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Acute Appendicitis: Common Surgical Emergency

Article · January 2014

DOI: 10.4103/0975-2870.144866

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Guest Editorial

Acute appendicitis: Common surgical emergency

Introduction appendix, the parietal peritoneum and adjacent structures
also become inflamed. This final stage causes a shift in
Acute appendicitis is one of the most common acute surgical pain perception from the periumbilical region to the right
conditions of the abdomen reporting to a general surgeon. lower quadrant of the abdomen. At this stage, the pain is
The worldwide incidence of appendicitis is estimated typically more severe, continuous, and often associated with
to be 86 cases annually/100,000 population.[1] Diagnosis constitutional symptoms, such as anorexia, fever, nausea,
of appendicitis is generally straightforward, made on and vomiting.[6] If untreated, appendicitis rarely resolves
clinical history, examination, supported by a routine blood spontaneously, and usually progresses to perforation.
investigation and urine test. However, in Infants and young Studies have suggested that a delay of >48 h in the diagnosis
children, the diagnosis is difficult because 33-50% will or in the treatment of appendicitis results in perforation
present atypically.[1] The mortality rate of nonperforated and complication rates >60%.[6] Bacterial peritonitis can
appendicitis is <1%; however, perforated appendicitis carries subsequently arise, which may result in overwhelming
a higher mortality rate of around 5%.[2] The incidence of sepsis and death.
complicated acute appendicitis like perforated or gangrenous
appendicitis also remains high despite the availability of Appendicitis due to foreign bodies is rare. Foreign
modern imaging.[2] Hence, although appendectomy for acute bodies leading to appendicitis or perforation are usually
appendicitis is one of the most common intra-abdominal sharp, pointed objects. It occurs in 0.0005% of cases of
surgical procedures performed by general surgeons, appendicitis. Various objects have been reported in the
morbidity rates in the postoperative period remain between literature, including bird shot, air gun pellets, bullets, pins,
9% and 18%, respectively.[3] needles, teeth, dental drill bits, toothpicks, bone fragments,
fish-bone, fruit seeds and pits, chewing gum, gallstones,
Pathophysiology fishhooks, coins, and earrings.[7]

Classically, appendicitis is described as a dynamic disease Rare cause of pain right lower abdomen may be diverticulitis
process that comprises five stages occurring over a of the vermiform appendix, the incidence of which is greater
24-36 h period.[4] The inciting event is the obstruction of than that generally appreciated. Due to the thinned wall,
the appendiceal lumen, which is unable to drain and, as a these diverticula are prone to perforate early in the presence
result, distends. The etiology is multifactorial, but fecoliths, of acute inflammation.[8] Although appendiceal diverticulitis
lymphoid hyperplasia, foreign bodies, malignancy, and is rare, clinicians should be aware of its occurrence, because
parasites have all been described. During the second stage, it can lead to early perforation due to the thin wall of the
stimulation of the 8th-10th visceral afferent thoracic nerves diverticulum.
causes a mild to moderate peri-umbilical pain that typically
lasts from 4 h to 6 h.[5] As intraluminal pressure increases, Appendicitis within an inguinal hernia (Amyand’s hernia)
appendiceal wall perfusion decreases due to arterial is another rare presentation, incidence being <1% and when
insufficiency. This third stage results in tissue ischemia and it occurs, it is usually misdiagnosed as strangulated inguinal
mucosal compromise. Bacteria are then able to invade the hernia, another surgical emergency. The proper treatment in
luminal wall, leading to transmural inflammation-the fourth such a case involves appendectomy through the herniotomy
stage. As transmural inflammation extends beyond the with primary hernia repair without the use of any synthetic
mesh.[9] A rarer presentation of appendicitis can be pain in
Access this article online the left lower quadrant if the patient happens to be the case
Quick Response Code: of situs inversus totalis. In such a case, chest radiograph
Website:
www.mjdrdypu.org will reveal dextrocardia, and left-sided appendicitis should
be suspected. A strong suspicion of appendicitis and an
emergency laparoscopic operation after confirmation of
DOI:
10.4103/0975-2870.144866 the diagnosis by imaging modalities including abdominal
computed tomography (CT) can reduce the likelihood

Medical Journal of Dr. D.Y. Patil University | November-December 2014 | Vol 7 | Issue 6 749
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Dogra: Appendicitis

of misdiagnosis and complications including perforation Role of Imaging Studies

and abscess.[10] Tawk et al. have reported a case of acute
appendicitis presenting with a left upper quadrant pain due • Abdominal radiographs taken for the evaluation
to intestinal malrotation. Such cases require abdominal CT, of patients with acute abdominal pain, include the
which will help in clinching the correct diagnosis.[11] abdominal radiograph in a standing position, as well as a
chest radiograph may be useful in patients with atypical
Role of Alvarado Score presentation. Perforated appendix may present with
pneumoperitoneum in only 1-2% of cases. Abdominal
In 1986, Alvarado constructed a 10-point clinical scoring radiographs may show a fecolith and localized ileus.
system, for the diagnosis of acute appendicitis as based on • Ultrasonography is often used as the initial diagnostic
symptoms, signs, and diagnostic tests in patients presenting imaging study in the majority of patients in whom
with suspected acute appendicitis[12] [Table 1]. the clinical diagnosis of appendicitis is equivocal. It
• Alvarado score 1-4: Discharge. has sensitivity of around 85% and specificity of more
• Alvarado score 5-6: Observations/admission. than 90%. In acute appendicitis, the appendix can be
• Alvarado score 7-10: Surgery. seen as a fluid filled, noncompressible tubular structure
with a diameter of more than 6 mm.[15] Other signs of
The Alvarado score enables risk identification in patients appendicitis include the presence of a fecolith, peri-cecal
presenting with abdominal pain, linking observation or or periappendiceal fluid, secondary to inflammation.
surgical intervention and further investigations, such as However, ultrasound examination is operator dependent
ultrasound and CT. and there may be difficulty in visualizing in obese
individual.
Relevance of C-Reactive Protein (CRP) • Computed tomography changes observed in a case
of appendicitis are an appendiceal diameter >6 mm,
C-reactive protein levels >1 mg/dL are common in patients thickening or enhancement of the appendix, and
with appendicitis. Very high levels of CRP in patients with periappendiceal fat stranding.[16] Moreover, CT is not
appendicitis indicate gangrenous appendicitis, especially if operator dependent, and is also very useful for evaluating
it is associated with leukocytosis and neutrophilia. the complications of appendicitis, identifying alternative
diagnoses, and is reported to be able to identify a
In adults who have had symptoms for longer than 24 h, a normal appendix in 67-100% of patients evaluated.[1]
normal CRP level has a negative predictive value of 97-100% CT is especially useful in distinguishing those patients
for appendicitis.[13] presenting late in their clinical course and who may have
developed an appendicular lump or abscess.
Urinary 5-Hydroxy Indole Acetic Acid
(5-HIAA) Appendicitis During Pregnancy
Urinary 5-hydroxy indole acetic acid levels increase Acute appendicitis during pregnancy presents diagnostic
significantly in acute appendicitis and decrease when the problems, because during the third trimester, the uterus
inflammation shifts to necrosis of the appendix. Therefore, is rapidly enlarging and causes displacement of the cecum
such decrease could be an early warning sign of perforation and appendix into the right upper abdomen. Thus, acute
of the appendix.[14] appendicitis in these patients causes symptoms and
signs higher and more lateral during the third trimester.
Diagnostic imaging techniques facilitate in clinching the
Table 1: Probability of appendicitis by Alvarado score diagnosis in such cases. Graded compression ultrasound
Features Score has shown to be highly sensitive and specific although
Migration of pain 1
to a lesser degree after a gestational age of 35 weeks due
Anorexia 1
to technical difficulties.[14] The ultrasound examination
Nausea 1
Tenderness in right lower quadrant 2
should be considered first in working up suspected acute
Rebound tenderness 1 appendicitis during pregnancy. CT has recently shown to
Elevated temperature 1 be a safe and potentially reliable tool to accurately identify
Leucocytosis 2 appendiceal changes in appendicitis. Magnetic resonance
Shift of white blood cell count to left 1 imaging is useful in pregnant patients if graded compression
Total points 10 ultrasonography is nondiagnostic.[17]

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Dogra: Appendicitis

Management This technique is a novel way of minimally invasive surgery

using a single incision. The use of SILS has the potential of
Traditional management of acute appendicitis has been further reducing postoperative port site complications as well
emergent appendectomy based on the theory that, if left as improving cosmesis and patient satisfaction.[21]
untreated simple appendicitis will progress to perforation,
with a resultant increase in morbidity and mortality. Conclusion
However, management of patients with an appendiceal mass
can usually be divided into the following three categories: Patients with appendicitis reporting with persistent right
a. Patients with an appendicular mass or a small abscess: lower abdominal pain, fever and having leukocytosis,
After intravenous antibiotic therapy, an interval need urgent admission and prompt treatment in the form
appendectomy can be performed 4-6 weeks later. of appendectomy. If the clinical picture is unclear, a short
b. Patients with a larger well-defined abscess: Under period of 4-6 h of watchful waiting and a CT scan may help
broad-spectrum antibiotic cover, percutaneous drainage arrive at the correct diagnosis.
is performed. The patient can be discharged with
the catheter in place. Interval appendectomy can be Bharat Bhushan Dogra
performed after the fistula is closed. Department of Surgery,
c. Patients with a multi-compartmental abscess: These Dr. D. Y. Patil Medical College Hospital and
patients require early surgical drainage. Research Centre, Pune, Maharashtra, India
E-mail: [email protected]
Preoperative antibiotics have been very effective in
decreasing postoperative wound infection rates in numerous References
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Dogra: Appendicitis

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18. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time How to cite this article: Dogra BB. Acute appendicitis: Common
surgical emergency. Med J DY Patil Univ 2014;7:749-52.
affects the risk of rupture in appendicitis. J Am Coll Surg
2006;202:401-6. Source of Support: Nil. Conflict of Interest: None declared.

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