Dilemma of Acute Appendicitis

Acute appendicitis is the most common cause of the acute abdomen requiring surgery with life time risk of ~7% which is maximal in childhood and declines steadily with age as the lymphoid tissue and vascularity atrophy [1,2]. Surgery for the acute abdomen caused by Appendicitis only evolved when the mortality associated with perforated appendicitis was found to be high. Conservative treatment with later drainage of any abscess had been the standard and diffuse peritonitis was usually fatal. Although only few patients progressed to the potentially lethal complications, early surgery for all patients with suspected appendicitis became the definitive method of preventing severe peritoneal sepsis [2-4]. Although a study demonstrated that simple appendicitis may be treated with antibiotics only, there is a 25% risk of recurrent attacks [4]. Even though recent advances in interventional radiological techniques for peritonitis have significantly reduced the morbidity and mortality of physiologically severe complicated abdominal infection, the best policy is early surgery when there is clinical suspicion of the acute abdomen and if diagnostic tools are not readily available [5]. The mortality of perforated viscous increases with delay in diagnosis and management and it is greatest in the elderly (25% when age >70 years) and those ill from intercurrent disease with a poor performance status (American Society of Anesthesiology -ASA score) [2,6-9].