periappendiceal abscess?
clindamycin 7.5-10 mg IV single dose
• Patient should undergo surgery as soon as the
(children)
diagnosis is made
All above are Level I Evidence Category A Recommendation • Level III Evidence Category A Recommendation
C. Recommended antibiotic treatment, its dose, and
route of administration for complicated appendicitis?
Adults Ertapenem 1 g IV every 24 hours
Tazobactam-piperacillin 3.375 g IV every 6 hrs or 4.5
mg IV every 8 hrs

If allergic to β-lactams:
Ciprofloxacin 400 mg IV every 12 hrs + metronidazole
500 mg IV every 6 hours
Pediatric Ticarcillin-clavulanic acid 75 mg/kg IV every 6 hrs
Alternative: imipenem-cilastatin 15-25 mg/kg IV
every 6 hours

If allergic to β-lactams:
Source: Schwartz’s Principles of Surgery 11th ed | Dr. Consuegra lecture | EBCPG: Acute Appendicitis (2002) insignis.de