Appendicitis. Improvements in diagnosis and treatment

The results of therapy in cases of suspected acute appendicitis were reviewed in 844 consecutive cases of appendicitis occurring over a 3-year period. A diagnostic accuracy of 87.4 per cent was found as well as a perforation rate of 18.4 per cent. Complication rates varied with the clinical state of the appendix: 16 per cent in perforated, 5.6 per cent in nonperforated, and 11.3 per cent in normal appendices. Excellent results were routinely obtainable employing early operative intervention, perioperative antibiotics, and a systematic surgical approach.     

Surgery may be curative for patients with a localized perforation of rectal carcinoma

BACKGROUND: Perforation at the time of operation adversely affects the prognosis of rectal cancer. These procedures have been termed 'palliative' or 'non-curative'. The long-term outcome of generalized perforations may be different from that of localized or contained perforations. Although the oncological results may be compromised when the tumour is perforated, results in cases where the perforation is contained may not be as bad as previously thought. An attempt was made to examine the intermediate and long-term results for locally contained perforated rectal cancers. METHODS: Some 848 patients with rectal cancer were operated on between March 1989 and December 1995. Of these, 42 (5 per cent) had a locally contained perforation of the rectum. Median follow-up was 23 (range 12-74) months. RESULTS: The survival of patients with locally contained tumour perforation who underwent resection without macroscopic residual disease (40 per cent at 5 years) was significantly better than that of patients with metastatic disease at the time of surgery (zero at 4 years) (P < 0.01). The survival of patients in whom the tumour was inadvertently perforated during operation was similar to that of patients with locally contained spontaneous tumour perforations. The incidence of local recurrence in these perforated cases was low provided that a wide tumour clearance was achievable at the time of operation. Operative mortality and morbidity rates were not significantly different but the incidence of postoperative wound infection was marginally higher among patients with perforation. CONCLUSION: If clear margins can be obtained at the time of operation the prognosis of locally contained perforated rectal cancers is good and approaches that of a potentially curative resection.     

Perforated and non-perforated acute appendicitis--one disease or two entities?

OBJECTIVE: To analyse the pattern of clinical presentation of perforated and non-perforated acute appendicitis in 544 unselected patients treated surgically for suspected acute appendicitis; to find out if their presentation differed. DESIGN: Open prospective population-based study. SETTING: Teaching hospital, western Norway. PATIENTS: All 434 patients operated on for suspected acute appendicitis from the catchment area of a single hospital in whom the diagnosis was confirmed. INTERVENTIONS: Appendicectomy; history, clinical findings, and inflammatory markers were recorded in all patients. MAIN OUTCOME MEASURES: Odds Ratio (OR) and 95% confidence interval (CI) obtained by logistic regression analysis of symptoms and signs of acute appendicitis with regard to independent predictors of perforation of the appendix. Receiver operating characteristic (ROC) curve analysis of inflammatory markers. RESULTS: The perforation rate was 20% (n = 88). Perforation was unlikely when abdominal pain was limited to the right iliac fossa, (OR 0.13, 95% CI 0.05 to 0.33). Increased C-reactive protein (CRP) concentration >50 U/L (OR 4.6, 95% Cl 2.44 to 8.75) and greater age (by decade; OR 1.18, 95% CI 1.02 to 1.36) were independent predictors of perforation of the appendix. CONCLUSIONS: Clinical differences between perforated and non-perforated acute appendicitis could be explained by the presence of advanced inflammation in patients with perforated appendicitis. Our data do not support the hypothesis that they are two clinically different diseases.     

Perforated appendicitis after colonoscopy

BACKGROUND: Acute appendicitis is a rare complication of colonoscopy that has been reported only 12 times in the English-language literature and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports have described findings of perforation of the appendix within 24 hours of colonoscopy. METHODS: We present the case report of a patient who underwent urgent laparotomy within 16 hours of colonoscopy for findings of free intraabdominal air and peritonitis from acute perforated appendicitis. RESULTS: Laparoscopy confirmed 2 perforations of the appendix and diffuse peritonitis. Laparotomy was necessary to perform appendectomy, exclude a right colonic injury, and control intraabdominal sepsis. CONCLUSION: In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for accurate diagnosis of perforated appendicitis. Perforation can occur hours after colonoscopy even when a biopsy is not performed.     

Balancing the normal appendectomy rate with the perforated appendicitis rate: implications for quality assurance.

Debate continues as to what should be the appropriate "negative" appendectomy rate for patients suspected of having acute appendicitis. The controversy centers around balancing the complications of appendectomy for a normal appendix with those for a perforated appendix. By using a decision analysis approach to the probable outcomes of appendectomy for a normal appendix, acute appendicitis, and perforated appendicitis, this study provides one answer to this question. These outcomes are based on a review of the results of over 10,000 appendectomies. There is an inverse relationship between the normal appendectomy rate and perforated appendicitis rate. The overall complication rate in patients suspected of having appendicitis improved when the rate of perforated appendicitis was lowered, even if this meant raising the negative appendectomy rate. The perforation rate seemed to level off at approximately 10 per cent. The quality of surgical care delivered to a given population should not be judged solely on the normal appendectomy rate, but this rate should be interpreted in the light of the perforated appendicitis rate. Quality assurance assessments should focus first on perforated appendicitis and only later on normal appendectomy.     

Spectrum of Perforation Peritonitis in Delhi: 77 Cases Experience

Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.     

Perforated appendicitis--the Malaysian experience

Perforated appendicitis, with its increased complication rate, today still poses a formidable problem in the Kuala Lumpur General Hospital. Out of 1694 emergency operations performed by our unit in 1987, there were 927 appendicectomies. A retrospective study of these cases showed 126 cases of perforated appendicitis, which were then subjected to detailed analysis. We have a diagnostic accuracy of 81% and perforation rate of 18%. In addition, it is interesting to note the racial differences in the relationship of diagnostic accuracy to perforation rate. Perforation is associated with an increased wound infection rate. Transperitoneal drainage in perforated appendicitis did not lead to a lower incidence of wound infection or improve postoperative performance. Distinguishing between perforated and non-perforated appendicitis may be difficult. Perforation could occur while awaiting operation. We recommend the early administration of systemic antibiotics should appendicectomy be delayed and the cautious use of drains in cases of perforated appendicitis.     

Acute appendicitis: is there a difference between children and adults?

Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 +/- 4.3 days vs 2.5 +/- 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 +/- 2.7 hours vs 5.7 +/- 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count > or =12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 +/- 3.3 days compared with nonperforated cases, 2.3 +/- 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.     

Ultrasonography in the diagnosis of acute appendicitis

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.     

What have we learned over the past 20 years about appendicitis in the elderly?

BACKGROUND: This study evaluates appendicitis in the elderly, comparing our findings to those previously published a decade earlier. METHODS: Comparison of appendicitis in the elderly (aged 60 years and older) from 1978 to 1988 with the following 10 years, 1988 to 1998. RESULTS: Overall (1978-1998) 26% of patients presented typically, one third delayed seeking care, with only half diagnosed correctly on admission. Computed tomography (CT) use increased (44% versus rarely in the previous decade). Perforation rates declined (72% first group versus 51% second group) with a concomitant drop in complications from 32% to 21% respectively. Overall, three fourths of complications occurred in patients with perforated appendicitis. Mortality rates remained constant. CONCLUSIONS: Appendicitis in the elderly is a difficult problem with delays in medical care, non-typical presentation resulting in incorrect diagnosis, relatively high rates of perforation often with associated postoperative complications and mortality. A higher index of suspicion with liberal early utilization of CT in uncertain cases may result in more appropriate management.     

Acute appendicitis in the over-sixty age group

58 (37 per cent) of the 155 patients over the age of 60 years presenting with appendicitis at East Birmingham Hospital from 1970 to 1982 were found to have perforated appendices; the corresponding proportion under the age of 60 was 346 out of 3608 patients (10 per cent), the difference being statistically significant (P less than 0.001). The delay before surgery and the length of in-patient treatment were significantly longer in the group who perforated, and the mortality was greater, although not achieving significance. Examination of the yearly incidence reveals neither an increasing trend of appendicitis in elderly patients, nor an increase in the perforation rate over the period studied. Delay, at all stages, appears to be the major factor responsible for the higher rate of perforation in this age group; only by an increased awareness of appendicitis in the elderly can this risk be minimized.     

Retrocecal appendix location and perforation at presentation

Retrocecal appendicitis has been theorized to follow a more insidious course than other anatomic variants. To determine the influence of retrocecal anatomy on clinical course of appendicitis, 200 adult patients treated at a major university medical center with the diagnosis of appendicitis from 2001 to 2004 were retrospectively studied. Computed tomography (CT) scans of adult patients with an ultimate diagnosis of appendicitis were analyzed to determine an association between retrocecal appendix and perforation of the appendix at presentation. A higher perforation rate in the retrocecal group would imply patient delay in presentation from more tolerable symptoms. CT scans were examined for retrocecal location and perforation. No significant association was found between retrocecal anatomy and perforation rates at presentation (chi-square = 2.1, P = 0.15, odds ratio = 1.6, 95% confidence interval [0.8-3.0]). However, the risk of perforation was 60 per cent higher in the retrocecal group. By regression analysis, age and the presence of a fecalith on CT scan were predictors of appendix perforation. Appendix location was not. In this study, we found no significant association between retrocecal appendix anatomy and perforation at presentation.     

An evidence-based definition for perforated appendicitis derived from a prospective randomized trial

Purpose

Appendicitis is the most common urgent condition in general surgery, and yet there is no evidence-based definition for perforation. Therefore, all retrospective data published on perforated appendicitis are unreliable because of an ill-defined denominator. For approximately 2 years beginning in April 2005, we performed a prospective randomized trial investigating 2 different antibiotic regimens for perforated appendicitis. During this study, we strictly defined perforation as a hole in the appendix or a fecalith in the abdomen. Before this prospective study, perforation was staff surgeon opinion. We investigated the abscess rates in both the perforated and nonperforated appendicitis populations before and during the study to determine if our definition was safe and that there was not an increased risk of abscess formation in patients treated as nonperforated.

Methods

Records of all patients undergoing laparoscopic appendectomy for appendicitis during the immediate 2 years before using the definition were compared to those treated in the 2 years after the definition was implemented. Interval and incidental appendectomies were ruled out. The postoperative abscess rate (when perforation was not defined) was compared to the abscess rate of those for whom perforation was strictly defined.

Results

There were 292 patients treated for acute nonperforated appendicitis in the 2 years before the definition and 388 patients after the definition. There were 131 patients treated for perforated appendicitis before the definition and 161 after the definition was implemented. The abscess rate in those with perforated appendicitis increased from 14% to 18% after the definition was used. However, after the definition began to be used, the abscess rate for those patients treated as nonperforated decreased from 1.7% to 0.8%.

Conclusions

Defining perforation as a hole in the appendix or a fecalith in the abdomen is effective in identifying the patients at risk for postoperative abscess formation. Application of these criteria would allow substantial reduction in therapy for patients with purulent or gangrenous appendicitis who do not possess the same abscess risk. These data outline the first evidence-based definition of perforation.     

The continuing challenge of acute and perforated appendicitis.

A two year review of 216 patients with a preoperative diagnosis of appendicitis is used to help clarify the continuing points of controversy concerning appendicitis. Morbidity of perforated appendicitis by far exceeds that of nonperforated cases. Twenty-nine per cent of patients had perforation with a postoperative complication rate of 33 per cent. Rate of wound infection after perforation was 15 per cent despite antibiotics and delayed wound closure. Pediatric patients in this study did not experience a higher incidence of perforation or complication. A decision tree for management of acute appendicitis is presented.     

A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.     

A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.     

Appendectomy: a contemporary appraisal.

OBJECTIVE: The authors present an accurate and comprehensive snapshot of appendicitis and the practice of appendectomy in the 1990s. METHODS: Appendectomies were performed on 4950 patients in 147 Department of Defense hospitals worldwide over a 12-month period ending January 31, 1993. RESULTS: The median age was 23 years (range, 6 months to 82 years) with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix in 632 (13%) cases, acute appendicitis in 3286 (66%) cases, and perforated appendicitis in 1032 (21%) cases. There were no differences in perforation and normal appendix rates between those operations performed in teaching hospitals versus community hospitals or between high-volume hospitals (> or = 100 appendectomies/year) versus low-volume hospitals. Both a preoperative temperature > or = 100.5 and a preoperative leukocyte count > or = 10,000 were incapable of discriminating between patients with appendicitis and those with a normal appendix. Multivariate analysis showed a significantly increased risk of perforation associated with age younger than or equal to 8 years (38% vs. 18%) and age older than or equal to 45 years (49% vs. 18%). Females had a significantly higher rate of normal appendices (19% vs. 9%) and a lower rate of perforation (18% vs. 23%). The complication rates to include reoperation and intraabdominal sepsis were markedly increased in those patients with perforation. There were four deaths in this series (0.08%). CONCLUSIONS: Despite a marked decline in associated mortality over the past 50 years, rates of perforation and negative appendectomy remain unchanged because they are influenced strongly by factors untouched by the intervening technologic advances.     

A case and review of bowel perforation secondary to metastatic lung cancer

Gastrointestinal tract perforation (GITP) secondary to metastatic lung cancer is extremely rare. We present a case of small bowel perforation secondary to metastatic lung cancer. The objective of this study was to review the current literature and further characterize the incidence, histology, and risk of GITP secondary to lung cancer metastasis. A Medline search was done to identify all the cases of GITP attributed to metastatic lung cancer reported in the literature. Data was collected and analyzed from a collection of cases in the medical literature since 1960. We identified 98 cases of perforated lung cancer metastasis to the small intestine. Four gastric perforations, three colonic perforations, and one appendiceal perforation were also identified but not analyzed. The mean age was 64.5 years. There was a male predominance of 89 per cent versus 11 per cent female. Perforations occurred most often in the jejunum (53%) followed by ileum (28%). Combined jejunum-ileum lesions accounted for 4 per cent of perforations. No duodenal perforations were reported, though a specific site was not determined in 13 per cent of cases. Small bowel perforations were most often caused by adenocarcinoma (23.7%), squamous cell carcinoma (22.7%), large cell carcinoma (20.6%), and small cell carcinoma (19.6%). The prevalence of small bowel perforation secondary to a given primary lung cancer histology varied by region. The mean survival was 66 days with 50 per cent of patients not surviving past 30 days. Despite a high incidence of lung cancer, small bowel perforation secondary to lung cancer metastasis remains relatively rare. Perforated metastases occur more often in men and are found more commonly in the jejunum. Small bowel perforations are caused most often by adenocarcinoma; however, squamous cell and large cell carcinoma metastases are more likely to result in perforation. Small bowel perforation in this setting has a significant impact on mortality, decreasing 1-year survival to less than 3 per cent.     

Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management

OBJECTIVE: Appendicitis has been declining in frequency for several decades. During the past 10 years, its preoperative diagnosis has been made more reliable by improved computed tomography (CT) imaging. Thresholds for surgical exploration have been lowered by the increased availability of laparoscopic exploration. These innovations should influence the number of appendectomies performed in the United States. We analyzed nationwide hospital discharge data to study the secular trends in appendicitis and appendectomy rates. METHODS: All appendicitis and appendiceal operations reported to the National Hospital Discharge Survey (NHDS) 1970-2004 were classified as perforated, nonperforated, negative, and incidental appendectomies and analyzed over time and by various demographic measures. Secular trends in the population-based incidence rates of nonperforated and perforated appendicitis and negative and incidental appendectomy were examined. RESULTS: Nonperforated appendicitis rates decreased between 1970 and 1995 but increased thereafter. The 25-year decreasing trend was accounted for almost entirely by a decreasing incidence in the 10-19 year age group. The rise after 1995 occurred in all age groups above 5 years and paralleled increasing rates of CT imaging and laparoscopic surgery on the appendix. Since 1995 the negative appendectomy rate has been falling, especially in women, and incidental appendectomies, frequent in prior decades, have been rarely performed. Despite these large changes, the rate of perforated appendicitis has increased steadily over the same period. Although perforated and nonperforated appendicitis rates were correlated in men, they were not significantly correlated in women nor were there significant negative correlations between perforated and negative appendectomy rates. CONCLUSION: The 25-year decline in nonperforated appendicitis and the recent increase in appendectomies coincident with more frequent use of CT imaging and laparoscopic appendectomies did not result in expected decreases in perforation rates. Similarly, time series analysis did not find a significant negative relationship between negative appendectomy and perforation rates. This disconnection of trends suggests that perforated and nonperforated appendicitis may have different pathophysiologies and that nonoperative management with antibiotic therapy may be appropriate for some initially nonperforated cases. Further efforts should be directed at identifying preoperative characteristics associated with nonperforating appendicitis that may eventually allow surgeons to defer operation for those cases of nonperforating appendicitis that have a low perforation risk.     

Preoperative examination findings in patients with a perforated appendix

Symptoms and clinical findings recorded from 379 patients (6.7 per cent of all cases of appendectomy) with perforated appendicitis, between 1970 and 1984, were retrospectively evaluated. Children up to 14 years of age accounted for 32.8 per cent, adults for 37.8 per cent, and adults above 50 years of age accounted for 30.2 per cent of the above group. More than three typical appendicitis symptoms were recordable from only 30 per cent of all patients. Decompressive and jolting pain was the most common clinical symptom and was recorded from 66.6 per cent of the above 379 patients. 50 per cent of the patients did not exhibit leucocytosis, and normal body temperatures were measured from 21.1 per cent in spite of perforated appendicitis. The event of perforation occurred both six hours after onset of complaints as well as four days later. Obesity, enteritis, and cardiovascular diseases were the most common diseases established in concomitance with perforated appendicitis. 9 patients (2.3 per cent) died of the consequences of peritonitis or accompanying diseases. In patients with suspected appendicitis it is not justified to delay surgery even in the presence of serious associated disease.