Acute Appendicitis: Controversies in Diagnosis and Management

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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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References (196)

  • M. Farahnak et al.

    The Alvarado score and antibiotics therapy as a corporate protocol versus conventional clinical management: randomized controlled pilot study of approach to acute appendicitis

    Am J Emerg Med

    (2007)
  • A.A. Malik et al.

    Conservative management of acute appendicitis

    J Gastrointest Surg

    (2009)
  • J. Shindoh et al.

    Predictive factors for negative outcomes in initial non-operative management of suspected appendicitis

    J Gastrointest Surg

    (2010)
  • M.T. Buckius et al.

    Changing epidemiology of acute appendicitis in the United States: study period 1993-2008

    J Surg Res

    (2012)
  • D.E. Deakin et al.

    Interval appendicectomy after resolution of adult inflammatory appendix mass—is it necessary?

    Surgeon

    (2007)
  • D. Puapong et al.

    Routine interval appendectomy in children is not indicated

    J Pediatr Surg

    (2007)
  • J.Z. Lugo et al.

    Can interval appendectomy be justified following conservative treatment of perforated acute appendicitis?

    J Surg Res

    (2010)
  • C. Simillis et al.

    A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon)

    Surgery

    (2010)
  • S.D. St Peter et al.

    Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

    J Pediatr Surg

    (2010)
  • K.K. Yau et al.

    Laparoscopic versus open appendectomy for complicated appendicitis

    J Am Coll Surg

    (2007)
  • B.K. Goh et al.

    Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study

    J Pediatr Surg

    (2005)
  • N.J. Hall et al.

    Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review

    J Pediatr Surg

    (2011)
  • S.H. Ein et al.

    Nonoperative management of pediatric ruptured appendix with inflammatory mass or abscess: presence of an appendicolith predicts recurrent appendicitis

    J Pediatr Surg

    (2005)
  • M.V. Raval et al.

    Dollars and sense of interval appendectomy in children: a cost analysis

    J Pediatr Surg

    (2010)
  • S.D. St Peter et al.

    Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

    J Pediatr Surg

    (2010)
  • S.L. Guthery et al.

    National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids' inpatient database

    J Pediatr

    (2004)
  • M.W. Gauderer et al.

    Acute appendicitis in children: the importance of family history

    J Pediatr Surg

    (2001)
  • A. Dilley et al.

    The impact of ultrasound examinations on the management of children with suspected appendicitis: a 3-year analysis

    J Pediatr Surg

    (2001)
  • K. Newman et al.

    Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals

    J Pediatr Surg

    (2003)
  • S.R. Thomson et al.

    Antibiotic prophylaxis in non-perforated appendicitis of childhood: tetracycline lavage compared with peroperative intravenous cefuroxime and metronidazole

    J Hosp Infect

    (1987)
  • S.D. St Peter et al.

    Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

    J Pediatr Surg

    (2008)
  • DeFrances CJ, Cullen KA, Kozak LJ. National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis and...
  • D.R. Flum et al.

    The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis

    Arch Surg

    (2002)
  • J.S. Solomkin et al.

    Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

    Surg Infect

    (2010)
  • R.E. Andersson

    Meta-analysis of the clinical and laboratory diagnosis of appendicitis

    Br J Surg

    (2004)
  • A. Halkin et al.

    Likelihood ratios: getting diagnostic testing into perspective

    QJM

    (1998)
  • D.G. Bundy et al.

    Does this child have appendicitis?

    J Am Med Assoc

    (2007)
  • J.M. Wagner et al.

    Does this patient have appendicitis?

    J Am Med Assoc

    (1996)
  • K. Yen et al.

    Interexaminer reliability in physical examination of pediatric patients with abdominal pain

    Arch Pediatr Adolesc Med

    (2005)
  • A.B. Kharbanda et al.

    Comparison of pediatric emergency physicians' and surgeons' evaluation and diagnosis of appendicitis

    Acad Emerg Med

    (2008)
  • U. Sack et al.

    Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children

    BMC Surg

    (2006)
  • A. Kentsis et al.

    Discovery and validation of urine markers of acute pediatric appendicitis using high-accuracy mass spectrometry

    Ann Emerg Med

    (2010)
  • A.B. Kharbanda et al.

    A clinical decision rule to identify children at low risk for appendicitis

    Pediatrics

    (2005)
  • H. Lintula et al.

    Diagnostic score in acute appendicitis. Validation of a diagnostic score (Lintula score) for adults with suspected appendicitis

    Langenbecks Arch Surg

    (2010)
  • H. Lintula et al.

    Appendicitis score for children with suspected appendicitis. A randomized clinical trial

    Langenbecks Arch Surg

    (2009)
  • H. Lintula et al.

    A diagnostic score for children with suspected appendicitis

    Langenbecks Arch Surg

    (2005)
  • A. Rezak et al.

    Decreased use of computed tomography with a modified clinical scoring system in diagnosis of pediatric acute appendicitis

    Arch Surg

    (2011)
  • D.R. Flum et al.

    Letter regarding negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program

    Ann Surg

    (2009)
  • D.J. Brenner et al.

    Computed tomography—an increasing source of radiation exposure

    N Engl J Med

    (2007)
  • A.S. Doria et al.

    US or CT for diagnosis of appendicitis in children and adults? A meta-analysis

    Radiology

    (2006)
  • Cited by (0)

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