Appendicitis

Question 1

Classic presentation

Answer 1

Vague epigastric or periumbilical pain.
Nausea, vomiting and anorexia.
Abdominal tenderness, migrating then localizing to the right lower quadrant.
Fever
Leukocytosis

Question 2

How may a retrocecal appendix present?

Answer 2

A retrocecal appendicitis may present a variety of ways including low back pain, left sided pain and even right upper quadrant pain.

Question 3

PE findings

Answer 3

Right lower quadrant pain and guarding generally have a high sensitivity (81%) for appendicitis, but poorly specific (53%). Abdominal rigidity is highly specific (83%) with a low sensitivity (27%). The classic Psoas, Obturator and Rosving’s signs are all relatively poor predictors of appendicitis. No single exam finding should be used to rule in or rule out the disease.

Question 4

Lab findings

Answer 4

CRP and WBC have a combined sensitivity of 98%, and if both labs are within normal limits the diagnosis is less likely.
Leukocytosis
UA (rule out pregnancy), check for kidney stone
Pyuria without bacteriuria indicates appendicitis

Question 5

Preferred imaging modality kids and pregnant

Answer 5

Ultrasound is the preferred imaging modality in children and pregnant patients with suspected appendicitis due to absence of radiation.

An appendix greater than 6-7 mm in diameter and noncompressible is indicative of appendicitis. Other findings that support the diagnosis are increase wall thickness, fecalith, and increased vascularity

Question 6

Preferred imaging modality adults

Answer 6

CT is the preferred imaging study for evaluating acute appendicitis in adult males and nonpregnant females

Question 7

CT findings

Answer 7

enlarged appendix over 6-7 mm, increased wall thickness, fecalith and periappendiceal stranding can support the diagnosis.

Use IV contact, but non-contrast is still highly sensitive and specific. If not IV, then use rectal before oral because it is faster in an emergency

Question 8

What if you have an indeterminate ultrasound in a low risk pediatric or pregnant patient?

Answer 8

For low risk pediatric and pregnant patients with an indeterminate ultrasound observation for serial exams is warranted to avoid radiation and/or contrast.

Question 9

Treatment

Answer 9

Prompt appendectomy is the treatment. Certain complicated cases like perforation with a walled off abscess will require drainage by interventional radiology.