Appendicitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Teresa Stahl, M.D. [2]

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 management of appendicitis according the American College of Emergency Physicians Clinical Policies.

Characterize the symptoms: ❑ Typical symptoms ❑ Abdominal pain ♦ Right lower quadrant pain ♦ Pain initially started in the periumbilical area ❑ Anorexia ❑ Nausea ❑ Vomiting ❑ Atypical symptoms (common at extremes of age) ❑ Maldigestion ❑ Flatulence ❑ Bowel irregularity ❑ Diarrhea ❑ Fatigue

Examine the patient: ❑ Vital signs ❑ Temperature ❑ Heart rate ❑ Skin ❑ Diaphoresis ❑ Pallor ❑ Abdomen ❑ Rigidity ❑ Garding ❑ McBurney's point tenderness ❑ Rovsing's sign ❑ Psoas sign (suggestive of retrocecal appendix) ❑ Obturator sign ❑ Digital rectal exam (tenderness may be present in retrocecal appendicitis) ❑ Pelvic exam in females

Order labs: ❑ Complete blood count ❑ Leukocytosis ❑ Shift to the left ❑ Pregnancy test in females

Consider alternative diagnoses: ❑ Intestinal obstruction ❑ Acute cholecystitis ❑ Perforated peptic ulcer ❑ Mesenteric adenitis ❑ Urinary tract infection ❑ Ectopic pregnancy ❑ Torted ovarian cyst ❑ Cecal diverticulitis ❑ Meckel's diverticulitis ❑ Ileitis ❑ Crohn's disease

❑ Evaluate Alvarado score in acute appendicitis ❑ Score 1-4: appendicitis unlikely ❑ Score 5-6: appendicitis possible ❑ Score 7-8: appendicitis probable ❑ Score 9-10: appendicitis very probable Findings Score Abdominal pain that migrates to the right lower quadrant 1 Anorexia and/or ketones in the urine 1 Nausea and/or vomiting 1 Right lower quadrant tenderness 2 Rebound pain 1 Fever higher than 37.3°C by oral measurement 1 >10000 white blood cells per microliter 2 Shift to the left with >75% neutrophils 1

Order imagining studies: ❑ Ultrasound for abdomen with or without ultrasound pelvis, or ❑ CT abdomen and pelvis with and/or without IV contrast, or ❑ MRI abdomen and pelvis with and/or without IV contrast, or ❑ X-ray abdomen

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 ♦ Ifclinical 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 safely

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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