eMedicine Specialties > Emergency Medicine > Gastrointestinal

Appendicitis, Acute: Follow-up

Author: Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center
Contributor Information and Disclosures

Updated: Jun 1, 2009

Follow-up

Further Inpatient Care

  • Open versus laparoscopic appendectomy
    • Initially performed in 1987, laparoscopic appendectomy has been performed in thousands of patients and is successful in 90-94% of attempts. Recent experience has also demonstrated that laparoscopic appendectomy is successful in approximately 90% of cases of perforated appendicitis.
    • Advantages of laparoscopic appendectomy include increased cosmetic satisfaction and a decrease in the postoperative wound-infection rate. Some studies show that laparoscopic appendectomy shortens the hospital stay and convalescent period compared with open appendectomy.
    • Disadvantages of laparoscopic appendectomy are increased cost and an operating time approximately 20 minutes longer than that of open appendectomy. The latter may resolve with increasing experience with laparoscopic technique.
    • Laparoscopic appendectomy is contraindicated in patients with significant intra-abdominal adhesions.
  • Emergent versus urgent appendectomy
    • One retrospective study suggests that the risk of appendiceal rupture is minimal in patients with less than 24-36 hours of untreated symptoms.52 Another recent retrospective study suggests that appendectomy within 12-24 hours of presentation is not associated with an increase in hospital length of stay, operative time, advanced stages of appendicitis, or complications compared to appendectomy within 12 hours of presentation.53
    • Additional studies are needed to demonstrate whether initiation of antibiotic therapy followed by urgent appendectomy is as effective as emergent appendectomy for patients with unperforated appendicitis.
  • Immediate versus interval appendectomy for appendicitis with perforation
    • Historically, immediate (emergent) appendectomy was recommended for all patients with appendicitis, whether perforated or unperforated.
    • Recent clinical experience suggests that patients with perforated appendicitis with mild symptoms and localized abscess or phlegmon on abdominopelvic CT scans can be initially treated with intravenous antibiotics and percutaneous or transrectal drainage of any localized abscess. If the patient's symptoms, WBC count, and fever satisfactorily resolve, therapy can be changed to oral antibiotics and the patient can be discharged home. Delayed (interval) appendectomy can then be performed 4-8 weeks later. This approach is successful in the vast majority of patients with perforated appendicitis and localized symptoms. Some have suggested that interval appendectomy is not necessary unless the patient presents with recurrent symptoms. Further studies are needed to clarify whether routine interval appendectomy is indicated.
    • Further studies are necessary to identify the optimal treatment strategy in patients with perforated appendicitis.

Complications

  • Wound infection
  • Dehiscence
  • Bowel obstruction
  • Abdominal/pelvic abscess
  • Stump appendicitis - Although rare, approximately 36 reported cases of appendicitis in the surgical stump after prior appendectomy exist.54
  • Death (rare)

Prognosis

  • The prognosis is excellent.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • For approximately 10% of adults with appendicitis, the condition is not diagnosed correctly on their first visit to the health care provider.
  • Failure to diagnose appendicitis is the leading cause of successful malpractice claims and the fifth most expensive source of claims against emergency physicians.

Special Concerns

  • Pregnant women
    • The incidence of appendicitis is unchanged in pregnancy, but the clinical presentation is more variable than at other times.
    • During pregnancy, the appendix migrates in a counterclockwise direction toward the right kidney, rising above the iliac crest at about 4.5 months' gestation.
    • RLQ pain and tenderness dominate in the first trimester, but in the latter half of pregnancy, right upper quadrant (RUQ) or right flank pain must be considered a possible sign of appendiceal inflammation.
    • Nausea, vomiting, and anorexia are common in uncomplicated first trimester pregnancies, but their reappearance later in gestation should be viewed with suspicion.
    • Physiologic leukocytosis during pregnancy makes the WBC count less useful in the diagnosis than at other times, and no reliable distinguishing WBC parameters are cited in the literature.
    • One study of 22 pregnant women in the first and second trimesters showed that graded compression ultrasonography had a sensitivity of 66% and specificity of 95%.55
    • Diagnostic laparoscopy has also been suggested for pregnant patients in the first trimester with suspected appendicitis.
    • Although negative appendectomy does not appear to adversely affect maternal or fetal health, diagnostic delay with perforation does increase fetal and maternal morbidity. Therefore, aggressive evaluation of the appendix is warranted in this group.
  • Nonpregnant women of childbearing age
    • Appendicitis is misdiagnosed in 33% of nonpregnant women of childbearing age. The most frequent misdiagnoses are PID, followed by gastroenteritis and urinary tract infection.
    • In distinguishing appendiceal pain from that of PID, anorexia and onset of pain more than 14 days after menses suggests appendicitis. Previous PID, vaginal discharge, or urinary symptoms indicates PID.
    • On physical examination, tenderness outside the RLQ, cervical motion tenderness, vaginal discharge, and positive urinalysis support the diagnosis of PID.
  • Children
    • Appendicitis is misdiagnosed in 25-30% of children, and the rate of initial misdiagnosis is inversely related to the age of the patient.
    • The most common misdiagnosis is gastroenteritis, followed by upper respiratory infection and lower respiratory infection.
    • Children with misdiagnosed appendicitis are more likely than their counterparts to have vomiting before pain onset, diarrhea, constipation, dysuria, signs and symptoms of upper respiratory infection, and lethargy or irritability.
    • Physical findings less likely to be documented in children with a misdiagnosis than in others include bowel sounds; peritoneal signs; rectal findings; and ear, nose, and throat findings.
  • Elderly patients
    • Appendicitis in patients older than 60 years accounts for 10% of all appendectomies.
    • The incidence of misdiagnosis is increased in elderly patients.
    • In patients with comorbid conditions, diagnostic delay is correlated with increased morbidity and mortality.
    • Older patients tend to seek medical attention later in the course of illness; therefore, a duration of symptoms in excess of 24-48 hours should not dissuade the clinician from the diagnosis.
 


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References
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Further Reading

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Keywords

appendicitis, acute appendicitis, appendectomy, acute inflammation of the appendix, abdominal pain, fecaliths, appendiceal perforation, right lower quadrant pain, vomiting, periumbilical pain, Rovsing sign, obturator sign, psoas sign, positive cough sign, burst appendix, luminal obstruction

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Contributor Information and Disclosures

Author

Sandy Craig, MD, Adjunct Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill, Carolinas Medical Center
Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William Lober, MD, Associate Professor, Department of Medical Education, Division of Biomedical and Health Informatics, University of Washington School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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