A 34-year-old man presents to your clinic asking about an elective appendectomy. He has no history of appendicitis. What are possible indications for appendectomy in this patient?
Incidental appendectomy is generally not indicted. A few select indications could be considered and they include children about to undergo chemotherapy, the disabled who cannot describe pain or react normally to pain, patients with Crohn disease when the cecum is free of macroscopic disease, and those patients planning to travel to remote areas with limited surgical care. While part of the traditional teaching, the ubiquity of antibiotics and the evolving understanding of our ability to treat at least some appendicitis nonoperatively may further limit the indications for elective, incidental appendectomy.
While reviewing pathology of a recent laparoscopic appendectomy, you note that in addition to acute appendicitis, the patient had a 1.5-cm carcinoid tumor located at the base of the appendix. The patient is otherwise healthy and recovering well from surgery. What would you recommend?
Appendiceal carcinoid is one of the most common neoplasms to identify in an appendectomy specimen. Lesions that are < 1 cm generally do not require additional therapy. Lesions larger than 1 or 2 cm, involving the appendiceal base or with lymph node metastasis of mesenteric invasion warrant right hemicolectomy. A radical appendectomy is not a described operation and adjuvant chemotherapy could be considered but only after definitive surgical care.
An 8-year-old boy presents to the emergency department complaining of generalized abdominal pain for the past 24 hours. Laboratory tests reveal a leukocytosis of 13,000 and he is tender in the RLQ on physical examination. He is taken to the operating room for laparoscopic appendectomy. Removal of the appendix has been associated with a protective effect of which of the following?
The appendix is an immunologic organ involved in secretion of immunoglobulins. An inverse association between appendectomy and development of ulcerative colitis has been reported. Routine resection of the normal appendix to improve the clinical course of ulcerative colitis is not generally indicated.
Which of the following physical signs is associated with the correct definition suggestive of acute appendicitis?
Appendicitis usually starts with periumbilical pain that migrates to the RLQ. Patients often have associated gastrointestinal symptoms such as anorexia, nausea, and vomiting. On physical examination, patients often prefer to remain lying supine and often guard due to peritoneal irritation. Rebound tenderness is when the examiner presses on the RLQ and the patient experiences a sudden pain upon removal of the hand. Rovsing sign is RLQ pain that is induced by palpation of the left lower quadrant and is highly suggestive of a RLQ inflammatory process. Dunphy sign elicits pain with coughing and is related to inflammation of the peritoneum. The obturator sign occurs with internal rotation of the right hip. Lastly, the iliopsoas sign is pain with extension of the right hip, attributed to a retrocecal appendix.
A 29-year-old woman presents with RLQ pain, fever, and leukocytosis. Prior to imaging studies the Alvarado score is used to determine the patient's likelihood of having appendicitis. All of the following variables make up the Alvarado score EXCEPT:
The Alvarado score is the most widespread scoring system useful for ruling out appendicitis and selecting patients for further imaging or intervention (Table below). The Alvarado score is calculated using RLQ tenderness, elevated temperature, rebound tenderness, migration of pain, anorexia, nausea/vomiting, leukocytosis, and a left shift on leukocyte differential as predictive factors. Several online calculators are freely available.
Scoring systems:
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