Acute Appendicitis: Controversies in Diagnosis and Management
Section snippets
Challenges in the Diagnosis of Acute Appendicitis
Appendicitis is a common problem; there are more than 300,000 hospital discharges for appendicitis in the United States per year.1 Although the clinical scenario of periumbilical pain migrating to the right lower quadrant is classically associated with acute appendicitis, the presentation is rarely typical and the diagnosis cannot always be based on history and physical examination alone. Diagnostic errors are common, with over-diagnosis leading to negative appendectomies and with delays in
Antibiotics vs Appendectomy for Acute Uncomplicated Appendicitis
Appendectomy for acute appendicitis is one of the most common surgical procedures performed worldwide. In the United States, appendectomy incurs considerable indirect costs resulting from time lost from work, school, or usual activities after the procedure.42 The individual lifetime risk of appendicitis is 8.6% for men and 6.7% for women.43 Uncomplicated acute appendicitis is considered almost universally to be an indication for an appendectomy. In 1889, open appendectomy was accepted as the
Management of Complicated Appendicitis
In the United States, approximately 11 of 10,000 people will develop acute appendicitis over their lifetime, with the typical age of onset between the ages of 11 and 19 years.61 Of these, an estimated 2%-6% of patients will present with an appendiceal mass, either in the form of an inflammatory phlegmon or abscess.62 The optimal management of acute appendicitis complicated by an inflammatory phlegmon or abscess remains controversial. There is no consensus in the surgical literature on whether
Laparoscopic vs Open Appendectomy
The open appendectomy was initially described by McBurney in 1894, and has remained relatively unchanged since its introduction. In 1983, Semm described a laparoscopic approach for removing the appendix, advocating the advantages of laparoscopic surgery for one of the most frequently performed surgical procedures.84 Because open appendectomy typically involves a small incision, short hospital stay, rapid return to normal activity, and low postoperative morbidity, demonstrating clear superiority
Pediatric Appendectomy
Acute appendicitis is one of the most common surgical diagnoses in pediatrics, with an estimated incidence of 59,000-70,000 children per year in the United States.88., 89. Appendicitis occurs in all age groups, but is rare in younger children. Although the highest incidence is in older children, with 25 cases per 10,000 pediatric patients per year between the ages of 10 and 17 years, there is a reported rate of 1-2 cases per 10,000 in children younger than 4 years of age. In most cases in the
Management of the Unanticipated Appendiceal Neoplasm
An unanticipated appendiceal neoplasm may be encountered at any elective or emergency abdominal operation. It is estimated that nearly 50% of cases manifest as appendicitis, but variable presentations have also been reported.147 The pathology and behavior of appendiceal neoplasms are diverse, which only complicates the confusing classification and terminology.148 Increasingly, an appendiceal neoplasm may be suspected on radiological cross-sectional imaging for diagnosis or staging of abdominal
Carcinoid Tumors
Carcinoid tumors can arise from the neuroendocrine cells of any part of the gastrointestinal tract, and are the most common primary neoplasm in the appendix.158., 159. The annual incidence of neuroendocrine tumors of the appendix is 0.16 per 100,000, with a comparable frequency in men and women.160 Little is known about the epidemiology of these tumors and associated risk factors.161 Appendiceal carcinoids are detected in 0.3%-0.9% of appendectomy specimens, and commonly present as appendicitis
Malignant Epithelial Lesions
Malignant epithelial tumors of the appendix range from low-grade mucinous neoplasms to invasive adenocarcinomas. This range incorporates a spectrum of disease, often difficult to classify histopathologically, with only the clinical behavior over time truly defining the biologic nature of the tumor. Ronnett and colleagues have classified appendiceal mucinous neoplasms into 3 groups: disseminated peritoneal adenomucinosis, peritoneal mucinous carcinomatosis, and an intermediate group.169., 170.
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