Perforated Appendix

[lsu1000]

Can someone please explain why UW would say that a perforated appendix only needs hydration and antibiotics?

I though all appendicitis was a surgical emergency, especially if ruptured.
This poor kid can't even walk the pain is so bad.

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[ucbdancn00]

if i'm not mistaken (forgive me b/c i'm on ortho now, so it's all about them bones, lol)

appendicitis--> impending surgical emergency b/c it can rupture, so you want to get that out as soon as possible

ruptured appendix-->

I think it depends on the surgeon's experience, b/c I saw ruptured appy's being taken to the OR. I believe part of it lies in the presence of peritoneal signs vs the lack there of

when the appendix ruptures initially--> temporary relief of symptoms b/c you are decreasing the pressure an inflammed appendix was creating on surrounding tissues.

That being said, if the appendix has ruptured---> with leakage of all sorts of crap (including inflammatory junk), then all the surrounding tissue is at risk for developing inflammation which can lead to peritonitis and if not treated, bowel infarction

If the patient is doing well, and you are fairly sure the appy has ruptured I think the rule of thumb is to let things simmer down with bowel rest (NPO), adequate hydration (b/c of fluid leakage from perforation/inflammation), ABx to help cover bowel flora (ie. good ol' flagyl to help cover anaerobes) and interval appendectomy to be done at a later date. Because the bowel is at risk for being friable, you are at risk for damaging bowel which is a big problem....so i believe that is part of the answer to your question.

Many times this maybe done in conjunction with percutaneous drainage of abscesses that can develop. I think the interval appendectomy may be done percutaneously as well.

hope this helps, and sorry to have rambled on

g'luck

ucb

 

[allylz]

forgive me if I am thinking of the wrong question, but isn't that one about a guy who's coming in after 5 days, so the point is that it's a sort of insidious appendicitis, and that's why you only need the IV hydration/antibiotics?

 

[lsu1000]

Yes, he does come in after many days and by that time it's ruptured.

 

[Idiopathic]

Yes, he does come in after many days and by that time it's ruptured.

Is that your assumption or is it spelled out?

 

[lsu1000]

Is that your assumption or is it spelled out?

The answer explanation says it's ruptured.

 

[SuitsYou]

Probably viewing it as a walled off abcess with appendectomy to be carried out at a later stage? Hence the need to treat with fluids and abx for now

 

[Shah_Patel_PT]

The answer explanation says it's ruptured.

Assuming the Q said, 5 day old ruptured appendix and pt. is stable:

You treat conservatively because to operate on this patient would be difficult if the abscess/scar ruptured, plus there is increased risk of peritonitis.

 

[46&2]

From Sabiston's Textbook of Surgery (please excuse the length):

There is general consensus that a localized appendiceal abscess from perforated appendicitis can be initially managed with CT-guided percutaneous drainage or limited surgical drainage. When the drainage is combined with adequate antibiotic and fluid administration, most patients will respond to this conservative management and can be discharged without fever or abdominal pain. Controversy exists, however, as to whether interval appendectomy (performing an elective appendectomy in the “interval” between bouts of appendicitis) is necessary to prevent recurrent bouts of appendicitis. In one study that compared early with delayed appendectomy after appendiceal mass formation, 15% of the patients in the delayed group had a recurrent acute episode during the waiting period. The authors concluded that despite a slightly higher incidence of wound infection in the early appendectomy group, it appeared safe and cost effective to remove the appendix early rather than waiting 6 to 10 weeks"

"In one long-term follow-up of patients with an appendiceal mass treated nonoperatively, only 1 of 10 patients required appendectomy. The rest remained asymptomatic with their appendix intact.[36] The risk of recurrent appendicitis must be balanced against the risk of interval appendectomy. In general, the younger the patient, the higher the lifetime risk of recurrent appendicitis and the lower the operative risk. Although many pediatric surgeons (including ourselves) perform interval appendectomy routinely at 8 to 12 weeks in children, the risk in patients older than 30 to 40 years of age probably would not support this policy."

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Coincidentally, we had a patient recently with a similar scenario, i.e. symptomatic appendicial abscess. They operated. In conference this AM, however, they discussed whether nonoperative management could be done. It's still controversial (as the book suggests) and depends on the particulars of the scenario.

 

[Doc Ivy]

I talked to my chief about this question, and she told me something that pretty much applies to any potential "itis" in the belly. If a patient has acute surgical abdomen and sxs have been present for 48 hours or less, you go to the OR as soon as possible. After 48 hours, that is a hostile abdomen and in general you'll want to cool the person off with IV fluids and anitbiotics and operate electively in 4-6 weeks when inflammation has settled down.

 

[Sugar72]

If the appendix has ruptured - there is nothing left to take out - it has exploded...it is gone. If there is an abscess you can drain it, if it is perforated there is still an appendix to take out so I would let it cool down like a previous poster said. In my experience with test questions and pimping there is a difference between perforated and ruptured.

 

[boston]

If the appendix has ruptured - there is nothing left to take out - it has exploded...it is gone. If there is an abscess you can drain it, if it is perforated there is still an appendix to take out so I would let it cool down like a previous poster said. In my experience with test questions and pimping there is a difference between perforated and ruptured.

What is the distinction between perforated and ruptured with regard to appendicitis? Please clarify...