Perforated appendicitis

O Primary peritonitis develops in up to 25% of patients with alcoholic cirrhosis.3 Patients undergoing continuous ambulatory peritoneal dialysis (CAPD) average one episode of peritonitis every 2 years.4 Secondary peritonitis may be caused by perforation of a peptic ulcer traumatic perforation of the stomach, small or large bowel, uterus, or urinary bladder appendicitis pancreatitis diverticulitis bowel infarction inflammatory bowel disease cholecystitis operative contamination of the peritoneum or diseases of the female genital tract such as septic abortion, postoperative uterine infection, endometritis, or salpingitis. Appendicitis is one of the most common causes of intraabdominal infection. In 1998, 278,000 appendectomies were performed in the United States for suspected appendicitis.5... 

Acute appendicitis without evidence of gangrene, perforation, abscess, or peritonitis requires only prophylactic administration of inexpensive regimens active against facultative and obligate anaerobes. 

Fire-toxin, as a pathological product as well as a pathogenic factor, can accumulate in the intestines. Fire-toxin should be eliminated as soon as possible, especially before long-term accumulation and when the blood is not strongly disturbed, in order to prevent further development of disease, such as in chronic mild infections of the intestines, or at the primary stage of acute appendicitis, acute pancreatitis, acute cholecystitis, hepatitis and ulcer perforation and inflammation. 

Baroliths are rare complications of barium contrast examinations and are usually seen in colonic diverticula. They are often asymptomatic but may be associated with abdominal pain, appendicitis, and bowel obstruction or perforation. A case of ileal obstruction by a barolith has been reported (12)... 

A 13-month-old boy presented with an acute abdomen and surgery was performed for a suspected perforated appendicitis (113). The appendix was normal but the pancreas was enlarged, edematous, and covered with fibrin, with areas of superficial necrosis. The serum amylase activity was 528 lU (normal under 200 lU). 

Pancreatitis, any cause (P-AMY T) Pancreatic trauma (P-AMYT) Biliary tract disease (P-AMYT) - Intestinal obstruction (PtAMYT) Mesenteric infarction (P-Alv4Y(t Perforated peptic ulcer (P-AMYiT) Gastritis, duodenitis (P-AMY ) Ruptured aortic aneurysm Acute appendicitis Peritonitis Trauma... 

The causes of intraabdominal abscess overlap those of peritonitis and, in fact, may occur sequentially or simultaneously. Appendicitis is the most frequent cause of abscess. Other potential causes of intraabdominal abscess include pancreatitis, diverticulitis, lesions of the biliary tract, genitourinary tract infections, perforating tumors in the abdomen, trauma, and leaking intestinal anastomoses. In addition, pelvic inflammatory disease in women may lead to tuboovarian abscess. For certain diseases, such as appendicitis and diverticulitis, abscesses occur more frequently than generalized peritonitis. 

Bennion RS, Baron EJ, Thompson JE, et al. The bacteriology of gangrenous and perforated appendicitis—Revisited. Ann Surg 1990 211 165-171. 

Mebendazole, albendazole, and pyrantel pamoate (antiminth, others) are preferred drugs all infected persons should be treated. Mebendazole and albendazole are preferred for therapy of asymptomatic-to-moderate ascariasis. Both compounds should be used with caution to treat heavy Ascaris infections, alone or with hookworms. Rarely, hyperactive ascarids may migrate to cause complications such as appendicitis, biliary or intestinal obstruction, and intestinal perforation— sometimes requiring surgery. Pyrantel is safe for use in pregnancy, whereas BZAs should be avoided during the first trimester (see below). 

Epidemiologic studies reveal that the lifetime risk of appendicitis is 8.6% for males and 6.7% for females. The lifetime risk of appendectomy is 12.0% for males and 23.1% for females (Addiss et al. 1990). These data stress the social and economic impact of appendicitis and the need to improve the diagnosis. The pathogenesis of appendicitis is conditioned by the speciflc cul-de-sac anatomy of the appendix being prone to develop ectasia, fecalith formation, obstruction and/or infection followed by ischemia, necrosis and perforation (Gray and Ashley 1986). 

Fig. 1. 61a-d. Perforated appendicitis phlegmon and abscess. a,b Phlegmon. Inflammatory mass composed of a complex fluid collection (C), prominent mesenteric fat (M), and adjacent thickened poorly defined intestinal bowel loops (B) just close to the appendiceal remnants (arrows). c,d Abscesses. Distant multiple abscesses in the pouch of Douglas and in the subhepatic region. A, abscess... 

Appendicitis may resolve spontaneously either in noncomplicated or perforated forms. Follow-up US examinations have shown these infrequent spontaneous resolutions. They are considered as a false positive diagnosis in most of the published studies, due to unavailability of surgical and pathological confirmation Oeffrey et al. 1987). Spontaneously resolving appendicitis occurs in at least 1 in 13 cases of appendicitis and has an overall recurrence rate of 38%, with the majority of cases recurring within 1 year. It is difficult to make therapeutic recom-... 

Fig. 1.63a,b. Perforated appendicitis, a Axial US scan shows air within the appendiceal dilated lumen arrow) and enlargement of the periappendicular fat. b Color Doppler demonstrates the enlarged periappendicular tissue to correspond to an inflammatory mass... 

Besides perforated appendicitis and intussusception, the most common causes of small howel obstruction are incarcerated hernias and adhesions. Other causes of small bowel obstruction comprise a miscellaneous group of rare conditions, such as midgut volvulus, Meckel s diverticulum, advanced stages of Crohn s disease, and bezoars. Adhesions usually result from prior surgery and are often multiple. There is an increasing tendency for initial conservative management rather than immediate operative intervention, as a proportion of cases will resolve spontaneously. 

Fig. 6.5a,b. CT of the abdomen in a 12-year-old girl with a perforated appendicitis, a A large collection of fluid in the abdomen with an appendicolith seen low in the pelvis, b Fluid extending throughout the abdomen with an associated air-fluid level... 

Perforation and abscess formation complicated appendicitis in 38%-55%, with the highest rates occurring in children and in elderly patients. 

Andersson RE, Hugander A, Thulin AJ (1992) Diagnostic accuracy and perforation rate in appendicitis association with age and sex of the patient and with appendectomy rate. Eur J Surg 158 37-41... 

St Peter SD, Sharp SW, Ostlie DJ. Influence of histamine receptor antagonists on the outcome of perforated appendicitis. Arch Surg 2010 145(2) 143-6. 

Balthazar EJ, Rofsky NM, Zucker R (1998) Appendicitis the impact of computed tomography imaging on negative appendectomy and perforation rates. Am J Gastroenterol 93 768-771... 

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