CHRONIC APPENDICITIS* APPENDECTOMY IN ABSENCE OF HISTORY OF ACUTE APPENDICITIS

OR OF APPENDICEAL COLIC

MANPRED KRAEMER, M.D., F.A.C.P.

Chief of GastrointestinaI Clinic, Newark Presbyterian Hospital; Instructor in Medicine, New York Medical CoIIege

NEWARK, NEW JERSEY

I N 1931 McCIure’ tabuIated 9,273 arti- cIes on appendicitis in the medica indices. Of these, 622 referred specifi-

caIIy to the chronic form. In the past five years, however, the rate of production of articIes on chronic appendicitis has shown a marked decIine. Such a decIine as a ruIe occurs when a subject is generaIIy understood by the profession or when al1 controversia1 matters in regard to etioIogy, diagnosis or mode of treatment have been settIed. The reading of forty of the more important papers on the subject forces me to con&de that no such reasons account for the cessation of writing on this subject. It is, rather, because the two schooIs of thought in regard to the vaIue of appendectomy for chronic appendicitis are so at Ioggerheads that both sides have simuItaneousIy given up hope of convincing each other.

There are a few students of the subject who, by painstaking foIIow-up studies, are graduaIIy bringing order out of chaos. Due credit must be given John B. Deaver213 for educating the doctors of his time in regard to acute appendicitis. However, Deaver was too enthusiastic in his reports on chronic appendicitis. He had an en- thusiasm which swayed his foIIowers, and by the use of such picturesque expressions as “I am not yet a picture doctor,” and “Touch, in the case of the diseased appendix is far superior to any x-ray examination,” he beIittIed the vaIue of diagnostic study.

Numerous carefuI investigators have controverted the exceIIent statistica resuIts

shown by Deaver, but even he3 admitted that in 421 appendectomies with no history of acute attacks, 56 per cent were not reheved seven to tweIve months postoperativeIy.

The present report concerns itseIf with patients seen in private practice and personaIIy observed within the past eight- een months. These consecutive patients a11 had had appendectomy performed for chronic appendicitis. The period since appendectomy had been performed varied from one to twenty-seven years, with an average interva1 of eight years. Great care was taken to excIude from the study a11 patients who, previous to appendectomy, had had a history of an acute attack at any time or had had an attack of appendicea1 coIic, and also a11 patients in whom appendectomy had been performed inci- denta to some other intra-abdomina1 operation, or where the operation was defIniteIy in error (Iaporatomy performed for acute appendix, chronic found and re- moved, diagnosis-pyeIitis or pneumonia). In aII, 128 cases of appendectomy for chronic appendicitis were considered, of whom seventy-eight fuIfIIIed the criteria for this study. The operations were per- formed by fifty-five different surgeons, seven cases being the maximum for any one operator.

Of the seventy-eight patients, only tweIve stated that they had been cured of a11 symptoms by the operation. One had partia1 reIief. Sixty presented them- seIves for exactIy the same compIaint for which the appendix had been removed, and

* From the Gastrointestinal Clinic, Newark Presbyterian HospitaI and the Department of Gastroenterology, New York MedicaI College.

398

NEW SERIES VOL. XLII, No. 2 Kraemer-Chronic Appendicitis American Journal of Surgery 399

nine were worse after the operation (cf. Bettman,4 who found that I 1.6 per cent of his patients were definiteIy worse after appendectomy for chronic appendicitis). Thirteen of our patients who were not benefited had previousIy had an x-ray diagnosis of chronic appendicitis, whiIe onIy one of the cured patients had had such an x-ray diagnosis made. Of the eIeven patients who were compIeteIy cured, four, previous to their operation, compIained of definite right Iower abdomina1 pain, but couId not recaI1 its IocaIization.

TABLE I Final Diagnoses No. of Patients

Duodenal ulcer.. 14 GastrointestinaI neurosis. . . I z Irritable coIon. I I Neurasthenia.. 7 Gastric hyperacidity. . 4 Achlorhydria.. . 3 Cholecystitis. . 3 Anal constipation. . . . z Pylorospasm. . 2 NeurocircuIatory asthenia.. . z Manic-depressive psychosis.. 2 Hysteria.......................... 2 Carcinoma of the stomach. I Diaphragmatic hernia.. . . I Rheumatic cardiac disease. I Chronic appendicitis.. . I SaIpingitis.. . . I Inguinal hernia.. . I Hyperthyroidism. . I Tooth infection.. . . I ChoIangitis.. . I Hypertensive cardiac disease. I Chronic interstitia1 enteritis.. I Petit ma1 epiIepsy. . . 1 ArterioscIerotic cardiac disease. I Sacroiliac arthritis. I

- TotaI........................... 78

The diseases from which these patients suffered are shown in TabIe I. It is interest- ing to note that in another study, of seventy-four consecutive patients with duodena1 ulcer, I found that twenty, or 27 per cent, had had a previous appendec- tomy for chronic appendicitis. The diag- noses are comparabIe to those in the group studies by Anderson” and MakeI.

TabIe II shows the chief compIaints of those patients who were seen for the same symptoms as those for which the appendix had been removed or who were worse after

the operation. This tabIe demonstrates how frequentIy distress in the epigastrium or right upper quadrant is wrongIy bIamed on the appendix. No patient with these compIaints had obtained reIief. It aIso shows the variety of complaints for which we are tempted to remove the appendix: fatigue, temperature eIevation, etc. This tendency to remove the appendix for al- most any symptom possibIy referabIe to

TABLE II CHIEF COMPLAINT OF PATIENTS IN WHOM APPENDIX IIAD

BEEN REMOVED WITHOUT BENEFIT

Epigastric pain or distress.. 18

Indefinite non-localized abdominal pain............................ 8

Right upper abdomina1 pain.. 7 Right lower quadrant abdomina1 pain 4 BeIching., 3 AbdominaI cramps.. 3 Diarrhea.......................... 3 Right sided abdomina1 pain., 3 Fatigue or exhaustion. 3 Indigestion or gas. 3 Constipation. 2 Nausea........................... 2 Vomiting.. . 2 Periodic temperature eIevation.. 2 Right inguina1 pain. I Information indefinite.. z

TotaI. 66

the digestive tract is a resuIt of some of the dicta pubIished by Deaver’ and KeIIey8 in the earIy years of the century.

COMMENT

WhiIe the usua1 x-ray criteria of chronic appendicitis (of May,g WoodlO Moore and Merritt,ll and others12,13,14) may satisfy the pathoIogist, patients in whom the usuaIIy mentioned abnormaIities occur (tenderness over the A uoroscopicaIIy visu- aIized appendix, beaded or fixed appendix, non-VisuaIization, etc.) are rareIy reIieved of symptoms unless there has been a history of coIic or of an acute attack. We may make a diagnosis of chronic appendicitis if the criteria of May are present, but we no Ionger advise appendectomy unIess there has been a history suggesting an acute attack or appendicea1 coIic. The great vaIue of the x-ray Iies in ruIing out

400 American Journal of Surgery Kraemer-Chronic Appendicitis NOVEMBER. 1938

disease eIsewhere.‘5,‘6 Even Carman in his cIassicaI textbook did not consider any x-ray signs reIiabIe in the diagnosis of chronic appendicitis and he treated the subject sarcasticaIIy.

Tenderness over the appendix is a much used sign.’ However, the majority of norma patients wiI1 complain of tenderness on pressure over the right Iower quadrant” and even over the ffuoroscopicaIIy visuaI- ized appendix if sufficient pressure is used. EspeciaIIy is this true two or three hours after meaIs, when the cecum is distended (a time which corresponds to the offIce hours of many doctors). Carnett’* in particuIar has shown how one may be misIed into the diagnosis of chronic appendicitis by eIiciting tenderness in the appendicea1 region.

It is apparent from this study that appendectomy for chronic appendicitis wiI1 rareIy benefit the patient. We do not incIude those patients who have had a definite history of an acute attack at some time or who had a definite attack of appendicea1 coIic. We have seen severa cases of appendicea1 coIic with severe cramps in which the x-ray showed a beaded appendix, usuaIIy with a constricted base. In these cases appendectomy has been aImost universaIIy successfu1 though such patients may never have a typica acute attack with fever, Ieucocytosis, and rigidity and tenderness over McBurney’s point.

It has been argued that remova of a questionabIe appendix is warranted if 0nIy for protection against an acute attack. Before considering such a recom- mendation to a patient it is we11 to recaI1 the work of WaIton,lg who studied 1,738 patients who had had operations for upper abdominal disease. The appendix was removed in onIy seventy-three of these cases, but onIy five of the remaining cases deveIoped acute appendicitis. This is an incidence of 0.28 per cent, which is not higher than the incidence in the genera1 popuIation and does not justify so-calIed “incidenta1” or “precautionary” appendectomy.

SUMMARY AND CONCLUSIONS

Seventy-eight patients who had appen- dectomy performed for chronic appendicitis were studied. None had ever had an acute attack nor a history of appendicea1 colic. The average time eIapsed since operation was eight years. OnIy tweIve cases were compIeteIy cured by the operation. Sixty presented themseIves for the same com- pIaint for which the appendix had been removed. It is unwise to perform appen- dectomy for chronic appendicitis unIess there is a history of an acute attack or of appendicea1 coIic.

REFERENCES

I. MCCLURE, ROY D. Chronic aonendicitis. Ann.

2.

3.

4.

5.

6.

7.

8.

9.

IO.

II.

12.

‘3.

14.

IE.

16.

17.

18.

‘9.

. . Surg., 94: 203 (Aug.) Ig3I.

DEAVER, JOHN B. Chronic appendicitis. Am. J. M. SC., 177: 749 (June) Igzg.

DEAVER, JOHN B. Chronic appendicitis. Proc. Inter-State Post-grad. M. A., MiIwaukee, Igz8: 88, 1929.

BETTMAN, H. W. Chronic appendicitis from the viewpoint of an internist. Ann. Int. Med., 2: pg (Dec.) 1928.

ANDERSON, A. F. R. MedicaI aspects of chronic appendicitis. Am. J. Surg., 5: 377 (Oct.) Igz8.

MAKEL, H. P. The chronic appendix. Mil. Surg.,

73: II7 (Sept.) ‘933. DEAVER, J. B. Appendicitis. PhiIadeIphia, Igoo.

P. Blakiston’s Sons. KELLY, HOWARD A. Appendicitis. PhiIadeIphia,

Igog. J. B. Lippincott. MAY, ERNST A. Chronic appendicitis. J. Med. Sot.

New Jersey, 34: gI (Feb.) 1937. WOOD, F. G. Radiology of the appendix. &it. M.

J., I: 640 (March 30) 1935. MOORE, A. B., and MERRITT, E. A. RoentgenoIogic

diagnosis of appendicitis. J. A. M. A., 97: 1456 (Nov. 14) Ig3I.

BARROW. S. C. X-rav diagnosis of chronic aooendi- citis. ?ri-State M.“J., i 954 (Sept.) Ig32: *

FELLOWS, H. H. What is a chronic appendix? M. Clin. North America, 12: 611-622 (November) 1928.

LAHEY, F. H. Notes on appendicitis. S. C&n. Nortb America, g: I3g5-I4oI (Dec.) Ig2g.

SALTZSTEIN, H. C. Chronic appendicitis. Ann. Znt. Med., 6: 278 (Aug.) 1932.

MILLER, T. Chronic appendicitis. Texas State M. J., 26: 37 (May) Ig3o.

SCHNACK, A. G. Chronic appendicitis. Radiology, 17: 70 (July) Ig3I.

CARNETT, JOHN B. Pain and tenderness of the abdomina1 wall. J. A. M. A., 102: 345 (Feb. 3)

1934. WALTON, A. J. Chronic appendicitis. Brit. M. J.,

3492: 1068 (Dec. IO) 1927.