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Appendicitis

Appendicitis is a condition characterised by inflammation of the appendix. While mild cases may resolve without treatment, most require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly due to peritonitis and shock. more...

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Causes

The cause of appendicitis is generally unknown, but the leading theory is that obstruction of the appendiceal orifice is the inciting factor. Obstruction may come from fecal matter lodged in the appendix, impaction of mucous, a small tumor (such as a carcinoid), or even a small blood clot. Viral infections, which can cause ulceration of the lining, can also lead to obstruction of the appendix through enlargement of lymph nodes in its walls, a possible explanation for seasonal variations in rates of appendicitis and clustering of cases. Regardless of the cause, obstruction of the appendix may lead to progressive appendiceal distension. This distension increases the pressure within the appendix, which in turn impairs its blood supply. Deprived of blood, the appendix loses the ability to fight infection and fecal bacteria begin to grow out of control. Although spontaneous recovery can rarely occur, with time and lack of treatment the walls of the appendix eventually become gangrenous from the infection and lack of blood flow. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture causing peritonitis, which may lead to septicemia and eventually death.

Although the model described above is traditionally taught in medical schools, histories of patients operated for appendicitis do not often correlate well with such a single disease progression. Specifically, those with atypical histories have findings at surgery that are consistent with a suppurative process that starts at the onset of symptoms and then smolders. Patients with typical histories may have findings suggesting resolution. Histories to suggest rupture of the appendix while patients are being diagnostically observed are exceedingly rare.

Thus appendicitis is now considered by some to behave as two distinct disease processes, typical and atypical (or suppurative). Approximately 2/3 of patients with appendicitis have typical histories, and findings suggest a virus or mild obstruction as a cause. In the 1/3 with atypical histories, an early suppurative process begins at the clinical onset, and severe unremitting obstruction is the likely cause. In any case, early operation is the best treatment for either type of appendicitis.

Signs, symptoms and findings

Appendicitis can be classified into two types, typical and atypical. The pain of typical acute appendicitis usually starts centrally (periumbilical) before localising to the right iliac fossa (the lower right side of the abdomen). There is usually associated loss of appetite and fever. Nausea, or vomiting may or may not occur. These classic signs and symptoms are more likely the younger the patient. Older patients (beyond their teenage years) may present with only one or two. Diagnosis is easier in typical acute appendicitis and surgery removes a swollen, inflamed appendix with little or no suppuration (pus) if operated early (within 24 hours of onset).

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Can we improve diagnosis of acute appendicitis? - Editorial
From British Medical Journal, 10/14/00 by Spencer W. Beasly

Ultrasonography may complement clinical assessment in some patients

"Diagnosis of appendicitis is usually easy"--thus thus wrote Sir Zachary Cope, but with the rider: "but there are difficulties which need to be discussed."[1] The essential features of appendicitis are well known to most clinicians; there is gradual onset of central abdominal pain, often followed by vomiting, with localisation of the pain to the right iliac fossa. Localised tenderness and evidence of peritoneal inflammation (guarding and percussion tenderness) make the diagnosis probable. Clinical diagnosis is based on showing that movement between adjacent inflamed peritoneal surfaces causes pain.[2] Laboratory investigations usually contribute little and can be misleading. For example, the proportion of gangrenous and perforated appendixes in patients with a normal white count is the same as in those with an raised count.[3] The diagnosis is essentially a clinical one--or so it would seem.

The "difficulty" alluded to by Cope relates to our inability to reliably diagnose appendicitis on clinical grounds. The vagaries of presentation and the variability of signs are such that even the most experienced surgeons may remove normal appendixes or "sit on" those that have perforated. The sequelae of delayed diagnosis may result from late presentation by the patient but are sometimes due to the initial failure of the clinician to make the correct diagnosis.[4] The sequelae of delayed treatment include a higher incidence of postoperative sepsis and longer hospital stay. Against this, it is generally accepted that unnecessary surgery should be avoided, and this aspect of care is usually measured by the proportion of appendixes that are normal on histology. The Australian Council of Healthcare Standards has chosen this criterion as one of its clinical indicators of outcome in appendicitis.[5]

Can we improve our clinical performance? Over the years various clinical scoring systems (some computer assisted) have been used, and, although their clinical benefit has varied, most reports describe some improvement in clinical performance with their use--at least for the duration of the study. The greatest beneficiaries may be junior staff, whose diagnostic accuracy increases from 58% to 71%.[6] In some reports perforation rates have dropped by 50% (in one study from 27% to 12.5%), but in others no reduction has been shown.[6 7] A prospective study of 118 children found that current clinical practice was more accurate than the modified Alvarado score (that measures the likelihood of appendicitis by producing a score based on various clinical and other parameters) in the diagnosis of acute appendicitis.[8] The main value of computer aided diagnosis may be as an ongoing stimulus to good clinical practice.[6 7] Despite initial optimism, it has become apparent that in most units the normal appendix rate remains 15-30%.

Can graded compression ultrasonography improve our diagnostic accuracy? In the study reported in this issue of the BMJ (p 919) the use of a diagnostic protocol incorporating both the Alvarado score and graded compression ultrasonography failed to produce better outcomes than unaided clinical diagnosis.[7a] The proportion of patients in each group who had an adverse outcome (either a non-therapeutic operation or delayed treatment in patients with appendiceal perforation) was nearly identical--about 12%. Graded compression ultrasonography performed by experienced ultrasonographers still produced a 5% false negative result.

Given the frequency of both false positives and false negatives with ultrasonography, should it be allowed to override clinical judgment? Could it cause too many patients to be subjected to non-therapeutic operations (arguably unnecessary surgery) where clinical judgment might have avoided this, or could it have resulted in surgery where observation alone would have led to resolution of symptoms? In contrast, a positive result on graded compression ultrasonography may enable earlier operation in some patients with equivocal clinical signs and facilitate prompt and appropriate surgical intervention, thus reducing morbidity.

Current evidence, mostly from series of patients and retrospective studies, suggests there is probably no role for ultrasonography where clinical evidence of appendicitis is convincing, given the known false negative rate of graded compression ultrasonography and the knowledge that it may delay appropriate surgery.[9] Moreover, the low false positive rate (6%) in clinically obvious cases of appendicitis does not warrant routine ultrasonography.[10] One prospective observational multicentre study of 2280 patients found no clinical benefit when routine ultrasonography was performed in all patients.[11]

The main role for ultrasonography may be for the equivocal case, where a combination of repeated clinical assessment and graded compression ultrasonography may provide the additional information required to determine whether surgery is necessary.[12] Finally, we should heed the advice offered by the authors in this issue that patients should not be sent home after negative results on ultrasonography unless there are also clinical grounds for their discharge. The hands of clinicians are not yet superfluous.

Spencer W Beasley Professor of pediatric surgery Christchurch Hospital, Christchurch, New Zealand spencerb@chhlth.govt.nz

[1] Cope Z. The early diagnosis of the acute abdomen. 14th ed. London, Oxford University Press, 1972.

[2] Hutson JM, Beasley SW. The surgical examination of children. Oxford: Heinemann Medical, 1988.

[3] Coleman C, Thompson JE, Bennion RS, Schmit PJ. White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis. Am Surg 1998;64:983-5.

[4] Bergeron E, Richer B, Gharib R, Giard A. Appendicitis is a place for clinical judgement. Am J Surg 1999;177:460-2

[5] Australian Council of Healthcare Standards Care Evaluation Program. Surgical indicators: Clinical indicators in pediatric surgery. Version 1, Sydney, ACHS, 1999.

[6] McAdam WA, Brock BM, Armitage T, Davenport P, Chan M, de Dombal FT. Twelve years' experience of computer-aided diagnosis in a district general hospital. Ann R Coll Surg 1990;72:140-6.

[7] Adams ID, Chan M, Clifford PC, Cooke WM, Dallos V, de Dombal FT, et al. Computer aided diagnosis of acute abdominal pain: a multicentre study. BMJ 1986;293:800-4.

[7a] Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000:321:919-22.

[8] Macklin CP, Radcliffe JS, Merei JM, Stringer MD. A prospective evaluation of the modified Alvarado score for acute appendicitis in children. Ann R Coll Surg 1997:79;203-5.

[9] Roosevelt GE, Reynolds SL. Does the use of ultrasonography improve the outcome of children with appendicitis? Acad Emerg Med 1998;5:1071-5.

[10] Lessin MS, Chan M, Catallozzi M, Gilchrist MF, Richards C, Manera L, et al. Selective use of ultrasonography for acute appendicitis in children. Am J Surg 1999; 177:193-6.

[11] Franke C, Bohner H, Yang Q, Ohmann C, Roher HD. Ultrasonography for diagnosis of acute appendicitis: results of a prospective multicenter trial. Acute abdominal pain study group. World J Surg 1999;23:141-6.

[12] Rice HE, Arbesman M, Martin DJ, Brown RL, Gollin G, Gilbert JC, et al. Does early ultrasonography affect management of pediatric appendicitis? A prospective analysis. J Pediatr Surg 1999;34:754-8.

BMJ 2000;321:907-8

COPYRIGHT 2000 British Medical Association
COPYRIGHT 2000 Gale Group

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