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L'appendicite Acuta Questa «Sconosciuta» L’appendicite acuta questa «sconosciuta» Monica Ortenzi XIX congresso SICE, Ancona, 30 Settembre-1 Ottobre 2019 1522 Mc Burney’s Berengario Da Carpi, first description point 1561 Gabriele Falloppio and the «worm» 1570 Caspar Bauhin and a new theory of its purpose The mysterious appendix De Souza SC et al. Journal of Coloproctology, 2015, 35.4: 212-216 Mestivier Lawson Mc Burney Ott Acute appendicitis Double purse string and his point Transvaginal route 1735 1812 1886 1902 1759 1880 1889 1908 Aymand Parkinson Fitz Sir Treves The perforated A new name Appendectomy First appendectomy appendix in English and antisepsis The technique before the disease 90–100 patients/100 000 inhabitants per year in developed countries Geographical differences: lifetime risks for appendicitis of 16% in South Korea, 9-0% in the USA, and 1-8% in Africa More common the second or third decade of life “……Since Dr Fitz described appendicitis in 1886 the incidence has climbed, declined, and then plateaued in Western countries, whereas newly industrialized countries appear to be in the first stage of this sequence….” The most common abdominal emergency worldwilde…. Ferris M, et al. Annals of Surgery, 2017, 266(2):237-241 Female 2500 Male 2000 1500 1000 500 1 2 3 4 5 6 7 8 9 10 11 12 Ceresoli M, et al. World J Gastrointest Surg. 2016;8(10):693–699. …….yet the least understood “..It seems surprising and somewhat ironic that the diagnosis of acute appendicitis, one of“ the most common made by anatomic pathologists, remains poorly defined, subject to misconceptions, and prone to variable terminology….” Bhangu A, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. The Lancet, 2015, 386.10000: 1278-1287 Gender prerogative? Slight male prevalence Non perforated appendicitis Non perforated appendicitis x Negative appendicetomy Negative appendectomy x Delayed diagnosis Livingston WH, et al. Annals of surgery, 2007, 245.6: 886 Buckius MT, et al. Journ of Surg Res, 2012, 175.2: 185-190 Marudanayagam R et al. Journ of gastr, 2006, 41.8: 745-749 Am J Epidemiol. 1990;132(5):910–25 Addiss DG, et al.. Seetahal S, et al. The Am Journ of Surg, 2011, 201.4: 433-437 Donlan S, et al. The Am jour of emerg med, 2009, 27.7: 856-858 ETHNICAL GENETIC ENVIROMENTAL DIET HERITAGE TRANSMISSION INFLUENCE ? ? ? ? 3 times higher risk if positive familiar Less common in non-white Seasonal peak during the summer Correlation with low fiber intake history Increased risk of perforation in 30% of variation in risk in twins minority groups Scand J Surg Wei PL, et al. J Surg Res 2012; 670–76 Anderson JE, et al. World J Surg 2012; 36: 2787–94 Ergul E. 2007; 96: 290–92. 178: Burkitt DP. Clin Radiol. 1973;24:271–280 Br J Surg Addiss DG, et al.. Am J Epidemiol. 1990;132(5):910–25 Lee SL, et al. Arch Surg 2011; 146: 156–61 Sadr Azodi O, et al. 2009; 96: 1336–40 Fares A. Ann Med Health Sci Res. 2014 Jan;4(1):18-21 Direct luminal obstruction…. FECOLITH LYMPHOID HYPERPLASIA IMPACTED STOOL PARASITES APPENDICEAL TUMOUR CECAL TUMOUR Forbes GB, et al. Calculous disease of the vermiform appendix. Gut, 1966, 7.6: 583 Arnbjörnsson E, et al . Acta chirurgica scandinavica, 1983, 149.8: 789-791 …..the exception rather than the rule Bacterial APPENDICITIS infection Peeters T, Toon, et al. Future microbiology, 2019, 14.02: 111-127 An infective disease? Swindisky A, et al. Gut, 2011, 60.1: 34-40 Lamps LW. Infect Dis Clin North Am 2010; 24: 995– 1018Zhong D et al. Journ of ped surg, 2014, 49.3: 441-446 Jackson H, et al. PloS one, 2014, 9.4: e95414 ACUTE APPENDICITIS Transmural appendix inflammation (neutrophilic infiltration of the mucosa, submucosa, and muscularis propria) SUPPURATIVE/PHLEGMONOUS MUCOSAL APPENDICITIS? GANGRENOUS More common in females Higher Alvarado scores No diagnostic imaging PERFORATED Carr N. Annals of diagnostic pathology, 2000, 4.1: 46-58 Pieper R, et al. Ann Surg. 1983 Mar;197(3):368-74 Mizumoto R, et al. ANZ journal of surgery, 2018, 88.4: E284-E288 Rosai J.10th ed. China: Mosby; 2011. p. 714-6 Most common misdiagnosis in men Percentage Abdominal pain in RLQ 16.4 Diverticulitis of the colon 10.2 Mesenteric lymphadenitis 3.3 Intestinal adheisons with obstruction 2.9 Benign colonic mass 2.6 Acute mesenteric ischemia 2.6 Gastroenteritis 1.9 Malignant sigmoid mass 1.5 Meckel’s diverticulitis 1.5 Abdominal pain with site unspecified 1.4 FEVER VOMITING Most common misdiagnosis in Percentage Most common misdiagnosis in Percentage Pain (91.2%) women (18-45) women (>45) Abdominal pain in RLQ 16.4 Malignant ovarian disease 16.5 Tenderness (69.6%) Ovarian cyst 9.2 Malignant uterine disease 4.6 Vomiting (42%) Endometriosis 6.8 Diverticulitis of the colom 4.6 Condition associated with antepartum 3.5 Uterine leiomyoma 4.0 Fever (24.7%) Mesenteric lymphadenitis 3.0 Benign ovarian neoplasm 3.8 Diffuse tenderness (11.7%) Leiomyoma 2.8 Intestinal adhesions with obstruction 2.6 Malignant ovarian disease 2.5 Peritoneal metastasis 2.6 Benign ovarian neoplasm 1.7 Benign colonic neoplasm 2.1 Sartelli et al. World Journal of Emergency Surgery (2018) 13:19 Female pelvic peritoneal adhesions 1.5 Endometriosis 1.9 Peritoneal adhesions 1.5 Ovarian cyst 1.7 Seethal S, et al. The American Journal of Surgery, 2011, 201.4: 433-437 From medical school textbooks BLUMBERG SIGN PSOAS SIGN ROVSING SIGN ROTTER SIGN AARON SIGN ARAPOV CONTRACTURE BASSLER SIGN DUNPHY SIGN MARKLE SIGN OBTURATOR MASSOUH SIGN SITKOVSKIY SIGN SIGN VOLKOVICH-KOCHER SIGN The natural history of perforation LUMINAL INTRA-LUMINAL VENOUS + LOSS OF OBSTRUCTION PRESSURE LYMPHATIC MUCOSAL BARRIER CONGESTION PERFORATION 15-35% AT 72 h When in doubt take it out? Temple C, et al. Annals of surgery, 1995, 221.3: 278 Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 January 10; 385(9963) RISKS? APPENDICITIS APPENDECTOMY SAGES guidelines SSA guidelines ACOI guidelines CONCLUSIONS Acute appendicitis is a poorly understood disease Its diagnosis is still based on clinical judgment There is great variability among surgeons The decrease of its incidence could be explained by the introduction of clinical scores and consequent more attention to diagnosis Of all the ills within the abdomen Which cause affliction to the sons of men There's none more often puts them in a fix Than trouble in the worm-like appendix- That caecal tail which sometimes tells a story Or figures in a scene which may be gory, That arch-deceiver, symbol of the devil Which leads to every kind of septic evil, That unexploded bomb which soon or late Aperients may serve to detonate; That worm which often turns to bad effect And makes us treat it with a great respect, That foul assassin whose supreme delight Choosing the place and knowing well the site To stab below the belt and on the right is Thank you…… Causing that dread disease - appendicitis..
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