Perforated appendix

Last revised by Raymond Chieng on 07 Nov 2022

A perforated appendix is one of the complications of acute appendicitis. When appendicitis is left untreated, necrosis (gangrene) of the appendiceal wall can occur and progress to a focal rupture.

The rate of perforated appendix vary from 16% to 40%, with higher incidence in younger age group and in patients older than 50 years 9. Perforation can be due late and atypical presentation of appendicitis, delay in diagnosis, delayed decision for surgery, and age-specific physiological changes 1.

A slight majority of patients with a perforated appendicitis present more than 48 hours after symptom onset 4.

Intraoperative or gross pathology examination reveals a full-thickness defect in the appendiceal wall. Histopathology demonstrates neutrophilic infiltration and transmural necrosis with extensive mucosal ulceration (gangrenous acute appendicitis).

Computed tomography can predict perforation with high specificity (95%) in patients with known appendicitis when certain findings are present 2-6:

  • focal defect in the enhancing appendiceal wall (most sensitive finding but its performance is heterogeneous across studies 7)

  • appendicular abscess

  • extraluminal gas (contained locules or free intraperitoneal gas)

  • extraluminal appendicolith

  • extraluminal leak of enteric contrast

Less specific findings include 7:

Although ultrasound is less accurate than a contrast-enhanced CT, the findings can be appreciated in experienced hands. Diagnosis of a perforated appendix relies mainly on demonstration of right iliac fossa abscess or phlegmon in association with signs of appendiceal inflammation and appendicolith.

Management of perforated acute appendicitis depends on the clinical stability of the patient and the presence of an abscess. A perforated appendix increases the risk of a postoperative abscess. If the patient is unstable or septic, urgent surgery is indicated. If the patient is stable, however, initial nonoperative management including antibiotics is safe 8. If an abscess is present, imaging-guided percutaneous drainage is prudent. Appendectomy should eventually be performed (unless comorbidities contraindicate elective surgery) to exclude an appendiceal neoplasm and prevent recurrent appendicitis.

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Cases and figures

  • Case 1
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  • Case 2
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  • Case 3
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  • Case 4: perforated appendix and small bowel obstruction
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  • Case 5: with abscess formation and fistulation
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  • Case 6
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  • Case 7: MRI
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  • Case 8: perforated acute appendicitis in pregnancy (MRI)
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  • Case 9: acute appendicitis in pregnancy with rupture into perinephric space
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  • Case 10
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