6 Acute Appendicitis

Question 1

Epidemiology of appendicitis

Answer 1

1. Most common i n age 10 to 19 years
2. most common nonobstetric surgical emergency in pregnancy

Question 2

McBurney’s point

Answer 2

One third of the distance from the anterior superior iliac spine to the umbilicus

Question 3

remarks on appendicial perforation

Answer 3

The release of intraluminal obstruction with perforation often results in sudden alleviation of pain; consider appendiceal perforation if the patient’s pain suddenly improved.

Question 4

These suggest peritonitis

Answer 4

Rebound tenderness and involuntary guarding

Question 5

Psoas sign

Answer 5

Elicited if abdominal pain is produced with passive extension of the right leg at the hip while the patient lies on the left side

Schwartz: pain with flexion of the hip (retrocecal appendix)

Question 6

Obturator sign

Answer 6

Elicits pain with passive internal and external rotation of the flexed right thigh at the hip

Schwartz: pain with internal rotation of the hip (pelvic appendix)

Question 7

Remarks in the diagnosis of appendicitis

Answer 7

1. The presence or absence of any exam finding in isolation is neither sufficiently sensitive nor specific to rule out or rule in the diagnosis.
2. Acute appendicitis is largely a clinical diagnosis, and no one adjunctive test is universally indicated.

Question 8

Modified Alvarado score

Answer 8

SYMPTOMS
Migration - 1
Anorexia - 1
Nausea or vomiting - 1

SIGNS
Tenderness, RLQ - 2
Rebound tenderness - 1
Elevated temperature (Fever) - 1

LABS
Leukocytosis - 2

1-4: low-risk
5-9: possible appendicitis

Question 9

Remarks on WBC in appendicitis

Answer 9

While numerous studies have evaluated the use of the WBC, there is no clear consensus on its utility.
WBC does not distinguish between simple and perforated appendicitis.

Question 10

Remarks on imaging in appendicitis

Answer 10

When adjunctive imaging is indicated, early surgical consultation may aid guidance in imaging selection.

The goal of imaging is
1. to establish the diagnosis of appendicitis
2. to avoid a negative appendectomy
3. to identify perforation
4. to exclude other causes of abdominal pain

Question 11

“Should be the initial imaging modality of choice in both pregnant females and children.”

Answer 11

Graded compression ultrasound
- it should be likewise be considered in young, nonobese adults
- typical findings in appendicitis are a thickened, noncompressible appendix >6 mm in diameter
- perforation may lead to disappearance of specific imaging hallmarks and difficult visualization of the appendix on US

Question 12

Remarks on CT in appendicitis

Answer 12

The 2015 Americal College of Radiology Appropriateness Criteria for RLQ pain state that although US is the preferred initial imaging modality in children, CT is overall the most accurate imaging modality for suspected appendicitis.

Question 13

Remarks on imaging in abdominal pain

Answer 13

The imaging evaluation of abdominal pain is time intensive and impacts ED overcrowding.
- unenhanced studies can significantly decrease the time to diagnosis and eliminate patient discomfort from PO or rectal contrast, and avoid altogether the risk of renal injury from IV contrast
- Noncontrast CT should be considered an acceptable imaging modality in the workup of acute appendicitis

Question 14

Remarks on MRI in appendicitis

Answer 14

Consider MRI as another reliable imaging technology in the evaluation of acute appendicitis, particularly in pregnant women.

Question 15

Antibiotics in appendicitis

Answer 15

Initiate perioperative antibiotics upon diagnosis or if the patient exhibits signs of peritonitis

Appropriate choice should broadly cover aerobic and anaerobic gram-negative organisms
- ampicillin-sulbactam 3g IV
- piperacillin-tazobactam 4.5g IV
- cefoxitin 2g IV
- metro 500mg + cipro 400mg IV

Question 16

Follow up for stable patients with unremarkable or elusive initial assessment

Answer 16

The stable, reliable patient without significant comorbidities may be a candidate for discharge provided they have a scheduled return visit to the ED or their primary physician (typically within 12 hours) for repeat examination.

Question 17

Remarks on appendicitis in pregnancy

Answer 17

1. acute appendicitis is the most common surgical emergency in pregnancy
2. If abdominal US is nondiagnostic, consider pelvic US, CT, or MRI
3. Many radiologists avoid CT in the first trimester given teratogenic concerns of ionizing radiation
4. Although iodinated contrast material is safe in pregnancy, avoid IV gadolinum
5. The use of abdominopelvic CT in evaluating pregnant patients with suspected acute appendicitis is reserved for circumstances in which ultrasonography is inconclusive and MRI is unavailable. (StatPearls)