Acute appendicitis
Complications
The patient will appear unwell and may have:
Signs of sepsis or shock.[2] See Shock, Sepsis in adults and Sepsis in children.
Localised peritonitis with guarding[25]
Generalised peritonitis; a tense, distended abdomen with guarding or rigidity and absent bowel sounds[25]
This is caused by free perforation in the peritoneal cavity[25]
A palpable mass
This is due to a peri-appendiceal abscess caused by a perforation that is contained by the omentum.[7]
Emergency appendicectomy (open or laparoscopic) should be performed in all cases. This can be done open or laparoscopically.[27]
It is now accepted that perforation is not merely a progression of an appendicitis but rather a completely different pathology.[7][13][125]
In practice it is currently not possible to predict early in the course of the condition which patients have uncomplicated (non-perforating) appendicitis and which have appendicitis that will progress to perforation.[13]
In certain patient groups (patients >65 years, those with comorbidities, and those with a delay of more than 12 hours before surgery is performed) there is some evidence of increased risk of perforation. Minimise surgical delay in these groups.[122]
Large perforation of acutely inflamed appendix results in generalised peritonitis.
Presents with a tense, distended abdomen with guarding or rigidity and absent bowel sounds.[25]
If the diagnosis is suspected as acute appendicitis, emergency appendicectomy should be performed. If diagnosis is in doubt, exploratory laparotomy should be performed through midline incision, and the inflamed appendix needs to be removed.[161]
Usually seen in patients with a relatively long history of symptoms.
Presents with tender right lower quadrant mass. Ultrasonography or computed tomographic scan will show a mass.
If the patient appears otherwise well, the initial management is conservative treatment with intravenous fluids and broad-spectrum antibiotics. If there is clinical improvement and the signs and symptoms are completely resolved, then there is no need for interval appendicectomy.[144][162][163] Interval appendicectomy is performed after 6 weeks if the symptoms are not completely resolved.[164]
Ensure any patient >40 years of age who has conservative management without interval appendicectomy also has investigations to rule out colon malignancy; these should include colonoscopy and interval full-dose contrast-enhanced CT scan.[7]
Usually occurs as a progression of the disease process, particularly after perforation.
Presents with tender right lower quadrant mass, swinging fever, and leukocytosis.
Ultrasonography or computed tomographic (CT) scan will show the abscess.
Initial treatment includes intravenous antibiotics and CT-guided drainage of abscess.
If there is clinical improvement and the signs and symptoms are completely resolved, then there is no need for interval appendicectomy.[144][162][163] Interval appendicectomy is performed after 6 weeks if the symptoms are not completely resolved.[164] There is evidence to suggest that laparoscopic appendicectomy may be a feasible first-line option over conservative treatment for appendiceal abscess in adults; however, this is not recommended.[147]
Ensure any patient >40 years of age who has conservative management without interval appendicectomy also has investigations to rule out colon malignancy; these should include colonoscopy and interval full-dose contrast-enhanced CT scan.[7]
One retrospective cohort study of 150 patients with perforated appendicitis with abscess or peritonitis found a laparoscopic approach reduced the incidence of surgical site infection and repeat surgery and led to a shorter length of stay compared with open surgery.[139]
There is also a decreased incidence of a surgical wound infection if prophylactic antibiotics are used.[165]
The risk of appendiceal neoplasm in patients treated with non-operative management of complicated appendicitis is 11%, increasing to 16% in patients aged 50 years and older and 43% in patients aged over 80.[150][151][152] Mucinous neoplasms are the most common form of appendiceal malignancy (43%), although the incidence of appendiceal carcinoid appendiceal tumours is rising, particularly in patients under 40 years of age.[166][150]
A rare complication which occurs in approximately 0.25% of patients following laparoscopic appendicectomy.[167] Presents with right lower quadrant pain, a median of 292 days following laparoscopic appendicectomy.[167] Treatment is surgical, with the majority of patients (97%) undergoing repeat laparoscopic appendicectomy.[167]
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