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]; Rim Halaby, M.D. [3]

Definition

Appendicitis is the inflammation of the appendix and it is considered a medical emergency.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Appendicitis is a life-threatening condition and must be treated as such irrespective of the 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.[3][4]

 
 
 
 
Characterize the symptoms:

❑ Typical symptoms

Abdominal pain
♦ Pain initially in the periumbilical area
♦ Migration of the pain to the right lower quadrant
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
❑ Guarding
McBurney's point tenderness
Rovsing's sign

Psoas sign (suggestive of retrocecal appendix)[5]
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Evaluate Alvarado score in acute appendicitis:[7]

❑ 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
White blood cells >10000 per microliter 2
Shift to the left with >75% neutrophils 1


❑ Administer IV fluid therapy when appendicitis is suspected

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imagining studies:[8]

Ultrasound of the abdomen with or without ultrasound of the 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 the resolution of symptoms, or
❑ Until a diagnosis is made

❑ Administer pain medication if needed

❑ Administer antipyretics if needed
 
Appendectomy (laparoscopy or open surgery) as soon as it is feasible
❑ Consider non-operative management in case of marked improvement
❑ Administer narrow spectrum antibiotics for 24 hours
 
❑ Urgent appendectomy
 

❑ Drain the abscess

❑ Percutaneous drainage, or
❑ Operative drainage
❑ Defer appendectomy
 
 



Antibiotics

Shown below is a table summarizing the choice of antibiotics to be administered in appendicitis. Antibiotics treatment should be administered to all patients with appendicitis. Note that:

  • Mild to moderate cases include perforated appendicitis and abscess.
  • High risk or severe cases include severe physiological disturbance, advanced age and immunosuppression.[3]
Mild-to-moderate severity High risk or severe
Single Agent Single Agent
Cefoxitin
OR
Ertapenem
OR
Moxifloxacin
OR
Tigecycline
OR
Ticarcillin-clavulanate
Imipenem-cilastatin
OR
Meropenem
OR
Doripenem
OR
Piperacillin-tazobactam
Combination Combination
Cefazolin
OR
Cefuroxime
OR
Ceftriaxone
OR
Cefotaxime
OR
Ciprofloxacin
OR
Levofloxacin
Cefepime
OR
Ceftazidime
OR
Ciprofloxacin
OR
Levofloxacin
PLUS PLUS
Metronidazole Metronidazole

Do´s

  • Imaging tests should be ordered among all females with suspicion of appendicitis.
  • Before proceeding with a CT scan in 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 tests were inconclusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.
  • Administer antimicrobial therapy among all patients with diagnosis of appendicitis.
  • Administer narrow spectrum antibiotics for 24 hours among patients with acute appendicitis without perforation, abscess or local peritonitis.
  • Begin resuscitation immediately and administer antibiotics as soon as possible among patients with shock.
  • 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.[3][4]

Don´ts

  • Do not delay the initial intervention.
  • Do not order blood cultures routinely in all patients.[3][4]

References

  1. 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. 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. 3.0 3.1 3.2 3.3 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.
  4. 4.0 4.1 4.2 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. 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.
  6. Humes DJ, Simpson J (2006). "Acute appendicitis". BMJ. 333 (7567): 530–4. doi:10.1136/bmj.38940.664363.AE. PMC 1562475. PMID 16960208.
  7. Alvarado A (1986). "A practical score for the early diagnosis of acute appendicitis". Ann Emerg Med. 15 (5): 557–64. PMID 3963537.
  8. 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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