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.
Perforation of the appendix is more common with advanced age, due to an increased frequency of late and atypical presentation of appendicitis, delay in diagnosis, delayed decision for surgery, and to the 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)
- periappendiceal 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 perforated appendix relies mainly on demonstration of right iliac fossa abscess or phlegmon in association with signs of appendiceal inflammation and appendicolith.
Treatment and prognosis
Management of perforated acute appendicitis depends on the clinical stability of the patient and the presence of an abscess. 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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- 2. Pinto Leite N, Pereira JM, Cunha R et-al. CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings. AJR Am J Roentgenol. 2005;185 (2): 406-17. doi:10.2214/ajr.185.2.01850406 - Pubmed citation
- 3. Horrow MM, White DS, Horrow JC. Differentiation of perforated from nonperforated appendicitis at CT. Radiology. 2003;227 (1): 46-51. doi:10.1148/radiol.2272020223 - Pubmed citation
- 4. Avanesov M, Wiese NJ, Karul M, Guerreiro H, Keller S, Busch P, Jacobsen F, Adam G, Yamamura J. Diagnostic prediction of complicated appendicitis by combined clinical and radiological appendicitis severity index (APSI). (2018) European radiology. 28 (9): 3601-3610. doi:10.1007/s00330-018-5339-9 - Pubmed
- 5. Tsuboi M, Takase K, Kaneda I, Ishibashi T, Yamada T, Kitami M, Higano S, Takahashi S. Perforated and nonperforated appendicitis: defect in enhancing appendiceal wall--depiction with multi-detector row CT. (2008) Radiology. 246 (1): 142-7. doi:10.1148/radiol.2461051760 - Pubmed
- 6. Kim MS, Park HW, Park JY, Park HJ, Lee SY, Hong HP, Kwag HJ, Kwon HJ. Differentiation of early perforated from nonperforated appendicitis: MDCT findings, MDCT diagnostic performance, and clinical outcome. (2014) Abdominal imaging. 39 (3): 459-66. doi:10.1007/s00261-014-0117-x - Pubmed
- 7. Kim HY, Park JH, Lee YJ, Lee SS, Jeon JJ, Lee KH. Systematic Review and Meta-Analysis of CT Features for Differentiating Complicated and Uncomplicated Appendicitis. (2018) Radiology. 287 (1): 104-115. doi:10.1148/radiol.2017171260 - Pubmed
- 8. Oliak D, Yamini D, Udani VM, Lewis RJ, Arnell T, Vargas H, Stamos MJ. Initial nonoperative management for periappendiceal abscess. (2001) Diseases of the colon and rectum. 44 (7): 936-41. doi:10.1007/bf02235479 - Pubmed
Related Radiopaedia articles
The appendix can be affected by numerous inflammatory, infectious and neoplastic conditions:
- appendiceal diverticulitis
- appendiceal mucocele
- appendiceal intussusception
neoplasms of the appendix
- appendiceal epithelial neoplasms
- Goblet cell carcinoid of the appendix
- appendiceal neuroendocrine tumors
- appendiceal lymphoma