Chapter 356 - Acute Appendicitis and Peritonitis

Question 1

Summarize the incidence and epidemiology of acute appedncitis.

Answer 1

“Appendicitis occurs more frequently in Westernized societies. Although its incidence is decreasing for uncertain reasons, acute appendicitis remains the most common emergency general surgical disease affecting the abdomen, with a rate of approximately 100 per 100 000 persons-years in Europe and the Americas or about 11 cases per 10 000 people anually. Approximately 9% of men and 7% of women will experience an episode during their lifetime. Appendicitis occurs most commmonly in 10- to 19-year-olds, although the average age at diagnosis appears to be gradually increasing, as its the frequency of the disease in African Americans, Asians, and Native Americans. Overall, 70% of patients are less than 30 years old and most are men; the male-to-female ratio is 1,4:1.”

Question 2

What is the frequency of perforated appedncitis at presentation?

Answer 2

20%.

This percentage is higher for those under 5 or over 65 years of age.

Question 3

What is the most common complication of appendicitis? Summarize its epidemiology.

Answer 3

Perforated appendix and peritonitis.
“In contrast to the trend observed for appendicitis and appendectomy, the incidence of perforated appendicitis (~20 cases per 100 000 persons-years) is increasing.”

Question 4

When was appedicitis first described and by whom?

Answer 4

1886 by Reginald Fitz.

Question 5

Name the most common factors that have been assocaited with inflammation of the appendix and appendicitis.

Answer 5

Fecaliths, incompletely digested food resiude, lymphoid hyperplasia, intraluminal scarring tumors, bacteria, viruses, and inflammatory bowel disease.

Question 6

Explain the traditional pathophysiology suggested for appendicitis and appendix perforation.

Answer 6

“Although not proven, obstruction of the appendiceal lumen is believed to be an important step in the development of appendicitis. In some cases, obstruction leads to bacterial overgrowth and luminal distension, with an increase in intraluminal pressure that can inhibit the flow of lymph and blood in some cases. Then, vascular thrombosis and ischemic necrosis with perforation of the distal appendix may occur.”

Question 7

Most perforation occur before they are evaluated by surgeons.
True or False?

Answer 7

True.

Question 8

In how many cases does one find appendiceal fecaliths (or appendicoliths in gangrenous appendicitis?

Answer 8

Approximately 50%.

Question 9

What is the most dreadful complication of acute appendicitis?

Answer 9

“Free perforation normally causes severe peritonitis. These patients may also develop infective suppurative thrombosis of the portal vein and its tributaries along with intrahepatic abcesses. The prognosis of the very unfortunate patients who develop this dreaded complication is very poor.”

Question 10

How low is the mortality rate associated with simple acute appendicitis?

Answer 10

Currently, less than 1%.

Question 11

Name the differential diagnosis for acute appendicitis.

Answer 11

Crohn’s disease, Cholecystitis or other gallbladder disease, diverticulitis, ectopic pregnancy, endometriosis, gastroenteritis or colitis, gastric or duodenal ulceration, hepatitis, kidney disease (including nepholithiasis), liver abcess, meckel’s diverticulitis, mittelschmerz, mesenteric adenitis, omental torsion, pancreatitis, lower lobe pneumonia, pelvic inflammatory disease, ruptured ovarian cyst or other cystic disease of the ovaries, small-bowel obstruction, urinary tract infection.

Question 12

Name a typical situation associated with an appendix located to the right upper quadrant.

Answer 12

Late pregnancy.

Question 13

What is the classic history of acute appendicitis?

Answer 13

“Nonspecific complaints occur first. Patients may notice changes in bowel habits or malaise and vague, perhaps intermittent, crampy, abdominal pain in the epigastric, or peri-umbilical region. The pain subsequently migrates to the right lower quadrant over 12-24 h, where it is sharper and can be definitively localized as transmural inflammation when the appendix irritates the parietal peritoneum. Parietal peritoneal irritation may be associated with local muscle rigidity and stiffness. Patients with appendicitis will most often observe that their nausea, if present, followed the development of abdominal pain, which can help distinguish them from patients with gastroenteritis, for example, where nausea occurs first. Emesis, if present, also occurs after the onset of pain and is typically mild and scant. Thus, timing of the onset of symptoms and the characteristics of the patient’s pain is so common that the diagnosis of appendicitis should be questioned in its absence.”

Question 14

Organize the following symptoms in order of increasing frequency in acute appendicitis: abdominal pain, anorexia, constipation, diarrhea, fever, migration of pain to right lower quadrant, nausea and vomiting.

Answer 14

Abdominal pain (>95%)
Anorexia (>70%)
Nausea (>65%)
Vomiting (50-75%)
Migration of pain to right lower quadrant (50-60%)
Fever (10-20%)
Constipation (4-16%)
Diarrhea (4-16%)

Question 15

What is the most frequent appendiceal location?

Answer 15

Retrocecal (64%).

Question 16

How do you test for Rovsing’s, obturator and iliopsoas sign? How frequent are they?

Answer 16

• Rovsing’s sign (5%): palpating in the left lower quadrant causes pain in the right lower quadrant.
• Obturator sign (5-10%): internal rotation of the hip causes pain, suggesting the possibility of an inflamed appendix located in the pelvis
• Iliopsoas sign (3-5%): extending the right hip causes pain along posterolateral back and hip, suggesting retrocecal appendicitis.

Question 17

Name three frequent differential diagnosis for acute appendicitis in women.

Answer 17

Pelvic inflammatory disease, ectopic pregnancy and ovarian torsion.

Question 18

Since acute appendicitis is usually associated with only a slight increase in pulse and temperature, what would you suspect if a patients has a temperature >38,3ºC?

Answer 18

Perforation, phlegmon or abcess formation, for example.

Question 19

Where is the most common location for maximal tenderness in acute appendicitis?

Answer 19

“McBurney’s point, which is located approximately one-third of the way along a line originating at the anterior iliac spine and running to the umbilicus.”

Question 20

How can one better elicite parietal peritoneal irritation?

Answer 20

“Evidence of parietal peritoneal irritation is often best elicited by gentle abdominal percussion, jiggling the patient’s gurney or bed, or midly bumping the feet.”

Question 21

Is there any possible explanation for the fact that perforated appendicitis in children might lead to free perforation and peritonitis?

Answer 21

“it is important to remember that the smaller omentum found in children may be less likely to wall off an appendiceal perforation.”

Question 22

Is there any differences in history regarding older versus younger patients in acute appendicitis?

Answer 22

Yes.
“Signs and symptoms of appendicitis can be subtle in the elderly who may not react as vigorously to appendicitis as younger people. Pain, if noticed, may be minimal and have originated in the right lower quadrant or, otherwise, where the appendix is located. It may never have been noticed to be intermittent, or there may only be significant discomfort with deep palpation. Nausea, anorexia, and emesis may be the predominant complaints. The rare patient may even present with signs and symptoms of distal bowel obstruction seconday to appendiceal inflammation and phegmon or abcess formation.”

Question 23

How high do you expect to find the white cell count in patients with simple acute appendicitis?

Answer 23

“The white blood cell count is only mildly to moderately elevated in approximately 70% of patients with simple appendicitis (with a leukocytosis of 10 000 to 18 000 cells/uL).”

Question 24

A “left shift” toward immature polymorphonuclear leukocytes is present in >95% of cases of appendicitis.
True or False?

Answer 24

True.

Question 25

What is the role of urinalysis in the differential of acute appendicitis?

Answer 25

“Patients with pelvic appendicitis are more likely to present with dysuria, urinary frequency, diarrhea, or tenesmus. They may only experience pain in the suprapubic region on palpation or on rectal or pelvic examination.”

“Urinalysis is indicated to help exclude genitourinary conditions that may mimic acute appendicitis, but a few red or white blood cells may be present as a nonspecific finding.”

Question 26

An about inflammed appendix might cause sterile pyuria and hematuria.
True or False?

Answer 26

True.

Question 27

If one would perform a plain film of the abdomen in acute appendicitis, how frequently would an opaque fecalith in the right lower quadrant be identified?

Answer 27

Less than 5%.

Question 28

The presence of a fecalith on plain radiographs is diagnostic of appendicitis.
True or False?

Answer 28

False.
“The presence of a fecalith is not diagnostic of appendicitis, although its presence in an appropriate location where the patient complains of pain is suggestive.”

Question 29

What does one find suggestive of acute appendicitis in ultrasonography? Does this technique have an acceptable sensitivy and especifity?

Answer 29

“Ultrassonographic findings suggesting the presence of appendicitis include wall thieckening, an increased appendiceal diameter, and the presence of free fluid.”
Sensitivity 86%
Specificity 81%

Question 30

Compare the sensitivity and specificityof CT scan versus utlrassonography in the diagnosis of acute appendicitis.

Answer 30

- CT scan:
Sensitivity 94%
Specificity 95%
- Ultrasonography
Sensitivity 86%
Specificity 81%

Question 31

What are the suggestive findings of acute appendicitis on CT scan?

Answer 31

“Suggestive findings on CT examination include dilation >6mm with wall thieckening, a lumen that does not fill with enteric contast, and fatty tissue stranding on air surrounding the appendix, which suggests inflammation.”

Question 32

In pregnant patients with acute appendicitis, what is the fetus mortality rate? Compare a non-perforated versus a perforated appendix.

Answer 32

5% and 20%, respectively.

Question 33

In the absence of contraindications, a patient who has a strongly suggestive medical history and physical examination with supportive laboratory fidings should undergo appendectomy urgently, without requiring imaging tests.
True or False?

Answer 33

True.

Question 34

How should one proceed when the diagnosis of acute appendicitis is not certain?

Answer 34

“In patients in whom the evaluation is suggestive but not convicing, imaging and further study are appropriate. Pelvic ultrasonography is indicated in women of childbearing age. Thereafter, CT may accurately indicate the presnece of appedncitis or other intraabdominal processes that warrant intervention. Whenever the diagnosis is uncertain, it is prudent to observe the patient and repeat the abdominal examination. Narcotics can be given to patients with severe discomfort especially if the first abdominal examination is completed before drugs are administered.”

Question 35

Is there any differences in treating simple acute appendicitis and phelgmon or abcess due to acute appendicitis?

Answer 35

Yes.
While simple acute appendicitis should promptly be treated with surgery, either laparoscopically or open appendectomy, the latter represents a more challenging treatment. “Such patients are best served by treatment with broad-spectrum antibiotics, drainage if there is an abcess >3cm in diamter, and perenteral fluids and bowel rest if they appear to respond to conservative management. The appendix can then be more safely removed 6-12 weeks later when inflammation has dimished.”

Question 36

In those admitted to appendectomy, how frequently should one expect a normal non-inflammed appendix?

Answer 36

15-20%.

Question 37

Name the vantages and disadvantages of a laparoscopic approach rather than open appendectomy.

Answer 37

“Laparoscopic appendectomy now accounts for approximately 60% of all appendectomies. Laparoscopic apprendectomy is associated with less postoperative pain and, possibly, a shorter lenght of stay and faster teturn to normal activity. Patients who undergo laparoscopic appendectomy also appear to have fewer wound infections, although the risk of intraabdominal abcess formation may be higher. A laproscopic approach may also be useful when the exact diagnosis is unecrtain, yet direct visualization and exploration of the abdomen are needed. A laparoscopic approach may also facilitate exposure in those who are very obese.”

Question 38

What is the most common complication of postoperative appendectomy?

Answer 38

Fever and leukocytosis which, if persistent (beyond 5 days), shouyld raiseconcern for the presence of an intraabdominal abcess.

Question 39

Compare the mortality rate for the following conditions: (i) nonperforated acute appendicitis; (ii) perforated acute appendicitis; (iii) complicated appendicitis in the elderly.

Answer 39

(i) 0,1-0,5%
(ii) 3%
(iii) 15%

Question 40

How does one differentiate pathophysiologicaly primary from secondary peritonitis?

Answer 40

“Acute peritonits, or inflammatio of the visceral and parietal peritonitoneum, is most often but not always infecious in origin, resulting from perforation of a hollow viscus. This is called secondary peritonis, as opposed to primary or spontaneous peritonitis, when a specific intraabdominal source cannot be identified. In either instance, the inflammation can be localized or diffuse.”

Question 41

Name all the causes of secondary bacterial peritonitis. Organize them by categories.

Answer 41

• Bowel perforation: appendicitis trauma (blunt or penetrating), anastomotic leakage, adhesion, diverticulitis, iatrogenic (including endoscopic perforation), ingested foreign body, inflammation, intussusception, neoplasms, obstruction, peptic ulcer disease, strangulated hernia, vascular (including ischemia or embolus);
• Perforation or leakage of other organs: biliary leakage (e.g., after liver biopsy), cholecystitic, intraperitoneal bleeding, pancreatitis, salpingitis, traumatic or other rupture of urinary bladder;
• Loss of peritoneal integrity: intraperitoneal chemotherapy, iatrogenic (e.g., postoperative foreign body), perinephric abcess, peritoneal dialysis or other indwelling devices, trauma.

Question 42

What is the most common cause of spontaneous/primary peritonitis?

Answer 42

“Over 90% of the cases of primary or spontaneous bacterial peritonitis occur in patients with ascites or hypoproteinemia (less than 1g/L).”

Question 43

Which components might be involved in aseptic peritonitis? Does this situation complicate into bacterial infection?

Answer 43

“Aseptic peritonitis is most commonly caused by the abnormal presence of physiologic fluids like gastric juice, bile, pancreatic enzymes, blood, or urine. It can also be caused by the effects of normally steril foreign bodies like surgical sponges or instruments. More rarely, it occurs as a complication of systemic diseases like lupus erythematosus, porphyria, and familial Mediterranean fever. The chemical irritation caused by stomach acid and activated pancreatic enzymes is extreme and secondary bacterial infection may occur.”

Question 44

Are there any differences in physical examination on a patient with diffuse versus localized peritonitis?

Answer 44

Yes.
“Diffuse, generalized peritonitis is most often recognized as diffuse abdominal tenderness with local guarding, rigidity, and other evidence of parietal peritoneal irritation. Physical findings may only be identified in a specific region of the abdomen if the intraperitoneal inflammatory process is limited or otherwise contained as may occur in patients with uncomplicated appendicitis or diverticulitis. Bowel sounds are usually absent to hypoactive.”

Question 45

In stable patients in whom ascites is present, diagnostic paracentesis is indicated, where the fluid is tested for protein and lactate dehydrogenase and the cell count is measured.
True or False?

Answer 45

True.

Question 46

Compare the mortality rate of peritonitis in the following groups: (i) reasonably healthy patients with relatively uncomplicated, localized peritonitis; (ii) elderly or immunocompromised patients.

Answer 46

(i) Less than 10%.

(ii) >40%.

Question 47

Summarize the treatments for peritonitis.

Answer 47

“Successful treatment depends on correcting any electrolyte abnormalities, restoration of fluid volume and stabilization of the cardiovascular system, appropriate antibiotic therapy, and surgical correction of any underlying abnormalities.”