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Perforation of the bowel associated with acute appendicitis
CASE REPORTS
Perforation
of the Bowel Associated Acute
with
Appendicitis
CARL R. GROSZ, M.D., PETER K. KOTTMEIER, M.D., ASCHER L. MESTEL, M.D.,AND BERTRAM D. COHN, M.D., Brooklyn, New York
From the Pediatric Surgical Service, Defiartment of Surgery, Bate Universityof New York Downstate Medical Center, Brooklyn, New York.
CUTE APPENDICITIS COntinUeS t0 be a com-
A
mon surgical problem. Although it would appear to be a well documented subject, the morbidity and mortality have not approached their potential low. The treatment of this disease has changed little since the inroads made by antibiotics. In many reports there is good evidence that morbidity and mortality are associated mainly with the ruptured appendix, and the complication rate is in the area of 30 to 40 per cent in cases of ruptured appendix whereas it is in the range of 2 to 6 per cent in cases of unruptured appendix [l-3]. Since acute appendicitis was first described by Heister in 1755 [4] and the first appendectomy was performed in 1884 [5], recorded complications have been numerous. The most common complications after acute appendicitis with rupture and perforation are infection of the superficial tissues, continuing peritonitis, and intestinal obstruction [2,4,6]. Although the terms “typhilitis,” “perityphilitis,” and “perityphilitic abscesses” were described by Fitz [7] many years ago, these terms have fallen into complete disuse, and there is little mention in the surgical literature of pathologic processes of the cecum or other areas of bowel as being associated with acute appendicitis. Bockus [4] stated that, “Fistula and sinus formation may eventually occur when an abscess forms. Inclusion in the wall of an ap-
pendiceal abscess of part of a hollow viscus such as the pelvis of the kidney, the cecum, urinary bladder, vagina, sigmoid, or rectum may result in rupture of the abscess into that organ with fistula formation.” In the past three years, we have had five cases of ruptured appendicitis which resulted in necrosis of a portion of the cecum or large bowel. This appears to be a formidable complication which, if unrecognized, could well be fatal, and it appears to us that it is worth while to point out this possibility as treatment is straightforward. CASE REPORTS CASE I. This four year old boy was admitted in June 1963 because of vomiting of three days’ duration and abdominal pain. The patient had also noted diarrhea for two days. On admission, the patient’s temperature was 39.1 "c.Physical examination revealed a rigid abdomen and hypoactive bowel sounds. The white blood cell count was 25,000 per cu. mm. The diagnosis of acute appendicitis was made and the patient was taken to the operating room. A necrotic, perforated appendix was found with abscess formation and necrosis of the anterior surface of the cecum and ascending colon which was in contact with the appendix and abscess. Appendectomy was performed and the portion of cecum and ascending colon with necrosis was exteriorized. This formed a functioning colostomy, and three weeks later the patient was returned to the operating room where resection of the distal ileum and ascending colon was performed with an ileotransverse anastomosis. The patient was discharged one week later.
Bowel Perforation and Acute Appendicitis CASE II. This eleven year old boy was admitted in May 1965 because of abdominal pains of three days’ duration which had been most notable in the right lower quadrant for the preceding twentyfour hours. Temperature on admission was 38”~. and the white blood count was 15,000 per cu. mm. The patient had tenderness throughout the abdomen with no rebound tenderness and active bowel sounds. .I diagnosis of acute appendicitis was made and the patient was taken to the operating room. On exploration, a perforated appendix with abscess formation was found, and the anterior surface of the cecum which was in contact with the abscess cavity was necrotic. A hole measuring 2 cm. in diameter was found in the cecum. The area of necrosis was trimmed from the cecum and a single layer interrupted silk closure was performed. The area was drained and the patient was discharged one week later. CASE III. This ten year old girl was admitted in August 1965 because of abdominal pain, nausea, anorexia, and vomiting for six days. Pain was localized to the lower part of the abdomen. Temperature on admission was 38.2’~. and the white blood count was 22,X0 per cu. mm. Physical examination revealed moderate tenderness with minimal guarding in the right and left lower quadrants. On rectal examination, a tender mass was present high in the cul de sac. The patient was taken to the operating room where a gangrenous appendix was found. After separating the appendix from adhesions to the posterior aspect of the rectosigmoid, a 3 cm. defect was noted in the rectosigmoid, with friable granulation tissue at its edges. There was no abscess cavity. Appendectomy was performed, the rent in the colon was approximated with several chromic sutures through all layers, and transverse colostomy was established through a separate incision The patient was discharged, and two and a half months later she was admitted for closure of the colostomy; her course, thereafter, was unevent-
id.
CASE IV. This eighteen year old girl was admitted in September 1965 because of abdominal pain, nausea, and vomiting. She had noticed the pain for three days was more severe in the lower part of the abdomen. The temperature was 38.2’~. and the white blood count was 18,200 per cu. mm. On physical examination the patient was in acute distress from abdominal pain, with diffuse abdominal tenderness and spasm. The patient was taken to the operating room where an acute gangrenous appendicitis with peritonitis was found. There was an area of cecal perforation, which was closed with interrupted silk sutures. The postoperative course was uneventful. CASE v. This six year old girl was admitted in February 1965 because of abdominal pain of three Vol.
113.
February
1967
27T
days’ duration which had become localized in the right lower quadrant in the previous twenty-four hours. The temperature was 38.2”~. and the white blood count was 15,000 per cu. mm. Physical examination revealed tenderness and spasm of the right lower quadrant. The patient was taken to the operating room where a perforated appendix was found attached to a necrotic cecum. The appendix was removed. The necrotic area of the cecum was debrided and the defect closed. The patient was discharged on the ninth postoperative day. COMMENTS Wangensteen et al. [8] appropriately described the appendix as the Uriah Heep of the abdomen. The cecum and contiguous bowel could certainly be described as the Mr. Wickfield of the abdominal cavity. The close association of the cecum with the appendix can and does cause disease of the bowel. Mock [9] thought the underlying cause of diseased organs in continuity with acute appendicitis was local interference of the blood supply. When the surrounding inflammatory mass is composed of cecum or other portions of bowel, it appears that the inflammation occasionally causes necrosis of the bowel also. These cases illustrate an interesting complication which may follow the perforation of an appendix. They point out the need for good exposure and exploration when a ruptured appendix is found. Certainly, in the past, it has been the practice many times to drain an abscess and perform an interval appendectomy. It is common practice for the operating surgeon to use a McBumey incision and then by blunt dissection with his finger to free the diseased appendix, bring it into the wound, and complete appendectomy without having visualized the bed of the appendix. If under these circumstances there is a perforation of the large intestine, the perforation might well be overlooked; the patient might then be added to the list of morbidities or mortalities. It seems worth while, therefore, to point out that good exposure of the appendix and the area surrounding it is paramount. SUMMARY Five cases of perforation of the bowel due to gangrenous appendicitis are presented. These cases emphasize the need for good exposure at the time of the original operation for gangrenous appendicitis. If perforation of the bowel is found at exploration, primary repair
278
et al.
may be possible; however, more extensive resection or exclusion may be necessary. REFERENCE
1. BALES, E. T., JR., IRETON, R. .T., and CLATWORTHY, H. W., JR. Acute appendicitis in children. Arch. surg., 79: 447, 1959. 2. HUBBELL, D. S., BARTON, W. K., and SOLOMON, 0. D. Appendicitis in older people. Surg. Gyner. 6 Obst., 110: 289, 1960. 3. MCLAUTHLIN, C. H. and PACKARD, G. B. Acute appendicitis in children. Am. J. Surg., 101: 619, 1961. 4. BOCKUS, H. I.. Diseases of the appendix. In: Gastroenterology, vol. 2, chapt. 75. Edited by Banks, R. W. Philadelphia, 1944. W. B. Saunders Co. 5. BONILLA, K. B., HIGHES, C. W., and BOU’ERS, W. F
6.
7.
8.
9.
Experiences with management of the ruptured appendix. Am. J. Swg., 102: 438, 1961. OCHSNER, A., GAGE, I. M., and GARSIDE, E. The intra-abdominal post-operative complications of appendicitis. Ann. Surg., 91: 544, 1930. FITZ, R. H. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Boston AL Ep S. J., 115: 13, 1886. WANGENSTEEN, 0. II., BUIRGE, R. E., DENNIS, C., and RITCHIE, W. P. Studies in the etiology of acute appendicitis. The significance of the structure and function of the vermiform appendix in the genesis of appendicitis. Ann. Surg., 106: 910, 1937. MOCK, H. E. Infective granuloma: non-specific chromic tumor-like producing inflammation of gastro-intestinal tract. Surg. Gynec. 6 Obst., 52: 672. 1931.
American
Journal
of Suvgery
Perforation
of the Bowel Associated Acute
with
Appendicitis
CARL R. GROSZ, M.D., PETER K. KOTTMEIER, M.D., ASCHER L. MESTEL, M.D.,AND BERTRAM D. COHN, M.D., Brooklyn, New York
From the Pediatric Surgical Service, Defiartment of Surgery, Bate Universityof New York Downstate Medical Center, Brooklyn, New York.
CUTE APPENDICITIS COntinUeS t0 be a com-
A
mon surgical problem. Although it would appear to be a well documented subject, the morbidity and mortality have not approached their potential low. The treatment of this disease has changed little since the inroads made by antibiotics. In many reports there is good evidence that morbidity and mortality are associated mainly with the ruptured appendix, and the complication rate is in the area of 30 to 40 per cent in cases of ruptured appendix whereas it is in the range of 2 to 6 per cent in cases of unruptured appendix [l-3]. Since acute appendicitis was first described by Heister in 1755 [4] and the first appendectomy was performed in 1884 [5], recorded complications have been numerous. The most common complications after acute appendicitis with rupture and perforation are infection of the superficial tissues, continuing peritonitis, and intestinal obstruction [2,4,6]. Although the terms “typhilitis,” “perityphilitis,” and “perityphilitic abscesses” were described by Fitz [7] many years ago, these terms have fallen into complete disuse, and there is little mention in the surgical literature of pathologic processes of the cecum or other areas of bowel as being associated with acute appendicitis. Bockus [4] stated that, “Fistula and sinus formation may eventually occur when an abscess forms. Inclusion in the wall of an ap-
pendiceal abscess of part of a hollow viscus such as the pelvis of the kidney, the cecum, urinary bladder, vagina, sigmoid, or rectum may result in rupture of the abscess into that organ with fistula formation.” In the past three years, we have had five cases of ruptured appendicitis which resulted in necrosis of a portion of the cecum or large bowel. This appears to be a formidable complication which, if unrecognized, could well be fatal, and it appears to us that it is worth while to point out this possibility as treatment is straightforward. CASE REPORTS CASE I. This four year old boy was admitted in June 1963 because of vomiting of three days’ duration and abdominal pain. The patient had also noted diarrhea for two days. On admission, the patient’s temperature was 39.1 "c.Physical examination revealed a rigid abdomen and hypoactive bowel sounds. The white blood cell count was 25,000 per cu. mm. The diagnosis of acute appendicitis was made and the patient was taken to the operating room. A necrotic, perforated appendix was found with abscess formation and necrosis of the anterior surface of the cecum and ascending colon which was in contact with the appendix and abscess. Appendectomy was performed and the portion of cecum and ascending colon with necrosis was exteriorized. This formed a functioning colostomy, and three weeks later the patient was returned to the operating room where resection of the distal ileum and ascending colon was performed with an ileotransverse anastomosis. The patient was discharged one week later.
Bowel Perforation and Acute Appendicitis CASE II. This eleven year old boy was admitted in May 1965 because of abdominal pains of three days’ duration which had been most notable in the right lower quadrant for the preceding twentyfour hours. Temperature on admission was 38”~. and the white blood count was 15,000 per cu. mm. The patient had tenderness throughout the abdomen with no rebound tenderness and active bowel sounds. .I diagnosis of acute appendicitis was made and the patient was taken to the operating room. On exploration, a perforated appendix with abscess formation was found, and the anterior surface of the cecum which was in contact with the abscess cavity was necrotic. A hole measuring 2 cm. in diameter was found in the cecum. The area of necrosis was trimmed from the cecum and a single layer interrupted silk closure was performed. The area was drained and the patient was discharged one week later. CASE III. This ten year old girl was admitted in August 1965 because of abdominal pain, nausea, anorexia, and vomiting for six days. Pain was localized to the lower part of the abdomen. Temperature on admission was 38.2’~. and the white blood count was 22,X0 per cu. mm. Physical examination revealed moderate tenderness with minimal guarding in the right and left lower quadrants. On rectal examination, a tender mass was present high in the cul de sac. The patient was taken to the operating room where a gangrenous appendix was found. After separating the appendix from adhesions to the posterior aspect of the rectosigmoid, a 3 cm. defect was noted in the rectosigmoid, with friable granulation tissue at its edges. There was no abscess cavity. Appendectomy was performed, the rent in the colon was approximated with several chromic sutures through all layers, and transverse colostomy was established through a separate incision The patient was discharged, and two and a half months later she was admitted for closure of the colostomy; her course, thereafter, was unevent-
id.
CASE IV. This eighteen year old girl was admitted in September 1965 because of abdominal pain, nausea, and vomiting. She had noticed the pain for three days was more severe in the lower part of the abdomen. The temperature was 38.2’~. and the white blood count was 18,200 per cu. mm. On physical examination the patient was in acute distress from abdominal pain, with diffuse abdominal tenderness and spasm. The patient was taken to the operating room where an acute gangrenous appendicitis with peritonitis was found. There was an area of cecal perforation, which was closed with interrupted silk sutures. The postoperative course was uneventful. CASE v. This six year old girl was admitted in February 1965 because of abdominal pain of three Vol.
113.
February
1967
27T
days’ duration which had become localized in the right lower quadrant in the previous twenty-four hours. The temperature was 38.2”~. and the white blood count was 15,000 per cu. mm. Physical examination revealed tenderness and spasm of the right lower quadrant. The patient was taken to the operating room where a perforated appendix was found attached to a necrotic cecum. The appendix was removed. The necrotic area of the cecum was debrided and the defect closed. The patient was discharged on the ninth postoperative day. COMMENTS Wangensteen et al. [8] appropriately described the appendix as the Uriah Heep of the abdomen. The cecum and contiguous bowel could certainly be described as the Mr. Wickfield of the abdominal cavity. The close association of the cecum with the appendix can and does cause disease of the bowel. Mock [9] thought the underlying cause of diseased organs in continuity with acute appendicitis was local interference of the blood supply. When the surrounding inflammatory mass is composed of cecum or other portions of bowel, it appears that the inflammation occasionally causes necrosis of the bowel also. These cases illustrate an interesting complication which may follow the perforation of an appendix. They point out the need for good exposure and exploration when a ruptured appendix is found. Certainly, in the past, it has been the practice many times to drain an abscess and perform an interval appendectomy. It is common practice for the operating surgeon to use a McBumey incision and then by blunt dissection with his finger to free the diseased appendix, bring it into the wound, and complete appendectomy without having visualized the bed of the appendix. If under these circumstances there is a perforation of the large intestine, the perforation might well be overlooked; the patient might then be added to the list of morbidities or mortalities. It seems worth while, therefore, to point out that good exposure of the appendix and the area surrounding it is paramount. SUMMARY Five cases of perforation of the bowel due to gangrenous appendicitis are presented. These cases emphasize the need for good exposure at the time of the original operation for gangrenous appendicitis. If perforation of the bowel is found at exploration, primary repair
278
et al.
may be possible; however, more extensive resection or exclusion may be necessary. REFERENCE
1. BALES, E. T., JR., IRETON, R. .T., and CLATWORTHY, H. W., JR. Acute appendicitis in children. Arch. surg., 79: 447, 1959. 2. HUBBELL, D. S., BARTON, W. K., and SOLOMON, 0. D. Appendicitis in older people. Surg. Gyner. 6 Obst., 110: 289, 1960. 3. MCLAUTHLIN, C. H. and PACKARD, G. B. Acute appendicitis in children. Am. J. Surg., 101: 619, 1961. 4. BOCKUS, H. I.. Diseases of the appendix. In: Gastroenterology, vol. 2, chapt. 75. Edited by Banks, R. W. Philadelphia, 1944. W. B. Saunders Co. 5. BONILLA, K. B., HIGHES, C. W., and BOU’ERS, W. F
6.
7.
8.
9.
Experiences with management of the ruptured appendix. Am. J. Swg., 102: 438, 1961. OCHSNER, A., GAGE, I. M., and GARSIDE, E. The intra-abdominal post-operative complications of appendicitis. Ann. Surg., 91: 544, 1930. FITZ, R. H. Perforating inflammation of the vermiform appendix with special reference to its early diagnosis and treatment. Boston AL Ep S. J., 115: 13, 1886. WANGENSTEEN, 0. II., BUIRGE, R. E., DENNIS, C., and RITCHIE, W. P. Studies in the etiology of acute appendicitis. The significance of the structure and function of the vermiform appendix in the genesis of appendicitis. Ann. Surg., 106: 910, 1937. MOCK, H. E. Infective granuloma: non-specific chromic tumor-like producing inflammation of gastro-intestinal tract. Surg. Gynec. 6 Obst., 52: 672. 1931.
American
Journal
of Suvgery