Complications of Appendicitis

• Death is rare• Perforated appendix ~30% complication rate Peritonitis• Wound infection +/-dehiscence• Intra-abdominal abscess• Fistulas• Small bowel obstruction (adhesions) (esp after perf)• Paralytic Ileus• Infertility• Sepsis

Complications

3

Case:

A 37-year-old woman with no past medical history went to ED complaining of vomiting and periumbilical abdominal pain for 6 hours. On physical examination, she was afebrile, BP 110/70, HR 85. Abdomen was soft, with no rebound or guarding. She was diagnosed with gastroenteritis, discharged with antiemetics, and told to return for persistent vomiting, pain, or new fever.

Case (cont.) :

Patient went to OPD 2 days later with persistent abdominal pain; vomiting had resolved. On physical exam, patient was afebrile, with normal vital signs. Abdomen was diffusely tender, with localization around the umbilicus. Pelvic exam revealed no cervical motion and mild adnexal tenderness. Diagnosis: Mittelschmerz vs. ovarian cyst. Transvaginal ultrasound ordered for following week. Patient told to take NSAIDS for pain.

Case (cont.):

The next day, the patient returned to the ED with persistent pain. She was seen by the same ED attending, who then asked a colleague to evaluate the case. This second ED attending performed a pelvic exam and ordered a CT scan of the abdomen and pelvis. CT revealed a perforated appendix.

Perforated Appendix

• The major reason for appendiceal perforation is delay in diagnosis and treatment.

• In general, the longer the delay between diagnosis and surgery, the more likely is perforation.

• The risk of perforation 36 hours after the onset of symptoms is at least 15%.

• Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.

Perforated Appendicitis

Perforated Appendicitis

• Patients very ill; may require several hours of fluid resuscitation before induction of general anaesthesia

• Broad spectrum antibiotics directed against gut aerobes and anaerobes are initiated early in the evaluation and resuscitation phase

• A laparoscopic approach to perforated appendix appears to reduce incidence of post operative wound infection and ileus and shorter hospital stay

• Diagnostic laparoscopy and assess whether or not to convert to an open appendectomy

• Any pus encountered is aspirated and sent for Gram stain and culture

• Oozing from inflamed retroperitoneum is easily controlled with argon beam coagulation(if available)

• Surgical excision of appendix as described

Perforated Appendicitis…Management

Perforated appendicitis

Peritonitis

• It’s secondary type of peritonitis• Life threatening if not treated quickly• Patient presents with

– Immobile with shallow thoracic breathing– Swelling and tenderness in the abdomen with pain ranging

from dull aches to severe, sharp pain – Fever and chills – Loss of appetite – Thirst – Nausea and vomiting – Limited urine output – Inability to pass gas or stool

Case (cont.): Missed Appendicitis

The patient was seen by general surgery and it was decided not to take her to the operating room immediately due to the peritonitis. She was admitted and started on IV antibiotics. Her hospital stay was prolonged due to ileus. On hospital day number #8, her WBC count began to rise. A repeat CT scan was obtained.

Intra-abdominal Abscess

Case (cont.): Missed Appendicitis

CT revealed an intra-abdominal abscess “the size of an orange.” The patient underwent percutaneous drainage by interventional radiology. On hospital day #13, she was discharged home with a plan to follow-up for elective appendectomy.

Pelvic abscess

• Can occur irrespective of position of appendix• Patient presents with spiking pyrexia several

days following appendicitis• Pelvic pressure symptoms like loose stools or

tenesmus• PR – Boggy mass in pelvis anterior to rectum• Managed normally by or transrectal drainage

under GA

Case (cont.): Missed Appendicitis

Shortly after discharge, the abdominal pain returned. The patient returned to the ED and underwent a repeat CT scan, which revealed a small bowel obstruction. The patient went to the operating room the next day for lysis of adhesions and appendectomy. Eight days later, the patient was discharged home. She has returned to her previous state of health.

Small bowel obstruction

• Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur.

Fistulas

• Typically for perforated appendicitis

• Fistulas to the skin generally close after any local infection is treated

• Fistulas to the bladder have been successfully diagnosed and treated laparoscopically in recent years

Infertility

• Many surgeons believe that girls and young women who suffer

perforation of the appendix are at risk of developing subsequent tubal infertility

• This conviction presumably arose from the clinical observation

that acute appendicitis complicated by perforation sometimes caused severe intra abdominal infection

• The resulting peritoneal adhesions were thought to obstruct the fallopian tubes, leading to tubal infertility

• Several previous studies have found an association between complicated appendicitis and female infertility (1–4), whereas others have not detected a relation

Sepsis

• A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body.

• This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.

Chronic or Recurrent Appendicitis

• A small number of patients report episodic bouts of RLA pain in absence of acute febrile illness

• Some are found to have appendicoliths on CT or sonographic evidence of an enlarged appendiceal diameter

• Most will have both surgical and pathologic evidence of chronic inflammation(fibrosis)

• Dilemma is more difficult when report of pain is not accompanied by other clinical or radiographic findings

Appendicitis in pregnancy

Complications:• More chances of perforations and peritonitis

– Incidence:4 -19% - non pregnant patients57% - pregnant women (Tracey & Fletcher,2000)

• Abortion , Fetal loss ~ 15% (1st trimester)• Decreased birth weight• Other surgical complication – wound infection, atelectasis• No congenital malformation• No stillborn infants

• Perforation – why more ???

Position change of appendix

No containment of infection by omentum

Inability of omentum to isolate infection

More generalized peritonitis

Complications of Appendicectomy

1. Pre-operative

2. Intra-operative

3. Post-operative

Pre-operative complications

Risks for any anesthesia include the following:

Problems with breathing

Chest infection

Reactions to medications

Intra-operative complications

1. If gridiron incision used – then ligation of arterial twig from Supf circum

iliac artery should be done to prevent excessive blood loss

– Sparing of iliohypogastric nerve

2. Normal-appearing appendixWhat to do?Consensus is still lacking even after introduction of

laparoscopyRecent practice is to remove the appendix and perform a

thorough search for other causes of patients’ symptomsCheck Small Intestine, Mesentery and Pelvis

3. Absent appendix Caecum should be mobilised and taenia coli

mobilised till confluence with caecum before diagnosis of ‘absent appendix’ is made

4. Appendicular tumour Small size( <2cm in diameter) appendicectomy Larger size Right Hemicolectomy

5. Internal injuries

Post-operative complications

• Relatively uncommon• Mainly reflect degree of peritonitis

1. Wound infection– Most common; occurs in 5-10% patients– Higher in those with perforation ; about 25%– Present as pain and erythemia of wound on 4th to 5th day post-

op– Treated by wound drainage and antibiotics– Most common organism Bacteriodes species and

Anaerobic streptococci

2. Intra-abdominal abscess– Rare because of pre-op antibiotics– Spiking fever, malaise and anorexia developing 5-7days

post-op– Sites Interloop, Paracolic, Pelvic and Subphrenic– Use Abdominal USG and CT– Drainage done mostly percutaneously– Laparotomy only to those where site cannot be identified

by imaging

3. Ileus– may last for some days especially after removal of

gangrenous appendix– If lasts for more than 4-5days with accompanying fever,

one should suspect intra-abdominal sepsis

4. Small bowel obstruction– Occurs in less than 1% of patients operated for

uncomplicated appendicitis and in 3% cases with perforation

– About half present within first year

5. Respiratory problems– Rare complication– Postoperative abdominal surgery patients require

analgesics to facilitate deep breathing, which minimizes the risk of atelectasis

– Some also advocate physiotherapy in severe cases

6. Stump Appendicitis– Residual tissue left after an initial appendectomy risks the

development of stump appendicitis– Typically, patients present with signs and symptoms

similar to acute appendicitis; however, due to prior surgery, the diagnosis is difficult and the rate of appendiceal stump perforation is extremely high

7. Portal pyaemia(Pylephlebitis)– Rare but serious complication of gangrenous appendicitis– Associated with high fever, jaundice and rigors– Due to septicemia in portal system– Development of intrahepatic abscesses– Treated by systemic antibiotics and percutaneous

drainage

8. Venous Thrombosis– Rare– Seen mainly in elderly and women on OCPs– Therefore there’s need for prophylaxis

9. Faecal fistulae– Occasionally seen following appendicectomy in Crohn’s

disease

10.Right inguinal Hernia– Seen when Gridiron incision done and injury to

iliohypogastric nerve

Thank you