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Perforated Appendix

A perforated appendix is a life-threatening complication of acute appendicitis, occurring predominantly because of the late recognition and delayed initiation of treatment. A sudden onset of abdominal pain, fever and vomiting must include acute appendicitis as a possible cause. Numerous imaging studies, although useful in confirming appendicitis, have failed to solidify their place in diagnosing perforation, implying that clinical judgment is the most important part during workup.


Presentation

Acute appendicitis is one of the more important disorders encountered in clinical practice, with more than 250,000 appendectomies performed in the United States on an annual basis [1] [2] [3]. The primary reason is the life-threatening risk of complications that may arise, the most important one being a perforated appendix [1] [4]. The clinical presentation of an acute appendicitis is characterized by a sudden onset of mild and cramping abdominal pain in the periumbilical area followed by its progression into a motion-aggravated and severe pain in the right lower quadrant after about 24 hours [2] [3]. Additional signs include fever (37.2-38.0°C) and anorexia (which is considered to be a diagnostic hallmark), whereas vomiting, altered bowel movements, and voiding difficulties are other notable findings [2] [3]. Studies have shown that the appendix can often perforate before patients arrive at the hospital and that younger age, as well as longer duration of abdominal pain, are indicative of this event [1] [5]. Moreover, a very high temperature (> 38.3°C), tachycardia, and profound tenderness of the abdomen have also been documented as possible signs of perforation [2]. Although the differential diagnosis of periumbilical and right lower quadrant pain is broad, acute appendicitis must be suspected early on as delay in diagnosis is the principal reason for mortality rates of a perforated appendix to increase up to 10 times [6].

Fever
  • Previous attacks of appendicitis predispose to an acute flare-up at any time during the course of typhoid fever. The symptoms may be so FULL TEXT[annals.org]
  • A sudden onset of abdominal pain, fever and vomiting must include acute appendicitis as a possible cause.[symptoma.com]
  • We present the emergency case of an 81-year-old patient with right inguinal pseudo-tumor, accompanied by marked local pain, nausea, low grade fever and bowel disorders.[ncbi.nlm.nih.gov]
  • Case History A one year old female patient presented with acute swelling at umbilicus with fever and vomiting since 48 hours. Patient also had developed abdominal distension since last 8 hours.[avensonline.org]
Inguinal Hernia
  • The authors describe in a neonate aged 14 days an unusual case of inguinal hernia containing a perforated appendix that was clinically considered as a strangulated inguinal hernia.[ncbi.nlm.nih.gov]
Pathologist
  • For a pathologist-physician like Reginald H. Fitz 2 , 3 to argue that the common and usually fatal disease called perityphlitis was . . . Ronald A. Malt, M.D. Massachusetts General Hospital Boston, MA 02114[nejm.org]
  • In cases of mucocele, lymphadenectomy in the mesoappendix is common to help the pathologist define the histology of the lesion.[scielo.br]
  • […] the terms “perforation,” “perforated,” or “gross peritonitis” were present in either the operative or pathologic report describing either the surgeon's clinical impression of the appendix or the histopathologic status of the appendix according to the pathologist[academic.oup.com]
Paraumbilical Hernia
  • Agarwal N, Goyal S, Kumar A, Garg A, Kaur N, et al. (2013) Appendicitis in paraumbilical hernia mimicking strangulation: a case report and review of the literature. Hernia 17: 531-532.[avensonline.org]
Ascitic Fluid
  • The initial surgery in cases of mucocele of the appendix is appendectomy, block resection of the appendicular fat and collection of mucinous ascitic fluid.[scielo.br]
Abdominal Pain
  • A sudden onset of abdominal pain, fever and vomiting must include acute appendicitis as a possible cause.[symptoma.com]
  • The patient returned a few days later with ongoing abdominal pain. A CT scan revealed a perforated appendix with acute appendicitis, as well as a small abscess with fluid.[theexpertinstitute.com]
  • Predictive factors significantly associated with perforated appendix were age younger than 9 years, abdominal pain of more than 2 days' duration, temperature of more than 37.9 degrees C, peritoneal signs, and erythrocyte sedimentation rate of more than[ncbi.nlm.nih.gov]
  • A 9-year-old boy presented with a 3-day history of right-sided constant abdominal pain associated with pyrexia. Examination revealed a tender right iliac fossa with localized peritonitis.[jcm.asm.org]
Severe Abdominal Pain
  • This condition, known as appendicitis, is one of the most common causes of severe abdominal pain.[health.harvard.edu]
  • The Digestive System Appendicitis is the most common cause of sudden, severe abdominal pain and abdominal surgery in the United States. Over 5% of the population develops appendicitis at some point.[merckmanuals.com]
  • It is important to remember that severe abdominal pain by itself is not a symptom of a burst appendix. Other signs and symptoms must also be considered in order to reach a diagnosis. Read more on appendix pain .[phaa.com]
Acute Abdomen
  • Some surgeons opt for a conservative treatment by means of an intravenous antibiotic therapy to solve acute abdomen [1–4] pain, planning a routinary interval appendectomy (IA) after some months.[ncbi.nlm.nih.gov]
  • Here we report a rare complication of a common ‘acute abdomen’ condition and the probable aetiologies and treatment modalities for the same.[npplweb.com]
  • Keywords Acute abdomen; Abdominal emergency; Markers Introduction A common reason for emergency department visits is an acute abdominal pain, which is defined as severe pain that requires immediate attention [ 1 ].[omicsonline.org]
  • Acute abdomen. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery . 20th ed. Philadelphia, PA: Elsevier; 2017:chap 45. Updated by: Raymond S.[medlineplus.gov]
  • In the present case, the cause of the acute abdomen was most likely a combination of tumor infiltration, as indicated by the histological and immunohistochemical findings, and paclitaxel therapy.[ispub.com]
Obturator Sign
  • Clinical data included a presence of right lower quadrant tenderness, rebound tenderness, Rovsing sign, Psoas sign and Obturator sign. Laboratory value variables included WBC count, PMN count, and ANC.[omicsonline.org]
  • Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.[aafp.org]
  • sign Prevalence common Blood work leukocytosis Radiology periappendiceal fat stranding, increased appendiceal diameter Prognosis good Clin.[librepathology.org]
  • sign) Possible signs of perforation include rigidity and high fever Possible signs of an atypical presentation include right upper quadrant pain, right flank pain, nonlocalizing abdominal pain and generalized abdominal pain of longer duration Clinical[pathologyoutlines.com]
Right Lower Quadrant Tenderness
  • Return to Ultrasound Findings Case 2 Perforated appendicitis. 2 year old girl was transferred from an outside hospital with a two day history of bilious vomiting, excessive crying, irritability, and right lower quadrant tenderness.[meddean.luc.edu]
  • Clinical data included a presence of right lower quadrant tenderness, rebound tenderness, Rovsing sign, Psoas sign and Obturator sign. Laboratory value variables included WBC count, PMN count, and ANC.[omicsonline.org]
  • The most important physical examination finding is right lower quadrant tenderness to palpation.[aafp.org]
Flushing
  • It seems to provide a safe haven for good bacteria when gastrointestinal illness flushes those bacteria from the rest of the intestines.This reservoir of gut microbes then repopulates the digestive system following the illness.[lactobacto.com]
  • This complication requires prompt surgery and the goal of the surgery is to clear the entire peritoneal cavity, flush it properly, and make sure the infection does not spread to the blood and cause septicemia.[ic.steadyhealth.com]
Impulsivity
  • The cough impulse was absent. Leucocyte counts were raised with neutrophilia. USG abdomen revealed a gut loop adherent to abdominal wall at umbilicus and surrounding fat stranding. There were no signs of obstruction on plain radiograph.[avensonline.org]
Excitement
  • Although an editorial in the Journal 20 years ago implied heady times approaching in the treatment of appendicitis, 1 token recognition and no excitement greeted the 100th anniversary of the codification of the appendicitis syndrome last June. 2 , 3 In[nejm.org]
  • Bell J: An appendix containing an ordinary pin as the exciting cause of a perforation. Canad Med Rec 1894;23:33. Bell J: Foreign bodies in the vermiform appendix. Phil Med J 1902;10:760. Bidwell LA: Foreign bodies in the vermiform appendix.[karger.com]
Pelvic Pain
  • Appendicitis that occurs in these people can cause lower back pain or pelvic pain. Mild fever Appendicitis usually causes a fever between 99 F (37.2 C) and 100.5 F (38 C). You may also have the chills.[healthline.com]
  • It is especially well suited in evaluating right lower quadrant or pelvic pain in pediatric and female patients. A normal appendix (6 mm or less in diameter) must be identified to rule out appendicitis.[aafp.org]

Workup

A detailed patient history and a thorough physical examination are the cornerstone in the diagnosis of an acute appendicitis and perforation [2] [3]. Physicians must determine the exact timeline regarding symptom onset, especially abdominal pain, and its location can confirm the diagnosis. Abdominal tenderness at the McBurney point (located in the first third of a line joining the anterior superior iliac spine and the umbilicus) is the most important finding that will suggest appendicitis, while guarding, severe tenderness, and even a localized mass are signs of perforation [2] [3]. In some patients, abdominal pain can be induced with passive internal rotation of the thigh in flexion and by right hip extension (the obturator and psoas signs, respectively). As soon as an infectious etiology is suspected to be the cause of abdominal pain, laboratory studies comprisingof a complete blood count (CBC) and evaluation of inflammatory parameters is mandatory, as leukocytosis of more than 20,000 cells/mm3 and increased levels of C-reactive protein (CRP) are not only present in acute appendicitis but are also probable signs of perforation [1] [2]. Additionally, hyperbilirubinemia and the neutrophil-to-lymphocyte ratio (NLR) were identified as key features that suggest a perforated appendix [4] [7]. The role of imaging studies is questionable when it comes to visualizing a perforated appendix. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) have all been identified as efficient methods to diagnose acute appendicitis, with helical CT and MRI showing the highest specificity and sensitivity rates [2] [3] [6]. Their respective roles in confirming perforation of the appendix, however, have not been confirmed [6], which is why the diagnosis rests on clinical and laboratory findings.

Hyponatremia
  • In a multivariable analysis, independent factors predictive of complicated appendicitis in children were as follows [13] : Age younger than 5 years Symptom duration longer than 24 hours Hyponatremia Leukocytosis Yeh B.[emedicine.medscape.com]

Treatment

  • Initial antibiotic treatment followed by interval appendectomy would become a more likely treatment option if our study results can be validated in a prospective study.[ncbi.nlm.nih.gov]
  • How did the usual treatment of doing an appendectomy (appendix removal) arise? In 1886 Dr.[lactobacto.com]
  • Women's abdomens had been entered occasionally for treatment of ovarian cysts — men's abdomens rarely, on any pretext. For a pathologist-physician like Reginald H.[nejm.org]

Prognosis

  • The prognosis is good in cases of integrity of the appendix.[scielo.br]
  • Post View 31 Comments Appendicitis - Prognosis Did you experience any complications with your appendicitis? Post View 5 Comments CONTINUE SCROLLING FOR RELATED ARTICLE[emedicinehealth.com]
  • For a ruptured appendix, the prognosis is more serious. Decades ago, a rupture was often fatal. Surgery and antibiotics have lowered the death rate to nearly zero, but repeated operations and a long recovery may be necessary.[merckmanuals.com]

Etiology

  • Surgeons should remember that an underlying oncologic process may be the etiology of appendicitis in a small but important subgroup of patients.[ncbi.nlm.nih.gov]
  • As soon as an infectious etiology is suspected to be the cause of abdominal pain, laboratory studies comprisingof a complete blood count (CBC) and evaluation of inflammatory parameters is mandatory, as leukocytosis of more than 20,000 cells/mm3 and increased[symptoma.com]
  • References Murata A, Okamoto K, Mayumi T, Maramatsu K, Matsuda S (2014) Age- related differences in outcomes and etiologies of acute abdominal pain based on a national administrative database. Tohoku J Exp Med 233: 9-15.[omicsonline.org]
  • . /- Vascular thrombosis (and necrosis ) - known as gangrenous appendicitis . [6] /- Findings suggestive of etiology - usu. absent: /- Fecalith. /- Viral inclusions (extremely rare) See adenovirus appendicitis .[librepathology.org]
  • Etiology Appendicitis is caused by obstruction of the appendiceal lumen.[emedicine.medscape.com]

Epidemiology

  • Also Read: Appendicitis: Classification and Types, Epidemiology, Pathophysiology, Causes, Risk Factors, Symptoms, Signs, Treatment, Tests Acute Appendicitis: Causes, Signs, Symptoms, Treatment[epainassist.com]
  • Carcinoid tumors of the appendix in children: epidemiology, clinical aspects and procedure. Eur J Pediatr Surg . 2000;11(6):372–7. doi: 10.1055/s-2008-1072394 . CrossRef Google Scholar 26.[link.springer.com]
  • An American Journal of Epidemiology study in 1990 found that appendicitis was a common condition affecting approximately 6.7% of females and 8.6% of males. In the U.S. 250,000 cases of appendicitis are reported annually.[emedicinehealth.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology The simple pathophysiology of appendicitis follows the typical pathophysiology of infection. Obstruction. The appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith, tumor, or foreign body.[nurseslabs.com]
  • Also Read: Appendicitis: Classification and Types, Epidemiology, Pathophysiology, Causes, Risk Factors, Symptoms, Signs, Treatment, Tests Acute Appendicitis: Causes, Signs, Symptoms, Treatment[epainassist.com]
  • Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis, 9e. Philadelphia, PA: Elsevier; 2010. Appendicitis. Mayo Clinic website. . Accessed April 16, 2014. Appendicitis.[innerbody.com]
  • […] and young adults, most commonly occurring between early teens and 25 but may occur at any age; higher incidence in younger subjects likely related to increased lymphoid tissue More common with a low bulk Western diet, less common in Africa and Asia Pathophysiology[pathologyoutlines.com]
  • Appendicitis may occur for several reasons, such as an infection of the appendix, but the most important factor is the obstruction of the appendiceal lumen (see Pathophysiology and Etiology ).[emedicine.medscape.com]

Prevention

  • This reason for an appendectomy (that it would prevent serious infection) became established in medical thought and still guides appendicitis management today. But nowadays we have antibiotics![lactobacto.com]
  • Advertisement American Journal of Preventive Medicine and Public Health SUBMIT YOUR ARTICLE NOW[scopemed.org]
  • The patient was then admitted for emergency surgery to remove the appendix and prevent further injury. Question(s) For Expert Witness 1. Do you routinely treat patients similar to the one described in the case? Please explain. 2.[theexpertinstitute.com]
  • As suggested in a study Levas et al. [ 8 ], equal access to care is the key to preventing any disparities in pediatric appendicitis outcome [ 9 ].[omicsonline.org]
  • Controversy exists, however, as to whether interval appendectomy (performing an elective appendectomy in the “interval” between bouts of appendicitis) is necessary to prevent recurrent bouts of appendicitis.[forums.studentdoctor.net]

References

Article

  1. Drake FT, Mottey NE, Farrokhi ET, et al. Time to Appendectomy and Risk of Perforation in Acute Appendicitis. JAMA surg. 2014;149(8):837-844.
  2. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.
  3. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012
  4. Chaudhary P, Kumar A, Saxena N, Biswal UC. Hyperbilirubinemia as a predictor of gangrenous/perforated appendicitis: a prospective study. Ann Gastroenterol. 2013;26(4):325-331.
  5. Hung MH, Lin LH, Chen DF. Clinical manifestations in children with ruptured appendicitis. Pediatr Emerg Care. 2012;28(5):433-435.
  6. Leeuwenburgh MM, Wiezer MJ, Wiarda BM, et al. Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg. 2014;101(1):e147-155.
  7. Sevinç MM, Kınacı E, Çakar E, et al. Diagnostic value of basic laboratory parameters for simple and perforated acute appendicitis: an analysis of 3392 cases. Ulus Travma Acil Cerrahi Derg. 2016;22(2):155-162.

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Last updated: 2019-07-11 21:19