Indications for surgery and risks of delay
An established diagnosis of acute appendicitis, including its phlegmonous form, is in itself an absolute indication for emergency surgical intervention — appendectomy. An expectant management strategy is unacceptable in surgical practice, because conservative treatment of destructive forms of inflammation cannot resolve the pathological process. It does not prevent further progression of the disease up to the development of gangrene and subsequent perforation of the organ wall.
The emergency nature of surgical intervention is strictly dictated by the high risk of developing severe complications with the slightest delay in surgery. Such life-threatening conditions include:
- Perforation of the appendix with the release of infected contents into the abdominal cavity.
- Development of local or diffuse peritonitis.
- Formation of a localized abscess — appendiceal abscess.
- Pylephlebitis — a most severe complication representing purulent thrombophlebitis of the portal vein.
Appendectomy itself can be performed using both traditional open access and laparoscopic technologies. However, if complicated forms (e.g., peritonitis) have already developed, the standard scope of surgical intervention inevitably expands: surgeons are required to perform thorough sanitation and adequate drainage of the abdominal cavity.
Erroneous interventions in Crohn's disease and endometriosis
A separate group of surgical complications consists of unjustified surgical interventions performed due to incorrect differential diagnosis. A classic example is the onset of Crohn's disease. Terminal ileitis (ileitis terminalis) in this disease very often proceeds under the clinical mask of acute appendicitis. Such a picture erroneously leads to unjustified appendectomies and even traumatic resections of the ileum.
To prevent such situations, there is a clear clarifying rule for operations in non-neoplastic lesions of the appendix against the background of terminal ileitis. If during abdominal revision the surgeon reveals a macroscopically unchanged appendix (i.e., there are no visual signs of secondary inflammation), it is strongly recommended to refrain from appendectomy. In this situation, bowel resection and ileocecal resection are also strictly not indicated (according to the clinical guidelines of the Russian Society of Surgeons from 2020).
In female patients, a frequent cause of emergency hospitalizations and erroneous surgical interventions is endometriosis. Acute pelvic pain in this pathology can reliably mimic the picture of an "acute abdomen" (abdomen acutum), including the clinical presentation not only of acute appendicitis, but also of acute intestinal obstruction, as well as intraperitoneal hemorrhage.
Infectious masks: yersiniosis, ascariasis, and amebiasis
A number of infectious and parasitic diseases can be accompanied by a clinical picture indistinguishable from classic appendicitis.
Special attention is deserved by yersiniosis ("pseudoappendicular") appendicitis. In approximately 30% of cases, the clinical presentation of yersiniosis completely mimics typical acute appendicitis. Symptoms usually develop against the background of pronounced intoxication and diarrheal syndrome, while specific extraintestinal manifestations such as rash and arthropathies are possible.
During the "pseudoappendicular variant" during surgery or diagnostic laparoscopy, the surgeon discovers pronounced changes (ranging from catarrhal to phlegmonous and gangrenous inflammation with perforation) in the distal small intestine, cecum, initial parts of the large intestine, and mesenteric lymph nodes. The appendix itself is minimally altered in this case. However, true appendicitis (from catarrhal to destructive forms) can also occur in yersiniosis. Destructive processes in the abdominal cavity during this infection are accompanied by extremely severe intoxication and are the main cause of complications and unfavorable outcomes. The final diagnosis and choice of tactics in such complex cases require the use of laparoscopy and laboratory diagnostics.
Regarding parasitic infestations, surgical complications of ascariasis can manifest as appendicitis, which is clinically no different from ordinary appendicitis and often becomes merely an accidental surgical finding. Similarly, appendicitis in amebiasis has no characteristic distinguishing features and proceeds as banal inflammation of the appendix.
Classic differential diagnosis
To minimize the risk of complications associated with incorrectly chosen tactics, the surgeon must clearly know the classic range of differential diagnosis for acute appendicitis. This list includes the following acute conditions:
- Pathologies of the digestive organs: acute cholecystitis, acute pancreatitis, perforated gastric and duodenal ulcer, acute intestinal obstruction, Meckel's diverticulitis, acute mesadenitis.
- Urological diseases: right-sided renal colic and acute pyelonephritis.
- Gynecological diseases (in women): acute adnexitis, ovarian cyst torsion, and ectopic pregnancy.
Thorough exclusion of these pathologies helps avoid both unjustified appendectomies and fatal delays in true destructive appendicitis.
The "Crohn-Ileitis" rule: if you see an inflamed bowel but a calm appendix — do not remove it! (To avoid unjustified resection and complications).
Class and exam questions
Why is it impossible to limit treatment to antibiotics in phlegmonous appendicitis?
Conservative treatment of destructive forms does not resolve the inflammatory process. It is unable to prevent the progression of the disease to gangrene and perforation of the appendix.
What complications will arise if surgery is delayed?
Delay leads to perforation of the appendiceal wall, development of local or diffuse peritonitis, formation of an appendiceal abscess, and pylephlebitis.
Should the appendix be removed if terminal ileitis is detected during surgery?
If the appendix is macroscopically unchanged and has no signs of secondary inflammation, appendectomy is strictly not indicated to avoid unjustified intervention.
How to distinguish yersiniosis appendicitis from ordinary appendicitis before surgery?
Yersiniosis is often accompanied by pronounced intoxication, diarrheal syndrome, and extraintestinal manifestations (rash, arthropathies). However, the final diagnosis often requires diagnostic laparoscopy and laboratory tests.
What else to study on this topic
- Pathogenesis and stages of development of pylephlebitis in destructive appendicitis.
- Technique of sanitation and drainage of the abdominal cavity in diffuse peritonitis.
- Laparoscopic picture of terminal ileitis in Crohn's disease.
- Differential diagnosis of acute appendicitis and Meckel's diverticulitis.
- Laboratory diagnostics of yersiniosis in emergency surgery.
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