Appendicitis resident survival guide

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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

Management

Shown below is an algorithm depicting the management of appendicitis according to the guidelines by the Surgical Infection Society and the Infectious Diseases Society of America and the clinical policies of the American College of Emergency Physicians.[4][5]


 
 
 
 
Characterize the symptoms:

❑ Typical symptoms[6]

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)[7]
Obturator signDigital 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Evaluate Alvarado score in acute appendicitis[9]

❑ 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:[10]

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative imaging
 
Inconclusive imaging
 
 
 
 
 
Confirmatory imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non perforated appendicitis
 
Perforated appendicitis
 
Periappendiceal abscess
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Follow up for 24 hours until the resolution of signs and symptoms
 

❑ Follow up the patient
❑ Hospitalize the patient in case of high suspicion of appendicitis
❑ Administer antibiotics

❑ For a minimum of 3 days, or
❑ Until resolution of symptoms, or
❑ Until a diagnosis is made

❑ Administer pain medication if needed

❑ Administer antipyretic medication if needed
 
Appendectomy (laparoscopy or open surgery)as soon as it is feasible
❑ Consider non-operative management in case of marked improvement
❑ Administer antibiotics
 
❑ Urgent appendectomy
 
❑ Percutaneous drainage, or
❑ Operative drainage
❑ Defer appendectomy
 
 




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

  • Imaging tests should be ordered among all females with suspicion of appendicitis.
  • Before proceeding with a CT scan among females in the child bearing age, a pregnancy test should be ordered.
  • Pregnant females should undergo ultrasound or magnetic resonance to avoid exposure to radiation. In case the previous test were inconlusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.
  • Begin resuscitation immediately among patients with shock.
  • Administer antimicrobial therapy among all patients with diagnosis of appendicitis.
  • Proceed with urgent intervention in case of perforated appendicitis.

Don´ts

  • Do not delay the initial intervention.
  • Do not order blood cultures routinely in all patients.
  • Order cultures in the case of perforated abscess or when the local rate of resistance to a common pathogen, such as E.coli, is elevated.

References

  1. name="pmid2385810">Nitecki S, Karmeli R, Sarr MG (1990). "Appendiceal calculi and fecaliths as indications for appendectomy". Surg Gynecol Obstet. 171 (3): 185–8. PMID 2385810.
  2. name="pmid2990360">Jones BA, Demetriades D, Segal I, Burkitt DP (1985). "The prevalence of appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa". Ann Surg. 202 (1): 80–2. PMC 1250841. PMID 2990360.
  3. name="pmid2385810">Nitecki S, Karmeli R, Sarr MG (1990). "Appendiceal calculi and fecaliths as indications for appendectomy". Surg Gynecol Obstet. 171 (3): 185–8. PMID 2385810.
  4. Howell JM, Eddy OL, Lukens TW, Thiessen ME, Weingart SD, Decker WW; et al. (2010). "Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected appendicitis". Ann Emerg Med. 55 (1): 71–116. doi:10.1016/j.annemergmed.2009.10.004. PMID 20116016.
  5. Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
  6. name="pmid11343547">Lee SL, Walsh AJ, Ho HS (2001). "Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis". Arch Surg. 136 (5): 556–62. PMID 11343547.
  7. name="pmid9880421">Andersson RE, Hugander AP, Ghazi SH, Ravn H, Offenbartl SK, Nyström PO; et al. (1999). "Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis". World J Surg. 23 (2): 133–40. PMID 9880421.
  8. name="pmid16960208">Humes DJ, Simpson J (2006). "Acute appendicitis". BMJ. 333 (7567): 530–4. doi:10.1136/bmj.38940.664363.AE. PMC 1562475. PMID 16960208.
  9. Alvarado A (1986). "A practical score for the early diagnosis of acute appendicitis". Ann Emerg Med. 15 (5): 557–64. PMID 3963537.
  10. Rosen MP, Ding A, Blake MA, Baker ME, Cash BD, Fidler JL; et al. (2011). "ACR Appropriateness Criteria® right lower quadrant pain--suspected appendicitis". J Am Coll Radiol. 8 (11): 749–55. doi:10.1016/j.jacr.2011.07.010. PMID 22051456.


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