Acute appendicitis incidental to gynecologic abdominal procedures

ACVMl E.

(From

M.

AZ%@S&DEGI~ A388mAL

ROSSET,

M.D.,

AND

A.

ZI’RB PIit S. (JONSTON,

3 M.D.,*

the Departmentof Gynecology and the Department

PHILADELPHIA, PA. of Pathology, Mt. Sinai Hoep~alj

NCIDENTAL appendectomy is practiced in the Department of Gynecology at the Mt. Sinai Hospital, providing the nature of t.he primary operation permits and the appendectomy does not contribute additional hazard to the patient. All tissues excised are examined by the Department of Pathology and their report invariably comments upon the appendix. These reports have indicated a definite incidence of “acute appendicitis” as a microscopic diagnosis of t,he incidentally removed appendix (Table 1 j. Since most of the patients iu our Department are nonemergenry admissions with a. one week’s wait before entering t.he hospital, and since they did not have obvious signs or symptoms of appendicitis, we hrcarne interested in the explanation for such findings. As a first step we reexamined our criteria for the diagnosis of appendicitis; we compared our st,andards for the microscopic diagnosis of early appendicitis with those of ot,her pathologists in this area, as well as with t,he criteria as outlined in the various textbooks of pathology; and finallyY we resurveyed the various theories of the pathogenesis of appendicitis. All this was done in the hope that we could find an explanation for the “acute appendicitis ’ ’ accidentally encountered during our gynetologic abdominal procedures. Material

I

Tn 401 abdominal gynecologic operations, from March 1, 1948, to Feb. 28, 1.950, inclusive, 210 incidental appendect,omies were performed. The failure to perform appendectomies in 191 caseswas probably due to the unwillingness under the circumstances to expose the pat.ieut t.o increased risk, or because of previous appendectomy. During this period 25 cases of incidental acute appendicitis of varying degrees were diagnosed micros.copically in the examination of 210 specimens (Table I). This 12 per cent incidence appeared to be st.rikingly high, especially since all f:ases with suspirious history or signs of appendicitis were discarded from bhe study. The age of this group of 25 patients ranged from 22 to 46 years with 60 per cent. between 35 and 45 years of age. Tn 21 of these 25 cases with inpidental appendicitis, primary surgery was for either fibromyoma or ovarian cyst. In one case, endometriosis of the pelvie organs was the sole lesion, and in three instances it was the associated lesion. Adenomyosis was encountered twice with fibromyomas. Four major lesions of the Fallopian tubes were noted, all representing inflammatory changes of varyi.ng degrees. The operative procedure usua.lly was total hysf.erectomy or removal of the affected adnexa. -*Now

Chief

of Laboratories,

Valley

Forge 13 31;

Army

Hospital,

Pa.

Volume Number

6I 5 TABLE

ACUTE I.

TYPE

APPENDICITIS

OF ACUTE

AND

GTNECOLOGIC

APPENDICITIS NOTED APPENDECTOMIES

Acute appendicitis Acute focal suppurative appendicitis Low-grade acute appendicitis Acute subsiding appendicitis Total

IN 25 INSTANCES

1137

PROCEDURES IN 210 INCIDE~YT~L

7 6” 7 25

--

In retrospect, we checked the clinical history of the 25 patients with a recent history of right “microscopic acute appendicitis. ” We considered lower quadrant abdominal pain and tenderness, elevated leucocyte count, recent fever, and nausea as the clinical criteria for diagnosis of appendicitis. In each reviewed instance where a patient had one or more of the a.bove symptoms or signs, a pathologic lesion ot,her than a,ppendicitis was present to account for the symptoms (Table JI). Tn most instances such lesions were degenerating fibromyomas or a degree of salpingitis. In one case (No. 15) early torsion of an ovarian cyst gave rise to elevated t,emperature, pain, and slightly increased leucocyte count. Criteria

for Histologic

Diagnosis

of Early Acute Appendicitis

Our histologic criteria for the earlier phases of appendicitis are based upon the presence of an appreciable number of neutrophilic leucocvtes in the appendiceal lumen, or the presence of neutrophilic leucocytes & mucosal stroma, with or without luminal exudate. An increased number of eosinophiles in the tissue was taken to indicate subsidence of the acute process. We do not classify lymphoid hyperplasia, per se, as a form of appendicitis. Our criteria follow those listed by Wangensteen’l, I2 more closely than those indicated in the standard textbooks of pathology. It should be revealed that as a rule only one or two sections of an appendix are taken for study. The majority of standard textbooksl> x 3. 4 consider t,he earliest lesion of acute appendicitis t,o be a focus of acute inflammation consisting of ulceration of the epithelium with an underlying collection of neutrophiles. HerbuP considers the earliest evidence of an inflammatory lesion to be congestion of the mucosal and submucosal capillaries with leucocytic margination and beginning extravasation. This is similar to the description of Foot” and Royd? for acute catarrhal appendicitis. Five .leading pathologists in the met~ropolitan area were questioned as to their criteria for the diagnosis of early appendicitis. The npinions varied greatly from t,hose essentially similar to ours to those more exacting. These basic criteria are listed as follows, each opinion being that of an individual pathologist : 1. Leucocytic estrarasation in perivascular spaces. 2. The presence of leucocytes in the lumen or in the gland crypts. 3. The presence of granulocytes in the muscularis (disregarding inflammatory cells in the mucosa). When leucocytes are present in the lumen more sections are taken. 4. Leucocytic infiltration of mucosa or mucosal ulceration in addition to luminal exudate to diagnose early appendicitis. 5. Acute inflammatory cells in muscularis or serosa; or, when these cells are present in the mucosa, epithelial ulceration. The 25 “acute” slides in our series were then re-examined and the criteria of these pathologists and those of the textbooks were applied and a coniposite table of diagnoses was made (Table III).

20

NO

so

x0

Two months npo and recently .s es

17

99.4 and 99.8 once in 5 days so

xl0

No

No

Occasionally in past 3 months Entire lower abdo men 3 months

9

15

NO

xi0

so

x

to 102 fo1 :; days

) PREOPERATIVE / FEVER No NO

ql

NO

7

Yes NO

SAUSEA

NO

KLQ and LLQ One episode 2 years ago

2 3

CASE NO.

--

RIGHTLOWER QUADRANTPAIN AND TENDERNESS

8,600

7,000

s1,300

6,500

14,200

6,800

9.100 131200

x0.

IS

SIGX

RRSPONSIHIX

OR SYMPTOM

1’BOHABT.T

POfl

tubal Fkgcnt~rated

Right

fibromyoma

pregnancy

I kgenerated fihromyoma (‘hroni(: hronrhiectasis with secondary polycythemia. Ovarian cyst IWmonarg tuberculosis probably xct,ivr, degenerat,ed fibromyoma I ktgenrratiug submucous myoma ijr6-l truding through cervix Endomrtriosis involving all pelvic o1 gane. Perisalpingitis Benign scrous cystadenoma left nvxry with early torsion

LESII

Volume Number

ACUTE

61 5

APPENDICITIS

AND

GYNECOLOGIC

1139

PROCEDURES

By consulting Table III, one notes a downward revision from our figures of incidental appendicitis, slight in one instance and more marked in others. Nonetheless, a definite percentage exists no matter what criteria are utilized. We, therefore, can point out with assurance that the incidentally removed appendix can present inflammatory changes in a rather significant incidence. TABLE

III.

VARIOYS ..____..

CRITERIA

AND

INCIDENCE ENCOUNTERED

-~__-. KO.OF CASES

-.

CRITERIA

-7;.

-___--~___

Sinai Pa.thology Pathologist Pathologist

series Hospital textbooks No. 1 No. 3

Pathologist No. 34 Pathologist No. 5 Average excluding Mt. -___-_.

OF &XTE

0

Sinai

series

APPENDICITIS

% TOTAT,

ACCIDENTALLY _ -.~--AGREEMENT %

Hi 17

12.0 4.9 10.5 8.1

40 88 68

178 17 15.1

3.8 X.1 8.1 7.3

ii 68 60 ~~~~ ~~~~~~~----~

25

~~~~~~

-

Utilizing these various groups of criteria, a definite incidence of pathologically acute appendicitis is noted to average 7.3 per cent (Table III). Shelley* in 2,065 consecutive incidental appendectomies noted acute appendicitis to occur in 2 per cent of his cases and chronic exudative appendicitis (late stage in recovery from acute appendicitis) in 8 per cent. This chronic exudative appendicitis is apparently similar to acute subsiding appendicitis in which the lumen, blood vessels, and perivascular tissues frequently contain some polymorphonuclear leucocytes, and there is an associated dense extensive infiltration with the various cells typical of chronic inflammation, and often chronic edema. Kline9 in reviewing 150 consecutive incidental appendectomies found an incidence of 5 per cent acute appendicitis chiefly in association with right inguinal herniorrhaphy. In his cases there was no elevation in temperat,ure or leucocyte count. There was nothing of significance in the history of his patients referable to acute appendicitis. The occasional case with indigestion or pain was interpreted as due to the presence of the hernia. Inspection at, the operating table, he felt, was unreliable in determining absence of early appendicitis and therefore he advised routine removal and microscopic esamination. Comment While our incidence of accidentally encountered appendicitis (12 per cent) is h.igher than the others quoted, we feel that a significant number of cases of asymptomatic appendicitis do occur. The pathogenesis of appendicitis is explained by one or both of two theories. The Aschoff theory of appendicitis, supported by Gray and Haifetz, as quoted by Malloy’O and associates, states that lymphoid hyperplasia in the appendix may cause stasis in mucosal crypts due to occlusion of either t.he appendiceal lumen or the crypts themselves. With stasis in crypts, inflammation within them may soon follow, spreading in the form of acute suppurative or gangrenous appendicitis. Wangensteen and collaboratorsll, lZ feel that appendicitis begins as a closed loop obstruction. They listed lymphoid hyperplasia as one of the fattors which may be responsible for the obstruction. This group of workers duplicated all phases of acute appendicitis in man by ligating the bases of exteriorized appendices ; a condition for success of the experiment was that the exteriorized appendix contain a secreting and relatively intact mucosa. Col-

11-M

l?ORHE’I

icky

pains

lion

of

were

~~rotluted

egress

01’

1e11tled 1)~ mirtinlal lion (cAitrly) I73LIltPd (‘Ill’fiS.“’

ill

l\S

in

rspedtrtetlt;tI

apl)entlicea[

flui(l.

illflWllllllatc,r~

1lLLlll~l’oLlS

1, ~‘~~SS’LV

appendicitis

Early

cb;rlrgr+.

1j.v telnpc,rylry

:il)penilicntiir ;11t<1 wI~:Ise

ill I)l*ollrj~t Ycxl);lil, I,!’ Ilrc* gyllrVc~~ogi~;li

:

)N

injluvcl

~l~)t~l’;liic~Jls.

,rl

!i>.f Lb i,, .,r hl .\ I ‘.’ o~~st~‘Lrv-

c~hstrnc~fic~ri bxh aI:I~bpentlic~c~irl ~~l~slr~i~~

fishlic. S;liZ’

lllilJ1.b’

l;lI’ye

;krlil

(‘r)l!i-

imrativelq- healthy i~]~l)t’ntlices. Iiut \t‘;1z1ill1 t)ressctl wii 11 the fwquc~rlcy (&I’ IIIOchanica.1 disturbances. c~ungenitwl ha 11~1s >III(l iuAamnt;ttt,ry adhesions whical! held the ;ll)pentlis in unnatural i)c)sititrlis tint1 Itlight t)(i int,erfering lvith iis emptying. BllZltolttic i’t’cali~ll.itics. h(i Iwlir~rtl, aplwar It+ he often respnr~sil~le for the development of the (slul)-shapeql aljl)rntlis or ot l1t.r loca.lixrtl inflanlmzltioli. .liatelp, (‘LxJ~I is has rr;dvisetl roI.It ine irrciclental ;LI)I~~II~le(~t~olIL!’ ruLlrss then)

are

definil

tx (‘(~lltl*iliJJtlic;lti(~JJS.

”

l‘herefo~~e, to vspl;tin the ilsYltll)t(ittlitfiC I’;ISC of ;~c*utr ;~ppeuclicitis. !IJI~! must postulate the o(a(+urretl(7’ 01’ v6’l.y i‘wcplc~tlt. e~Gsotlcs of app~~ndifXlliii* itiflammation without ;I I)redolni~l;r~lt ot~strut~ti\-e fat*tor to protluce symptoms. The nhility of the appentlis to ht~itl has IKW~ show1 11y \V’anpensteen ad his co-workers.“. ” ;mtl it’ ;Il)l’c’l~(li(.ul;rr, c)l~t rlldion is miGil~)nl and SOOIL releasetl ;Ind if the ~)C?‘~fOtl~‘ill Slll’fiIC’t’S :lI’P Ilot ill\-ll~~CV~. S~~J~JI,toIllS Will 1JOt hWJTlP Xl’jxiJ.eJJt.

Many authorities”‘, ’ I. “’ ~iin 1x1 quotc~l iis pr;retic*ing routine inc~itlental ;IJ)~xnclectomy. except xvhere ol)vicbusly inadvisable Itecausc of its position antII cliffitultg in removal, or l~aose of ill(~rensecl haz,wrd 111the poor-risk patient 1)~ increasing thtb Ieng:‘th of the o])cr:l~iori. I:erkelry ;III~I RP,ortnvy.“’ I~ow~rt~~~. clissent l’~wm t,his opinion. There is 110 I1e~c1 :\t the I)rrsent to llt.ge the routine irlcitlt~ll~al removal of the nppcnrlis (luring the cursed of i1 Idvie operation, since such praet,ice has heen alulost uni\-ersally ;Itloptetl. I:ut it is gratifying to realize that as a resuit of this l)t*il(~ti~e, iIlJ inflamed though asyrl-ptomatie appendix has. O~J OF casion. heen csdsrtl.

Conclusions I. There is :I clefirlite incitleller ~)f ttticroscopic* i\c*ute appendicitis in I he incidentally removetl al)ptdis. 2. l’heories of pathogenesix can explain t.he asymptomatic case of appendicitis. If the factors of production. especially- ol&ruction. are minimal. slight changes may occur without sympt,oms. :I. Acute infl;lnmlation of the apl)ettdis may OCCLW wit,h greater Frequenry t,han appreciated. since such episodes can be asymptomntic. 4. Continuation of routine incictental appendectomy is aclvisahle provided risk to patient is nd incmasecl.

References 1. Boyd, William: A Text-Book of Pathology, ed. 5, Philadelphia, 1947, Lea & Febiger. 2. MacCallum, W. CT.: Textbook of Pathology. ed. 6. Philailelphia, 1937, 1%‘. B. Saunders Company. ::. Ogilvie, R. F.: Pathological Histology. ed. 3, Baltimore, 1947, The Williams & Wilkins Cornpan)-. 4. Forbus, Wiley I).: Beaction t,o Injury, HaItimore, 1943. The Williams & Wilkins Corn. pany. 5. Herbut, Peter A.: Surgical Pathology, Philadelphia, 1948, Lea. $ Febiger. 6. Foot, N. Chandler: Pathology in Surgery, Philadelphia, 1945, J. R. Lippineott Company. 7. Boyd, William: Surgical Pathology, ed. 6, Philadelphia, X947, W. 3. Saunders Company. 8. Shelley, H. J.: Arch. Surg. 35: 621, 1947.

Volume 61 Number 5

ACUTE

APPENDICITIS

AND

GYNECOLOGIC

PROCEDURES

1141

9. Kline, L. B.: M. Bull. Vet. Admin. 13: 32, 1936. 10. Malloy, H. R., Jason, R. S., and Drew, C. R.: Am. J. Surg. 67: 81, 1945. Il. Wangensteen, 0. H., Buirge, G. E., Dennis, C., and Ritchie, TY. I’.: Ann. Hurg. 106: 930, 1937. 13. Burge, R. E., Dennis, C., Vareo, R. L., and Wangansteen, 0. H.: Arch. Path. 30: 481, 1940. Textbook of Gynecology, ed. 5, Philadelphia, 194i, W. B. Saunders 13. Curtis, Arthur H.: Company, p. 681. 14. Wharton, Lawrence R.: Gynecology With a Section on Female Urology, Philadelphia, 1943, TV. B. Saunders Company, p. 733. 15. Te Linde, R. W.: Operative Gynecology, Philadelphia, 1946, J. B. Lippincott Company. A Textbook of Gynecological Surgery, ed. 5, 16. Berkeley, Comyns, and Bonney, Victor: New York, 1948, Paul B. Hoeber, Inc. 255

SOUTH

17~~

STREET