31
APPENDIX, MECKEL’S, AND
OTHER SMALL BOWEL
DIVERTICULA
William H. Peranteau • Douglas S. Smink
HISTORY
he first descriptions of the appendix date to the 16th cen-
tury.1–3 Although sketched in the anatomic notebooks of Leon-
ardo da Vinci around 1500, the appendix was not formally
described until 1524 by da Capri4 and 1543 by Vesalius.5 Per-
haps the first description of a case of appendicitis was by Fernel
in 1554,6 in which a 7-year-old girl with diarrhea was treated
with a large quince. Soon thereafter, she developed severe
abdominal pain and died. Autopsy showed that the quince had
obstructed the appendiceal lumen, resulting in appendiceal
necrosis and perforation. For the next few centuries, such cases
of appendicitis were typically diagnosed at autopsy.
Amyand is credited with the first appendectomy in 1736,
when he operated on a boy with an enterocutaneous fistula
within an inguinal hernia.7 On exploration of the hernia sac,
he discovered the appendix, which had been perforated by
a pin resulting in a fecal fistula. As a result of his original
description, an inguinal hernia containing the appendix car-
ries Amyand’s eponym to this day.8 Nearly 150 years passed
until Lawson Tait in London presented the first successful
transabdominal appendectomy for gangrenous appendix in
1880.9 Less than a decade later, in 1886, Reginald Fitz of
Harvard Medical School first described the natural history of
the inflamed appendix, coining the term “appendicitis.” 10 In
1889, Charles McBurney of the Columbia College of Physi-
cians and Surgeons in New York presented his series of cases
of surgically treated appendicitis and in so doing described
the anatomic landmark that now bears his name. McBurney’s
point is the location of maximal tenderness “very exactly
between an inch and a half and two inches from the anterior
spinous process of the ileum on a straight line drawn from
that process to the umbilicus.”11 In the 1890s, Sir Frederick
Treves of London Hospital advocated conservative manage-
ment of acute appendicitis followed by appendectomy after
the infection had subsided12; unfortunately, his youngest
daughter developed perforated appendicitis and died from
such treatment.
Numerous advances in the diagnosis and treatment of
appendicitis have emerged in the past 125 years. Nonethe-
less, acute appendicitis continues to challenge surgeons to
this day.
ANATOMY
Embryologically, the appendix and cecum develop as out-
pouchings of the caudal limb of the midgut loop in the 6th
week of human development. By the 5th month, the appen-
dix elongates into its vermiform shape. At birth, the appendix
is located at the tip of the cecum, but, because of unequal
elongation of the lateral wall of the cecum, the adult appen-
dix typically originates from the posteromedial wall of the
cecum, caudal to the ileocecal valve. he appendix averages
9 cm in length,3 with its outside diameter ranging from 3 to
8 mm and its lumen ranging from 1 to 3 mm. he base of
the appendix is consistently found by following the teniae
coli of the colon to their confluence at the base of the cecum.
he appendiceal tip, however, can vary significantly in loca-
tion (Fig. 31-1). Although usually located in the right lower
quadrant (RLQ) or pelvis, the tip can occasionally reside in
the left lower or right upper quadrants (RUQ).
he arterial supply of the appendix comes from the appen-
dicular branch of the ileocolic artery, which originates poste-
rior to the terminal ileum and enters the mesoappendix near
the base of the appendix (Fig. 31-2). Lymphatic drainage
flows to lymph nodes along the ileocolic artery.
ACUTE APPENDICITIS
Epidemiology
Addiss and associates13 estimated the incidence of acute
appendicitis in the United States to be 11 cases per 10,000
population annually. he disease is slightly more common in
623
624 Part V Intestine and Colon
1
2
5
FIGURE 31-1 Anatomic variation in the position of the appendix.
(1) Preilieal; (2) postilieal; (3) promontoric; (4) pelvic; (5) subcecal;
(6) paracolic or prececal. (Redrawn from Wakeley CP. he position
on the vermiform appendix as ascertained by analysis of 10,000 cases.
J Anat. 1933;67:277. After Waldron.)
males, with a male: female ratio of 1.4:1. In a lifetime, 8.6%
of males and 6.7% of females can be expected to develop
acute appendicitis. Young age is a risk factor, as nearly 70%
of patients with acute appendicitis are younger than 30 years.
he highest incidence of appendicitis in males is in the 10- to
14-year-old age group (27.6 cases per 10,000 population),
while the highest female incidence is in the 15- to 19-year-
old age group (20.5 cases per 10,000 population). Patients at
extremes of age are more likely to develop perforated appen-
dicitis. Overall, perforation was present in 19.2% of cases
of acute appendicitis. his number was significantly higher,
however, in patients younger than 5 and older than 65 years.
Although less common in people older than 65 years, acute
appendicitis in the elderly progresses to perforation more
than 50% of the time.13
Etiology and Pathophysiology
Appendicitis, diverticular disease, and colorectal carcinoma
have been shown to be diseases of developed civilizations.
Burkitt14 found an increased incidence of appendicitis in
Western countries compared to Africa, as well as in wealthy,
urban communities compared to rural areas. He attributed
FIGURE 31-2 he appendix and its arterial supply.
this to the Western diet, which is low in dietary fiber and high
in refined sugars and fat, and postulated that low-fiber diets
lead to less bulky bowel contents, prolonged intestinal transit
time, and increased intraluminal pressure. Burkitt theorized
that the combination of firm stool leading to appendiceal
obstruction and increased intraluminal pressure causing bac-
terial translocation across the bowel wall resulted in appen-
dicitis. In examining appendixes removed for reasons other
than appendicitis, he found fecaliths to be more prevalent
in Canadian (32%) than in South African (4%) adults. In a
group of patients with appendicitis, fecaliths were more com-
mon in Canadians (52%) than in South Africans (23%).15
He felt this was confirmation that appendiceal obstruction
resulted in appendicitis. Of note, however, the majority of
patients with appendicitis in his study did not have evidence
of a fecalith.
Wangensteen extensively studied the structure and func-
tion of the appendix and the role of obstruction in appendici-
tis.16,17 Based on anatomic studies, he postulated that mucosal
folds and a sphincter-like orientation of muscle fibers at the
appendiceal orifice make the appendix susceptible to obstruc-
tion. He proposed the following sequence of events to explain
appendicitis: (1) Closed-loop obstruction is caused by a feca-
lith and swelling of the mucosal and submucosal lymphoid
tissue at the base of the appendix; (2) intraluminal pressure
rises as the appendiceal mucosa secretes fluid against the fixed
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
obstruction; (3) increased pressure in the appendiceal wall
exceeds capillary pressure and causes mucosal ischemia; and
(4) luminal bacterial overgrowth and translocation of bacteria
across the appendiceal wall result in inflammation, edema,
and ultimately necrosis. If the appendix is not removed, per-
foration can ensue.
Although appendiceal obstruction is widely accepted as the
primary cause of appendicitis, evidence suggests that this may
be only one of many possible etiologies. First, some patients
with a fecalith have a histologically normal appendix, and
the majority of patients with appendicitis show no evidence
for a fecalith.15,18,19 Arnbjornsson and Bengmark20 studied at
laparotomy the appendixes of patients with suspected appen-
dicitis. hey found the intraluminal pressure of the appendix
prior to removal to be elevated in only 8 of 27 patients with
nonperforated appendicitis. hey found no signs of obstruc-
tion in the remaining patients with nonperforated appendi-
citis, as well as all patients with a normal appendix. Taken
together, these studies imply that obstruction is but one of
the possible etiologies of acute appendicitis.
Presentation
Perhaps the most common surgically correctable cause of
abdominal pain, the diagnosis of acute appendicitis remains
difficult in many instances. Some of the signs and symptoms
can be subtle to both the clinician and the patient and may
not be present in all instances. Arriving at the correct diagno-
sis is essential, however, as a delay in diagnosis may allow pro-
gression to perforation and significantly increased morbidity
and mortality. Incorrectly diagnosing a patient with appendi-
citis, although not catastrophic, often subjects the patient to
an unnecessary operation.
he classic presentation of acute appendicitis begins with
crampy, intermittent abdominal pain, thought to be due
to obstruction of the appendiceal lumen. he pain may be
either periumbilical or diRuse and difficult to localize. his
is typically followed shortly thereafter with nausea; vom-
iting may or may not be present. If nausea and vomiting
precede the pain, patients are likely to have another cause
for their abdominal pain, such as gastroenteritis. Classically,
the pain migrates to the right lower quadrant as transmural
inflammation of the appendix leads to inflammation of the
peritoneal lining of the right lower abdomen. his usually
occurs within 12–24 hours of the onset of symptoms. he
character of the pain also changes from dull and colicky to
sharp and constant. Movement or Valsalva maneuver often
worsens this pain, so that the patient typically desires to lie
still; some patients describe pain with every bump in the car
or ambulance ride to the hospital. Patients may report low-
grade fever up to 101F (38.3C). Higher temperatures and
shaking chills should again alert the surgeon to other diag-
noses, including appendiceal perforation or nonappendiceal
sources. When questioned, patients who have appendicitis
commonly report anorexia; appendicitis is unlikely in those
with a normal appetite.
625
he surgeon is constantly reminded that in practice, the
classic presentation of acute appendicitis is not present in all
patients. Patients may have none or only a few of the symp-
toms just described. For instance, they may not notice or
recall the initial colicky pain. When the pain becomes con-
stant, it may localize to other quadrants of the abdomen due
to an alteration in appendiceal anatomy as in late pregnancy
or malrotation. In patients with a retrocecal appendix, the
pain may never localize until generalized peritonitis from per-
forated appendicitis occurs. Urinary or bowel frequency may
be present due to appendiceal inflammation irritating the
adjacent bladder or rectum. Because appendicitis is so com-
mon, a high index of suspicion for appendicitis is warranted
in all patients with abdominal pain.
Perforated Appendicitis
It is a commonly held belief that if left untreated, appen-
diceal inflammation will progress inevitably to necrosis, and
ultimately to perforation. he time course of this progres-
sion varies among patients. In one study of the natural history
of appendicitis, the authors questioned patients undergoing
appendectomy for suspected appendicitis about their dura-
tion of symptoms.21 Patients with nonperforated appendi-
citis reported an average of 22 hours of symptoms prior to
presentation to the hospital, while patients with perforated
appendicitis reported an average of 57 hours. However, 20%
of cases of perforated appendicitis presented within 24 hours
of the onset of symptoms; one of those patients had symp-
toms for only 11 hours. Although concern for perforation
should be present when evaluating a patient with more than
24 hours of symptoms, the clinician must remember that per-
foration can develop more rapidly.
Some authors have questioned whether some perforations
in acute appendicitis are attributable to delay in diagnosis
after a patient seeks medical attention. Velanovich and Satava
postulated a surgeon’s misdiagnosis rate (the percentage of
normal appendixes found at appendectomy) to be inversely
related to the perforation rate (the percentage of perforated
appendixes found at laparotomy). 22 hey believed that sur-
geons are obliged to operate quickly when appendicitis is
suspected, thus minimizing the likelihood of perforation
in exchange for a higher rate of misdiagnosis. More recent
studies suggest that this reasoning is flawed. Temple and col-
leagues showed that patients with perforated appendicitis
were operated on more quickly than those with nonperfo-
rated appendicitis (6.5 vs 9 hours), but perforated patients
had significantly longer prehospital symptoms (57 vs 22
hours).21 hese findings are confirmed by two other studies,
both showing that longer duration of prehospital delay is the
major contributor to perforation. 23,24 Perforation after pre-
senting to surgical attention appears to be uncommon.
When acute appendicitis has progressed to appendiceal
perforation, other symptoms may be present. Patients will
often complain of two or more days of abdominal pain, but
their duration of symptoms may be shorter, as previously
626 Part V Intestine and Colon
discussed. he pain usually localizes to the right lower quad-
rant if the perforation has been walled oR by surrounding
intra-abdominal structures including the omentum, but it
may be diRuse if generalized peritonitis ensues. he pain may
be so severe that patients do not remember the antecedent
colicky pain. Patients with perforation often have rigors and
high fevers to 102F (38.9C) or above. A history of poor
oral intake and dehydration may also be present.
Most patients with perforated appendicitis present with
symptoms related to the inflamed appendix itself or to a
localized intraperitoneal abscess from perforation. Other
more rare presentations do occur, however. hese are most
likely to occur in the very young and very old, who cannot
express their symptoms and often present late in the course of
their disease. For instance, abscesses can also form in the ret-
roperitoneum due to perforation of a retrocecal appendix, or
in the liver from hematogenous spread of infection through
the portal venous system. An intraperitoneal abscess could
fistulize to the skin, resulting in an enterocutaneous fistula.
Pylephlebitis (septic portal vein thrombosis) presents with
high fevers and jaundice and can be confused with cholangi-
tis; it is a dreaded complication of acute appendicitis and car-
ries a high mortality.25 On occasion, patients will have bilious
vomiting and obstipation due to a small bowel obstruction
resulting from appendiceal perforation. Because appendicitis
is so common, these rare presentations should alert the sur-
geon to the possibility of appendicitis.
Diagnosis
HISTORY AND PHYSICAL EXAMINATION
As always, the diagnosis begins with a thorough history and
physical examination. he patient should be asked about the
classic symptoms of appendicitis, but the surgeon should not
be dissuaded by the absence of many of the symptoms. Many
patients with acute appendicitis do not have a classic history.
Because the diRerential diagnosis of appendicitis is extensive,
patients should be queried about certain symptoms that may
suggest an alternative diagnosis. Surgeons must also remem-
ber that a previous appendectomy does not definitively
exclude the diagnosis of appendicitis, as “stump appendicitis”
(appendicitis in the remaining appendiceal stump after
appendectomy), although rare, has been described.26
On inspection, patients look mildly ill and may have
slightly elevated temperature and pulse. hey often lie still
to avoid the peritoneal irritation caused by movement. he
surgeon should systematically examine the entire abdomen,
starting in the left upper quadrant away from the patient’s
described pain. Maximal tenderness is typically in the right
lower quadrant, at or near McBurney’s point, located one-
third of the way from the anterior superior iliac spine to the
umbilicus. his tenderness is often associated with localized
muscle rigidity and signs of peritoneal inflammation, includ-
ing rebound, shake, or tap tenderness. RLQ tenderness is most
consistent of all signs of acute appendicitis27,28; its presence
should always raise the specter of appendicitis, even in the
absence of other signs and symptoms. Because of the vari-
ous anatomic locations of the appendix, however, it is pos-
sible for the tenderness to be in the right flank or right upper
quadrant, the suprapubic region, or the left lower quadrant.
Patients with a retrocecal or pelvic appendix may have no
abdominal tenderness whatsoever. In such cases, rectal exami-
nation can be helpful to elicit right-sided pelvic tenderness.
Multiple signs can be detected on physical examination
to contribute to the diagnosis of appendicitis. Rovsing’s sign,
pain in the right lower quadrant on palpation of the left lower
quadrant, results from localized peritoneal inflammation in
the right lower quadrant. Psoas sign, pain with flexion of the
leg at the right hip, can be seen with a retrocecal appendix
due to inflammation adjacent to the psoas muscle. he obtu-
rator sign, pain with rotating the flexed right thigh internally,
indicates inflammation adjacent to the obturator muscle in
the pelvis.
In cases of perforated appendicitis, patients can look
gravely ill, appearing flushed with dry mucous membranes
and considerable elevations in temperature or pulse. If sepsis
has developed, blood pressure can be depressed. If the perfo-
ration has been walled oR by surrounding structures to create
an abscess or phlegmon, a mass may be palpable in the right
lower quadrant. If free intraperitoneal rupture has occurred,
the patient can have signs of generalized peritonitis with dif-
fuse rebound tenderness.
LABORATORY STUDIES
Laboratory studies can be helpful in the diagnosis of appendi-
citis, but no single test is definitive. A white blood cell count
(WBC) is perhaps the most useful laboratory test. Typically,
the WBC is slightly elevated in nonperforated appendicitis
but may be quite elevated in the presence of perforation.
he clinician must remember, however, that the WBC can
be normal in patients with acute appendicitis, particularly in
early cases. Serial WBC measurements improve the diagnos-
tic accuracy, with a rising value over time commonly seen in
patients with appendicitis. 29 Urinalysis is performed to diag-
nose other potential causes for abdominal pain, specifically
urinary tract infection and ureteral stone. Significant hematu-
ria with colicky abdominal pain suggests ureterolithiasis, and
testing directed at this diagnosis is indicated. A urinary tract
infection, on the other hand, is not uncommon in patients
with appendicitis. Its presence does not exclude the diagnosis
of acute appendicitis, but it should be identified and treated.
Although pyuria suggests urinary tract infection, it is not
uncommon for the urinalysis in a patient with appendicitis
to show a few white blood cells solely due to inflammation of
the ureter by the adjacent appendix.
In certain patient populations, other laboratory tests are
indicated. Measurement of serum liver enzymes and amylase
can be helpful in diagnosing liver, gallbladder, or pancreatic
disease in patients complaining of midabdominal or RUQ
pain. In women of childbearing age, the urine -human cho-
rionic gonadotropin should be checked to alert the clinician
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
to the possibility of ectopic or concurrent pregnancy. Ecto-
pic pregnancy is another cause of RLQ pain that demands
emergent diagnosis and treatment. Concurrent pregnancy
should be known before a patient with suspected appendicitis
is subjected to ionizing radiation from imaging studies or to
general anesthesia.
DIAGNOSTIC SCORES
Diagnostic scoring systems have been developed in an
attempt to improve the diagnostic accuracy of acute appen-
dicitis.18,30 he most prominent of those scores, developed
by Alvarado,30 was based on a retrospective analysis of 305
patients with abdominal pain suspicious for appendicitis.
his scoring system gives points for symptoms (migration
of pain, anorexia, and nausea), physical signs (RLQ tender-
ness, rebound tenderness, and pyrexia), and laboratory values
(leukocytosis and a left shift). Although these scores can help
guide clinical thinking, they do not markedly improve diag-
nostic accuracy.31 With the recent improvement in imaging
studies, these scores play a smaller role in diagnosis.
IMAGING STUDIES
he potential imaging modalities for diagnosis of acute
appendicitis include plain radiographs, ultrasound (US), and
computed tomography (CT). Prior to the widespread use
of modern imaging techniques, plain abdominal films were
often obtained in patients with abdominal pain, and a right
lower quadrant fecalith (or appendicolith) was considered
pathognomonic for acute appendicitis. A number of stud-
ies question this teaching, however. Teicher and colleagues18
reviewed the abdominal radiographs of 200 appendectomy
patients—100 with pathologically proven appendicitis and
100 with a normal appendix. Of those with appendicitis,
10.5% had an appendicolith on x-ray, compared to 3.3% of
those without appendicitis. An extensive review of appendec-
tomy specimens at the Mayo Clinic19 showed that fecaliths
or appendiceal calculi were present in 9% of patients with
nonperforated appendicitis and 21% of those with perforated
appendicitis. Interestingly, fecaliths were also present in 7%
of patients with suspected appendicitis who had a pathologi-
cally normal appendix and in 2% of patients who had an
appendectomy for other reasons.
hese studies show that fecaliths are not pathognomonic
for appendicitis, as some patients with abdominal pain and a
fecalith have a normal appendix. In addition, fecaliths are not
common enough in patients with appendicitis to be used as
a reliable sign. As a result, plain abdominal radiographs are
neither helpful nor cost-eRective and are not recommended
for the diagnosis of acute appendicitis. Plain radiographs are
indicated in elderly patients with severe abdominal pain, in
whom a perforated viscus is included in the diRerential diag-
nosis. In this patient population, an upright chest x-ray can
assess for the presence of free air.
Abdominal ultrasonography is a popular imaging modality
for acute appendicitis. Findings that suggest appendicitis include
627
FIGURE 31-3 Appendiceal ultrasound showing distended, noncom-
pressible appendix measuring 1.7 cm in transverse dimension (>0.6 cm is
abnormal). (Used, with permission, from M. Stephen Ledbetter, MD,
MPH, Brigham and Women’s Hospital, Boston, MA.)
thickening of the appendiceal wall, loss of wall compressibil-
ity, increased echogenicity of the surrounding fat signifying
inflammation, and loculated pericecal fluid (Fig. 31-3). he
advantages of ultrasound include its widespread availability,
as well as the avoidance of ionizing radiation and the side
eRects of intravenous contrast such as renal toxicity and aller-
gic reactions. In addition, ultrasound (both abdominal and
transvaginal) is particularly useful in assessing obstetric and
gynecological causes of abdominal pain in women of childbear-
ing age. Ultrasound is highly operator-dependent, however,
and it is frequently unable to visualize the normal appendix.32
A recent meta-analysis of 14 prospective studies showed ultra-
sound to have a sensitivity of 0.86 and a specificity of 0.81.33
CT is yet another imaging modality for acute appendicitis.
CT benefits from a high diagnostic accuracy for appendicitis33
and visualization and diagnosis of many of the other causes
of abdominal pain that can be confused with appendicitis.
he radiographic findings of appendicitis on CT include a
dilated (>6 mm), thick-walled appendix that does not fill
with enteric contrast or air, as well as surrounding fat strand-
ing to suggest inflammation (Fig. 31-4).34 In a meta-analysis
of 12 prospective studies, CT demonstrated a sensitivity of
0.94 and a specificity of 0.95.33 CT thus has a high negative
predictive value, making it particularly useful in excluding
appendicitis in patients for whom the diagnosis is in doubt.
Appendicitis is highly unlikely if enteric contrast fills the
lumen of the appendix and no surrounding inflammation is
present. he clinician must remember, however, that a CT
performed early in the course of appendicitis might not show
628 Part V Intestine and Colon

FIGURE 31-4 CT of acute appendicitis. he arrow points to an

enlarged, fluid-filled appendix with wall hyperemia that does not fill
with oral contrast. he paucity of intra-abdominal fat limits identifi-
cation of fat stranding. (Used, with permission, from M. Stephen Led-
better, MD, MPH, Brigham and Women’s Hospital, Boston, MA.)

FIGURE 31-5 CT of perforated appendix. Note retrocecal abscess

(arrows) with enhancing wall and periappendiceal fat stranding and
the typical radiographic findings. In confusing cases, it is rea- adjacent cecal thickening (arrowhead). (Used, with permission,
sonable to repeat the CT after 24 hours of observation. from M. Stephen Ledbetter, MD, MPH, Brigham and Women’s
A number of recent prospective studies have compared Hospital, Boston, MA.)
the accuracy of CT and ultrasound in imaging the appendix
(Table 31-1).32,35,36 Balthazar and associates35 performed CT
and ultrasound on 100 consecutive patients with suspected results, with CT having higher sensitivity (96 vs 62%) and
appendicitis. he sensitivity of CT was considerably higher specificity (92 vs 71%) than ultrasound.32 Again, CT was also
(96% for CT, 76% for US), while the specificity was compa- better able to visualize other intra-abdominal pathology in
rable (89% for CT, 91% for US), yielding a higher accuracy the absence of appendicitis.
for CT (94 vs 83%). CT was also able to provide an alterna- In a study of 100 patients evaluated by CT with rectal
tive diagnosis in more patients and was better able to visualize and intravenous contrast, Rao and coworkers 37 showed that
abscesses or phlegmons (Fig. 31-5). Horton and colleagues36 CT can reduce the use of hospital resources and costs. CT
randomized patients with suspected appendicitis to either CT changed the management of 59 patients, avoiding 13 unnec-
or ultrasound. heir findings echo those of Balthazar, with essary appendectomies and eliminating a total of 50 inpatient
both CT and ultrasound having high specificity (100% for hospital days for observation of unexplained abdominal pain.
CT, 90% for US) but CT having significantly higher sensitiv- Even factoring in the cost of the CT scans, the authors calcu-
ity (97 vs 76%). Yet another prospective study showed similar lated a net savings of US$447 per patient.
Taken together, these studies suggest an algorithm for eval-
uation of patients with suspected acute appendicitis. Patients
with a history, physical examination, and laboratory stud-
ies classic for appendicitis should undergo appendectomy.
TABLE 31-1: ACCURACY OF CT AND US FOR In those with an evaluation suggestive but not convincing
THE DIAGNOSIS OF ACUTE APPENDICITIS for appendicitis, further imaging is warranted. In women of
childbearing age, this should begin with a pelvic ultrasound to
Sensitivity Specificity Accuracy evaluate for ovarian pathology. In other patients, transabdom-
(%) (%) (%)
inal ultrasound or abdominopelvic CT should be considered,
depending on study availability and expertise of the consulting
Balthazar et al35 CT 96 89 94
radiologist. CT does have the advantage of improved accuracy
US 76 91 83
in diagnosing both appendiceal and other intra-abdominal
Horton et al36 CT 97 100 98
pathology. his can be supplemented with rectal contrast CT,
US 76 90 80 32,37

Wise et al32 CT 96 92 93
if needed, to better visualize the appendix. Patients with
US 62 71 69
a CT showing nonperforated appendicitis should undergo
Terasawa et al33 CT 94 95 N/A
appendectomy. In many instances, patients with a normal CT
(meta-analysis) US 86 81 N/A do not require hospital admission. If symptoms persist, admis-
sion to the hospital for observation, and perhaps a repeat CT
CT, computed tomography; N/A, not applicable; US, ultrasound. scan, is warranted.
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula 629

DIFFERENTIAL DIAGNOSIS some diagnoses are more likely than others in certain patient
groups. For instance, in young males with a suggestive his-
Because many of its signs and symptoms are nonspecific, the
tory and physical examination, acute appendicitis is the most
diRerential diagnosis of acute appendicitis is extensive and
likely cause of RLQ pain. Meckel’s diverticulitis causes simi-
includes virtually all possible abdominal sources of pain, as 38
well as some nonabdominal sources (Table 31-2). However, lar symptoms but is relatively uncommon. Gastroenteri-
tis is considerably more common and should be expected
when nausea and vomiting precede the abdominal pain,
or when diarrhea is a prominent symptom. Crohn’s disease
TABLE 31-2: DIFFERENTIAL DIAGNOSIS OF aRecting the terminal ileum may resemble appendicitis in its
ACUTE APPENDICITIS initial presentation, but on further questioning the patient
typically describes a subacute course, including fever, weight
Gastrointestinal causes loss, and pain.
Cecal diverticulitis In middle-aged and older adults, other inflammatory con-
Sigmoid diverticulitis ditions should be considered, including peptic or duodenal
Meckel’s diverticulitis ulcer (with fluid tracking into the right paracolic gutter),
Epiploica appendicitis cholecystitis, and pancreatitis. In addition, cecal or sigmoid
Mesenteric adenitis diverticulitis can be confused with acute appendicitis. Cecal
Omental torsion diverticulitis is quite similar in pathogenesis and presentation
Crohn’s disease to appendicitis, because cecal diverticula, like the appendix,
Cecal carcinoma are true diverticula containing all layers of the intestinal wall.
Appendiceal neoplasm Because a redundant, floppy sigmoid colon can extend to the
Lymphoma right side of the abdomen, patients with sigmoid diverticu-
Typhlitis litis can sometimes present with RLQ pain. hose patients
Small bowel obstruction typically describe a quicker progression to localized tender-
Perforated duodenal ulcer ness, as well as a prodrome of an alteration in bowel habits.
Intussusception Malignancies can present with acute RLQ pain due to perfo-
Acute cholecystitis ration of a cecal carcinoma or appendicitis caused by a mass
Hepatitis obstructing the appendiceal orifice.39 hese patients will also
Pancreatitis typically have guaiac-positive stools, anemia, and a history of
Infectious causes weight loss.
Infectious terminal ileitis (Yersinia, tuberculosis, or In women of childbearing years, the diagnosis of RLQ
cytomegalovirus) pain can be even more difficult. In addition to the causes
Gastroenteritis of RLQ pain mentioned for young men, young women can
Cytomegalovirus colitis also have pain from obstetric and gynecological causes such
Genitourinary causes as ruptured ovarian cyst or follicle, ovarian torsion, ectopic
Pyelonephritis or perinephric abscess pregnancy, acute salpingitis, and tubo-ovarian abscess. A
Nephrolithiasis complete history including recent menstrual history, as well
Hydronephrosis as pelvic examination, can be helpful in diRerentiating these
Urinary tract infection causes of pain from acute appendicitis. Nonetheless, appen-
Nonabdominal causes dicitis can be difficult to diagnose in this patient popula-
Streptococcal pharyngitis tion, and higher rates of misdiagnosis have been described in
Lower lobe pneumonia women of childbearing age.40
Rectus muscle hematoma
In women
Ovarian cyst (ruptured or not ruptured) SPECIAL CONSIDERATIONS
Corpus luteal cyst (ruptured or not ruptured)
Ovarian torsion Children. Appendicitis most commonly aRects children age
Endometriosis 10–19, with an overall incidence of approximately 20 cases
Pelvic inflammatory disease per 10,000 population annually. 13 Among those younger
Tubo-ovarian abscess than 20, infants aged 0–4 have the lowest incidence of
In pregnancy appendicitis (2 cases per 10,000 annually), but up to two-
Ectopic pregnancy thirds will present with perforation. 41 Perforation is common
Round ligament pain because infants often present later in their disease course and
Chorioamnionitis because of the difficulty in obtaining an accurate history. he
Placental abruption diagnosis is further complicated by diseases of childhood that
Preterm labor can mimic appendicitis. For instance, mesenteric adenitis, an
inflammation of the mesenteric lymph nodes secondary to
630 Part V Intestine and Colon
upper respiratory tract infection, can present with fever and
RLQ pain. Streptococcal pharyngitis and bacterial meningi-
tis can also present with fever, nausea, and abdominal pain.
hese diagnoses and others including ovarian cysts, ovarian
torsion, urinary tract infection, pelvic inflammatory disease,
and complications of a Meckel’s diverticulum should be con-
sidered when evaluating children or adolescents for suspected
appendicitis.
In children with an equivocal history and physical exam-
ination, imaging with either a CT scan or US can signifi-
cantly reduce the negative appendectomy rate from 14 to
37% down to 2 to 10%.42 he pertinent question is which
study is preferable. As with adults, both CT and US have
been shown to be highly accurate in diagnosing appendicitis
in children, although CT scan is believed to have a higher
specificity and sensitivity. In an early study Garcia Pena and
associates compared ultrasonography and rectal contrast CT
in 139 children with suspected appendicitis and found CT
to be more sensitive (97% for CT, 44% for US), more spe-
cific (94% for CT, 93% for US), and more accurate (94% for
CT, 76% for US).43 CT correctly changed the management
of 73% of patients, while ultrasound correctly changed 19%.
More recent meta-analysis and reviews evaluating CT and/or
ultrasound in pediatric populations found the specificity of
the two imaging modalities to be similar (92–95%) but the
sensitivity of ultrasound (88–90%) to be less than that of CT
scan (94–95%).42,44 An important determinant in the diag-
nostic success of ultrasound is the body mass index (BMI) of
the child. he sensitivity of ultrasound has been reported by
some to be 76% in children with a BMI below 25, 37% in
children with a BMI greater than 25, and 82% in one study
in which the patient population had a mean BMI of 17.42,45,46
he use of CT can be recommended for children with one
caveat. he radiation from a CT in childhood theoretically
causes a small increase in the lifetime risk of certain cancers.47
Based on estimated radiation exposure from a CT scan,
studies have hypothesized that a 1-year-old and 15-year-old
would have a 0.18 and 0.11% lifetime risk, respectively, of
fatal radiation-induced malignancy following a CT scan.42
herefore, clinicians should consider the risks and benefits
of CT, and eRorts should be directed toward reducing radia-
tion dose when imaging children.48 In the pediatric patients
with suspected appendicitis, an algorithm starting with an
ultrasound, especially in low BMI children and females, fol-
lowed by CT scan if the ultrasound is equivocal may allow
the maximum benefit of radiologic imaging while minimiz-
ing potential deleterious radiation eRects. he use of mag-
netic resonance imaging (MRI) in the evaluation of children
has only recently begun to be investigated. Although its abil-
ity to identify the appendix has been established, the use of
MRI in the diagnosis of appendicitis in children requires
further study.
Elderly. Although appendicitis is more common in younger
age groups, it is still an important cause of abdominal pain
in the elderly. Perhaps because of a diminished inflamma-
tory response, the elderly can present with less impressive
symptoms and physical signs, longer duration of symptoms,
and decreased leukocytosis compared to younger patients. 49
Perforation is thus more common, occurring in as many as
50% of patients older than 65.13 hese patients may have
cardiac, pulmonary, and renal conditions, resulting in con-
siderable morbidity and mortality from perforation. In one
series, the mortality from perforated appendicitis in patients
older than 80 was 21%.50 hese factors argue that RLQ pain
in elderly patients must be aggressively investigated. Because
of the multiple other possible causes of abdominal pain in
this patient population (including malignancy, diverticuli-
tis, and perforated peptic ulcer disease), prompt CT scan is
advocated when the diagnosis is in question.
Pregnancy. he diagnosis of acute appendicitis in the
pregnant patient can be particularly challenging, as nausea,
anorexia, and abdominal pain may be symptoms of both
appendicitis and normal pregnancy. In addition, the gravid
uterus can displace the abdominal viscera, shifting the loca-
tion of the appendix from the right lower quadrant. Appendi-
citis aRects 1 in every 1400 pregnancies, an incidence similar
to that of the nonpregnant female population.51 It can occur
in any trimester, with perhaps a slight increase in frequency
during the second trimester. 51,52 Perforation is more common
in the third trimester, however, and results from a longer dura-
tion from the onset of symptoms to operation.53 he diReren-
tial diagnosis of appendicitis includes not only the conditions
possible in nonpregnant women but also certain conditions
specific to pregnancy: ectopic pregnancy, chorioamnionitis,
preterm labor, placental abruption, and round ligament pain.
In the first and early second trimesters, the presentation of
appendicitis is similar to that seen in nonpregnant women. In
the third trimester, women may not present with RLQ pain
due to displacement of the appendix by the gravid uterus. Baer
and associates performed barium enemas on normal pregnant
women and found the appendix to migrate superiorly toward
the right upper quadrant in later stages of pregnancy.54 heir
findings suggest that appendicitis should present with RUQ
or flank pain in late pregnancy. Two retrospective studies
contradict this, however, showing that even in the third tri-
mester, pain and tenderness are more common in the right
lower than the right upper quadrant.51,52 Nonetheless, RUQ
pain did predominate in some third-trimester patients with
appendicitis in each study,51,52 reminding the clinician that
right upper quadrant and right flank symptoms could be due
to appendicitis in an appendix displaced by the gravid uterus.
Recent studies highlight the difficulty of assigning a clinical
picture to a pregnant patient with appendicitis. Brown et al55
reviewed case-control studies attempting to correlate preop-
erative signs and symptoms with the postoperative diagnosis
of appendicitis in pregnant patients. Although patients pre-
sented with RUQ pain, RLQ pain, and fevers, only nausea,
vomiting, and peritonitis were found to significantly correlate
with the diagnosis of appendicitis.
Ultrasound is accurate in pregnancy 56 and is a useful first
radiological study because it has no known adverse fetal
eRects.57 Rectal contrast CT has also been shown to be highly
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
accurate in the pregnant population. 58 Although ionizing
radiation has risks to the fetus, the radiation from a typical
abdominopelvic CT is below the threshold of 5 rad at which
teratogenic eRects are seen.59 When the diagnosis is in doubt,
the risk of radiation should be weighed against the risk of spon-
taneous abortion from an unnecessary laparotomy or from
undiagnosed appendicitis progressing to perforation. Hospital
admission with close observation for progression of symptoms
is a viable alternative if the risks of radiation from CT scan
are deemed excessive. Additionally, MRI has been recently
used to aid in the diagnosis of appendicitis in the pregnant
patient when ultrasound results are equivocal. In those preg-
nant patients with a normal or inconclusive ultrasound, MRI
is a diagnostic option, with accuracy that rivals CT; MRI has
a sensitivity of 80% and specificity of 99%, compared with
85.7 and 97.4% for CT. Although MRI does not carry a risk
of radiation, it does have theoretical risks of static and time-
varying magnetic fields, heating eRects of the radiofrequency
pulses and acoustic noise generated by the spatial encoding
gradients do exist. To date, however, no adverse eRects of MRI
on the developing fetus have been reported.60
he pregnant patient should proceed directly to appen-
dectomy if appendicitis is suspected. A normal appendix is
not an uncommon finding, as negative appendectomy has
been reported in approximately one-third of cases due to
the difficulty of diagnosis in this population.51,52,61 Negative
appendectomy should not be considered an error in diagno-
sis, because the risk to the fetus varies directly with the sever-
ity of appendicitis. In one series, fetal loss occurred in only 1
(3%) of 30 negative laparotomies. 51 Fetal mortality rises to
5% in cases of nonperforated appendicitis and increases to
20–35% when the appendix perforates. 55,61 hese data war-
rant an aggressive approach to appendectomy. Early negative
exploration is justified to minimize the likelihood of progres-
sion to perforation.
As laparoscopic appendectomy has become increasingly
popular, it has been utilized more frequently during preg-
nancy.62 Pregnancy can increase the complexity of the proce-
dure, as the gravid uterus can make laparoscopic visualization
difficult, particularly if the appendix is located in the pelvis. In
addition, carbon dioxide insuÆation of the abdomen results
in fetal hypercarbia and decreased placental blood flow, the
eRects of which have not been completely studied.63 Recent
case series, however, have supported the safety of laparoscopic
appendectomy in the pregnant patient. In a retrospective
review of 45 cases, Lemieux et al64 demonstrated that 4% of
patients had a major complication (uterine perforation, intra-
abdominal abscess), 4% of patients had a minor complica-
tion (cystitis, ileus), 18% delivered before 37 weeks gestation,
and there was no fetal loss. here was also no diRerence in
complications, preterm delivery, or operative time associated
with performing the appendectomy during the first, second,
or third trimester. A retrospective review directly comparing
laparoscopic to open appendectomy in 42 pregnant women
found no intra- or postoperative complications in either
group and one fetal loss in both groups.65 hus, the feasibility
and safety of laparoscopy during pregnancy are supported by
631
these studies, but larger studies are required for it to become
fully accepted.
Immunocompromise. he immunocompromised state
alters the normal response to acute infection and wound
healing. Appendicitis aRects all types of patients and must
be considered in those who have undergone organ trans-
plant, are receiving chemotherapy, have hematological malig-
nancy, or are infected with the human immunodeficiency
virus (HIV). he diRerential diagnosis of abdominal pain in
this population is broad and includes hepatitis, pancreatitis
(from medications or cytomegalovirus infection), acalculous
cholecystitis, intra-abdominal opportunistic infections (cyto-
megalovirus colitis or mycobacterial ileitis), secondary malig-
nancies (lymphoma or Kaposi’s sarcoma), graft-versus-host
disease, and typhlitis. his broad diRerential diagnosis often
results in delay in diagnosis and late presentation to surgical
evaluation, at which time perforation may be more likely.66,67
Appendicitis in patients with HIV and acquired immu-
nodeficiency syndrome (AIDS) presents unique challenges.
Abdominal pain is not an uncommon symptom in these
patients, making diRerentiation between surgical and non-
surgical causes difficult. Nonetheless, immunocompromised
patients with appendicitis present with symptoms similar to
those of the general population, 66 and RLQ pain, nausea,
and anorexia. Fever and WBC may not be helpful in this
population, so imaging studies, particularly CT, have been
supported by some authors. 67 here is no specific contrain-
dication to operation in immunocompromised patients, so
once diagnosed with appendicitis, appendectomy should be
performed promptly.
Treatment
NONOPERATIVE MANAGEMENT
Appendectomy was one of the first intra-abdominal opera-
tions performed, and appendicitis has long been a surgically
treated disease. Rare descriptions of nonsurgical management
dot the surgical literature, however. Treves was an advocate
of early nonoperative management of acute appendicitis,
even prior to the advent of antibiotics. 12 In the postantibi-
otic era, Coldrey presented his retrospective series of 471
patients with appendicitis treated with antibiotics.68 his
treatment failed in at least 57 patients, with 48 requiring
appendectomy and 9 requiring drainage of an appendiceal
abscess. An early randomized controlled trial, performed by
Eriksson and associates, sought to address this issue.69 heir
results show a high rate of recurrence of appendicitis treated
nonsurgically. he authors randomized 40 adults with pre-
sumed appendicitis to appendectomy or 10 days of intrave-
nous and oral antibiotics. Eight (40%) of the 20 patients in
the antibiotic group required appendectomy within 1 year:
one patient for perforation within 12 hours of randomiza-
tion and another seven for recurrent appendicitis (one of
whom had perforation). Based on the high rate of failure
632 Part V Intestine and Colon
with antibiotics alone, nonoperative management of acute
appendicitis has not been recommended.
Recently, a larger randomized clinical trial evaluating anti-
biotic therapy versus appendectomy as the primary treatment
for acute appendicitis in unselected patients was performed.70
In this study 202 patients were assigned to antibiotic treat-
ment and 167 patients to appendectomy. Treatment efficacy,
defined as definite improvement without the need for surgery
within a median follow-up of 1 year for the antibiotic group
and confirmed appendicitis or another appropriate surgical
indication at the time of the operation for the appendec-
tomy group, was found to be similar between the antibiotic
and appendectomy groups (90.8 and 89.2% respectively).
In the antibiotic group, recurrent appendicitis occurred in
13.9% after a median of 1 year. A third of the recurrences
occurred within 10 days and two-thirds occurred within 3
and 16 months after discharge. Minor complications were
similar between the two groups while major complications,
defined as the need for reoperation, abscess, bowel obstruc-
tion, wound rupture or hernia, and serious anesthesia or
cardiac-related problems, were three times higher in the
appendectomy group. Close evaluation of this study, how-
ever, highlights the need for further studies and caution when
applying their findings to clinical practice. Specifically, only
52.5% of those allocated to the antibiotic group completed
antibiotic treatment. he remaining patients were transferred
to the appendectomy group based on either the patient’s or
surgeon’s discretion. Evaluation of those patients transferred
to the surgery group indicate that they had a higher WBC
and elevated temperature suggesting that they may have been
clinically sicker. he efficacy of the antibiotic group reported
as 90.8% was based only on those that completed antibiotic
therapy and thus excluded the potentially sicker patients who
crossed over from the antibiotic group to the surgery group.
Evaluation of efficacy based on intention-to-treat (all 202
patients originally allocated to the antibiotic group including
the 47.5% that switched to surgery) results in an efficacy of
48% for the antibiotic group. hese studies suggest that anti-
biotic treatment may be a useful first-line treatment for acute
appendicitis in selected patients; however, further studies are
required to determine their usefulness as the lone treatment
option. Nevertheless, antibiotic treatment may be a useful
temporizing measure in environments with no surgical capa-
bilities such as in space flight and submarine travel.71
PREOPERATIVE PREPARATION
When the decision is made to perform an appendectomy for
acute appendicitis, the patient should proceed to the operat-
ing room with little delay to minimize the chance of progres-
sion to perforation. Such occurrences are rare, however, as
most cases of appendiceal perforation occur prior to surgi-
cal evaluation.23,24 Patients with appendicitis may be dehy-
drated from fever and poor oral intake, so intravenous fluids
should be begun, and pulse, blood pressure, and urine output
should be closely monitored. Markedly dehydrated patients
may require a Foley catheter to ensure adequate urine output.
Severe electrolyte abnormalities are uncommon with non-
perforated appendicitis, as vomiting and fever have typically
been present for 24 hours or less but may be significant in
cases of perforation. Any electrolyte deficiencies should be
corrected prior to the induction of general anesthesia.
Intravenous antibiotics have been shown to reduce signifi-
cantly the incidence of postoperative wound infection and
intra-abdominal abscess.72 Antibiotics should be adminis-
tered 30 minutes prior to incision to achieve adequate tissue
levels. he typical flora of the appendix resembles that of the
colon and includes gram-negative aerobes (primarily Esch-
erichia coli) and anaerobes (Bacteroides spp.). No standard-
ized antibiotic regimen exists. Acceptable options include a
second-generation cephalosporin or a combination of anti-
biotics directed at gram negatives and anaerobes. In nonper-
forated appendicitis, a single preoperative dose of cefoxitin
suffices.73 In cases of perforation, an extended course of at
least 5 days of antibiotics is advocated.74
OPEN VERSUS LAPAROSCOPIC
APPENDECTOMY
Once the diagnosis of appendicitis is made, the surgeon
must decide whether to perform an open (OA) or laparo-
scopic (LA) appendectomy. Numerous randomized con-
trolled trials have compared these two methods, sometimes
with conflicting results. 75,76 Meta-analyses and systematic
reviews have combined these studies to address the con-
troversy (Table 31-3).77–79 hese meta-analyses have similar
findings, which can be summarized as follows: (1) OA can be
performed more quickly; (2) LA patients have less postop-
erative pain and reduced narcotic requirements; (3) there is a
trend toward reduced length of stay with LA; (4) LA patients
have fewer wound infections; (5) OA patients develop fewer
intra-abdominal abscesses; (6) LA patients return to work
more quickly; (7) operating room and hospital costs are less
with OA; and (8) societal costs may be less with LA.77–79
TABLE 31-3: LAPAROSCOPIC VERSUS OPEN
APPENDECTOMY
Favors Laparoscopy Favors Open
Diagnosis of other conditions
Decreased pain and lower Shorter operating room time
narcotic requirement
Reduced length of stay Lower operating room costs
Fewer wound infections Fewer intra-abdominal abscesses
Quicker return to usual activities Lower hospital costs
Lower societal cost
Data from McCall JL, Sharples K, Jadallah F. Systemic review of randomized
controlled trials comparing laparoscopic with open appendicectomy: a meta-
analysis. J Am Coll Surg. 1998; 186:545–553; and Sauerland S, Lefering R,
Neugebaur EA. Laparoscopic versus open surgery for suspected appendicitis.
Cochrane Database Syst Rev. 2004;4:CD001546.
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
Based on the data available, one cannot convincingly rec-
ommend either OA or LA over the other. Each method has
its advantages and disadvantages that should be considered
when deciding how to perform appendectomy.
One situation in which laparoscopic appendectomy may
be advisable is when the diagnosis of appendicitis is in doubt.
his can be particularly useful in women of childbearing age,
in whom obstetric and gynecological pathology may also be
likely. In this population, a normal appendix can be found
in more than 40% of patients with suspected appendicitis.80
Laparoscopy can thus be both diagnostic and therapeutic,
and a laparotomy can be avoided if gynecologic pathology is
found. he ovaries, fallopian tubes, and uterus can be exam-
ined for nonappendiceal causes of abdominal pain, including
ovarian cyst or torsion, endometriosis, or pelvic inflamma-
tory disease. Laparoscopy makes this evaluation considerably
easier and less morbid for the patient. In one study, when
a normal appendix was discovered, gynecological pathol-
ogy was found in 73% of women explored laparoscopically
but only 17% of women who had an open appendectomy.81
Although diagnostic accuracy will likely improve in young
women with more widespread use of CT scans, this popula-
tion will continue to provide diagnostic dilemmas that may
be aided by laparoscopy.
Open Appendectomy. If open appendectomy is chosen,
the surgeon must then decide on the location and type of
incision. Prior to incision, a single dose of antibiotics should
be administered, typically a second-generation cephalospo-
rin.73 he patient should be reexamined after the induction
of general anesthesia, which enables deep palpation of the
abdomen. If a mass representing the inflamed appendix can
be palpated, the incision can be centered at that location. If
no appendiceal mass is detected, the incision should be cen-
tered over McBurney’s point, one-third of the distance from
the anterior superior iliac spine to the umbilicus. A curvi-
linear incision, now known as McBurney’s incision, is made
in a natural skin fold. It is important not to make the inci-
sion too medial or too lateral. An incision placed too medial
opens onto the anterior rectus sheath, rather than the desired
oblique muscles, while an incision placed too lateral may be
lateral to the abdominal cavity.
he operation proceeds much as McBurney first described
it in 1894.82 he incision extends through the subcutaneous
tissue, exposing the aponeurosis of the external oblique mus-
cle, which is divided, either sharply or with electrocautery, in
the direction of its fibers (Fig. 31-6). A muscle-splitting tech-
nique is typically used, in which the external oblique, inter-
nal oblique, and transversus abdominis muscles are separated
along the orientation of their muscle fibers. he peritoneum
is thus exposed, grasped with forceps, and opened sharply
along the orientation of the incision, taking care not to injure
the underlying abdominal contents. Hemostats can be placed
on the peritoneum to facilitate its identification at the time of
wound closure. Cloudy fluid may be encountered on entering
the peritoneum. Although some advocate bacterial culture
of the peritoneal fluid, studies show that this neither helps
633
direct the antibiotic regimen 83 nor reduces infectious com-
plications.84
With a correctly placed incision, the cecum will be visible
at the base of the wound. he incision should be explored with
a finger in an attempt to locate the appendix. If the appen-
dix is palpable and free from surrounding structures, it can be
delivered into the incision. Frequently, the appendix is palpa-
ble, but it adheres to surrounding structures. Filmy adhesions
can be divided using blunt dissection, but thicker adhesions
should be divided under direct vision. To facilitate this, the
cecum can be partially delivered into the incision to pro-
vide better exposure of the appendix. If necessary to improve
exposure, the incision can be extended medially by partially
dividing the rectus muscle or laterally by further dividing the
oblique and transversus abdominis muscles. If the appendix
cannot be visualized, it can be located by following the teniae
coli of the cecum to the cecal base, from which the appendix
invariably originates. Once located, the appendix is delivered
through the incision. Grasping the mesentery with a Babcock
clamp can sometimes facilitate this maneuver. Care should be
taken to avoid perforation of the appendix, with spillage of
pus or enteric contents into the abdomen.
he arterial supply to the appendix, which runs in the
mesoappendix, is now divided between clamps and tied with
3-0 polyglactin or silk suture. his is usually performed in an
antegrade fashion, from the appendiceal tip toward the base.
Division of the artery to the appendiceal base is necessary to
ensure that the entire appendix can be removed without leav-
ing an excessively long appendiceal stump.
In excising the appendix, the surgeon must decide
whether or not to invert the appendiceal stump. Tradition-
ally, the appendix was ligated and divided, and its stump was
inverted with a purse-string suture for the theoretical purpose
of avoiding bacterial contamination of the peritoneum and
subsequent adhesion formation.85,86 However, recent prospec-
tive studies show no advantages to appendiceal stump inver-
sion.87,88 In one such study, 735 appendectomy patients were
randomly assigned to ligation plus inversion or simple ligation
of the appendiceal stump. here was no diRerence between
the two groups in the incidence of wound infection or adhe-
sion formation, and operating time was shorter in the simple
ligation group. Inversion may also have the deleterious eRect
of deforming the cecal wall, which could be misinterpreted as
a cecal mass on future contrast radiographs.88 Furthermore,
the long-standing notion that stump inversion reduces post-
operative adhesions was discredited by Street and colleagues.89
In their analysis, postoperative adhesions requiring operation
were significantly increased in the inversion group.
To divide the appendix, the surgeon can use either suture
ligation or a gastrointestinal stapler. For ligation, two hemostat
clamps are placed at the base of the appendix. he clamp clos-
est to the cecum is removed, having crushed the appendix at
that site. Two heavy, absorbable sutures such as 0 chromic gut
is used to doubly ligate the appendix, and the appendix is sub-
sequently divided proximal to the second clamp. he exposed
mucosa of the appendiceal stump can be cauterized to mini-
mize the theoretical risk of postoperative mucocele, although
634 Part V Intestine and Colon

A B

E F
FIGURE 31-6 Open appendectomy technique.
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula 635

G H

I J
FIGURE 31-6 (Continued)

no data exist to support this. If appendiceal stump inversion is
chosen, a seromuscular purse-string 3-0 silk suture is placed in
the cecum around the appendiceal base after ligation but prior
to division of the appendix. he purse-string suture should
be placed approximately 1 cm from the base of the appendix,
as placing it too close to the appendix makes stump inver-
sion difficult. After the appendix is divided, the purse-string
suture is tightened and tied while the assistant uses forceps to
invaginate the appendiceal stump. Alternatively, the appen-
dix can be divided at its base using a TA-30 stapler. Again,
the stump need not be inverted, but can be if desired, using
interrupted Lembert sutures with 3-0 silk suture. No matter
how the appendix is divided, the residual appendiceal stump
should be no longer than 3 mm to minimize the possibility of
stump appendicitis in the future.26
Occasionally, inflammation at the tip of the appendix
makes antegrade removal of the appendix difficult. In such
cases, the appendix can be removed in a retrograde fashion.
In so doing, the appendix is divided at its base using one of
the methods described previously. he mesoappendix is then
divided between clamps, starting at the appendiceal base and
progressing toward the tip (Fig. 31-7).
In certain cases, the appendiceal inflammation extends
to the base of the appendix or beyond to the cecum. Divi-
sion of the appendix through inflamed, infected tissue
leaves the potential for leakage of cecal contents with a
resultant abscess or fistula. Ensuring that the resection
margin is grossly free of active inflammation can minimize
this risk. If the base of the cecum is also inflamed but there
is sufficient uninflamed cecum between the appendix and
the ileocecal valve, an appendectomy with partial cecec-
tomy can be performed using a stapling device. 90 Care
should be taken to avoid narrowing the cecum at the ileo-
cecal valve. If the inflammation extends to the ileocecal
junction, an ileocecectomy with primary anastomosis may
be necessary.
636 Part V Intestine and Colon
FIGURE 31-7 Retrograde dissection of the appendix.
After the appendix is removed, hemostasis is achieved
and the right lower quadrant and pelvis are irrigated with
warm saline. he peritoneum is closed with a continuous
0 absorbable suture; this layer provides no strength but
helps to contain the abdominal contents during abdominal
wall closure. he internal and external oblique muscles are
then closed in succession using continuous 0 absorbable
suture. To decrease postoperative narcotic requirements, the
external oblique fascia can be infused with local anesthetic.
Interrupted absorbable sutures are typically placed in Scar-
pa’s fascia, and the skin can be closed with a subcuticular
absorbable suture. With a preoperative dose of intravenous
antibiotics and primary closure of the skin, fewer than 5%
of patients with nonperforated appendicitis can be expected
to develop a wound infection.91
Laparoscopic Appendectomy. Multiple port placements
for laparoscopic appendectomy exist. he authors utilize a
three-port technique, with one umbilical and one suprapubic
port. Although the third port can be placed in either the left
or right lower quadrant, we prefer the left lower quadrant. his
follows the laparoscopic principle of triangulation, such that the
port locations direct the camera and instruments toward the
right lower quadrant for optimal visualization of the appendix.
he patient is positioned supine on the operating room
table with the left arm tucked (Fig. 31-8). he video monitor
is placed at the patient’s right side, because once pneumoperi-
toneum is performed, the surgeon and assistant both stand on
the patient’s left. A single dose of a second-generation cepha-
losporin is administered prophylactically. Prior to incision,
a nasogastric tube and a Foley catheter are placed to decom-
press the stomach and urinary bladder. A Foley catheter can
be avoided if a reliable patient urinates immediately prior to
entering the operating room. A 1- to 2-cm vertical or transverse
incision is made just inferior to the umbilicus and carried down
to the midline fascia. A 12-mm trocar is placed using either
Hassan or Veress technique, depending on surgeon preference.
After insuÆation of the abdomen and inspection through the
umbilical port, a 5-mm suprapubic port is placed in the mid-
line, taking care to avoid injury to the bladder, and another
5-mm port is placed in the left lower quadrant. hese port sites
typically provide excellent cosmesis postoperatively due to their
small size and peripheral location on the abdomen.
A 5-mm, 30-degree laparoscope is inserted through the
left lower quadrant trocar. Placing the laparoscope in the
left lower quadrant allows triangulation of the appendix in
the right lower quadrant by instruments placed through the
two midline trocars. he surgeon operates the two dissect-
ing instruments and the assistant operates the laparoscope.
he appendix is identified at the base of the cecum, and
any adhesions to surrounding structures can be lysed with
a combination of blunt and sharp dissection supplemented
with electrocautery. If a retrocecal appendix is encountered,
division of the lateral peritoneal attachments of the cecum
to the abdominal wall often improves visualization. Care
must be taken to avoid underlying retroperitoneal structures,
specifically the right ureter and iliac vessels. he appendix or
mesoappendix can be gently grasped with a Babcock clamp
placed through the suprapubic port and retracted anteriorly.
A dissecting forceps placed through the umbilical port cre-
ates a window in the mesoappendix at the appendiceal base.
Caution should be taken not to injure the appendiceal artery
during this maneuver. As in the open procedure, the base of
the appendix should be adequately dissected so that it can
be divided without leaving a significant stump.26 he appen-
dix should be divided at the confluence of the appendix and
cecum, or just onto the cecal wall, to avoid the possibility of
stump appendicitis or mucocele (see Fig. 31-8).
he appendix can be removed in a retrograde fashion,
first dividing the appendix, followed by division of the
mesoappendix. A laparoscopic gastrointestinal anastomosis
(GIA) stapler is placed through the umbilical port and fired
across the appendiceal base. After reloading, the stapler is
again inserted through the umbilical port and placed across
the mesoappendix, which is divided with firing of the sta-
pler. Alternatively, the appendix can be secured using an
Endoloop92 (Ethicon, Endo-Surgery, Cincinnati, Ohio) and
the mesoappendix with an Endoloop of cautery device. If
desired, the appendix can be removed antegrade, by first
dividing the mesoappendix prior to directing attention to
the base. he appendix should be placed in a retrieval bag
and removed through the umbilical port site to minimize
the risk of wound infection. he operative field is inspected
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula 637

Surgeon A
Umbilicus

12 mm

Monitor 5 mm

5 mm

A B

C D

FIGURE 31-8 Laparoscopic appendectomy technique.

638 Part V Intestine and Colon
FIGURE 31-8 (Continued )
for hemostasis and can be irrigated with saline. Finally, the
fascial defect at the umbilicus is closed with interrupted 0
absorbable suture, and all skin incisions are closed with fine
subcuticular absorbable suture.
Postoperative Care
Patients with nonperforated appendicitis typically require a
24- to 48-hour hospital stay. Postoperative care for both the
laparoscopic and open approaches is similar. Patients can be
started on a clear liquid diet immediately, and their diet can
be advanced as tolerated. No postoperative doses of antibiot-
ics are required. Patients can be discharged when they tolerate
a regular diet and oral analgesics.
Perforated Appendicitis
When appendicitis progresses to perforation, management
depends on the nature of the perforation. If the perforation
is contained, a solid or semisolid periappendiceal mass of
F
inflammatory tissue can form, referred to as a phlegmon. In
other cases, contained perforation may result in a pus-filled
abscess cavity. Finally, free perforation can occur, causing
intraperitoneal dissemination of pus and fecal material. In the
case of free perforation, the patient is typically quite ill and
perhaps septic. Urgent laparotomy is necessary for appendec-
tomy and irrigation and drainage of the peritoneal cavity. If
the diagnosis of perforated appendicitis is known, the appen-
dectomy can be performed through an RLQ incision, and the
technique follows that previously described for open appen-
dectomy. Sometimes patients with free perforation present
with an acute abdomen and generalized peritonitis, and the
decision to perform a laparotomy is made without a definitive
diagnosis. In such instances, a midline incision is prudent.
Once perforated appendicitis is discovered, appendectomy
again proceeds as described previously. Peritoneal drains are
not necessary, as they do not reduce the incidence of wound
infection or abscess after appendectomy for perforated appen-
dicitis.93,94 he final operative decision is whether or not to
close the incision. Because of wound infection rates ranging
from 30 to 50% with primary closure of grossly contaminated
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
wounds, many advocate delayed primary or secondary clo-
sure.91,95 However, a cost-utility analysis of contaminated
appendectomy wounds showed primary closure to be the
most cost-eRective method of wound management.96 Our
technique of skin closure is interrupted permanent sutures
or staples every 2 cm with loose wound packing in between.
Removal of the packing in 48 hours often leaves an excellent
cosmetic result with an acceptable incidence of wound infec-
tion. Patients are often continued on broad-spectrum anti-
biotics for 5–7 days and should remain in the hospital until
afebrile and tolerating a regular diet.
If the patient does not have signs of generalized peritonitis
but an abscess or phlegmon is suspected by history and physi-
cal exam, a CT scan can be particularly helpful to confirm the
diagnosis. A solid, inflammatory mass in the RLQ without
evidence of a fluid-filled abscess cavity suggests a phlegmon.
In such instances, appendectomy can be difficult due to dense
adhesions and inflammation. Ileocecectomy may be neces-
sary if the inflammation extends to the wall of the cecum.
Complications such as inadvertent enterotomy, postopera-
tive abscess, or enterocutaneous fistula may ensue. Because
of these potential complications, many support an initially
nonoperative approach. 97–99 Such an approach is only advis-
able if the patient is not ill appearing. Nonoperative manage-
ment includes intravenous antibiotics and fluids as well as
bowel rest. Patients should be closely monitored in the hospi-
tal during this time. Treatment failure, as evidenced by bowel
obstruction, sepsis, or persistent pain, fever, or leukocytosis,
requires immediate appendectomy. If fever, tenderness, and
leukocytosis improve, diet can be slowly advanced, usually
within 3–5 days. Patients are discharged home when clinical
parameters have normalized. Using this approach, more than
80% of patients can be spared an appendectomy at the time
of initial presentation.97,98
If imaging studies demonstrate an abscess cavity, CT- or
ultrasound-guided drainage can often be performed per-
cutaneously or transrectally. 100,101 Studies suggest that this
approach to appendiceal abscesses results in fewer complica-
tions and shorter overall length of stay. 99,102 Again, following
drainage the patient is closely monitored in the hospital and
is placed on bowel rest with intravenous antibiotics and flu-
ids. Advancement of diet and hospital discharge progress as
clinically indicated.
Interval Appendectomy
Treatment following initial nonoperative management of
an appendiceal phlegmon or abscess is controversial. Some
recommend interval appendectomy 102–105 (appendectomy
performed approximately 6 weeks after inflammation has
subsided), while others consider subsequent appendectomy
unnecessary.98,106,107 Factors to be considered when advising
patients on interval appendectomy include a relatively low
incidence of future appendicitis (8–10% and often asso-
ciated with an appendicolith) and a morbidity associated
with an interval appendectomy of approximately 11%.106
639
hese factors must be weighed against the higher morbid-
ity associated with an immediate appendectomy in the set-
ting of acute recurrent appendicitis in the future (as high as
36% when appendicitis is associated with a phlegmon or
abscess)106 as well as the possibility of an ongoing appendi-
ceal pathology, including inflammatory bowel disease and
cancer.103,105,106 Because it can now be performed laparo-
scopically on an outpatient basis with low morbidity,104,108
interval appendectomy should be considered for patients
who were initially treated with nonoperative management,
but there is not convincing evidence to recommend this
approach.
Normal Appendix
Because of the difficulty in diagnosing appendicitis, it is not
uncommon for a normal appendix to be found at appendec-
tomy. Sometimes referred to as misdiagnosis, this can occur
more than 15% of the time, with considerably higher per-
centages in infants, the elderly, and young women.40 Nega-
tive appendectomy is to be avoided when possible, because of
the risk of surgical complications and the cost associated with
unnecessary surgery.109 Nonetheless, in certain instances, the
diagnosis is in doubt, and a noninflamed appendix is found
at laparotomy or laparoscopy. he surgeon must then decide
whether or not to remove the appendix. For multiple rea-
sons, it is advisable to remove the grossly normal appendix.
First, if the pain recurs and the appendix has been removed,
appendicitis will no longer be a possibility and can be
removed from the diRerential diagnosis. If the patient suf-
fers RLQ pain in the future and the appendix has not been
removed, but the patient has a classic RLQ scar, a surgeon
evaluating the patient may assume a history of appendectomy
and erroneously remove appendicitis from consideration. As
laparoscopic appendectomy becomes more popular, this may
even be true for patients with port site scars suggestive of
appendectomy. Finally, there is strong evidence that a sur-
geon’s gross assessment of the appendix can be inaccurate.
In one study, 11 (26%) out of 43 appendectomy specimens
described as normal by the surgeon showed acute appendi-
citis on pathological examination.110 As a result, removal of
a grossly normal appendix at the time of appendectomy is
recommended.
When a normal appendix is discovered at appendectomy,
it is important to search for other possible causes of the
patient’s symptoms. he terminal ileum can be inspected for
evidence of terminal ileitis, which could be from infectious
causes (Yersinia or tuberculosis) or Crohn’s disease. In the
absence of perforation, resection should not be performed for
Crohn’s disease and appropriate medical therapy should be
initiated postoperatively. he ileum should also be evaluated
for an inflamed or perforated Meckel’s diverticulum, which
should be excised. In females, the ovaries, fallopian tubes, and
uterus should be examined for pathology as well. Evaluation
of the left adnexa can be difficult through an RLQ incision,
highlighting the utility of laparoscopy in female patients.
640 Part V Intestine and Colon
Chronic Appendicitis
Although rare, chronic appendicitis can explain persistent
abdominal pain in some patients. Patients do not present
with the typical symptoms of acute appendicitis. Instead, they
complain of weeks to years of RLQ pain and may have had
multiple medical evaluations in the past. When queried, they
may describe an initial episode with more classic symptoms of
acute appendicitis, for which no treatment was delivered. 111
Diagnosis can be difficult, as laboratory and radiological
studies are typically normal. Pathology evaluation revealing
chronic inflammation confirms the diagnosis. Because the
diagnosis is often uncertain preoperatively, laparoscopy can
be a useful tool to allow exploration of the abdomen.112
Asymptomatic Appendicolith
As CT scans become more widely utilized, it is likely that
an increasing number of asymptomatic appendicoliths will
be discovered. As discussed previously, appendicoliths are not
pathognomonic for appendicitis but should only be consid-
ered in conjunction with the clinical presentation and other
diagnostic studies. Lowe and associates113 studied CT scans of
children with suspected appendicitis and compared them to
CT scans of children with abdominal trauma. Six (14%) of
44 patients with suspected appendicitis had an appendicolith
but proved not to have appendicitis. In addition, 2 (3%) of
the 74 trauma patients had an appendicolith on CT. hese
children were not followed to see if appendicitis developed
later in life, but the considerable number of asymptomatic
appendicoliths seen on adult abdominal radiographs suggests
that many patients with an appendicolith will never develop
appendicitis.18,19 Based on this, appendectomy for asymp-
tomatic appendicolith cannot be recommended.
NEOPLASMS OF THE APPENDIX
Neoplasms of the appendix are rare, aRecting less than 1% of
appendectomies. Signs and symptoms of appendicitis prompt
appendectomy in up to 50% of patients, and it is not uncom-
mon for the patients with an appendiceal neoplasm to have
acute appendicitis as well. 114 Patients may also present with
a palpable mass, intussusception, urologic symptoms, or an
incidentally discovered mass on abdominal imaging or at
laparotomy for another purpose. Typically, the diagnosis is
not known until laparotomy or pathologic evaluation of the
appendectomy specimen, but preoperative diagnosis may
become more common as imaging techniques become more
widely used. Because of their common embryologic origin,
the appendix and colon are susceptible to many of the same
neoplastic growths. he most common appendiceal tumors
include cystic neoplasms, carcinoid tumors, adenocarcinoma,
and metastases. Other tumors have been reported but are
extremely rare, such as lymphoma, stromal tumors (leiomy-
oma and leiomyosarcoma), and Kaposi’s sarcoma.115
Cystic Neoplasms and
Pseudomyxoma Peritonei
Sometimes referred to as mucoceles, mucinous neoplasms of
the appendix include a spectrum of diseases, including simple
cyst, mucinous cystadenoma, mucinous cystadenocarcinoma,
and pseudomyxoma peritonei. Mucocele is not a true patho-
logic diagnosis and instead refers to the macroscopic appear-
ance of an appendix distended with mucus. Any of the above
conditions can form a mucocele, but the more specific diag-
nostic term is preferable.116 A simple cyst results from non-
neoplastic occlusion of the appendiceal lumen, is usually less
than 2 cm in diameter, and is often an incidental finding at
appendectomy. In contrast, mucinous cystadenomas, benign
tumors that represent the majority of “mucoceles,” can grow
to 8 cm or larger (Fig. 31-9).117 hey typically remain asymp-
tomatic due to slow-growing distension of the appendix and
instead present incidentally as a mass on physical examina-
tion or abdominal imaging (Fig. 31-10). On plain radiograph
or CT, wall calcification is characteristic.116
It is recommended that all mucinous appendiceal masses
2 cm or larger be surgically removed.117 For mucinous cyst-
adenoma, appendectomy is sufficient if the lesion does not
involve the appendiceal base. Occasionally, the mass will rup-
ture prior to or at the time of removal, but this rupture is
typically contained to the right lower quadrant and is con-
sidered localized pseudomyxoma peritonei. If the mass is
benign, appendectomy and removal of any residual mucin
is curative.118 Laparoscopic appendectomy is not currently
recommended because of the possibility of malignancy and
spillage of mucin-secreting cells throughout the abdomen. 119
Because of an association with colon and rectal carcinoma,
a screening colonoscopy is recommended postoperatively.117
Mucinous cystadenocarcinoma represents the malignant
form of cystic neoplasms of the appendix. In contrast to cyst-
adenoma, patients are usually symptomatic with abdominal
FIGURE 31-9 A 14-cm mucinous cystadenoma of the appendix.
he appendiceal tip is to the left, the base to the right. (Used, with
permission, from Jacqueline M. Wilson, MD, PhD, Brigham and
Women’s Hospital, Boston, MA.)
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
FIGURE 31-10 CT axial image at the level of the terminal ileum
shows a fluid-filled mass (arrowhead) corresponding to the mucinous
cystadenoma seen in Fig 31-9. he more proximal appendix (arrow) is
seen between the mass and cecum. (Used, with permission, from M.
Stephen Ledbetter, MD, Brigham and Women’s Hospital, Boston, MA.)
pain, weight loss, an abdominal mass, or signs of acute
appendicitis. Increasing abdominal girth may also be present
and suggests development of pseudomyxoma peritonei from
perforation and peritoneal dissemination of mucin-secreting
cells. DiRuse pseudomyxoma peritonei is highly predictive of
malignancy; in one series, 95% of patients with pseudomyx-
oma had an associated mucinous cystadenocarcinoma.117 he
recommended treatment consists of right hemicolectomy
with debulking of any gross spread of disease and removal
of all mucin. It is not uncommon, however, for the diagnosis
to be unknown until the time of pathologic evaluation of
the appendectomy specimen. In such cases, reoperation with
right hemicolectomy is recommended, as 5-year survival for
mucinous cystadenocarcinoma is 75% after hemicolectomy
and less than 50% after appendectomy alone.120 Some refer-
ral centers advocate extensive initial resections including
omentectomy, as well as repeated debulking procedures for
recurrent disease.121
Adenocarcinoma
Primary adenocarcinoma of the appendix is classified into
two types: mucinous (discussed previously) and colonic. he
colonic type is less common, less likely to secrete mucus, and
more likely to present with acute appendicitis due to obstruc-
tion of the appendiceal lumen.116 Because of similarities with
colon carcinoma, appendiceal adenocarcinomas are classified
as Dukes stage A, B, C, and D, with 5-year survival rates of
100, 67, 50, and 6%, respectively. he colonic type has a
less favorable prognosis, with only 41% 5-year survival after
641
treatment, compared to 71% for the mucinous type. he
optimal treatment is right hemicolectomy, and reoperation
should be recommended if the diagnosis is made on patho-
logic evaluation of an appendectomy specimen.120
Carcinoid Tumors
he most common neoplasm of the appendix, carci-
noid tumors comprise more than 50% of all appendiceal
tumors.114 Among malignant tumors of the appendix, car-
cinoids are less aggressive and carry a much more favor-
able prognosis than adenocarcinomas, with 5-year survival
approaching 90%.122 Most appendiceal carcinoids are found
incidentally at the time of appendectomy for appendicitis.
However, because the majority of appendiceal carcinoids are
located at the tip of the appendix, the carcinoid mass is the
cause of appendicitis only 25% of the time.115 Tumor size
is the primary determinant of malignant potential. About
75% of carcinoids are less than 1 cm in size and 5–10% are
over 2 cm. Lymph node invasion and distant metastases are
exceedingly rare except in tumors over 2 cm. 123 Histologi-
cally, carcinoids of the appendix are categorized as goblet cell
and classic carcinoid. Mortality is higher for goblet cell but
is still lower than that of adenocarcinoma.122
Treatment of appendiceal carcinoids is dictated primarily
by tumor size. Simple appendectomy is sufficient for tumors
less than 1 cm because of the low likelihood of lymph node
involvement. For masses larger than 2 cm, right hemicolec-
tomy is recommended. Because of a concern for increased
metastatic potential, some authors also advocate right hemi-
colectomy in young patients; in carcinoids at the appen-
diceal base; and when there is evidence of lymphatic inva-
sion, lymph node involvement, spread to the mesoappendix,
tumor-positive resection margins, or cellular pleomorphism
with a high mitotic index.123–125
Small Bowel Diverticula
Small bowel diverticula can be characterized according to
their anatomic location (duodenal, jejunoileal, and distal
ileal diverticula) or the type of diverticula (false or true diver-
ticula). False diverticula do not contain all the layers of the
bowel wall. hey are acquired defects predominantly located
in the duodenal and jejunoileal portions of the small bowel.
hese diverticula involve herniated mucosa and submucosa
and typically occur at points of weakness, where blood vessels
enter the mesenteric border of the small bowel. In contrast,
a distal ileal (Meckel’s) diverticulum is a true diverticulum
containing all of the layers of the small bowel. It is a congeni-
tal anomaly resulting from the failure of the vitelline duct to
obliterate and is located along the antimesenteric border of
the distal ileum. Although the presence of small bowel diver-
ticula is not uncommon, most are asymptomatic and thus not
appreciated. Less than 4% of small bowel diverticula cause
642 Part V Intestine and Colon
symptoms, including inflammation, hemorrhage, obstruc-
tion, perforation, and malabsorption.
DUODENAL DIVERTICULA
Duodenal diverticula (DD) account for approximately 45%
of small bowel diverticula and have a reported incidence on
radiologic and autopsy studies of 5–22%.126,127 hey are rarely
multiple (12%) and are predominantly located in the medial
wall of the second portion of the duodenum (88%).128 When
the diverticulum is located adjacent to the ampulla of Vater,
as is often the case, it is known as a perivaterian or periampul-
lary diverticulum. DD typically occur in patients aged 50–65
years and are often asymptomatic at presentation. Less than
5% of patients with DD present with symptoms, including
nausea, vomiting, RUQ abdominal pain, fevers, chills, and
bleeding. hese presentations result from one of many poten-
tial complications, including inflammation, obstruction of
the duodenum or biliary-pancreatic duct, fistula formation
in the bile duct, bezoar formation inside the diverticulum,
and perforation. Although it is the most unusual compli-
cation, DD perforation is the most serious and can carry
a mortality of up to 20%. Perforation usually results from
acute inflammation but may also result from enterolithiasis,
ulceration, increased intraluminal pressure (eg, during endos-
copy), abdominal trauma, gallstones, or ischemia. Perforation
usually occurs posteriorly and can result in a retroperitoneal
abscess and sepsis. Anterior perforation can also occur, result-
ing in intraperitoneal spillage or communication with the
pancreas, colon, gallbladder, or aorta causing a duodenocolic
fistula or acute gastrointestinal hemorrhage secondary to per-
foration into the aorta.126,129
he nonspecific nature of the presenting symptoms and
their commonality with other gastrointestinal diseases such
as pancreatitis, cholecystitis, cholangitis, and peptic ulcer
disease highlight the fact that the diagnosis of a complicated
DD is often one of exclusion. Radiologic studies includ-
ing plain abdominal films and ultrasound may be helpful
to exclude other etiologies but are not definitive. CT scan
and upper endoscopy are the modalities of choice for eval-
uation. In the case of an inflamed diverticulum, CT may
demonstrate a thickened duodenal wall and surrounding fat
inflammation. If perforation has occurred, an extraluminal
collection of air and fluid (predominantly retroperitoneal)
may be identified. Additionally, the administration of oral
contrast with a CT scan or an upper gastrointestinal swal-
low study may define the extent of a leak in the case of a
perforation. However, it is not uncommon to be unable to
identify a DD on CT scan, and additional studies may be
required. Side-viewing endoscopy and endoscopic retrograde
cholangiopancreatography (ERCP) are very valuable in cor-
rectly diagnosing the presence of a DD as well as potentially
treating some of the associated complications. Successful
endoscopic management of hemorrhage, duodenal obstruc-
tion, pancreatobiliary obstruction resulting in pancreatitis or
cholangitis, and retroperitoneal abscess drainage associated
with a DD have been reported.130–133
he management of DD depends on the presence
or absence of symptoms and the clinical stability of the
patient. Given the precarious location of a DD and the
morbidity associated with resection, asymptomatic DD
discovered on imaging or endoscopy for other reasons
should be observed. Symptomatic DD can be managed
endoscopically, nonoperatively, or with surgical exploration
and resection or bypass. If inflammation with or without
perforation is present, nonoperative management, includ-
ing nasogastric decompression, antibiotics, serial examina-
tions, and radiologic-guided drainage if an abscess is pres-
ent, has been reported. his approach can be considered
in patients with mild symptoms who are clinically stable
or when CT confirms a contained leak.126,128,130,134 If the
patient is not a candidate for nonoperative management
because of hemodynamic instability, generalized peritoni-
tis, or persistent severe symptoms, the choice of surgical
intervention depends on such factors as the location of the
diverticulum and other intraoperative findings. A simple
closure of the perforated diverticulum or diverticulectomy
with single- or double-layer duodenal closure after kocher-
izing the duodenum is the treatment of choice if there
is minimal inflammation and the anatomy of the diver-
ticulum permits. After repair, appropriate drainage tubes
should be placed and the greater omentum can be used to
reinforce the repair. It is imperative to avoid damaging the
pancreatic and distal common bile duct during the repair,
so cannulation of the ampulla of Vater either retrograde or
antegrade through the cystic duct (with subsequent chole-
cystectomy) can be performed to help visualize the ampulla
prior to dissecting the diverticulum. If there is significant
inflammation at the site of the diverticulum or the divertic-
ulum lays buried in the pancreatic head or the papilla lays
deep in the diverticulum, a diversion should be performed.
Diversion can be performed by either a distal gastrectomy
with a Billroth-II reconstruction or a Roux-en-Y gastroje-
junostomy. Again, appropriate drainage tubes are typically
placed to drain the aRected area. In addition to diversion
and diverticulectomy, segmental duodenal resection for a
perforated DD has also been reported for the rare case of
a DD located in segment III or IV of the duodenum. A
pancreaticoduodenectomy may also be necessary if the DD
lies in close proximity to the common bile and pancreatic
ducts and the inflammation is thought to be too severe for
safe diversion or drainage.126,129,130 If symptoms are related
not to perforation of the DD but to obstruction of the pan-
creaticobiliary system causing cholangitis or pancreatitis,
resection of the duodenum may not be required and treat-
ment may consist of diversion of bile flow with a Roux-en-Y
choledochojejunostomy and duodenojejnuostomy.130,135
JEJUNOILEAL DIVERTICULA
Least common of the small bowel diverticula, jejunoileal diver-
ticula (JID) have an incidence of 0.002–5% based on postmor-
tem and enteroclysis studies. heir incidence increases with
age and peaks in the sixth and seventh decades of life. JID are
 Chapter 31 Appendix, Meckel’s, and Other Small Bowel Diverticula
acquired pseudodiverticula believed to result from a jejunoileal
dyskinesia causing increased intraluminal pressures and hernia-
tion of the mucosa and submucosa through the weakest site
of the muscularis of the bowel wall (ie, the mesenteric border
where paired blood vessels enter the bowel wall). hey can be
single (33%) or multiple (66%) and located in the jejunum
(55–80%), ileum (15–38%), or both (5–7%).136 Interestingly,
patients with JID also frequently have other coexisting gastro-
intestinal diverticula, including those found in the colon (20–
70%), duodenum (10–40%), esophagus, and stomach (2%)
highlighting a potential common etiology.137–139
he diagnosis of a JID is often challenging because most
patients are asymptomatic (up to 70%) or present with vague
abdominal complaints. here is, in fact, no gold standard
imaging technique used to diagnose a JID. Upper gastrointes-
tinal studies with small bowel follow-through as well as tradi-
tional enteroclysis and CT enteroclysis studies are beneficial.
CT, tagged red blood cell scan, or angiogram may demon-
strate findings consistent with a complication of a JID such as
inflammation, perforation, or bleeding. Capsule endoscopy
and double-balloon endoscopy are useful in diagnosing small
bowel disorders and may be of benefit in identifying JID in a
nonacute setting.137,140,141 Ultimately, JID are often identified
on exploratory laparotomy or laparoscopy for other indica-
tions or for the evaluation of chronic or acute symptoms.137
Asymptomatic, incidentally discovered JID need not be
resected. When symptomatic, patients with JID can be divided
into those with acute or chronic symptoms. Forty to sixty per-
cent of patients with a known diagnosis of JID present with
chronic symptoms. hese symptoms are often nonspecific and
include nausea, vomiting, postprandial bloating, recurrent
abdominal pain, cramping, weight loss, fatigue, and failure to
thrive. Because of the vague nature of the presenting symp-
toms, these patients often go undiagnosed or misdiagnosed for
several months (average 22 months) prior to being correctly
diagnosed.136,141,142 he pathophysiology of the chronic symp-
toms is believed to be related to either intestinal dyskinesia or
bacterial overgrowth from blind loop syndrome due to stasis in
the diverticular lumen. When bacterial overgrowth and a blind
loop syndrome are present, the patient may develop malab-
sorption, steatorrhea, and megaloblastic anemia resulting from
vitamin B12 deficiency. Frequently, chronic symptoms from
JID can be successfully managed medically. Medical manage-
ment consists of a low-residue diet, antispasmodics, antacids,
analgesics, and vitamin B12 supplementation. Bacterial over-
growth and blind loop syndrome can be initially managed with
antibiotics. If medical management fails, patients may require
resection of the segment of bowel containing the diverticulum
with subsequent primary anastomosis.
Approximately 10–19% of patients with JID present
with acute, often emergent, symptoms resulting from a
complication of the diverticulum, including gastrointesti-
nal hemorrhage, diverticulitis with or without perforation,
obstruction, fistula formation, sepsis, liver abscesses and
pneumoperitoneum. he presentation and management of
a patient with an acute complication of a JID depends on
643
the complication. Inflammation resulting in diverticulitis
occurs in 2.3–6.4% of patients with JID and can present as
mild abdominal pain or diRuse peritonitis associated with
free perforation.136 If perforation occurs in the setting of full-
thickness necrosis, it can be associated with a mortality of
up to 40%.136,143 Traumatic and foreign body perforations of
JID have also been described. If the perforation is contained
within the mesentery, nonoperative management with bowel
rest and antibiotics with or without percutaneous drainage
can be attempted. Similarly, asymptomatic pneumoperito-
neum in the setting of a known JID is not an indication for
surgery and can be managed conservatively.136,144,145 Lack of
clinical improvement after a period of nonoperative manage-
ment mandates resection of the aRected segment of bowel
with a primary anastomosis. Similarly, patients presenting
with a more significant findings of fever, elevated WBC,
peritonitis, and septic physiology require immediate lapa-
rotomy with resection of the aRected segment of bowel.136
Of patients with JID, 2–4.6% present with obstruction
related to adhesions, intussusception, volvulus, and extrinsic
compression from a fluid-filled diverticulum or, rarely, from
an enterolith formed in the diverticulum causing obstruc-
tion at the diverticulum or at the ileocecal valve. Obstruc-
tion believed to be secondary to adhesions can initially be
managed conservatively. However, if nonoperative manage-
ment fails, lysis of adhesions and segmental bowel resection
of the JID with a primary anastomosis are required. Similarly,
surgical resection is indicated for the management of obstruc-
tion resulting from intussusception, volvulus, or extrinsic
compression.137 Enterolith ileus associated with a JID is
best managed by an initial attempt at manual lysis of the
stone without an enterotomy. If not possible, the stone can
be removed through an enterotomy made in a nonedema-
tous segment of bowel. If one or multiple diverticula appear
inflamed or scarred, segmental resection of the involved bowel
with a primary anastomosis is mandated. However, many
patients often have multiple diverticula over a long stretch of
bowel, and thus, if no evidence of inflammation or scarring
is present, no resection is indicated.136 Approximately 3–8%
of patients with JID present with bleeding complications.
Hemorrhage from a JID can be slow and chronic in nature or
acute and massive presenting with hemorrhagic shock. Upper
and lower endoscopies are often negative, and the diagnosis is
made with angiographic and radioactive red blood cell stud-
ies. Although treatment with angiographic embolization has
been documented, segmental bowel resection is frequently
the required treatment.136,146
MECKEL’S DIVERTICULA
Meckel’s diverticula are the most common congenital mal-
formation of the gastrointestinal tract, occurring in approxi-
mately 1% of the population.147–149 A Meckel’s diverticulum
is a true diverticulum containing all three layers of the intes-
tinal wall and results from the failure of the obliteration of
the omphalomesenteric duct during fetal life. It is typically
644 Part V Intestine and Colon
located on the antimesenteric border of the small bowel
within 100 cm of the ileocecal valve. Although often lined
with ileal mucosa, ectopic gastric, duodenal, colonic, and
endometrial mucosa as well as pancreatic tissue, carcinoid
tissue, Brunner’s glands, and hepatobiliary tissue have been
found in Meckel’s diverticula.147
Similar to other small bowel diverticula, the majority of
Meckel’s diverticula are asymptomatic and discovered inci-
dentally at the time of an operation for other indications.
Recent reviews indicate that up to 84% of Meckel’s diver-
ticula found at operation were asymptomatic. A symptom-
atic Meckel diverticulum can present in both the pediatric
and adult population; the frequency of presentation decreases
with increasing age. here is a male predominance (3:1) of
both symptomatic and asymptomatic Meckel’s diverticula in
both the pediatric and adult population.147,149
Symptomatic presentation results from one of many
potential complications, including bleeding, obstruction,
diverticulitis, perforation, intussusception, ulceration, and
rarely the presence of malignancy (carcinoid tumor, sarcoma,
stromal tumors, carcinoma, adenocarcinoma, intraductal
papillary mucinous adenoma of pancreatic tissue) within the
Meckel diverticulum. In the adult population the most com-
mon presentations are bleeding (38%), obstruction (34%),
and diverticulitis (28%). In the pediatric population the
most common presentations are obstruction (40%), bleed-
ing (31%), and diverticulitis (29%). 147,149 Obstruction may
result from the Meckel diverticulum serving as a lead point
for intussusception or volvulus or as a result of an adhesive
band to the diverticulum. Bleeding in the setting of a Meckel
diverticulum is believed to result from acid secretion from
ectopic gastric mucosa leading to ulceration of and subse-
quent bleeding from adjacent ileal mucosa.
Preoperative diagnosis of a symptomatic Meckel diverticu-
lum can be difficult. A technetium-99m pertechnetate scan is
the most common and accurate noninvasive study used to eval-
uate the presence of a Meckel diverticulum. he tracer used in
this study is specific for ectopic gastric mucosa, and thus false-
positive results may occur when a duplication cyst containing
gastric mucosa is present. Moreover, a Meckel diverticulum
can be missed if it does not contain ectopic gastric mucosa.
Studies have found technetium-99m pertechnetate scans to be
highly sensitive and specific in both the pediatric and adult
populations.149–151 In cases of a suspected bleeding, Meckel’s
diverticulum, angiography, and a tagged RBC scan may be
of diagnostic value. If suspicion is high, other etiologies have
been ruled out, and noninvasive diagnostic tools exhausted,
exploratory laparoscopy may be required to diagnose and treat
a complicated Meckel diverticulum.
Surgical resection is indicated for symptomatic Meckel’s
diverticula. Options for resection include a diverticulectomy or a
segmental bowel resection with a primary anastomosis. A diver-
ticulectomy can be performed if amputating the diverticulum
at its base will not compromise the ileal lumen. If diverticulitis
is present, the line of resection should be free of inflammation.
Amputation should be performed in a transverse orientation
and can utilize a surgical stapling device. he staple line can
then be oversewn with interrupted 3-0 silk Lembert sutures.
Alternatively, the diverticulum can be resected between bowel
clamps and the defect sutured closed in two layers, using a con-
tinuous inner layer of 3-0 Vicryl or chromic suture followed by
an outer layer of 3-0 silk Lembert sutures.
In certain cases, simple diverticulectomy is not recom-
mended. Such instances include the presence of diverticulitis
or palpable ectopic tissue at the diverticular-intestinal junc-
tion.147 In such cases, or if the Meckel diverticulum is associ-
ated with ischemia, perforation, or an ulcer in the adjacent
intestine, a segmental ileal resection with a primary anasto-
mosis is indicated.
he optimum management of an asymptomatic Meckel
diverticulum discovered at laparotomy for a separate indica-
tion remains unclear. Some authors argue that certain asymp-
tomatic patients are more likely to develop symptoms and
thus recommend resection of an incidentally detected diver-
ticulum in a patient who fulfills any of the following crite-
ria: (1) younger than 50 years, (2) male sex, (3) diverticulum
greater than 2 cm in length, and (4) ectopic or abnormal
features within a diverticulum.147 A recent review contradicts
these findings, however. In this study, the risk of postopera-
tive complications, including infection and intestinal obstruc-
tion, was significantly higher following resection than leaving
the diverticulum in situ (5.3 vs 1.3%). Moreover, of the 64
patients in this study who did not undergo resection of their
asymptomatic Meckel’s diverticulum, no patient developed
complications with long-term follow-up.148 Another study
found the morbidity associated with the resection of an inci-
dental Meckel diverticulum to be higher than that associated
with the resection of a symptomatic Meckel diverticulum (20
vs 13%).147 Based on these studies, there is no convincing
evidence to recommend resection of a Meckel diverticulum
detected incidentally at laparotomy, but it should be consid-
ered in certain patient populations.
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