COMPLICATIONS ASSOCIATED WITH APPENDICITIS* HENRY K. RANSOM, M.D. Associate Professor of Surgery, University of Michigan MedicaI School ANN ARBOR, MICHIGAN N a discussion of postoperative com- according to AIIen,2 is responsibIe for 94 per phcations CutIer and Scott’ state that, cent of the deaths from this disease. The I “With the period that fohows opera- obstruction of the appendix is usuahy due tive intervention begin the triaIs and to a fecaIith. The process advances rapidIy tribuIations of the surgeon.” This state- due to interference with the bIood supply ment is probably nowhere more true than of the appendix and consequent necrosis in the case of those patients who require of its waI1. Perforation may occur as earIy surgical attention because of a septic as four hours folIowing the onset of symp- appendix, and in whom infection has toms. Due to the sudden flooding of the extended beyond the confines of this unprepared peritoneum with septic mate- organ. It is a we11 known fact that today the rial, Iittle opportunity is afforded for the mortaIity of appendectomy for uncom- usua1 waIIing-off process to take pIace and plicated acute appendicitis is almost negh- a diffuse or genera1 peritonitis ensues. gibIe, whereas in the more advanced cases, CoIIer and Potter3 found eighty-eight cases when peritonitis of some degree has super- of genera1 peritonitis among 336 patients vened, the mortaIity continues to be with acute appendicitis, in a11 stages of the disturbingIy high. For the most part, disease, admitted to the University of deaths from acute appendicitis are due Michigan HospitaI over a three-year period, to some phase of peritonitis either directIy, an incidence of 22.2 per cent. Stafford and as from toxemia, severe sepsis and iIeus, Sprong4 found 196 instances of genera1 or indirectIy from the Iater compIications peritonitis in a simiIar group of 1,3 17 of peritonitis, e.g., intestina1 obstruction, patients admitted to the Johns Hopkins empyema, pneumonia, etc. If one consuIts HospitaI over an eight-year period. The the records of the surgical cIinic in any incidence of peritonitis in this group was, Iarge hospita1, the more serious complica- therefore, 14.9 per cent. Barrow and tions of acute appendicitis wiII be found Ochsner” found 179 cases of general to incIude genera1 peritonitis, residua1 or peritonitis in a group of 1,039 cases of secondary abscesses, intestinal obstruction, acute appendicitis admitted to the Charity major wound sepsis, pneumonia, pyIephIe- HospitaI in New OrIeans, an incidence of bitis, Iiver abscess, empyema, puImonary 17 per cent. The diagnosis of acute ap- embohsm, feca1 fistuIa, postoperative hem- pendicitis with genera1 peritonitis is not orrhage and thrombophIebitis. The present difFrcuIt. The patient compIains of severe discussion is concerned with the abdomina1 generaILed abdomina1 pain, with nausea comphcations encountered in the manage- and vomiting. The abdomen becomes dis- ment of the perforated appendix and, in tended, tense and rigid. There is tenderness particuIar, with those which occur foIIow- throughout, aIthough it remains more ing operative intervention. marked in the right Iower quadrant. AuscuItation reveaIs a siIent abdomen. GENERAL PERITONITIS The temperature is considerabIy higher Diffuse peritonitis is most often the (IO I’F.) than in uncompIicated acute result of sudden perforation in the obstruc- appendicitis, and the p&e rate is increased tive type of acute appendicitis which, accordingIy. The Ieucocyte count is aIso * From the Department of Surgery, University of Michigan, Ann Arbor, Michigan. 102 NE\V SERIES VOI.. LVI. No. I Ransom--Appendicitis high, e.g., 25,000 to 30,000. If the infection as many as 77.3 per cent of patients dying continues unchecked, the unmistakable of appendicitis. Fortunately, general peri- picture of a terminal peritonitis develops. tonitis is not one of the common post- The pulse becomes rapid and thready, operative complications. When it does there is profuse diaphoresis, the skin -is occur, it mav be due (I) to contamination cold and clammy, abdominal distention of the peritoneum by transperitoneal is marked, the eyes are sunken, the expres- drainage of abscesses, (2) to failure on sion is anxious and there is paIIor and the part of the surgeon to drain when cyanosis, signs which denote impending drainage is indicated at the time of the death. It goes without saying that the most original operation, or (3) to an ill timed important treatment is prophylactic, i.e., operation whereby early- adhesion forma- recognition of the disease and removal of tion is interfered with; and what would be the appendix before infection has spread a localized infection if let alone, is con- beyond this viscus. The management of the verted into a spreading peritonitis. Occa- patient with general peritonitis remains sionally, because of an especially virulent a controversial matter. Many authors, type of infection, general peritonitis will (Horsley,6 Herrick,j Davis, Stafford and supervene regardless of the time and type Spron$ and others), advise prompt oper- of the original operative procedure. The ation regardless of the stage of the disease. subject of drainage is again a controversial It is our opinion that these patients with matter. The present day trend is to drain widespread or genera1 peritonitis are best less frequently than formerly, especially in treated by delayed operation and we cases in which a diffuse peritonitis is found recommend the Ochsner regimen in order at operation. However, the axiom, “When to improve the patient’s genera1 condition in doubt, don’t drain,” is capable of doing and to allow localization of the infection harm in the hands of young or inexperi- to take place before any operative proce- enced surgeons. Hanford”’ gives the follokv- dure is performed. However, we agree ing indications for drainage : with Allen and his associates that if one i I ) Any appendiceal abscess. With this sees these patients within four to six hours statement practically all authors agree. from the time of perforation, prompt Drainage is also advised when tissue of operation is best. By means of a careful doubtful viability must be Ieft in the history, very often the time of perforation abdominal cavity, e.g., (a) necrotic tissue, can be determined. There is often an acute such as part of the wall of an abscess; increase in the severity of the pain fol- (b) part of the appendix; CC) the whole lowed bv a period of temporary relief. of the appendix; (d) damaged tissue. In such instances, while there is soiling of such as the meso-appendix stump, which the regional peritoneum and perhaps an might become necrotic in the presence of early local peritonitis, the peritoneum is infection. capable of handling this limited amount of (2) In acute diffuse peritonitis with infection, provided further contamination creamv purulent or fibrinopurulent exudate is prevented by removal of the appendix. of considerable amount or with a malodor- Moreover, protective adhesions have not ous exudate. Some authors would disagree yet formed so that harm does not come with this statement. from an operation in this stage. (3) Insecure or doubtful closure of the As a postoperative compIication, general cecum or the appendix stump. peritonitis must be regarded as one of the (4) An unrecovered Ioose fecalith. most serious since the mortality is aIways (5) Gross soiling by cecal contents. high. From their study of the literature, (6) Infection or contamination of the Ochsner, Gage and Garsideg concIuded that retroperitonea1 tissue as in a retrocecal peritonitis may be the cause of death in appendix. 104 American Journal of Surgery Ransom-Appendicitis (7) UncontroIIed bIeeding or doubt as cIinica1 picture. In young and otherwise to the controI of bleeding. heaIthy aduIt patients, the usua1 picture As previousIy mentioned, genera1 peri- of genera1 peritonitis described above may tonitis may be the result of operative be observed. However, in eIderIy persons intervention which interferes with the or those weakened by their infection, fluid waIIing-off of a IocaI peritonitis folIowing and saIt imbaIance or by a proIonged perforation. In the case of a sIow perfora- operation invoIving excessive trauma and tion, as in the inflammatory type of hemorrhage, spreading or genera1 perito- appendicitis, the infection is effIcientIy nitis may exhibit a very atypica1 course. Iocalized if given a chance. In these Here the usua1 signs of peritonitis are sIow perforations, the defensive mecha- apt to be far Iess striking than usual. nisms of the peritoneum come into pIay There is commonly some abdomina1 dis- and prevent spread of the process by comfort and distention, associated with limiting the infection to the right Iower absence of peristaItic sounds. Nausea and quadrant or pelvis. Loops of intestine vomiting are common. The temperature and the omentum become adherent to may be high or, again, may be but sIightIy the cecum and appendix and adhesions eIevated. The puIse is rapid and Iater quickIy form. An abdomina1 mass may becomes thready and uncountabIe. There- become paIpabIe, aIthough this need not fore, in any patient who fails to do we11 be an abscess in the strict sense of this folIowing operation, the possibiIity of a term. The process terminates by progress- genera1 peritonitis shouId be considered ing to the stage of suppuration or, more and when suspected the usua1 regimen often, by spontaneous resoIution. Thus, (Ochsner) for the treatment of peritonitis in cases seen during the third, fourth or shouId be instituted. This consists in fifth day of the disease, with a mass FowIer’s position, hot appIications to the present or in the stage of deveIopment, abdomen, nothing by mouth, IiberaI quan- operation is best deferred. If performed tities of morphine, duodena1 syphonage, during this so-caIIed “danger period,” intravenous fluids, gIucose and sodium Love” points out that protective adhesions chIoride, bIood transfusions, oxygen and are broken down and a spreading or gen- drugs of the suIfonamide group.