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

Diagnostic Approach

Shown below is an algorithm depicting the therapeutic approach to appendicitis


 
 
 
 
 
 
 
Characterize the symptoms:

❑ Typical symptoms[4]

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

McBurney's point tenderness
Rovsing's sign
The 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

Pregnancy test in females
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspected appendicitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imagining studies:[7]

Ultrasound for abdomen with or without ultrasound pelvis, or
CT abdomen and pelvis with and/or without contrast, or
MRI abdomen and pelvis with and/or without 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.[8]

 
 
 
 
 
 
 
 
 
 
Initial management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative imaging
 
Inconclusive imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirmatory imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up for 24 hr to confirm resolution of signs and symptoms
 
Initiate[9]

❑ 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
[10]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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.[11]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



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

  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. 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.
  5. 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.
  6. 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.
  7. 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.
  8. name="pmid19787402">Korndorffer JR, Fellinger E, Reed W (2010). "SAGES guideline for laparoscopic appendectomy". Surg Endosc. 24 (4): 757–61. doi:10.1007/s00464-009-0632-y. PMID 19787402.
  9. name="pmid20163262">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". Surg Infect (Larchmt). 11 (1): 79–109. doi:10.1089/sur.2009.9930. PMID 20163262.
  10. name="pmid20163262">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". Surg Infect (Larchmt). 11 (1): 79–109. doi:10.1089/sur.2009.9930. PMID 20163262.
  11. name="pmid20163262">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". Surg Infect (Larchmt). 11 (1): 79–109. doi:10.1089/sur.2009.9930. PMID 20163262.


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