VIDEO
CONTENT
QUIZ
MATERIALS
Introduction
Epidemiology
Etiology
Pathogenesis
Signs and Symptoms
Diagnosis
Classification
Differential Diagnosis
Treatment
ICD
Research
Summary
Introduction to Appendicitis
Appendicitis, characterized by the inflammation of the appendix, is a critical medical condition that demands prompt attention. This section provides an overview of its key aspects:
- Definition: Appendicitis refers to the inflammation of the appendix, a small pouch attached to the large intestine.
- Prevalence: It is one of the most common causes of emergency abdominal surgery worldwide.
- Age Group Affected: Although it can occur at any age, it is most prevalent among people in their 10s to 30s.
- Significance: Due to the risk of rupture leading to serious complications, appendicitis is treated as a medical emergency.
- Symptoms: The condition is typically marked by pain in the lower right abdomen, nausea, and fever, among other symptoms.
- Treatment: The standard treatment involves surgical removal of the appendix, known as an appendectomy.
Epidemiology of Appendicitis
Appendicitis is a common condition with distinct epidemiological characteristics:
- Age Prevalence: The incidence of appendicitis is most frequent in younger individuals, particularly those in their second and third decades of life.
- Highest Incidence Age Group: The 10 to 19-year-old demographic shows the highest incidence rate.
- Incidence Rate: The overall incidence is approximately 233 cases per 100,000 population.
- Gender Disparity:
- Higher in Males: There is a higher incidence among males with a male to female ratio of 1.4:1.
- Lifetime Incidence:
- Males: 8.6 percent lifetime incidence.
- Females: 6.7 percent lifetime incidence.
Etiology of Appendicitis
Appendicitis arises from various causes that lead to the inflammation of the appendix. The key factors contributing to its development include:
- Appendiceal Obstruction: The most commonly identified cause of appendicitis is the obstruction of the appendix lumen. This can occur due to several factors:
- Fecaliths: Hardened stool that blocks the appendiceal opening.
- Lymphoid Hyperplasia: Enlargement of lymphatic tissue within the appendix, often due to infections.
- Foreign Bodies: Rarely, ingested objects can obstruct the appendix.
- Tumors: Both benign and malignant growths can lead to obstruction.
- Infections: Bacterial infections are a significant contributing factor, leading to the proliferation of bacteria within the appendix and subsequent inflammation.
- Genetic Factors: While not a direct cause, genetic predispositions may influence the likelihood of developing appendicitis.
- Dietary Factors: Some studies suggest that a low-fiber diet might increase the risk of developing appendicitis.
- Other Causes: Rarely, parasitic infections or vascular disorders can contribute to the development of appendicitis.
Pathogenesis of Appendicitis
The development of appendicitis involves a sequence of events similar to other inflammatory conditions affecting hollow organs. Below is a detailed overview of its pathogenesis:
Initial Inflammatory Phase
- Inflammation of the Appendiceal Wall: The process begins with inflammation of the appendiceal wall.
- Ischemia Development: Followed by localized ischemia.
- Perforation Risk: There is a risk of perforation and subsequent complications like abscess or peritonitis.
Role of Appendiceal Obstruction
- Primary Cause: Obstruction is proposed as the primary cause, although it’s not always identified.
- Occurrence in Patients: Studies indicate elevated intraluminal pressure in only a third of nonperforated appendicitis cases.
- Causes of Obstruction: It can be due to fecaliths, calculi, lymphoid hyperplasia, infections, and tumors.
- Fecaliths Observation: Not all patients with a fecalith exhibit appendicitis, and not all appendicitis cases involve a fecalith.
Mechanism of Obstruction and Pain
- Increased Pressure: Obstruction leads to increased luminal and intramural pressure.
- Vascular and Lymphatic Compromise: Resulting in thrombosis, occlusion of small vessels, and stasis of lymphatic flow.
- Pain Development: Initially, central or periumbilical pain occurs, becoming well-localized as the inflammation spreads.
Age-Dependent Variations
- Young Patients: Lymphoid follicular hyperplasia due to infection is common.
- Older Patients: Fibrosis, fecaliths, or neoplasia are typical causes.
- Parasitic Obstruction: In endemic areas, parasites can be a cause in any age group.
Progression to Necrosis and Bacterial Growth
- Mucus Accumulation: Leads to further distension and pressure increase.
- Ischemia and Necrosis: The appendix becomes ischemic and then necrotic.
- Bacterial Overgrowth: Aerobic organisms initially dominate, followed by mixed infections in late stages.
- Common Organisms: E. coli, Peptostreptococcus, Bacteroides fragilis, and Pseudomonas.
Inflammatory and Necrotic Stage
- Neutrophilic Exudate: Causes a fibropurulent reaction, leading to irritation of the parietal peritoneum and localized pain.
- Progression without Perforation: In the first 24 hours, inflammation and necrosis occur, but perforation is less common.
- Perforation Predictors: The type of obstruction can indicate the risk of perforation.
Risk and Timeline of Perforation
- Perforation Risks: Significant inflammation and necrosis heighten the risk.
- Time to Perforation: Variable, with some cases perforating within 24 hours, while others take longer.
Clinical Features of Appendicitis
Clinical Manifestations
History
- Abdominal Pain: The most common and significant symptom, present in nearly all cases.
- Pain Progression: Typically starts periumbilical and migrates to the right lower quadrant as inflammation progresses.
- Migratory Pain Frequency: Occurs in 50-60% of patients.
- Nausea and Vomiting: Usually follow the onset of pain.
- Fever: Tends to appear later in the illness.
Atypical Presentations
- Symptoms: May include indigestion, flatulence, bowel irregularity, diarrhea, and malaise.
- Pain Location Variations: Depend on the appendix’s position; may cause urinary or rectal symptoms in atypical locations.
Physical Examination
Early Signs
- Fever: Low-grade, reaching up to 101.0°F (38.3°C).
- Abdominal Examination: Initially may not reveal much; parietal peritoneum involvement leads to localized right lower quadrant tenderness.
Specialized Examinations
- Rectal Examination: Generally not additional diagnostic value.
- Pelvic Examination in Women: Can be challenging to differentiate from pelvic tenderness.
- Retrocecal Appendix Presentation: Might not show marked right lower quadrant tenderness.
Physical Signs
- McBurney’s Point Tenderness: Maximal tenderness located 1.5 to 2 inches from the anterior superior iliac spine towards the umbilicus.
- Rovsing’s Sign: Right lower quadrant pain upon palpation of the left lower quadrant.
- Psoas Sign: Pain with passive right hip extension, associated with a retrocecal appendix.
- Obturator Sign: Associated with a pelvic appendix; elicited by internally rotating the flexed right hip.
Sensitivity and Specificity of Physical Signs
- These signs vary in sensitivity and specificity and should be used cautiously to inform the differential diagnosis.
- No single physical finding definitively confirms appendicitis.
Laboratory Findings in Acute Appendicitis
White Blood Cell Count
- Presence of Leukocytosis: Mild leukocytosis (>10,000 cells/microL) is common in acute appendicitis.
- Frequency and Shift: Approximately 80% of patients show leukocytosis and a left shift (increased total WBC count, bands, and neutrophils).
- Sensitivity and Specificity: Elevated WBC has a sensitivity of 80% and specificity of 55% for acute appendicitis.
Variations in WBC Count
- Early Course of Illness: Normal WBC count may occur in the very early stages.
- Severity Correlation:
- Acute Appendicitis: Mean WBC count is around 14,500 ± 7,300 cells/microL.
- Gangrenous Appendicitis: Mean WBC count rises to 17,100 ± 3,900 cells/microL.
- Perforated Appendicitis: Further increase to 17,900 ± 2,100 cells/microL.
Serum Bilirubin
- Elevations as a Marker: Mild elevations in serum bilirubin (>1.0 mg/dL) can indicate appendiceal perforation.
- Sensitivity and Specificity: Sensitivity of 70% and specificity of 86% for appendiceal perforation.
Imaging Studies in Diagnosis
Computed Tomography (CT) Findings
- Standard Abdominal CT Scanning: Identifies appendicitis through enlarged appendiceal diameter, wall thickening, fat stranding, wall enhancement, and presence of appendicolith.
Ultrasound Findings
- Key Indicator: Appendiceal diameter >6 mm.
- Plain Radiograph Findings: Limited utility but may show right lower quadrant appendicolith, ileus, loss of the psoas shadow, free air, or cecal deformity.
Magnetic Resonance Imaging (MRI)
- Useful in Pregnancy: Assists in evaluating acute abdominal and pelvic pain.
- Findings: An enlarged fluid-filled appendix (>7 mm) is considered abnormal.
Diagnostic Approach
- Based on Clinical Evaluation: History, physical examination, supported by laboratory/imaging findings.
- Diagnostic Accuracy: Clinical evaluation alone has an accuracy of 75 to 90%.
- Challenging Settings: Children under 3, adults over 60, and pregnant women in the second/third trimesters.
Diagnostic Scoring Systems
Alvarado Score
- Components: Includes migratory right iliac fossa pain, anorexia, nausea/vomiting, right iliac fossa tenderness, fever, leukocytosis.
- Utility: Low score (<5) helps rule out appendicitis; high score (≥7) less definitive.
Diagnostic Evaluation
Imaging
- Use of CT and Ultrasonography: Supports clinical diagnosis but does not replace clinical judgment.
- CT Scan: Alters treatment plan in 58% of cases; sensitivity and specificity vary.
Laboratory Tests
- Role: Supportive in diagnosis; includes CBC with differential and pregnancy test for women of childbearing age.
- Serum Bilirubin: Not generally discriminatory for appendicitis.
Exploratory Laparotomy/Laparoscopy
- Nontherapeutic Appendectomy Rate (NAR): Varies by patient age and sex; higher acceptability in young women due to differential diagnosis complexity.
Classification of Appendicitis (Modified after Carr 2000 and Bhangu et al. 2015)
Uncomplicated Form
- Catarrhal Appendicitis
- Macroscopically normal appearance
- Possibly hyperemic vascular drawing
- Inflammation of the mucosa and submucosa
- Purulent/Phlegmonous Appendicitis
- Enlargement in length and diameter
- Edema, redness, exudation
- Transmural inflammation
Complicated Form
- Gangrenous Appendicitis
- Livid, greenish, brownish, or black discoloration
- With brittle wall
- Transmural inflammation with necrosis
- Perforated Appendicitis
- overed Perforation
- Free Perforation
- Transmural inflammation with perforation
- Periappendicitis, perityphlitic abscess
- Local peritonitis, possibly inflammatory conglomerate
- Diffuse peritonitis, purulent/fecal
Differential Diagnosis of Acute Appendicitis
Conditions Mimicking Acute Appendicitis
- Perforated Appendix: Risk of perforation with localized abscess or diffuse peritonitis increases after 24 hours of symptom onset.
- Cecal Diverticulitis: Common in young adults, can mimic appendicitis symptoms. Common in Asian populations.
- Meckel’s Diverticulitis: Presents similarly to appendicitis. It’s a congenital remnant located near the ileocecal valve.
- Acute Ileitis: Often due to infections like Yersinia or Campylobacter. Presents with diarrhea and right lower quadrant pain.
- Crohn’s Disease: Particularly when affecting the distal ileum. Presents with fatigue, diarrhea, abdominal pain, weight loss, and fever.
- Gynecologic Conditions: Including tubo-ovarian abscess, pelvic inflammatory disease, ruptured ovarian cyst, mittelschmerz, ovarian and fallopian tube torsion, endometriosis, ovarian hyperstimulation syndrome, and ectopic pregnancy.
- Acute Endometritis: Occurs post-delivery or post-uterine procedures.
Urological Conditions
- Renal Colic: Characterized by intense pain due to urinary obstruction.
- Testicular Torsion: Emergency condition involving twisting of the testis, common in neonates and postpubertal boys.
- Epididymitis: Common in late adolescents, presenting with scrotal pain and tenderness.
- Torsion of Appendix Testis or Appendix Epididymis: Causes scrotal pain, primarily in children aged 7 to 14 years.
Diagnostic Considerations
- Perforated Appendix:
- Symptoms: High fever (>103.0°F), elevated WBC count, fluid collection in right lower quadrant.
- Imaging: Essential for diagnosis.
- Cecal Diverticulitis:
- Diagnosis: CT scanning with IV and oral contrast.
- Prevalence: More common in certain populations.
- Meckel’s Diverticulitis:
- Consideration: Check for inflamed Meckel’s diverticulum if no appendicitis is found during abdominal exploration.
- Acute Ileitis:
- Common Agents: Yersinia, Campylobacter, Salmonella.
- Symptoms: Acute diarrhea, abdominal pain, fever, nausea/vomiting.
- Crohn’s Disease:
- Symptoms: Similar to appendicitis, especially in acute exacerbation.
- Gynecologic Conditions:
- Diagnostic Challenge: Overlapping symptoms with appendicitis.
- Importance: Detailed history and CT imaging for differentiation.
- Urological Conditions:
- Symptoms: Pain, often intense and associated with urinary tract involvement.
- Importance: Differentiation from appendicitis to guide appropriate management.
Therapy Goals, Indications, and Treatment Alternatives
- Historical Dogma of Immediate Appendectomy:
- The recommendation for appendectomy within 4 hours is increasingly being questioned.
- Differentiating Between Complicated and Uncomplicated Appendicitis:
- Complicated appendicitis (20% of cases) includes cases with gangrene, impending or existing perforation.
- Uncomplicated appendicitis (80% of cases) can be treated conservatively.
- Antibiotic Therapy as an Alternative:
- For uncomplicated appendicitis, antibiotic treatment is a viable option. 20% of these patients may require surgery later, but the risk of complications is lower than with immediate surgery.
Antibiotic Therapy
- Trial Involving Amoxicillin Plus Clavulanic Acid:
- Participants: 243 patients with uncomplicated appendicitis confirmed by preoperative CT.
- Treatment: Random assignment to either medical therapy with amoxicillin plus clavulanic acid for 8 to 15 days or appendectomy.
- Findings:
- 20% in the appendectomy arm had complicated appendicitis at surgery.
- Higher incidence of postoperative peritonitis in the antibiotic group (8%) compared to the appendectomy group (2%).
- 12% of patients treated with antibiotics underwent appendectomy within 30 days.
- Additional 30 patients required appendectomy within a year, with 26 having confirmed acute appendicitis.
- Review of Three Randomized Clinical Trials:
- Treatment: Comparison of appendectomy to nonoperative management of acute, nonperforated appendicitis with antibiotics.
- Findings:
- 32% of patients treated with antibiotics alone required appendectomy due to failure of medical therapy.
- 16% of patients who initially responded to antibiotics experienced recurrent symptoms within one year and underwent appendectomy.
- 58% of patients treated with antibiotics remained asymptomatic at one-year follow-up.
- Retrospective Review of CT-Evaluated Appendicitis:
- Participants: 2283 patients assessed with CT for appendicitis; 516 had probable or definite appendicitis.
- Findings:
- 3% of patients with appendicitis improved and were discharged without surgery.
- Of these, 5 patients eventually had appendectomy, with histology showing various stages of inflammation and perforation in some cases.
Conclusion:
- Surgical Favoritism: While some patients with acute appendicitis can be successfully treated with antibiotics, surgery remains the preferred option for most, given the risks of developing complicated appendicitis and the considerable rate of recurrence.
- Risks in Specific Populations: Nonoperative management may pose particular risks for elderly and immunocompromised patients.
Indications for Surgery
- In cases of complicated appendicitis, quick surgical intervention is still recommended, especially in the presence of local or generalized peritonitis.
Choice of Surgical Procedure (Conventional or Laparoscopic)
- Traditional Open Approach:
- The open appendectomy was the standard until the 1990s.
- Laparoscopic Appendectomy:
- Now considered the gold standard, particularly when the necessary expertise and equipment are available.
- Advantageous for diagnostics and minimally invasive resolution of differential diagnoses.
- In children under 5 years, the open approach is often preferred.
Surgical Technique and Intraoperative Complications
- Appendix Stump Management:
- Can be done using various methods (Röder loop, clips, stapler), depending on the situation and surgeon’s decision.
- Use of Drains and Lavage:
- Not recommended in complicated appendectomy due to higher complication rates and longer hospital stays.
Postoperative Considerations
- Removal of the Appendix in Case of Unremarkable Findings:
- Recommended to reduce the possibility of persisting symptoms.
- Approach to Appendicitis with Phlegmon and Abscess:
- Both conservative (antibiotics ± drainage) and surgical approaches are viable.
- Decision depends on the expertise and equipment of the treating team.
Long-term Considerations
- Interval Appendectomy:
- Not as a routine but based on the occurrence of symptomatic recurrences after conservative therapy.
- Diagnostic After Conservative Therapy for Complicated Appendicitis:
- Recommended, especially in patients over 40 years, to rule out neoplasms.
| Code | Description |
|---|---|
| K35 | Acute appendicitis |
| K35.0 | Unspecified appendicitis |
| K35.1 | Acute appendicitis without perforation |
| K35.2 | Acute appendicitis with generalized peritonitis |
| K35.3 | Acute appendicitis with localized peritonitis |
| K35.8 | Other acute appendicitis |
| K36 | Other appendicitis |
| K36.0 | Chronic appendicitis |
| K36.1 | Recurrent appendicitis |
| K36.8 | Other specified appendicitis |
| K38 | Other diseases of appendix |
| K38.0 | Hyperplasia of appendix |
| K38.1 | Appendicular concretions |
| K38.2 | Diverticulum of appendix |
| K38.3 | Fistula of appendix |
| K38.8 | Other specified diseases of appendix |
| K38.9 | Disease of appendix, unspecified |
Diagnosis and treatment of appendicitis: systematic review and meta-analysis
Ryan Lamm1 · Sunjay S. Kumar1,15 · Amelia T. Collings2 · Ivy N. Haskins3 · Ahmed Abou‐Setta4 · Nisha Narula5 · Pramod Nepal6 · Nader M. Hanna7 · Dimitrios I. Athanasiadis8 · Stefan Scholz9 · Joel F. Bradley 3rd10 ·
Arianne T. Train11 · Philip H. Pucher12 · Francisco Quinteros13 · Bethany Slater14
Key Question 1 (KQ 1): Should abdominal CT versus alternative imaging be used for diagnosing acute appendicitis?
Adults:
- A total of 94 studies met inclusion criteria for KQ1 in the adult subpopulation.
- 26 (28%) studies had low risk of bias, 47 had high (50%), and 21 (22%) had an unclear risk of bias.
Imaging Techniques and Sensitivity/Specificity in Adults:
- Computed Tomography (CT) scan: Sensitivity > 80%, Specificity 35-100%.
- Low dose CT scan: Sensitivity > 95%, Specificity 93-100%.
- Non-contrast CT scan: Sensitivity 59-92%, Specificity 83-100%.
- Magnetic Resonance Imaging (MRI): Sensitivity > 80%, Specificity 0-100%.
- Ultrasound (US): Sensitivity 37-100%, Specificity 0-100%.
- Point of Care Ultrasound (POCUS): Sensitivity 43-100%, Specificity 32-98%.
Pediatric:
- 57 studies met inclusion criteria for KQ1 in the pediatric subpopulation.
- 1 RCT was low risk of bias (100%), while observational studies had varying risk of bias.
Imaging Techniques and Rates in Pediatric Patients:
- CT scan: Additional imaging rate 0.3%, Negative diagnostic laparoscopy rate 6.7%.
- Low dose CT scan: Limited data.
- Ultrasound: Additional imaging rate 17.3%, Negative diagnostic laparoscopy rate 9.6%.
- POCUS: Additional imaging rate 64.2%, Negative diagnostic laparoscopy rate 3.2%.
- MRI: Additional imaging rate 0.7%, Negative diagnostic laparoscopy rate 8.4%.
Nondiagnostic Findings on Imaging:
- CT scan: 5.5%.
- Ultrasound: 35.7%.
- POCUS: 43.6%.
- MRI: 13.9%.
These findings suggest that CT scans, especially low dose CT scans, tend to have high sensitivity and specificity for diagnosing acute appendicitis in both adults and children. However, the choice of imaging method should consider factors such as radiation exposure, cost, and the patient’s age and clinical presentation. It’s essential to consult with a healthcare professional to determine the most appropriate imaging approach for a specific case.
Key Question 2 (KQ 2): Should adult and pediatric patients with acute, uncomplicated appendicitis be managed nonoperatively with antibiotics versus appendectomy?
Adults:
- 18 studies met inclusion criteria for KQ2 in the adult subpopulation.
- 6 RCTs and 12 observational studies were included.
- RCTs had varying levels of risk of bias.
Outcomes in Adults:
- No significant difference in abscess formation between antibiotics and appendectomy.
- Lower cost with antibiotics in one RCT and several cohort studies.
- Higher rates of drain placement with antibiotics in one RCT, while two cohort studies showed no difference.
- No significant difference in length of hospital stay between antibiotics and appendectomy.
- Zero mortality in both treatment arms in one RCT, but higher mortality with antibiotics in six cohort studies.
- No significant difference in the need for a new course of antibiotics in one RCT, but lower odds following antibiotics in one cohort study.
- No significant difference in quality of life in one RCT (no cohort studies reported).
- Higher odds of readmission following antibiotics in two RCTs and nine cohort studies.
- Higher odds of reoperation at any time point following antibiotics in two RCTs and six cohort studies.
- No significant difference in reoperation within 30 days in two RCTs, but higher odds following antibiotics in seven cohort studies.
- Higher odds of reoperation between 30 days and 1 year following antibiotics in two RCTs and six cohort studies.
- No significant difference in time to return to work/school in one RCT, but less time following antibiotics in four cohort studies.
Pediatric:
- 17 studies met inclusion criteria for KQ2 in the pediatric subpopulation.
- 4 RCTs and 13 observational studies were included.
- RCTs had varying levels of risk of bias.
Outcomes in Pediatric Patients:
- No significant difference in abscess formation between antibiotics and appendectomy in four cohort studies.
- No significant difference in cost between antibiotics and appendectomy in one RCT and three cohort studies.
- No significant difference in the need for drain placement in two cohort studies.
- No significant difference in ICU admission in one cohort study.
- No significant difference in length of hospital stay in six cohort studies.
- Zero mortality in both treatment arms in one RCT (no cohort studies reported).
- No significant difference in the need for a new course of antibiotics in one RCT and two cohort studies.
- No significant difference in quality of life in two cohort studies.
- Higher odds of readmission following antibiotics in four RCTs and nine cohort studies.
- Higher odds of reoperation at any time point following antibiotics in two RCTs and six cohort studies.
- No significant difference in reoperation within 30 days in two RCTs, but higher odds following antibiotics in seven cohort studies.
- Higher odds of reoperation between 30 days and 1 year following antibiotics in two RCTs and six cohort studies.
- No significant difference in time to return to work/school in one RCT, but less time following antibiotics in four cohort studies.
These findings provide insights into the management of acute, uncomplicated appendicitis with antibiotics versus appendectomy in both adult and pediatric populations. However, the decision should be made considering individual patient factors and clinical context, and consultation with healthcare professionals is essential.
Key Question 3 (KQ 3) 1. In adult and pediatric patients with complicated appendicitis, should operative management versus nonoperative management be used?
Adults:
- 11 studies met the inclusion criteria for KQ3 in the adult subpopulation.
- 1 RCT and 10 observational studies were included.
- The one RCT had a low risk of bias, while observational studies had varying levels of risk.
Outcomes in Adults:
- No significant difference in abscess formation between antibiotics and appendectomy in one RCT and eight cohort studies.
- No significant difference in cost between antibiotics and appendectomy in one cohort study.
- Higher odds of drain placement following antibiotics in one RCT and four cohort studies.
- Lower odds of ICU admission following antibiotics in one cohort study.
- Longer hospital lengths of stay following antibiotics in one RCT, but no significant difference in five cohort studies.
- No significant difference in mortality between antibiotics and appendectomy in one RCT and three cohort studies.
- Higher odds of readmission following antibiotics in one RCT and eight cohort studies.
- Higher odds of reoperation at any time point following antibiotics in one RCT and four cohort studies.
- Longer time to return to work/school following antibiotics in one RCT.
Pediatric:
- 12 studies met the inclusion criteria for KQ3 in the pediatric subpopulation.
- 3 RCTs and 9 observational studies were included.
- One RCT had a low risk of bias, while the remaining RCTs had an unclear risk. Observational studies had varying levels of risk.
Outcomes in Pediatric Patients:
- Higher odds of abscess formation following antibiotics in two RCTs, but no significant difference in four cohort studies.
- No significant difference in cost between antibiotics and appendectomy in one RCT and one cohort study.
- Higher odds of drain placement following antibiotics in two cohort studies.
- Longer hospital lengths of stay following antibiotics in two RCTs, but no significant difference in six cohort studies.
- Higher odds of needing a new course of antibiotics following antibiotics in one cohort study.
- Higher quality of life following antibiotics in one RCT, but no significant difference in one cohort study.
- Higher odds of readmission following antibiotics in one RCT and six cohort studies.
- No significant difference in reoperation at any time point between antibiotics and appendectomy in one RCT and three cohort studies.
- Longer time to return to work/school following antibiotics in one RCT.
These findings provide insights into the management of complicated appendicitis with operative and nonoperative approaches in both adult and pediatric populations. However, individual patient factors and clinical context should guide the decision-making process, and consultation with healthcare professionals is essential.
Key Question 4 (KQ 4) regarding the timing of surgical intervention for appendectomy in both adults and pediatric patients with uncomplicated appendicitis:
Adults:
- 9 studies met the inclusion criteria for KQ4 in the adult subpopulation, all of which were observational studies.
- 3 (33%) studies had a low risk of bias, 5 (55%) had a high risk of bias, and 1 (11%) had an unclear risk of bias.
Outcomes in Adults:
- Eight cohort studies reported on abscess formation and found no statistically significant difference between surgery within 12 hours or after 12 hours of diagnosis.
- One cohort study reported on the need for drain placement and found no statistically significant difference between early and late surgery.
- One cohort study reported that early surgery favored a shorter length of hospital stay compared to late surgery.
- Four cohort studies reported on the need for readmission and found no statistically significant difference between early and late surgery.
- One cohort study reported on reoperation at any time point and found no statistically significant difference between early and late surgery.
Pediatric:
- 3 studies met the inclusion criteria for KQ4 in the pediatric subpopulation, all of which were observational studies.
- 1 (33%) study had a low risk of bias, and 2 (67%) had an unclear risk of bias.
Outcomes in Pediatric Patients:
- Two cohort studies reported on abscess formation and found no statistical difference in abscess formation between surgery performed within 12 hours or after 12 hours of diagnosis.
- One cohort study reported on readmission and showed lower odds of abscess formation if surgery was performed after 12 hours of diagnosis.
- One cohort study reported on reoperation at any time point and found no statistically significant difference between early and late surgery.
These findings suggest that, in both adult and pediatric populations with uncomplicated appendicitis, the timing of surgical intervention (early or late) does not significantly impact the risk of abscess formation or the need for reoperation. However, early surgery may be associated with a shorter length of hospital stay in adult patients. As with any medical decision, individual patient factors and clinical judgment should guide the timing of surgery, and consultation with healthcare professionals is essential.
Key Question 5 (KQ 5): In adult and pediatric patients undergoing appendectomy for perforated appendicitis, should suction and lavage versus suction alone be used?
Adults:
- Four RCTs and two observational studies were included in the adult subpopulation.
- Three RCTs (75%) had a low risk of bias, one (25%) had a high risk of bias, and none had an unclear risk of bias.
Outcomes in Adults:
- Four RCTs reported on abscess formation and found no statistically significant difference between suction and lavage and suction alone.
- Three RCTs reported on the need for drain placement and found no statistically significant difference between the two approaches.
- Two RCTs reported on the length of hospital stay and found no statistically significant difference.
- One RCT reported on mortality and found no statistically significant difference.
- Two RCTs reported on readmission and found no statistically significant difference.
- Three RCTs reported on reoperation at any time point and found no statistically significant difference.
Pediatric:
- Three RCTs and two observational studies were included in the pediatric subpopulation.
- All three RCTs (100%) had a low risk of bias, while both observational studies had an unclear risk of bias.
Outcomes in Pediatric Patients:
- Three RCTs reported on abscess formation and found no statistically significant difference between suction and lavage and suction alone.
- Two RCTs reported on the need for drain placement and found no statistically significant difference between the two approaches.
- Two RCTs reported on the length of hospital stay and found no statistically significant difference.
- None of the RCTs reported any mortality in either group.
- Two RCTs reported on readmission and found no statistically significant difference.
- Four RCTs reported on reoperation at any time point and found no statistically significant difference.
In summary, for both adults and pediatric patients undergoing appendectomy for perforated appendicitis, there is no significant difference in outcomes between using suction and lavage versus suction alone. These outcomes include abscess formation, the need for drain placement, length of hospital stay, mortality, readmission, and reoperation at any time point. The choice between these approaches should be based on individual patient factors and clinical judgment.
Key Question 6 (KQ 6): In adult and pediatric patients undergoing appendectomy for complicated appendicitis, should routine drain placement versus no routine drain placement be used?
Adults:
- Six observational studies were included in the adult subpopulation.
- One study (17%) had a low risk of bias, four (67%) had a high risk of bias, and one (17%) had an unclear risk of bias.
Outcomes in Adults:
- Six cohort studies reported on abscess formation and found no statistically significant difference between drain placement and no drain placement.
- Three cohort studies reported on the need for a new course of antibiotics and found no statistically significant difference.
- Two cohort studies reported on the need for readmission and found no statistically significant difference.
- One cohort study reported on reoperation at any time point and found no statistically significant difference.
- Two cohort studies reported on the length of hospital stay and found no statistically significant difference.
Pediatric:
- Three observational studies were included in the pediatric subpopulation.
- Two studies (67%) had a low risk of bias, and one (33%) had a high risk of bias.
Outcomes in Pediatric Patients:
- Three cohort studies reported on abscess formation and found no statistically significant difference between drain placement and no drain placement.
- One cohort study reported on the need for subsequent drain placement and found no statistically significant difference.
- Two cohort studies reported on readmission and found no statistically significant difference.
- Two cohort studies reported on reoperation at any time point and found a higher risk of reoperation in patients with drains placed.
In summary, for both adults and pediatric patients undergoing appendectomy for complicated appendicitis, there is no significant difference in abscess formation, the need for a new course of antibiotics, the need for readmission, or the length of hospital stay between routine drain placement and no routine drain placement. However, in pediatric patients, there was a higher risk of reoperation in those with drains placed. The decision to use routine drain placement should be made based on individual patient factors and clinical judgment.
Key Question 7 (KQ 7): Should adult and pediatric patients who undergo appendectomy for complicated appendicitis be given postoperative antibiotics for short term vs. long term?
Adults:
- Eight studies met inclusion criteria in the adult subpopulation.
- One RCT (100%) had an unclear risk of bias, and among observational studies, 3 (43%) had low risk of bias, while 4 (57%) had high risk of bias.
Outcomes in Adults:
- One RCT reported no statistically significant difference in abscess formation between short-term and long-term postoperative antibiotics.
- Six cohort studies reported no statistically significant difference in abscess formation.
- Two cohort studies found no significant difference in contracting Clostridium difficile.
- One RCT showed no statistically significant difference in drain placement.
- One RCT reported shorter length of hospital stays with short-term antibiotics.
- One cohort study found no statistically significant difference in length of hospital stay.
- One RCT reported no statistically significant difference in the need for a new course of antibiotics.
- One RCT reported no statistically significant difference in readmission.
- Six cohort studies showed no statistically significant difference in readmission.
- Two cohort studies reported no statistically significant difference in reoperation at any time point.
- One RCT and one cohort study reported no statistically significant difference in total complications.
Pediatric:
- Eight studies met inclusion criteria in the pediatric subpopulation.
- Among two RCTs, one (50%) had low risk of bias, and one (50%) had an unclear risk of bias. Among observational studies, 2 (33%) had low risk of bias, while 4 (67%) had high risk of bias.
Outcomes in Pediatric Patients:
- Two RCTs reported no statistically significant difference in abscess formation between short-term and long-term postoperative antibiotics.
- Six cohort studies reported no statistically significant difference in abscess formation.
- One RCT showed no statistically significant difference in contracting Clostridium difficile.
- One cohort study found no significant difference in contracting Clostridium difficile.
- Three cohort studies found no statistically significant difference in the need for drain placement.
- Two RCTs showed no statistically significant difference in length of hospital stay.
- Three cohort studies reported no statistically significant difference in length of hospital stay.
- One cohort study found no statistically significant difference in the need for a new course of antibiotics.
- One RCT reported a lower risk of readmission with short-term antibiotics.
- Four cohort studies reported no statistically significant difference in readmission.
- One RCT and one cohort study showed no statistically significant difference in reoperation at any time point.
In summary, for both adults and pediatric patients who undergo appendectomy for complicated appendicitis, there is no significant difference in abscess formation, the risk of contracting Clostridium difficile, the need for drain placement, and most other outcomes between short-term and long-term postoperative antibiotics. However, in adults, short-term antibiotics were associated with shorter hospital stays, and in adults, there was a lower risk of readmission with short-term antibiotics. The choice of antibiotic duration should be individualized based on patient factors and clinical judgment.
Key Question 8 (KQ 8): In asymptomatic adult and pediatric patients with previous complicated appendicitis treated nonoperatively, should an interval appendectomy be performed versus observation?
Adults:
- Three studies met inclusion criteria in the adult subpopulation.
- One RCT (100%) had a low risk of bias, and among observational studies, 1 (50%) had high risk of bias, while 1 (23%) had unclear risk of bias.
Outcomes in Adults:
- One RCT reported no statistically significant difference in abscess formation between interval appendectomy and observation.
- One RCT found no statistically significant difference in the need for drain placement.
- One cohort study reported no statistically significant difference in length of hospital stay.
- One cohort study showed no statistically significant difference in mortality.
- One RCT reported no statistically significant difference in neoplasm formation.
- One RCT and one cohort study reported no statistically significant difference in reoperation within 30 days of diagnosis.
- One RCT demonstrated lower odds of reoperation between 30 days and 1 year for patients who received interval appendectomy.
Pediatric:
- One observational study met inclusion criteria in the pediatric subpopulation.
- The observational study had an unclear (100%) risk of bias.
Outcome in Pediatric Patients:
- The observational study reported lower odds of readmission for patients who received interval appendectomy compared to observation.
In summary, for adults with previous complicated appendicitis treated nonoperatively, there was no significant difference in abscess formation, the need for drain placement, length of hospital stay, mortality, neoplasm formation, or reoperation within 30 days of diagnosis between interval appendectomy and observation. However, there were lower odds of reoperation between 30 days and 1 year for patients who received interval appendectomy. In pediatric patients, the observational study showed lower odds of readmission for those who received interval appendectomy. The decision to perform an interval appendectomy should be individualized based on clinical factors and patient preferences.
Appendicitis
Introduction
Appendicitis is an inflammatory condition of the appendix, a small, tube-shaped sac attached to the lower right side of the large intestine. It’s a common cause of acute abdominal pain and is often considered a surgical emergency.
Etiology
The exact cause of appendicitis is often unclear. It’s commonly believed to result from obstruction of the appendix, leading to bacterial overgrowth. Potential causes of obstruction include:
- Fecaliths (hardened stool)
- Lymphoid hyperplasia
- Foreign bodies
- Intestinal worms
- Tumors
Pathogenesis
When the appendix is obstructed, bacteria inside proliferate, leading to inflammation. This process results in:
- Increased intraluminal pressure
- Reduced blood flow
- Ischemia
- Bacterial invasion of appendiceal wall
As the condition progresses, the appendix may become gangrenous or rupture, leading to peritonitis.
Signs and Symptoms
Common symptoms include:
- Abdominal pain, often starting around the navel and shifting to the lower right abdomen
- Loss of appetite
- Nausea or vomiting
- Abdominal swelling
- Fever
- Constipation or diarrhea
- Inability to pass gas
Diagnosis
Diagnosis is primarily clinical, supported by:
- Physical examination (e.g., rebound tenderness, Rovsing’s sign)
- Laboratory tests (elevated white blood cell count)
- Imaging studies (ultrasound, CT scan)
Differential Diagnosis
Conditions to consider include:
- Gastroenteritis
- Ectopic pregnancy (in women)
- Mesenteric adenitis
- Crohn’s disease
- Urinary tract infection
- Pelvic inflammatory disease
Treatment
The standard treatment is surgical removal of the appendix (appendectomy). Antibiotic therapy is also essential, especially if perforation or peritonitis is suspected.
Prevention
There are no specific preventive measures for appendicitis. However, a high-fiber diet might reduce the risk.
Prognosis
With prompt treatment, the prognosis for appendicitis is generally good. Complications can include abscess formation or peritonitis, especially if there is a delay in treatment.
ICD Codes
- ICD-10: K35 (Acute appendicitis)
Modified Alvarado Score, which is used to assist in the diagnosis of appendicitis:
| Criteria | Points |
|---|---|
| Migratory right iliac fossa pain | 1 point |
| Anorexia | 1 point |
| Nausea/vomiting | 1 point |
| Tenderness in right iliac fossa | 2 points |
| Rebound tenderness in right iliac fossa | 1 point |
| Fever >37.5°C | 1 point |
| Leukocytosis | 2 points |
Interpretation of Total Points:
- 0 to 3 points: Low probability of appendicitis; consider discharge with follow-up.
- 4 to 6 points: Intermediate probability; consider further observation, diagnostic imaging, or consultation.
- 7 to 9 points: High probability; consider surgical intervention.