MANAGEMENT OF APPENDICITISUncomplicated AppendicitisThe preferred approach to manage patients with uncomplicatedappendicitis is an appendectomy. Several recent randomizedtrials and cohort studies have examined the role of nonopera-tive management of adult patients with appendicitis. 23,24,25 Ineach of these well-designed studies with noninferiority as theendpoint, patients were randomized to either receiving antibiot-ics or undergoing an appendectomy, which was frequently per-formed open. A majority of the patients in the nonoperative armreceived intravenous antibiotics for a short course followed bya course of a fluoroquinolone and metronidazole, or oral amoxi-cillin/clavulanic acid. 23,26,27 Meta-analysis of the published datafound that 26.5% of patients in the nonoperative group requiredan appendectomy within 1 year. In addition, the rate of adverseevents following antibiotics therapy was higher (relative risk[RR] 3.18, 95% CI 1.63–6.21, P = 0.0007), and patients whorecurred presented more frequently with complicated appen-dicitis (RR 2.52, 95% CI 1.17–5.43, P = 0.02). 28,29 Currently,conservative management can be offered to informed patientsusing techniques of shared decision-making, but it is not thestandard modality of management of appendicitis, except inpatients with significant phobia of surgery. 30 Societal costs andlong-term implications of the conservative strategy have not yetbeen completely evaluated.Timing of Surgery. Emergent surgery is often performed inpatients with appendicitis, but studies have evaluated the perfor-mance of urgent surgery (waiting less than 12 hours) in a semi-elective setting after administering antibiotics upon admission.The studies did not reveal any significant difference in outcomes,except for a slightly longer hospital stay in those undergoingurgent surgery.31-33 Currently, delaying surgery less than 12 hoursis acceptable in patients with short duration of symptoms (lessthan 48 hours) and in nonperforated, nongangrenous appendicitis.Approach of Surgery. Numerous meta-analyses comparinglaparoscopic to open appendectomy have demonstrated relativeequivalence of the techniques, with laparoscopic appendec-tomy resulting in a shorter length of stay (LOS), faster return towork, and lower superficial wound infection rates, especiallyin obese patients. 34,35 Open appendectomy results in shorteroperative times and lower intra-abdominal infection rates.36Costs of the two techniques are relatively similar because ofthe offset of costs in laparoscopic techniques by shorter LOS.In the United States, laparoscopic appendectomies are increas-ingly utilized. 37Complicated AppendicitisPerforated and gangrenous appendicitis and appendicitis withabscess or phlegmon formation are considered complicatedconditions. Patients with perforated appendicitis usually pres-ent after 24 hours of onset, although 20% of patients presentwithin 24 hours. Such patients are often acutely ill and dehy-drated and require resuscitation. Usually, the perforated abscessis walled off in the right lower quadrant, although retroperito-neal abscesses including psoas abscess, liver abscesses, fistu-las, and pylephlebitis (portal vein inflammation) can also occurwhen left untreated.Perforated appendicitis can be managed either operativelyor nonoperatively. Immediate surgery is necessary inpatients that appear septic, but this is usually associatedwith higher complications, including abscesses and enterocuta-neous fistulae due to dense adhesions and inflammation.The management of long-duration, complicated appendici-tis is often staged.38,39 Patients are resuscitated and treated withIV antibiotics. 40,41 Patients with longstanding perforation arebetter treated with adequate percutaneous image-guided drain-age.42 This strategy is successful in 79% of patients who achievecomplete resolution, which occurs more often in lower-gradeabscesses, transgluteal drainage, and with CT- (vs. ultrasound-)guided drainage43 Operative intervention is performed in patientswho fail conservative management and in patients with free intra-peritoneal perforation.Interval Appendectomy. The majority of patients with perfo-rated appendicitis (80%) have resolution of their symptoms withdrainage and antibiotics. There remains debate about the valueof performing an interval appendectomy 6 to 8 weeks after theoriginal inflammatory episode. 44-46 Proponents of this approachcite the incidence of recurrent appendicitis (7.4%–8.8%) and thepresence of appendiceal neoplasms detected on the appendec-tomy (relevant benign lesions 0.7%, malignant lesions 1.3%).47Opponents cite the high incidence of no future events after amedian follow-up of 34 months in 91% of patients. Currently,shared decision-making is necessary before proceeding with aninterval appendectom
Question
MANAGEMENT OF APPENDICITISUncomplicated AppendicitisThe preferred approach to manage patients with uncomplicatedappendicitis is an appendectomy. Several recent randomizedtrials and cohort studies have examined the role of nonopera-tive management of adult patients with appendicitis. 23,24,25 Ineach of these well-designed studies with noninferiority as theendpoint, patients were randomized to either receiving antibiot-ics or undergoing an appendectomy, which was frequently per-formed open. A majority of the patients in the nonoperative armreceived intravenous antibiotics for a short course followed bya course of a fluoroquinolone and metronidazole, or oral amoxi-cillin/clavulanic acid. 23,26,27 Meta-analysis of the published datafound that 26.5% of patients in the nonoperative group requiredan appendectomy within 1 year. In addition, the rate of adverseevents following antibiotics therapy was higher (relative risk[RR] 3.18, 95% CI 1.63–6.21, P = 0.0007), and patients whorecurred presented more frequently with complicated appen-dicitis (RR 2.52, 95% CI 1.17–5.43, P = 0.02). 28,29 Currently,conservative management can be offered to informed patientsusing techniques of shared decision-making, but it is not thestandard modality of management of appendicitis, except inpatients with significant phobia of surgery. 30 Societal costs andlong-term implications of the conservative strategy have not yetbeen completely evaluated.Timing of Surgery. Emergent surgery is often performed inpatients with appendicitis, but studies have evaluated the perfor-mance of urgent surgery (waiting less than 12 hours) in a semi-elective setting after administering antibiotics upon admission.The studies did not reveal any significant difference in outcomes,except for a slightly longer hospital stay in those undergoingurgent surgery.31-33 Currently, delaying surgery less than 12 hoursis acceptable in patients with short duration of symptoms (lessthan 48 hours) and in nonperforated, nongangrenous appendicitis.Approach of Surgery. Numerous meta-analyses comparinglaparoscopic to open appendectomy have demonstrated relativeequivalence of the techniques, with laparoscopic appendec-tomy resulting in a shorter length of stay (LOS), faster return towork, and lower superficial wound infection rates, especiallyin obese patients. 34,35 Open appendectomy results in shorteroperative times and lower intra-abdominal infection rates.36Costs of the two techniques are relatively similar because ofthe offset of costs in laparoscopic techniques by shorter LOS.In the United States, laparoscopic appendectomies are increas-ingly utilized. 37Complicated AppendicitisPerforated and gangrenous appendicitis and appendicitis withabscess or phlegmon formation are considered complicatedconditions. Patients with perforated appendicitis usually pres-ent after 24 hours of onset, although 20% of patients presentwithin 24 hours. Such patients are often acutely ill and dehy-drated and require resuscitation. Usually, the perforated abscessis walled off in the right lower quadrant, although retroperito-neal abscesses including psoas abscess, liver abscesses, fistu-las, and pylephlebitis (portal vein inflammation) can also occurwhen left untreated.Perforated appendicitis can be managed either operativelyor nonoperatively. Immediate surgery is necessary inpatients that appear septic, but this is usually associatedwith higher complications, including abscesses and enterocuta-neous fistulae due to dense adhesions and inflammation.The management of long-duration, complicated appendici-tis is often staged.38,39 Patients are resuscitated and treated withIV antibiotics. 40,41 Patients with longstanding perforation arebetter treated with adequate percutaneous image-guided drain-age.42 This strategy is successful in 79% of patients who achievecomplete resolution, which occurs more often in lower-gradeabscesses, transgluteal drainage, and with CT- (vs. ultrasound-)guided drainage43 Operative intervention is performed in patientswho fail conservative management and in patients with free intra-peritoneal perforation.Interval Appendectomy. The majority of patients with perfo-rated appendicitis (80%) have resolution of their symptoms withdrainage and antibiotics. There remains debate about the valueof performing an interval appendectomy 6 to 8 weeks after theoriginal inflammatory episode. 44-46 Proponents of this approachcite the incidence of recurrent appendicitis (7.4%–8.8%) and thepresence of appendiceal neoplasms detected on the appendec-tomy (relevant benign lesions 0.7%, malignant lesions 1.3%).47Opponents cite the high incidence of no future events after amedian follow-up of 34 months in 91% of patients. Currently,shared decision-making is necessary before proceeding with aninterval appendectom
Solution
The text you provided is a detailed explanation of the management of appendicitis, both uncomplicated and complicated. It discusses the different approaches to treatment, including surgery (appendectomy) and non-operative management with antibiotics. The text also discusses the timing of surgery, the approach of surgery (laparoscopic vs open appendectomy), and the management of complicated appendicitis, including perforated and gangrenous appendicitis. It also mentions the concept of interval appendectomy, which is a delayed surgery performed 6 to 8 weeks after the initial inflammatory episode. The text emphasizes the importance of shared decision-making in determining the best course of treatment.
Similar Questions
ImagingImaging is often utilized to confirm a diagnosis of appendici-tis because a negative operation rate is acceptable in <10% ofmale patients and <20% of female patients. Routine use of cross-sectional imaging somewhat reduces the rate of negative laparot-omies. Imaging studies are most appropriate for patients in whoma diagnosis of appendicitis is unclear or who are at high risk fromoperative intervention and general anesthesia, such as pregnantpatients or patients with multiple comorbidities. Commonlyutilized imaging modalities include computerized tomography(CT), ultrasound (US), and magnetic resonance imaging (MRI).CT Scan. A contrast-enhanced CT scan has a sensitivity of0.96 (95% confidence interval [CI] 0.95–0.97) and specificity of0.96 (95% CI 0.93–0.97) in diagnosing acute appendicitis. 16,17Features on a CT scan that suggest appendicitis includeenlarged lumen and double wall thickness (greater than 6 mm)
Appendectomy is contraindicated in case of:Select one:a.coagulopathy.b.appendicular massc.III-rd trimester of pregnancyd.bilateral pneumoniae.miocardial infarction
A week after open appendectomy for perforated appendicitis, the Lanz incision is noted to be erythematous, slightly swollen and tender. The appropriate treatment is:Question 45Select one:a.Incision and drainageb.Systemic antibioticsc.Topical antibiotics’d.Local heat therapye.Regional ultrasound
EMBRYOLOGY, ANATOMY, AND HISTOLOGYPreviously considered a vestigial organ, the appendix is nowlinked to the development and preservation of gut-associatedlymphoid tissue (GALT) and to the maintenance of intestinalflora. It has been suggested that appendectomy is associated withincreased Clostridium difficile infections and increased subse-quent cancer (colon, esophageal) as a result of microbial altera-tion, although this is currently unproven.3 The protective effect ofan early appendectomy against development of ulcerative colitishas been proposed to be mechanistically linked to the release ofdimeric forms of IgA from plasma B cells and the Th2 responsemediated by IL-13–producing natural killer T cells.4The appendix, along with the ileum and the colon, devel-ops from the midgut and first appears at 8 weeks of gestation.As the gut rotates medially, the cecum becomes fixed in theright lower quadrant, thus determining the final position of theappendix. The appendix is a true diverticulum of the cecum asit contains all the histological layers of the colon, although cer-tain differences in the irregularity of crypts remain. The averageappendix measures 6 to 9 cm and derives its blood supply fromthe appendicular branch of the ileocolic artery. Visceral innerva-tion occurs along the superior mesenteric plexus (T10-L1) andthe vagus nerves. The appendix is intraperitoneal and retrocecalin location, but it can be pelvic (30%) and retroperitoneal (7%). 5Grossly, the appendiceal base can be identified by tracing theconvergence of the cecal taeneia.ACUTE APPENDICITISInflammation of the appendix is a significant public health prob-lem with a lifetime incidence of 8.6% in men and 6.7% inwomen, with the highest incidence occurring in the secondand third decade of life. 6 While the rate of appendectomy indeveloped countries has decreased over the last several decades,it remains one of the most frequent emergent abdominaloperations. 7The etiology of appendicitis is perhaps due to luminalobstruction that occurs as a result of lymphoid hyperplasia inpediatric populations; in adults, it may be due to fecaliths, fibro-sis, foreign bodies (food, parasites, calculi), or neoplasia.5,8-10Early obstruction leads to bacterial overgrowth of aerobicorganisms in the early period, and subsequently, it leads tomixed flora. Obstruction generally leads to increased intralumi-nal pressure and referred visceral pain to the periumbilicalregion.10 It is postulated that this leads to impaired venous drain-age, mucosal ischemia leading to bacterial translocation, andsubsequent gangrene and intraperitoneal infection. Escherichiacoli and Bacteroides fragilis are the most common aerobicand anaerobic bacteria isolated in perforated appendicitis.
The nurse is caring for a client with appendicitis experiencing pain. Which pain relief method would be inappropriate for this client?A. Applying ice packs to the abdomenB. Practicing breathing exercises with the patientC. Using a heating pad on the abdomenD. Encouraging rest
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