37 APPENDICITIS
Alden H. Harken M.D.

1. What is the classic presentation of acute appendicitis?

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Periumbilical pain that migrates to the right lower quadrant (RLQ) in a patient who is anorexic.

2. Where is McBurney’s point?

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One third the distance between the anterosuperior iliac spine and the umbilicus.

3. What is McBurney’s point?

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The point of maximal tenderness in acute appendicitis.

4. Was McBurney a cop from Boston?

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Probably. Another McBurney was a surgeon from New York who, in collaboration with a surgeon named Fitz, coined the term appendicitis in classic papers published in 1886 and 1889.

5. What are the typical laboratory findings of a patient with appendicitis?

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* White blood cell (WBC) count: 12,000-14,000
* Negative urinalysis results (no WBCs)
* Negative pregnancy test result

6. What layers does the surgeon encounter on exposing the appendix through a Rockey-Davis incision?

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Skin, subcutaneous fat, aponeurosis of the external oblique muscle, internal oblique muscle, transversalis fascia and muscle, and peritoneum.

7. Who was Rockey-Davis?

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Rockey-Davis was a pair of surgeons-A.E. Rockey and G.G. Davis-who developed RLQ transverse, muscle-splitting incisions that extend into the rectus sheath.

8. What is the blood supply to the appendix and right colon?

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The ileocolic and right colic arteries.

9. Does surgery for appendicitis involve a risk of mortality?

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No surgical procedure is devoid of risk.

10. What patient groups are at higher risk of death from perforated appendicitis?

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1. Very young patients (younger than 2 years)
2. Elderly patients (older than 70 years) who exhibit diminished abdominal innervation and present late
3. Diabetic patients, who present late because of diabetic visceral neuropathy
4. Patients taking steroids, steroids mask everything

11. What is the role of ultrasound in the diagnosis of acute appendicitis?

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Ultrasound can be both negatively and positively helpful. It is nice to see a perfectly normal right fallopian tube and ovary (to rule out an ectopic pregnancy and tubo-ovarian abscess [TOA]). It is also reassuring to see an inflamed, edematous appendix.

12. Is laparoscopic appendectomy replacing the traditional approach?

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Surgeons are now facile with laparoscopic cholecystectomy, colectomy, and hiatus herniorrhaphy. The normal appendix can be removed easily and safely via the laparoscope, but the inflamed or perforated appendix is tougher. Laparoscopic appendectomy probably should be reserved for the normal appendix.

13. What is a “white worm”?

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A normal appendix.

14. What is the differential diagnosis of right lower quadrant pain?

KEY POINTS: APPENDICEAL CARCINOID

1. 60% of carcinoid tumors occur in the appendix; 0.03% of appendectomies reveal incidental carcinoid.
2. This malignant but slow tumor spreads to lymph nodes, liver, and right heart.
3. If tumor size is < 2 cm and does not involve the base of the appendix, appendectomy alone may suffice; however, bowel should be assessed because of 30% chance of synchronous lesion.
4. If tumor size is > 2 cm or involves the base of the appendix, right hemicolectomy is necessary.

15. What is a Meckel’s diverticulum?

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Meckel’s diverticulum is a congenital omphalomesenteric mucosa remnant that may contain ectopic gastric mucosa. It is found in 2% of the population, 2 feet upward from the ileocecal valve. It becomes inflamed in 2% of patients (i.e., the rule of 2’s).

16. Can chronic diverticulitis masquerade as appendicitis?

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Yes. Fifty percent of patients aged 50 years and older have colonic diverticula. The appendix is just a big cecal diverticulum. Thus, it makes sense that appendicitis and diverticulitis should look, act, and smell alike.

17. Can a woman with a negative pregnancy test present with an ectopic pregnancy?

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Yes. The fallopian tube must be inspected for a walnut-sized lump. Appropriate surgical therapy is a longitudinal incision to “shell out” the fetus with subsequent repair of the tube. This approach (as opposed to salpingectomy) is designed to preserve fertility. Methotrexate also may precipitate spontaneous evacuation.

18. Can Crohn’s disease initially present as appendicitis?

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Yes; this presentation is typical. Crohn’s disease is boggy, edematous, granulomatous inflammation of the distal ileum. Traditional surgical dictum suggests that it is appropriate to remove the appendix in patients with Crohn’s disease unless the cecum at the appendiceal base is involved.

19. Is it possible to confuse appendicitis with a TOA?

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Of course. An ovarian abscess buried deep in an inflamed, edematous, matted right adnexa can be treated successfully with intravenous antibiotics alone. Do not drain pus into the free peritoneal cavity-this will only make the patient sicker.

20. Can pelvic inflammatory disease (PID) resemble appendicitis?

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PID can look exactly like appendicitis except for a positive “chandelier sign.” On pelvic examination, manual tug on the cervix moves the inflamed, painful adnexae, and the patient hits the chandelier. Patients with PID should be treated with antibiotics (either orally or intravenously, depending on how sick the patient is).

21. How does one deal with an appendiceal carcinoid tumor?

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Carcinoid tumors may present anywhere along the gastrointestinal tract; 60%, however, are in the appendix. An obstructing carcinoid tumor, much like a fecalith, can lead to appendicitis-and in 0.3% of appendectomies, carcinoid tumors are the culprit. Most carcinoid tumors are small (< 1.5 cm) and benign; 70% are located in the distal appendix. They are effectively treated with appendectomy alone. A large carcinoid tumor (> 2.0 cm) at the appendiceal base, especially with invasion into the mesoappendix, must be considered malignant and mandates a right hemicolectomy.

22. Can appendicitis be mistaken for acute cholecystitis?

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Occasionally, yes. Both entities reflect acute, localized, intraperitoneal inflammation. Laboratory studies may be identical: WBC count of 12,000-14,000, negative urinalysis result, and negative pregnancy test result. Thus, if one is thinking “appendicitis,” the major difference may be only right upper versus right lower quadrant pain. Laparoscopic cholecystectomy is possible for acute cholecystitis, but conversion to an open procedure should be more frequent.

References
WEB SITES

1. http://www.acssurgery.com/abstracts/acs/acs0324.htm
2. http://www.pmppals.org/appendiceal_carcinoid.htm

BIBLIOGRAPHY
1. Fitz RH: Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Trans Assoc Am Physicians 1:107, 1886.
2. Meakins JL: Appendectomy and appendicitis. Can J Surg 42:90, 1999. Medline Similar articles
3. Rockey AE: Transverse incisions in abdominal operations. Med Rec 68:779, 1905.
4. Samuel M: Pediatric appendicitis score. J Pediatric Surg 37:877-881, 2002. Full article
5. Urbach DR, Cohen MM: Is perforation of the appendix a risk factor for tubal infertility and ectopic pregnancy? An appraisal of the evidence. Can J Surg 42:101-108, 1999. Medline Similar articles