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Appendicitis: Advances in Diagnosis and Treatment

Bryan J. DickenAssistant Professor of Surgery

Stollery Children’s Hospital

Objectives

At the completion of this discussion, participants should be able to recognize and outline:

1. Pathophysiology and presentation of acute appendicitis.

2. Provide a diagnostic approach to the pediatric patient with suspected appendicitis

3. Recognize the role and limitations of diagnostic ultrasound

4. Describe the role of CT in appendicitis

5. Recognize the role/limitations of non-operative management of acute appendicitis

6. Compare outcomes between open and laparoscopic appendectomy

Appendicitis: History with repeated examination-still more reliable than CT

or U/S Appendicitis is still a clinical diagnosis!

Atypical-variable presentations Stoic

Toddlers

Elderly and/or Demented Pelvic Appendix

Gastroenteritis – does NOT present with pain Be aware of the child presenting with abdominal pain and a

bowel obstruction – likely a perforated/missed appendix!

Acute Abdomen

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Lymphoid Hyper.FecalithWorms

F.B.Tumour

s

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ASIS

UMBILICUS

AppendicitisMost common pediatric surgical emergencyOverall mortality in early 20th century 15-35% Mortality in last 20 years less than 1%

What changed?Most likely advance is access to medical care and higher index of suspicion.Antibiotics – particularly in the management of complicated appendicitis and the septic patient.Imaging – NO!

Acute Abdomen

Most important diagnostic points?History is still “king”

Persistent and progressive pain, migratoryAnorexia, nausea, vomiting, diarrhea (perforation), fever

McBurney’s tendernessWBC > 14.0Temperature >38.0 CRP elevation Sensitivity much higher for males (91-97%) vs females (77-86%)

Appendicitis?

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Work-upHistory and PhysicalCBC + diffCRPUrine + B-HCG

If clinical examination is compatible with history and labs surgeryIf history and labs suggestive, but exam unclear serial exam or U/SIf history, labs and exam not convincing send home with directions to return if fails to improve

Bounce-back with progression of symptoms – no shame in this. Not much different than serial examinations

Appendicitis?

Clinical Practice Guidelines (34) – 8 in pediatric literatureSmink et al. Journal of Pediatric Surgery 39(3):458 (2004) (Boston/Miami)Dado et al. Journal of Pediatric Surgery 35(9):1320 (2000) (Udine, Italy)Warmer et al. Journal of Pediatric Surgery 33(10)1371 (1998) (Denver)

Theoretically should streamline patient care, but… physicians are not good at following others orders….

“Why make this more complex than it has to be…”

Clinical Practice Guidelines: What does literature report?

Imaging Appendicitis

Plain AXRUseful screening test if history and exam not clear

Should be directed by history and exam

Fecalith

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High –grade small bowel obstruction

History – abdominal distension, bilious emesis, intermittent “crampy” pain,minimal flatus.

UltrasoundLee et al. Seminars in Ultrasound, CT and MRI 24(2):69 (2003) (Seattle/UCDavis)Dilley et al. Journal of Pediatric Surgery 36(2):303 (2001)(Houston)Garcia et al. JAMA 282:1041 (1999)(Boston)

Sensitivity in non-perforated appendicitis 80-92%

Specificity 89-97%

Reduction of negative appendectomy rate to 2-8%

In control patients, appendix not seen 65-82%

Useful adjunct in “moderate risk” of appendicitis

No ionizing radiation

Imaging

Incidence of Appendicitis:0% with negative US10% for nonvisualized appendix68% for inconclusive report

Borderline size, focal pain with probe, free fluid. 85% for positive report

Negative Appendix rate – 2.9%

Canadian Assoc. of Radiologist J. 62 (2011).

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If the working diagnosis is appendicitis:NEVER needs to be done during after hours

The purpose of the US is not to confirm what you already know, but to include/exclude alternate diagnosis.

Ultrasound should be reserved for the indeterminate case

Ovarian torsion/tumorMeckel’s

Urachal abscessCrohn’s disease

Ultrasound

CT Scan?

Fecalith

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Appendix

Computer Tomography (CT)

However…Probability of removing a normal appendix has not changed with the introduction of CT (16%); therefore, don’t do it.

Best reserved when alternate diagnosis is contemplated, and US either not helpful or unavailable.

Especially true of suspected IBD or malignancy

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No difference in negative appendectomy rates were identifiedbetween patients studied and those with no study.

Arch Surg. May 2001

AJR ; 176, February 2001

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BMJ 2013;346:2360

Lancet 2012;380:499

Non-Operative Management?Pain worsens

8/8 pediatric practice guidelines suggest:Open appendectomy or Laparoscopic exploration

Pain ameliorates or resolves3/8 pediatric guidelines suggest discharge if

WBC normal Afebrile for 24 hours

Pain unchangedA role for imaging0/8 advocate automatic appendectomy7/8 suggest non-progressive pain for >48 hrs not suggestive of appendicitis

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Group 1 = Non-op Mgt20% required drainage of abscess by day 520% had persistent abdo pain and/or persistent abscessInterval appendectomy required in 39.6% by 4 weeksRemaining 60.4% completed interval appy by 11 weeks

World Journal of Surgery 2010;34:199

Surgical Infections 2012, 13(2):74

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Non-Operative Management?

So who should we consider for Nonsurgical Therapy?Very selected population

Early appendicitis onlyHigh stakes scenarios

Pro sports?

Foreign Travel (ie: no insurance and need to return home)

Parent refusal to surgery (need to be admitted for 24 hours to ensure no progression or be very reliable)

Military or Unable to obtain surgical care

We must remember that acute appendicitis still has a small but meaningful mortality risk if left inadequately treated!

Appendectomy – What is the best Method?

Open Appendectomy

Appendectomy

Laparoscopic Appendectomy

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Laparoscopic Appendectomy

ContraindicationsVery few – relative contraindicationsSevere cardiopulmonary diseaseUncorrected coagulopathyPatient refusal

Journal of Pediatric Surgery 2012;47:317

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The literature

BenefitsFewer wound complicationsLess post-operative painShorter Time in Hospital

Uncomplicated Home within 24 hoursComplicated need to be Afebrile X 24 hrs, Normal WBC, DAT

Quicker Recovery to Normal Activity

DetrimentsExpenseSlightly longer OR times

Objectives

At the completion of this discussion, participants should be able to recognize and outline:

1. Pathophysiology and presentation of acute appendicitis.

2. Provide a diagnostic approach to the pediatric patient with suspected appendicitis

3. Recognize the role and limitations of diagnostic ultrasound

4. Describe the role of CT in appendicitis

5. Recognize the role/limitations of non-operative management of acute appendicitis

6. Compare outcomes between open and laparoscopic appendectomy

Appendicitis: Advances in Diagnosis and Treatment

Questions/Comments?