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]; 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

• Fecaliths
• Lymphoid hyperplasia

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 ♦ 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) ❑ 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 ❑ Tortuous ovarian cyst ❑ Cecal 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 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: ❑ 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.

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.

Don´ts

• Do not delay the initial intervention.
• Do not order blood cultures routinely in all patients.

References

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