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Evidence-based Clinical Practice Guidelines for

Acute Nontraumatic RLQ Abdominal Pain and Tenderness and

Acute Appendicitis

 

Clinical Issue/Question

What do we do when we encounter a grossly normal appendix when we operate with a diagnosis of acute appendicitis?

 

Format of Guidelines Development

 

 

 

Clinical Scenario and Issue

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With a primary clinical and preoperative diagnosis of acute appendicitis,

Patient is operated on,

What do we do when we encounter a grossly normal appendix when we operate with a diagnosis of acute appendicitis?

 

 

Statement of Premises:

 

Non-immunocompromised patient with preop diagnosis of acute appendicitis.

 

Intraoperative findings:

 

Appendix grossly normal

No peritonitis

No gross abnormality noted in the abdomen

No definite alternative diagnosis

 

Question: To remove the appendix or not? 

 

Operational Definition of Terms in the Issue/Question:

 

Non-immunocompromised patient with preop diagnosis of acute appendicitis.

 

Intraoperative findings:

 

Appendix grossly normal

No peritonitis

No gross abnormality noted in the abdomen

No definite alternative diagnosis

 

Question: To remove the appendix or not? 

 

 

Evidence Appraisal Plan:

 

End-points in answering the question:

 

During an operation for acute appendicitis, to remove a grossly normal appendix or not and why.

 

 

Approach in answering the question:

 

Look for frequency of microscopic appendicitis in grossly normal appendices removed.

 

Look for data that show consequences of not removing grossly normal appendix.

 

 

 

Search Methodology:

 

Tracking:

Medline for international journal publications

Herdin for local journal publications

Internet using various search engines such as AltaVista, Infoseek, Lycos, etc.

 

Retrieval:

 

Retrieval of whole journal article was done through the various libraries of the Metro Manila medical schools, Department of Science and Technology (DOST), and acquaintances.

 

Appraisal (Inclusion Criteria):

 

Appraisal (Inclusion Criteria):

 

        Papers on finding of normal appendices and what to do with them

        With data on histopathologic results of the grossly normal and consequences of leaving them behind 

 

 

Search and Tracking Outcome:

 

        Total no. of papers and abstracts appraised: 3

        Level of evidences: Level III Evidences

 

Tracking and Retrieval Results:

 

Database

Search engine

Search span

Search words

No. of titles

Relevant abstracts/papers

Medline

1966-1999 (August)

Ap + laparoscopy

157

3

Herdin

 

Appendicitis

107

0

AltaVista, Infoseek, Lycos, etc

 

Appendicitis

Tntc

0

 

 

 

 

Presentation of Primary Evidences:

 

Authors

Grossly normal appendix

removed /left behind

N

Microscopic

appendicitis

Operated for the 2nd time for appendicitis

Barrat, 1999

Left behind

 

65

 

5-10% (Removed)

1(1%)

Greason, 1998

Left behind

Removed

28

44

 

2 (5%)

1(3.5%)

Grunewald, 1993

Removed

43

11(26%)

 

See References

 

 

 

Distillation of all available evidences to come out with recommendations or answers to the clinical issue/question:

 

In view of the fact that a grossly normal appendix may have microscopic appendicitis or may be in the early stage of appendicitis in which there is only mucosal involvement (5-26%), removal of the grossly normal appendix is recommended.

 

This will avoid a second operation in case the appendix was not removed and the appendiceal disease process progresses.

 

 

  

Summary of Answer to Question or Recommendations:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With a primary clinical and preoperative diagnosis of acute appendicitis,

Patient is operated on,

What do we do when we encounter a grossly normal appendix when we operate with a diagnosis of acute appendicitis?

 

When we encounter a grossly normal appendix during an operation for acute appendicitis,

 

in the absence of an alternative diagnosis,

 

REMOVE THE APPENDIX.

 

In view of the fact that a grossly normal appendix may have microscopic appendicitis or may be in the early stage of appendicitis in which there is only mucosal involvement (5-26%), removal of the grossly normal appendix is recommended.

 

This will avoid a second operation in case the appendix was not removed and the appendiceal disease process progresses.

 

 

 

 

Future Research Issues/Questions Arising from Attempts to Answer Issue:

 

None at the moment

 

 

 

References:

 

1.      Greason KL, Rappold JF, Liberman MA.

Incidental laparoscopic appendectomy for acute right lower quadrant abdominal pain. Its time has come. Surg Endosc, 1998 Mar, 12:3, 223-5.

 

2.      Grunewald B, Keating J.

Should the 'normal' appendix be removed at operation for appendicitis?

J R Coll Surg Edinb, 1993 Jun, 38:3, 158-60

 

3.      Barrat C; Catheline JM; Rizk N; Champault GG

Does laparoscopy reduce the incidence of unnecessary appendicectomies?

Surg Laparosc Endosc, 1999 Jan, 9:1, 27-31

 

 

Quick Reference Guide or Algorithm:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With a primary clinical and preoperative diagnosis of acute appendicitis,

Patient is operated on,

What do we do when we encounter a grossly normal appendix when we operate with a diagnosis of acute appendicitis?

 

When we encounter a grossly normal appendix during an operation for acute appendicitis,

 

in the absence of an alternative diagnosis,

 

REMOVE THE APPENDIX.

 

In view of the fact that a grossly normal appendix may have microscopic appendicitis or may be in the early stage of appendicitis in which there is only mucosal involvement (5-26%), removal of the grossly normal appendix is recommended.

 

This will avoid a second operation in case the appendix was not removed and the appendiceal disease process progresses.