CHAPTER 15 Appendectomy
Case Study
A 19-year-old male presents to the emergency room complaining of severe right-sided lower abdominal pain, nausea, and anorexia, which began 24 hours earlier. On physical examination, he has a fever of 100.5°F. His abdomen is focally tender on palpation of the right lower quadrant. His white blood cell count is within the normal range. A computed tomography (CT) scan of the abdomen and pelvis shows a thickened appendix and periappendiceal inflammation (Fig. 15-1).
Figure 15-1 Computed tomography scan showing a thickened appendix (A) and adjacent inflammation (B).
(From Rakel RE [ed]: Textbook of Family Medicine, 7th ed. Philadelphia, Saunders, 2007, courtesy of Dr. Perry Pernicano, Department of Radiology, University of Michigan Medical School, Ann Arbor, MI.)
BACKGROUND
The appendix is a blind-ended tubular structure arising from the cecum approximately 2 cm below the ileocecal valve (Fig. 15-2). Obstruction of the lumen of the appendix by fecal material (i.e., fecalith), a tumor, or lymphoid hyperplasia may result in elevated intraluminal pressures, vascular congestion, stasis, bacterial overgrowth, and inflammation. Without intervention, the resulting appendicitis may progress to wall necrosis and appendiceal perforation. Prompt diagnosis and management are critical to the successful treatment of appendicitis. Despite the high incidence of appendicitis, however, its diagnosis is not always straightforward. The differential diagnosis of appendicitis is broad and may include gastroenteritis, Meckel’s diverticulitis, colonic diverticulitis, inflammatory bowel disease, urinary tract infection, epididymitis, and gastrointestinal and reproductive tract malignancies. Women of childbearing age who present with abdominal pain pose a particular diagnostic challenge because pelvic inflammatory disease, ovarian cysts, and ovarian torsion can also mimic appendicitis.