Appendicitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

Appendicitis is the inflammation of the appendix and is considered a medical emergency. It is one of the most common causes of acute abdomen and the leading cause of emergency abdominal surgery. If it is treated promptly the patient can recover without difficulty, if not, it can burst causing infection and even death.

Causes

Common Causes

• Fecaliths
• Calculi
• Lymphoid hyperplasia
• Neoplasm
• Benign tumor
• Ascariasis
• Bacteroides
• Taenia infection

Management

Diagnostic Approach

Shown below is an algorithm depicting the therapeutic approach to appendicitis

Characterize the symptoms ❑ Typical symptoms ♦ Abdominal pain(right anterior iliac fosa) ♦ Anorexia ♦ Nausea and vomiting ❑ Atypical symptoms (common at extremes of age) ♦ Indigestion ♦ Flatulence ♦ Bowel irregularity ♦ Diarrhoea ♦ General malaise

Examine the patient ❑ Vitals ♦ Temperature: low grade fever of 101.0 Fº (higher fever as inflammation progreses) ♦ Heart rate: Tachycardia associated to fever ❑Abdomen ♦ McBurney's point tenderness ♦ Rovsing's sign ♦ The psoas sign is related to retrocecal appendix ♦ Obturator sign ❑ Skin ♦ Diaphoresis may be present ♦ Pallor

Order labs ❑ Complete blood count: leukocytosis ❑ Electrolytes ❑ Urea

Differential diagnosis ❑ Intestinal obstruction ❑ Acute cholecystitis ❑ Perforated peptic ulcer ❑ Mesenteric adenitis ❑ Urinary tract infection ❑ Ectopic pregnancy ❑ Torted ovarian cyst

Suspected appendicitis

Imagining study ❑ Helical CT of the abdomen and pelvis with intravenous contrast ❑ Diagnostic imaging should be performed to all female patients ❑ Patients with first trimester of pregnancy should undergo ultrasound or magnetic resonance ❑ If these studies do not define the diagnose, laparoscopy or CT scanning may be considered

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach of appendicitis based on the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for laparoscopic appendectomy.

Initial management

Negative imaging

Inconclusive imaging

Confirmatory imaging

Follow up for 24 hr to confirm resolution of signs and symptoms

Initiate ❑ Antimicrobial therapy ♦ Minumim of 3 days OR ♦ Clinical signs and symptoms of infection are resolved OR ♦ A definitive diagnosis is made AND ❑ Pain medication AND ❑ Antipyretic medication if indicated

If no other diagnosis is found, the decision of removing the appendix relies on the surgeons criteria and clinical scenario

Uncomplicated appendicitis

Perforated appendicitis

Women of childbearing age

Elderly patients (>65 years)

Well circumscribed periappendical abscess

Obesity

Pregnancy

Laparoscopy appendectomy as alternative to open appendectomy

Laparoscopic appendectomy may be performed saftley

Laparoscopic appendectomy

Laparoscopic appendectomy

Percutaneous drainage or operative drainage if necessary

Laparoscopic appendectomy

Laparoscopic appendectomy

Male patients admitted in the hospital for 48hr and shows sustained improvement within 24h while reciving antimicrobial therapy can be considered to non operative management.

	Mild to moderate severity: perforated or abscessed appendicitis	High risk or severity: severe psychologic disturbance, elderly, inmunoincompetent
Mono therapy	Cefoxitin ertapenem moxifloxacin tigecycline and ticarcillin-clavulanic acid	imipenem-cilastatin meropenem doripenem and piperacillin-tazobactam
Combined therapy	Cefazolin cefuroxime ceftriaxone cefotaxime ciprofloxacin or levofloxacin each in combination with metronidazole	Cefepime ceftazidime ciprofloxacin or levofloxacin each in combination with metronidazole

Do´s

• All female patients should undergo diagnostic imaging.
• If the patient is in septic shock begin resuscitation immediately.
• Administer antimicrobial therapy to all patients with diagnosis of appendicitis.
• Perforated appendicitis should undergo urgent intervention.

Don´ts

• Do not delay the initial intervention.
• Do not perform a second laparotomy in patients with severe peritonitis in the absence of initial discontinuity, abdomen fascial loss that prevents abdomen wall closure or intra-abdominal hypertension.

References

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