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Weall fear perforation,withits increased morbidity andmortality.We
have been taught that delay is dangerous and thatperforations can be
prevented by early diagnosis and operation, even at the expense of a
high proportion of unnecessary operations (up to 30% ‘white’
appendectomies in some series). This is also what families and
lawyers tend to believe. But in a population study, when we
compared the number of perforations per 100,000 inhabitants in
different geographical areas, we found out that this is almost
identical at centers that apply liberal or restrictive policies to
appendectomy2.Centersthatapplyaliberalpolicyhaveofcoursemore
negative explorations but we also found that they operated on more
cases with true appendicitis than centers with a restrictive attitude to
appendectomy. This teaches us that a restrained attitude allows
patients with mild appendicitis to resolve, undetected, without
treatmentandwithoutcausingmorecasestoperforate.However,as
fewer cases of mild appendicitis are detected, the denominator will be
smaller giving a higher proportion ofperforation. A high proportion of
perforationsthereforerepresentsasatisfactorysituationasitisthe
consequence of allowing cases of mild appendicitis to resolve
withoutoperation.Capisce?
CharlesMcBurneyrecognizedthismorethan100yearsago:
But, lest I give a wrong impression, I must distinctly state
here, that there are many cases of appendicitis of a mild
character which rapidly convalesce under no other
treatment than that just referred to, and that not a few
severecaseseventuallyrecoverwithoutotheractiveaid.
We know, and hope you do too, that perforation is a different
disease, one that is essentially unpreventable. Most perforations
developearly,before the patient arrives at hospital— they do not
perforate while weinvestigateor observe them. Sure, sometimes a
‘masked’ perforation is diagnosed after a delay and a perforation may
rarelyoccurin obstructedappendicitisthatarrivesearlyathospital,but
that’sanother,uncommon,story.
Diagnosis
Classification
AAstartsasaninflammationwhichcanprogresstoinfection.The
inflammation may be caused by an obstruction of the outlet of the
appendix(byanappendicolithforexample)andthiscanprogressrapidly
tonecrosis,perforationandlife-threateningfreeperitonitis.However,mild
attacks of spontaneously resolving phlegmonousappendicitis that do
notneedanytreatmentarecommon—ifyourushtodiagnoseitbyCT,
andthenoperateuponsuchearlymildcases,youwillneverrealizehow
commonsuchself-limitedattacksare.Youwillcontinuetobelievethat
youarepreventingperforations!(Isn’tthatwhatyoutellthefamilyafter
theoperation:“wewereluckytocatchitintime!”?)
Let us bring here a simple classification of AA to facilitate the
discussion of diagnosis and management. In essence, AA is either
simpleorcomplicated:
•
‘Simple’AAimpliesinflammationoftheappendixintheabsenceof
appendicealgangrene,perforationoranyassociatedpusformation.
•
‘Complicated’ AA exists whenever any of the aforementioned
Some pathologists may report small inflammatory changes as
“endoappendicitis”, “early appendicitis”, “catarrhal appendicitis” or
“chronicappendicitis”.Suchinflammatorychangesarecommonlyseenin
asymptomaticpatientswhohavehadappendectomyenpassant.(Some
pathologists,asyouknow,wouldgooutoftheirwaytoreportsomething
‘positive’ on any pristine appendix placed on their desk…). These
entities have no clinical significance. It is not the beginning of a
progressive disease that will end with perforation and should not be
calledappendicitis.
Another entity you should be familiar with — because it requires a
differentapproach—istheappendicealmass,developinglateinthe
naturalhistoryofAA. The‘mass’isan inflammatory phlegmonmade
of omentum and/or adjacent viscera, walling off a complicated
appendicitis. A mass containing a variable amount of pus is an
appendicealabscess.
“Whatabout‘chronicappendicitis’?”someofyoumayask.Youfinda
patientwithchronictendernessintherightiliacfossa.Ifyouoperatehe
will probably be thankful for your understanding attitude of taking his
problemseriously,buthe willvery likely comeback after6months with
thesame(orother)problems.Theplaceboeffectisstrongbutshort-
lived.
Clinicalfeatures
The classic signs and symptoms of AA are well known; even your
dentistcan diagnose classic AA ( Figure 23.1): a history of ‘gastric
upset’withvomitingor nausea,associatedwithmid-abdominal‘visceral’
discomfort which gradually migrates to the right lower quadrant (RLQ)
and becomes ‘somatic’. Add to this the physical findings of localized
peritoneal irritation and, most important, clinical and/or laboratory
evidence of systemic inflammation. But as you know, a number of
otherconditions can haveasimilarpresentation and notallcases
ofAAfollowthisclassicpath.
Figure23.1.“Evendentistscandiagnoseit!”
In fact, the clinicalpresentation of AAvaries considerably depending
onthe duration ofsymptoms,the stage ofinflammation, the anatomical
position of the appendix (e.g. retrocecal, pelvic) and the patient’s
physiognomy.Forsomepatientsthediagnosisisevidentandforothersit
is very vague. Thus, not all patients with suspected AA can be
approachedthesameway.Weneedastructuredmanagementbased
onthedegreeofsuspicion.
Analgorithmforastructuredapproach
Figure23.2.AnalgorithmforastructuredapproachtosuspectedAA.
Figure23.2depictsanalgorithmofhowwemanagethesepatients.It
isbasedontheAIRscore(see Table23.1),whichisasimpletoolthat
can help to determine the probability of appendicitis. There is nothing
magicwithitbutbasedonobjectivefindingsitcanhelptoputthingsinto
perspectivewithregardtoyourpatient.It isbased onthe variablesthat
are most important for making the diagnosis, and it assigns a proper
weighttoeachofthesevariables.Thecut-offpointsarechosenbasedon
theoutcomeofmanyhundredsofsimilarpatients.Validationstudieson
thousands of patients from different hospitals, in different
countries, have shown that the results are valid and can be
replicated.Thismeansthatthescorehasabuiltinexperienceofmore
patientsthananysurgeonwilleverseeinhiscareer.Itcanthereforebe
especiallyusefulforthelessexperiencedsurgeonatthebeginningofhis
career, let alone for the physician or ER doc who sees these patients
initially.
Thescoredividesthepatientsintothreegroupsaccordingtothe
probabilityoftheirsufferingfromAA—high,lowandintermediate:
•
PatientswithahighprobabilityofAA.Suchpatients,Ibelieve,
don’tneed anyfurtherwork-up.A negative imaging studywould
not rule out AA in a young man with a classic presentation, the
presence of rebound or guarding tenderness and a strong
inflammatory response (i.e.AIR score >8). Before sending such a
patientforimagingyoumayaskyourselfwhatyouractionwouldbe
if it turned out negative. Youwouldprobably need to do at least a
diagnosticlaparoscopyanywaysotheimagingwillnotchangeyour
management.
•
PatientswithalowprobabilityofAA.Take forexample ayoung
patient with abdominal pain but no signs of peritonism and no
inflammatory response (i.e. AIR score <5) and no other alarm
symptoms—herethe probabilityof complicatedAAinneedof
promptappendectomy is extremely low! Animaging studymay
only lead to a false-positive examination or youmay detect a mild
appendicitis that may resolve withouttreatment withina fewhours
— I hear from my American friends, who almost routinely obtain
CTs, about the entity of so-called ‘CT appendicitis’ (see below).
Most of these patients can be safely observed at home and
returnforre-examinationaftersomehoursifnotimproved.
•
Patients with an intermediate probability of AA. Periodic re-
evaluationisatime-honoredandprovendiagnosticmodalityin
thedoubtfulcase.Unfortunately,theartofactiveobservationand
the virtue of patience are disappearing from the scene of modern
practice. Instead, the current emphasis is on obsessive activity,
where in order to prove oneself one must always ‘do something’.
However, in the absence of clear peritonitis and strong
inflammatory response, very rarely are attacks of AA a true
emergency requiringan immediate operation. So if the clinical
presentationis indeterminate (AIR score 5-8),admitthepatient for
activeobservation,which meansplannedcompletere-examination,
includinglaboratorywork-upandrescoringafter6-8hours.Inmost
instances,AAwilldeclareitselfandinnon-specificabdominal
painthe‘attack’willwane.(Ifthediagnosisstillremainsunclearat
the reassessment you may order imaging or diagnostic
laparoscopy.)Asignificantdecreaseintheinflammatoryresponseat
the re-evaluation (especially thewhite blood cell [WBC]count and
proportion of neutrophils, whereas the C-reactive protein [CRP]
levels can increase as explained below) may indicate a resolving
appendicitis. If you give such a patient a second round of
observation you may often find that he is ready to be discharged
home. Remember: such patients do not perforate under
surgicalobservation!
Indicatorsofinflammation
TheEditorsaskedmeforan explanationofmy viewsonthis topic—
here it is: The most important diagnostic informationin AAcomes from
the inflammatory variables — temperature, WBC, proportion of
neutrophils and CRP. I contendthat some of these variables are in
fact strongerpredictors than signs of peritoneal irritation. That is
whyyoushouldmakeuseofthem!
But remember that the inflammatory response is dynamic — it
takessometimeto start up (please do not use the term ‘kick-off’)
and it also decelerates with a delay. This is especially true for
temperature and CRP which reactswith at least a 12-hour delay while
theWBC countandproportion ofneutrophils can changerapidly,within
hours.InanAApatientwithonlyafewhours’durationofsymptoms,you
maythereforehave (almost)normal laboratoryresults.Thatiswhythe
diagnostic information of the inflammatory variables increases if
yourepeatthemafterafewhoursofobservation.
Just as an increase in the inflammatory response can suggest the
presenceofAA,amarkeddecreasecansuggestspontaneousresolution.
Here the decrease comes in reverse order. You will first notice it in a
decrease in the WBC count and proportion of neutrophils, whereas the
slowreactingCRPcanstillbeontheincrease.Itmaytakeanother24
hoursfortheCRPtostartthedecline.
Whataboutantibioticsduring‘observation’?
Ifyoudecidetoobservethepatient,donotadministerantibioticsas
they may mask the findingsor ‘partiallytreat’ which may just delaythe
diagnosis and time until surgery. Reports and experience that
appendicitis may be curedby antibioticsis noproof that the antibiotics
were efficient. The inflammation may have resolved all by itself. Of
course, if you diagnose AA and decide to treat it with antibiotics
thenthisisadifferentstory(seebelow).
Theatypicalpatientistheonewhereimagingisindicated
Patients with atypical presentation (>3 days’ duration of symptoms,
recurrent episodes ofabdominal pain, a palpable mass, the elderly or
patients where the intensity of pain is out of proportion to the weak
clinicalorlaboratoryfindings;orwhenthereisadiscrepancybetweenthe
clinicalandlaboratoryfindings)needspecialconsideration.Imagingmay
be indicated to detect/exclude an appendiceal phlegmon or abscess,
Crohn’sdisease, diverticulitis, tumor,strangulated intestinalobstruction,
torsion of the ovary, appendicitis epiploicae, torsion of the omentum,
ureteralcalculiorotherdifferentialdiagnoses.
Abdominalimaginginacuteappendicitis
Ibelievethatimaginghasarole,especiallyinselectedpatientslikethe
elderly or in thosewhose presentation is atypicalas mentioned above,
butitsefficiencyasauniversaltooltodetectorexcludeappendicitishas
been overemphasized. A CT scanner is also not readily available
everywhere.CTandultrasoundaretwowonderfultechniquesbut“afool
withatoolisstillafool”.Indiscriminateandnon-selectiveuseofmodern
diagnostic technology is notgoing to help. Whatis needed is common
senseandrationaldeploymentof availableinvestigations.Ultrasoundin
goodhandshasbeenreportedtobeaccurateinthediagnosisofAAand
is useful in excluding other diagnoses, which may require a different
therapy (e.g. hydronephrosis), or incision (e.g. acute cholecystitis), or
indeednotherapyatall(e.g.ovariancyst—inwomenendovaginalUS
isagreattooltoexclude/diagnosepelvicpathology!).However,most
ofus do notworkin an institutionwherewe can besoconfident of the
radiologist’sdiagnosisofappendicitisonthebasisofultrasound.Inmost
settingsCTexaminationismorereliablethanultrasound.Thevalue
of CT in diagnosing conditions which mimic AA but may not need
operativetreatment(e.g.cecaldiverticulitis)isemphasizedin Chapter
5.
So we order imagingselectively.Unfortunately in manyplaces the
diagnosticalgorithmisincreasinglydrivenbydogmaticemergency
roompersonnelwhoperformCTscansinlieuofclinicalevaluation.
SuchindiscriminateuseofCTscanningleadstoanewsyndromeof‘CT
appendicitis’: you admit for observation a patient with right lower
quadrantpainandambiguousclinicalfindings.Meanwhiletheemergency
room doctor orders a CT, which is reported by the radiologist the
following morning. At this stage, the patient feels much better, his
abdomenisbenign,andhewantstogohomebuttheradiologistclaims
that the appendixis inflamed (“cannot exclude AA…” or “suggestive of
AA...”).But shouldwe treat theCT image orthe patient?Youknowthe
answer.
Diagnosticlaparoscopy
Diagnostic laparoscopy is a wonderful technique, but it is
invasiveandshouldnotreplaceconventionalclinicaldiagnosisand
imaging.Ithasbeenrecommendedthatamacroscopicallynon-inflamed
appendixbe leftin situ,thus reducingthe ‘negativeappendectomyrate’
but this is just a white wash. It is still an unproductive abdominal
exploration which is associated with unnecessary pain, risk of
complicationsandincreasedcosts.Anyway,mostsurgeonsIknoware
reluctantnottoremovetheappendixinsuchcircumstances—what
about you? If your non-therapeutic laparoscopic exploration rate is
higherthan15%youaremisusingtheprocedure.
Diagnosticlaparoscopyisusefulforthepatientwithanequivocal
diagnosisof appendicitis that has notimproved afterobservation,
when imaging has not clarified the situation and the patient’s
presentationissuchthathecannotbedischarged.
In my practice I have never had such a patient — I find no need for diagnostic laparoscopy
whenusingCT!Moshe
SohereishowIdoitinSweden.
First I gather all the data needed to calculate the AIR score. It
helps me put the patient into a wider perspective. I never make any
decision until I have all this information. For premenopausal women a
gynecological examination including a transvaginal ultrasound is also
done,asthiscandetectovarianpathology( Chapter35).
•
PatientswithalowprobabilityofAA—noperitonealirritation,
all inflammatory variables normal (score <5). This group
representsthemajorityof allpatientswithsuspectedAA.Theycan
safely be observed at home if there are no other symptoms that
motivate observation at hospital. Plan a reassessment after 6-12
hours (i.e. the next morning). Imaging is not indicated unless you
thinkthepatientmayhaveanotherdisease.
•
Patients witha typical presentation — presence of peritoneal
irritation and stronginflammatory response (score >8). These
patientsneedanoperation!Afewhours’delayisacceptable,but
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