Appendicitis resident survival guide

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

• Fecaliths
• Calculi
• Lymphoid hyperplasia
• Neoplasm
• Benign tumor
• Ascariasis
• Bacteroides
• Taenia infection

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.

Characterize the symptoms: ❑ Typical symptoms ❑ 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) ❑ 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

Consider alternative diagnoses: ❑ Intestinal obstruction ❑ Acute cholecystitis ❑ Perforated peptic ulcer ❑ Mesenteric adenitis ❑ Urinary tract infection ❑ Ectopic pregnancy ❑ Torted ovarian cyst ❑ Cecal diverticulitis ❑ Meckel's diverticulitis ❑ Ileitis ❑ Crohn's disease

❑ Evaluate Alvarado score in acute appendicitis ❑ 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: ❑ 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 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

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