Appendicitis

Question 1

Which of the following is a criterion in the Alvarado scoring system for appendicitis?

A. C-reactive protein

B. Nausea and vomiting

C. Rovsing’s sign

D. Diffuse peritonitis

E. Sick contacts

Answer 1

ANSWER: B

COMMENTS: Appendicitis is the most common cause of surgical emergency in the pediatric population.

Appendicitis is generally felt to be the result of an obstruction of the appendiceal lumen by either inflammation or appendicolith.

The classic presentation for appendicitis is initial periumbilical pain that then localizes to the right lower quadrant and anorexia.

Scoring systems to better predict the likelihood of appendicitis have been created.

The Alvarado scoring system includes localized right lower quadrant tenderness, leukocytosis, pain migration, left shift, fever, nausea and vomiting, anorexia, and peritoneal irritation.

A score of at least 6 has a 90% specificity for appendicitis.

Ultrasound may improve the diagnostic accuracy with findings such as a thickened appendix, thickened appendiceal walls, appendix diameter of >7 mm, and a noncompressible appendix with palpation.

Once the diagnosis of appendicitis is made, antibiotics should be initiated, and an appendectomy should be completed within 12h of presentation to minimize the risks of perforation.

Although there is some literature supporting antibiotics and observation without surgery, the persistence and recurrence rates are substantial, and the morbidity of a laparoscopic appendectomy is very low.

Therefore most surgeons in the United States continue to treat acute appendicitis with surgery.

Question 2

Is knowledge of appendicitis important in the surgical care of children?

Answer 2

Acute appendicitis is the most common surgical emergency in children.

The life-time risk of developing appendicitis is 7–8%, with a peak incidence during the second decade of life.

Appendectomy remains the standard treatment for acute appendicitis.

Although appendectomy is generally a simple procedure, it requires general anesthesia and it is an abdominal operation with potential complications.

Question 3

What is the cause of appendicitis?

Answer 3

The cause of acute appendicitis remains poorly understood.

Traditionally, luminal obstruction was considered the most important factor.

It has been shown that other factors contribute to the etiology.

Both genetic and environmental factors as well as infections are important [1].

Question 4

Does acute appendicitis always progress to perforation?

Answer 4

The definition of perforated appendicitis varies from perforation verified by the histopathologist to a visible hole in the appendix or a free fecalith in the abdomen seen by the surgeon.

Approximately 25% of children with acute appendicitis have perforated appendicitis.

The perforation rate is even higher in young children.

The traditional understanding has been that acute appendicitis always progresses to perforation.

However, it has been convincingly shown that the inflammation resolves without treatment in a subset of patients.

The increasing proportion of perforations over time is explained by selection due to resolution of inflammation in patients with non-perforated appendicitis [2].

Question 5

How do children with appendicitis present?

Answer 5

Typical presentation begins with vague periumbilical pain.

Older children describe that the pain migrates to the right lower quadrant.

Fever is common and usually low-grade in acute appendicitis.

Nausea and vomiting often follows the onset of pain.

Diarrhea is common in perforated appendicitis.

Atypical symptoms are common in children with appendicitis.

Question 6

How is appendicitis diagnosed and what is the role of “appendicitis scores”?

Answer 6

Appendicitis risk scores are designed to estimate the risk for appendicitis.

The most commonly used scores, Alvarado score and Pediatric Appendicitis Score (PAS), were initially shown to have high sensitivity, specificity, negative predictive value and positive predictive value.

However, validation studies have shown less favourable outcomes.

The more recently described Appendicitis Inflammatory Response (AIR) score appears preferable in young children.

Scores should not be used as the only diagnostic modality and for the decision-making it is important to take into account both history, clinical findings, laboratory tests, as well as imaging results.

In many centers acute appendicitis is confirmed by imaging, primarily ultrasound, in more or less all children.

Question 7

What are the clinical findings of acute appendicitis?

Answer 7

Tenderness in the right lower quadrant is the main finding in children with acute appendicitis.

Particularly rebound tenderness increases the likelihood of appendicitis.

Question 8

Are laboratory tests important?

Answer 8

A moderately elevated white blood cell count, particularly elevated neutrophils, increases the risk for appendicitis.

In non-perforated appendicitis CRP is usually slightly elevated.

On the other hand, normal white blood cell count and CRP do not exclude appendicitis.

Recent findings indicate that hyponatremia increases the risk for perforation in patients with appendicitis.

Question 9

Is imaging useful?

Answer 9

One important advantage with imaging is that the negative appendectomy rate can be significantly reduced.

Although ultrasound is depending on the experience of the examiner it generally has a high sensitivity and specificity to diagnose appendicitis in children.

Ultrasound should be the first option to limit exposure to radiation.

In approximately 10% of children a computed tomography is needed in addition to ultrasound.

Magnetic resonance imaging may be useful to diagnose appendicitis but its availability is limited in most centres.

Question 10

What other diagnoses can be confused with appendicitis?

Answer 10

The workup to diagnose suspected appendicitis in children should always include the possibility of differential diagnoses.

The differential diagnoses include gastrointestinal disorders (mesenteric lymphadenitis, Crohn’s disease, Meckel diverticulitis, viral gastroenteritis, pancreatitis, cholecystitis), genitourinary tract disorders (urinary tract infection, hydronephrosis, ovarian torsion, ruptured ovarian cyst, salpingitis, testicular torsion), and other conditions (pneumonia, Henoch-Schönlein purpura, sickle cell disease, porphyria).

Question 11

How is uncomplicated, non-perforated acute appendicitis treated?

Answer 11

Laparoscopic appendectomy is the standard approach for non-perforated acute appendicitis.

Three-port appendectomy is the most common approach, although single-incision laparoscopy has similar outcomes.

Question 12

Is laparoscopic appendectomy better than open appendectomy?

Answer 12

Laparoscopic appendectomy is currently the treatment of choice for acute appendicitis in children.

The risk for wound infections as well as adhesive small bowel obstruction is lower compared to open appendectomy.

Question 13

How common are negative appendectomies?

Answer 13

The incidence of negative appendectomy has dropped below 5% in many major centres.

This is explained by the introduction of both active expectancy and imaging.

Also introduction of appendicitis scores may have contributed.

Question 14

Is there a role for non-operative treatment of non-perforated appendicitis with antibiotics?

Answer 14

Recent data suggest that non-perforated appendicitis can be treated with antibiotics, with a success rate of about 90%.

After the initial success some patients will have a relapse in acute appendicitis.

Antibiotics can very well be used as an alternative in cases where surgery or general anaesthesia is associated with an increased risk.

When more long-term follow-up data becomes available, antibiotic treatment of non-perforated appendicitis will be included as an alternative treat- ment option for patients and parents to choose [3].

Question 15

How often does appendicitis recur after treatment with antibiotics?

Answer 15

After initial successful treatment with antibiotics about 10% may recur during the first year and another 10–20% during the following five years.

The data on this outcome in children are very limited.

Question 16

How is perforated appendicitis treated?

Answer 16

Perforated appendicitis in children should be treated with surgery.

But, the most important initial treatment is fluid resuscitation and intravenous antibiotics, and surgery should be performed after stabilisation.

Question 17

For how long should the patient remain on antibiotics after perforated appendicitis?

Answer 17

Traditionally, perforated appendicitis has been treated with seven to ten days of broad-spectrum antibiotics.

More recently, it has been shown that, when the patient tolerates a light diet, it is safe to change intravenous to per oral antibiotics and discharge the patient.

Also, when the patient tolerates a light diet and has no leukocytosis, it is safe to discharge the patient home without any antibiotics at all [4].

Question 18

How should an appendiceal mass or abscess be treated?

Answer 18

An appendiceal mass should be treated with antibiotics, with or without a drain, to minimize the risk of complicated surgery, bowel injury and/or generalized peritonitis during early surgery.

Question 19

When should an abscess be drained?

Answer 19

Most appendiceal masses or abscesses can be treated with antibiotics only.

In focal abscesses larger than approximately five centimetres is it likely that the evacuation of pus will shorten the course of the disease.

This has to be weighed against the increased morbidity associated with the drain itself.

Question 20

Is it wrong to do an appendectomy in patients with an appendiceal mass or abscess?

Answer 20

In a setting where you perform an interval appendectomy the total complications and hospital stay is similar if you perform an early appendectomy or initial non-operative treatment followed by an interval appendectomy.

If you do not include the interval appendectomy, the non-operative approach would be preferable.

Question 21

Is there a role for interval appendectomy after conservative treatment?

Answer 21

Traditionally, an interval appendectomy has been performed after initial non-operative treatment of an appendiceal mass or abscess, mainly to prevent the risk of recurrence.

This regimen has been questioned and stopped in many centres since decades.

A recent randomized controlled trial showed that the risk of recurrence was low and that interval appendectomy should be restricted to patients who develop recurrent symptoms.

Less than a quarter of the patients had to undergo a late appendectomy using this wait-and-see approach [5].

Question 22

What are the short term complications of appendectomy?

Answer 22

Laparoscopic appendectomy is a safe procedure with a low risk of complications.

1–2% of patients develop a wound infection and 3–5% of patients develop a post- operative abscess.

In children with perforated appendicitis this risk may be as high as 10%.

Question 23

Is there a risk for future mechanical small bowel obstruction?

Answer 23

The risk of small bowel obstruction is small, but present.

Hospitalization for small bowel obstruction after appendectomy is 0.5–1.0% with about half the patients undergoing adhesiolysis.

The risk is greater after open appendectomy than after laparoscopic appendectomy and greater after perforated than after non-perforated appendicitis.

The risk may also be greater after surgery when no appendicitis were found.

Question 24

Is there a risk for impaired fertility in girls with appendicitis?

Answer 24

There is no impaired risk for impaired fertility in girls after appendicitis.

One meta-analysis described a slight increased risk of ectopic pregnancy.

The question has been raised due to the risk of adhesion after appendectomy and that the adhesions may cause infertility.

As there is an increased risk of adhesions after open compared to laparoscopic appendectomy it may very well be the surgical intervention rather than the inflamed, sometimes perforated, appendix that causes these adhesions.

Question 25

How common are appendiceal tumors in children?

Answer 25

The incidence of carcinoid tumors in histopathology specimens after appendectomy is about 1 in 300.

Other appendiceal tumours such as appendiceal adeno- carcinoma and lymphoma are even rarer.

Most appendiceal tumors are found in histopathological specimens without clinical suspicion of a tumor and most of them are most likely asymptomatic.

Question 26

If on laparotomy, appendix is encountered normal, which statement is false?

A. Appendix should be removed in malrotation.
B. Appendix should not be removed in Crohn’s disease.
C. Do not removed appendix in patients who are candidates for urological reconstruction.
D. Do not remove appendix in patient with faecal incontinence.
E. All of the above are false.

Answer 26

?

Question 27

Regarding appendectomy, which one is false?

A. Lanz incision is a transverse one.
B. Gridiron incision is an oblique one.
C. Placement of drain in perforated appendix is optional.
D. Burring of appendix is an optional procedure.
E. Duration of postoperative antibiotic in catarrhal appendicitis is 5 days.

Answer 27

E. Duration of postoperative antibiotic in catarrhal appendicitis is 5 days.

Question 28

A 12-year-old female patient presents to the emergency department with a history of a ten-day progressive right lower quadrant abdominal pain. She has a temperature of 101.7 F (38.7 C), and a heart rate of 106 beats per minute. She has focal discomfort in the right lower quadrant without rebound tenderness and is not asking for food. She has not had menarche. An ultrasound of the right lower quadrant shows a complex fluid collection near the cecum, with a feca-lith present in the collection. Lab tests reveal a white blood cell count of 11,500 cells/mm^3, and polymorphonuclear 81%. What is the best immediate intervention for this problem?

Choices:
1. Laparoscopic irrigation and drain placement
2. Interventional radiology-guided drain placement
3. Midline laparotomy and extensive irrigation
4. Intravenous antibiotics alone

Answer 28

Answer: 2 - Interventional radiology-guided drain placement

Explanations:
• The best option for chronically perforated appendicitis, as evidenced by symptoms suggestive of acute appendicitis for longer than 4 to 5 days in the pediatric population, without sepsis or signs of diffuse peritonitis, is a minimally invasive drain placement with imaging guidance.
• This allows the infection to improve with antibiotic treatment.
• Planning for interval appendectomy at a later date is possible with a minimally invasive approach via laparoscopy.
•Surgical intervention at this time is more likely to result in laparot-omy, wider resection area, possibly ileocolic resection, a longer re-covery, and a higher risk of intraabdominal and wound infections.

StatPearls

Question 29

A 17-year-old female patient presents with a 3-day history of periumbilical pain, which has now localized to the right lower quadrant. She describes the pain as dull, intermittent, and aggravated by movement. She also complained of urinary frequency and burning with micturition for the past few days. Her vital signs show a blood pressure of 137/89 mmH, a heart rate of 96 beats per minute, a respiratory rate of 18 breaths per minute, and a temperature of 101.3 F
(38.5 C). Physical examination is unremarkable for the most part, apart from mild tenderness in the right iliac fossa. There is no costovertebral angle tenderness. Complete blood count (CBC) shows leukocytosis with the left shift. Ultrasound of the abdomen is unremarkable. Her urine pregnancy test is negative. She is retained overnight in the hospital and discharged the next day on oral antibiotics. Which of the following findings most likely led to this decision?
Choices:
1. Resolution of her tachvcardia
2. Repeat CBC showing resolution of the leukocytosis
3. Resolution of her right low quadrant tenderness
4. Urinalysis positive for nitrites and leukocytes

Answer 29

Answer: 4 - Urinalysis positive for nitrites and leukocytes
Explanations:
• Once a diagnosis of appendicitis is reached, appendectomy is the treatment of choice. Although the evidence for treating uncomplicated cases with conservative management is mounting, it is not the recommended strategy for management.
The only possible scenario for the patient getting discharged is if the clinician is convinced of an alternative diagnosis. This patient most likely has a urinary tract infection (UTI) rather than acute appendicitis.
•UTI is one of the most common differentials of acute appendicitis.
In this vignette, key features suggestive of UTI include burning micturition and the dull and intermittent nature of pain. Moreover, appendicitis is less likely due to a longer duration of symptoms.
By this time, tenderness and rebound tenderness would have been much more pronounced if the underlying pathophysiology was acute appendicitis.
• A urinalysis positive for nitrites is highly specific for bacteriuria, suggesting UTI as the underlying diagnosis. Resolution of fever and tachycardia can occur due to the IV antibiotic dose received during the hospital stay. The same holds for the resolution of tenderness and leukocytosis. A UTI can be easily treated using a 3-day course of oral antibiotics.

StatPearls

Question 30

Which of the following is true with regard to acute appendicitis?

A It is common at any age group.

B It is more common in females.

C It is rare in a neonatal population.

D The white cell count is always raised.

E It is easy to diagnose with various imaging techniques.

Answer 30

C

Although appendicitis can happen at any age, it commonly affects older children above 10 years of age.

Boys are at a slightly higher risk of getting appendicitis.

White cell count is usually raised but it is possible to have a normal count with appendicitis.

Despite various imaging modalities the diagnosis of appendicitis is best based on a combination of clinical picture, blood investigations and imaging.

SPSE 1

Question 31

Which investigation is required to be performed for suspected appendicitis?

A white cell count
B ultrasound scan
C CT scan
D abdominal X–ray
E none of the above

Answer 31

E

It is possible to diagnose appendicitis in most patients simply on the basis of history and clinical examination.

Investigations may be performed when the diagnosis is not clear on presentation.

SPSE 1

Question 32

Which of the following can be considered as a definitive diagnostic test for appendicitis?

A CT scan
B ultrasound scan
C diagnostic laparoscopy
D white cell scan
E none of the above

Answer 32

E

ultrasound scan and CT scan are becoming increasingly popular investigations for diagnosing appendicitis.

ultrasound is commonly used in the uK while CT and ultrasonography are used in the united States.

Although there are reports claiming a high sensitivity and specificity for both, their main use is for the equivocal cases where clinical diagnosis is not possible.

Similarly a normal looking appendix at laparoscopy may indeed show inflammation under the microscope.

SPSE 1

Question 33

Differential diagnosis for appendicitis does not include:

A pancreatitis
B pneumonitis
C urinary tract infection
D ectopic pregnancy
E gastro-oesophageal reflux disease (GORD).

Answer 33

E

Abdominal pain is a common symptom in children for a variety of disorders that can mimic the clinical picture of appendicitis.

GoRD typically presents with heartburn, regurgitation and dysphagia.

SPSE 1

Question 34

While performing appendicectomy for perforated appendicitis one should always:

A bury the stump
B leave a drain
C look for and remove any faecoliths
D irrigate with saline plus antibiotic solution
E avoid primary skin closure.

Answer 34

C

A variety of steps are employed by surgeons to prevent postoperative complications, but there is no conclusive evidence that they help.

A retained faecolith is very likely to cause postoperative sepsis and it is good practice to remove it.

SPSE 1

Question 35

Laparoscopic appendicectomy is contraindicated in:

A children under the age of 5 years

B perforated appendicitis

C an overweight patient

D an immunocompromised patient

E none of the above.

Answer 35

E

SPSE 1

Question 36

In the postoperative period for perforated appendicitis:

A keep the patient nil oral for 48 hours

B check white cell count daily

C change the dressing daily

D give broad-spectrum antibiotics for >24 hours

E perform ultrasound of abdomen after 5 days.

Answer 36

D

Antibiotic policies vary from hospital to hospital. However, most surgeons prescribe a combination of antibiotics covering a broad spectrum, for a period of 1–7 days.

SPSE 1

Question 37

Postoperative complications following appendicectomy include:

A lung consolidation

B intussusception

C necrotising fasciitis

D intra-abdominal abscess

E all of above.

Answer 37

E

SPSE 1

Question 38

Appendicectomy is usually performed as part of which procedure?

A gastroschisis repair
B congenital diaphragmatic hernia repair
C Ladd’s procedure
D laparotomy for meconium obstruction
E pull-through procedure for Hirschsprung’s disease

Answer 38

C

most surgeons advocate removal of the appendix following a ladd’s procedure for malrotation. This is because following a ladd’s procedure, the malrotated bowel is orientated such that the appendix tends to be in the left side of the abdomen.

If these patients present with appendicitis at a later date, the clinical signs may be confusing and misleading.

These cases are done using an inversion appendicectomy, without any contamination of the peritoneal cavity.

SPSE 1

Question 39

A 12-year-old girl has undergone appendicectomy for perforated appendicitis with pus in the pelvis. The parents want to know about long-term problems. Which of the following statements is true?

A There is an increased risk of infertility.

B There is a increased risk of ovarian torsion.

C There is an increased risk of adhesive intestinal obstruction.

D There is an increased risk of endometriosis.

E All of the above.

Answer 39

C

SPSE 1

Question 40

What is false about the primary peritonitis?

A. It is an infectious process of the peritoneal cavity that has intraabdominal source.

B. The most common organism is Streptococcus pneumonia. C. An associated common condition is nephrotic syndrome.

D. It may develop in children with splenectomy.

E. It has been in children on long-term steroid treatment.

Answer 40

A

Primary peritonitis is an infectious process of abdominal cavity that has no intra-abdominal source.

Syed/MCQ

Question 41

Regarding appendicitis in children, which of the following are true?

A. Less chance of mass formation.

B. Less chance of perforation.

C. Laparoscopic appendectomy is a better option in thin patients than obese.

D. Open appendectomy has increased chance of bleeding than laparoscopic.

E. Longer hospital stay in laparoscopic appendectomy.

Answer 41

A

Children have small omentum, so there is less chance of mass formation but more chance of perforation.

Laparoscopic appendectomy is better in obese patients and is easy to do.

Incidence of bleeding noted in laparoscopic appendectomy is more than open.

Laparoscopic has shorter hospital stay.

Syed/MCQ

Question 42

If on laparotomy appendix is encountered normal, which statement is false?

A. Appendix should be removed in malrotation.

B. Appendix should not be removed in Crohn’s disease.

C. Do not remove appendix in patients who are candidate for urological reconstruction.

D. Do not remove appendix in patient with faecal incontinence.

E. All of the above are false.

Answer 42

E

Statement A, B, C and D are true.

Appendix should be removed in malrotation because of potential confusion caused by appendix in ectopic location.

Appendix should not be removed in Crohn’s disease because of increased chance of fistula formation.

Appendix may be used in certain GIT and urological reconstruction surgery, so it should not be removed in faecal or urinary incontinent patients.

Syed/MCQ

Question 43

Regarding appendectomy, which one is false?

A. Lanz incision is a transverse one.

B. Gridiron incision is an oblique one.

C. Placement of drain in perforated appendix is optional.

D. Burring of appendix is an optional procedure.

E. Duration of post-operative antibiotic in catarrhal appendicitis is 5 days.

Answer 43

E

Duration of postoperative antibiotic in catarrhal appendicitis is about 48 hours.

Drain placement in perforated appendix is optional. It has the advantage of draining fluid and collection. It has the disadvantage of the chance of adhesion, infection, perforation, and fistula formation.

Burring of stump is also optional. Burring of stump has the advantage of less chance of adhesion formation by retained stump and less chance of recurrent appendicitis.

The disadvantages of burring stump are the chance of faecal fistula formation (if caecum is friable) and confusion by filling defect on future barium enema.

Syed/MCQ

Question 44

The incidence of perforation of appendix in children with appendicitis under 3 years of age is:

A. 40 percent.

B. 50 percent.

C. 60 percent.

D. 70 percent.

E. 80 percent.

Answer 44

E 80 percent

Syed/MCQ