APPENDIX

Epidemiology
6% of population, M>F
• 80% between 5-35 yr of age
Pathogenesis
• luminal obstruction → bacterial overgrowth → inflammation/swelling → increased pressure →
localized ischemia → gangrene/perforation → localized abscess (walled off by omentum) or
peritonitis
• etiology
■ children or young adult: hyperplasia of lymphoid follicles, initiated by infection
■ adult: fibrosis/stricture, fecolith, or obstructing neoplasm
■ other causes: parasites, or foreign body
Clinical Features
• most reliable feature is progression of signs and symptoms
• low grade fever (38ºC), rises if perforation
• abdominal pain then anorexia, N/V
• classic pattern: pain initially periumbilical; constant, dull, poorly localized, then well localized pain
over McBurney’s point
■ due to progression of disease from visceral irritation (causing referred pain from structures of the
embryonic midgut, including the appendix) to irritation of parietal structures
■ McBurney’s sign
• signs
■ inferior appendix: McBurney’s sign (see sidebar), Rovsing’s sign (palpation pressure to left abdomen
causes McBurney’s point tenderness). McBurney’s sign is present whenever the opening of the
appendix at the cecum is directly under McBurney’s point; therefore McBurney’s sign is present even
when the append x is in different locations
■ retrocecal appendix: psoas sign (pain on flexion of hip against resistance or passive hyperextension of
hip)
■ pelvic appendix: obturator sign (flexion then external or internal rotation about right hip causes pain)
• complications
■ perforation (especially if >24 h duration)
■ abscess, phlegmon
■ sepsis

Investigations
• laboratory
■ mild leukocytosis with left shift (may have normal WBC counts)
■ higher leukocyte count with perforation
■ β-hCG to rule out ectopic pregnancy
■ urinalysis

• imaging
■ U/S: may visualize appendix, but also helps rule out gynecological causes – overall accuracy 90-94%,
can rule in but CANNOT rule out appendicitis (if >6 mm, SENS/SPEC/NPV/PPV 98%)
■ CT scan: thick wall, enlarged(>6 mm), wall enhancement, appendicolith, and inflammatory
changes
– overall accuracy 94-100%, optimal investigation
Treatment
• hydrate, correct electrolyte abnormalities
• appendectomy (gold standard)
■ laparoscopic vs. open (see sidebar)
■ complications: intra-abdominal abscess, appendiceal stump leak
■ perioperative antibiotics:
◆ cefazolin + metronidazole if uncomplicated peri-operative dose is adequate
◆ consider treatment with post-operative antibiotics for perforated appendicitis
• for patients who present with an abscess (palpable mass or phlegmon on imaging and often delayed
diagnosis with symptoms for >4-5 d), consider radiologic drainage + antibiotics x 14 d ± interval
appendectomy once inflammation has resolved = (controversial)
• recent research supports antibiotic only treatment as reasonable for uncomplicated appendicitis, with
10-20% recurrence rates
• colonoscopy in the elderly to rule out other etiology (neoplasm)
McBurney’s Sign
Tenderness 1/3 the distance from the ASIS to the umbilicus on the right side
Laparoscopic vs. Open Appendectomy Cochrane DB Syst Rev 2010;10:CD001546
 Laparoscopic Surgery
• Wound infection less likely
• Intra-abdominal abscesses 2x more likely
• Reduced pain on POD #1
• Reduced hospital stay by 1.1 d
• Sooner return to normal activity, work, and sport
• Costs outside hospital are reduced
• Open Surgery
• Shorter duration of surgery
• Lower operation costs
• Overview
Diagnostic laparos opy and laparoscopic appendectomy appear to be
advantageous over open appendectomy, particularly for young female patients
and obese patients
Effect of Delay to Operation on Outcomes in Adults with Acute Appendicitis
Arch Surg 2010;145:886-892
Purpose: To examine the effect of delay to appendectomy on morbidity and mortality
among adults with appendicitis.
Method: Retrospective cohort study with he main exposure being time to operation, and
main outcomes being 30 d overall morbidity and serious morbidity/mortality.
Results: Of 32,782 patients in the study, 75.2%, 15.1%, and 9.8% underwent surgeries
within 6 h, 6-12 h, and >12 h of admission, respectively.
Differences in operative duration and length of post-operative stay were statistically
significant but not clini ally meaningful. No significant differences we e observed in
adjusted overall morbidity or serious morbidity/mortality. Duration from surgical admission
to anesthesia induction was not predictive in regression models for either outcomes.
Conclusions: Delay of appendectomy for acute appendicitis among adults does not
adversely affect outcomes.

Prognosis
• mortality rate: 0.08% (non-perforated), 0.5% (perforated appendicitis)