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Appendicitis
From WikEM
(Redirected from Appy)
For pediatric patients see Appendicitis (peds)
Contents
Background
- Most common nonobstetric surgical emergency in pregnancy
- Most commonly caused by luminal obstruction by a fecalith
- There are no historical or physical exam findings that can definitively rule out appy
Clinical Features
History
- Early on primarily malaise, indigestion, anorexia
- Later patient develops abdominal pain
- Initially vague, periumbilical (visceral innervation)
- Later migrates to McBurney point (parietal innervation)
- Later patient develops abdominal pain
- Nausea, with or with out emesis, typically follows onset of pain
- Fever may or not occur
- Urinary symptoms common given proximity of appendix to urinary tract (sterile pyuria)
- Sudden improvement suggests perforation
- 33% of patients have atypical presentation
- Retrocecal appendix can cause flank or pelvic pain
- Gravid uterus sometimes displaces appendix superiorly → RUQ pain
Physical Exam
- Rovsing sign (palpation of LLQ worsens RLQ pain)
- Psoas sign (extension of right leg at hip while patient lies on left side elicits abdominal pain)
- Obturator sign (internal and external rotation of thigh at hip elicits pain
- Peritonitis suggested by:
- Right heel strike elicits pain
- Guarding
Clinical Examination Operating Characteristics
| Procedure | LR+ | LR- |
| RLQ pain | 7.3-8.4 | 0-0.28 |
| Rigidity | 3.76 | 0.82 |
| Migration | 3.18 | 0.50 |
| Pain before vomiting | 2.76 | NA |
| Psoas sign | 2.38 | 0.90 |
| Fever | 1.94 | 0.58 |
| Rebound | 1.1-6.3 | 0-0.86 |
| Guarding | 1.65-1.78 | 0-0.54 |
| No similar pain previously | 1.5 | 0.32 |
| Anorexia | 1.27 | 0.64 |
| Nausea | 0.69-1.2 | 0.70-0.84 |
| Vomiting | 0.92 | 1.12 |
Differential Diagnosis
RLQ Pain
- Appendicitis
- Abdominal aortic aneurysm
- Crohn's disease (terminal ileitis)
- Diverticulitis (cecal, Asian patients)
- Ectopic
- Endometriosis
- Epiploic appendagitis
- Herpes zoster
- Inguinal hernia
- Ischemic colitis
- Meckel's diverticulum
- Mesenteric lymphadenitis
- Mittelschmerz
- Ovarian cyst
- Ovarian torsion
- PID
- Psoas abscess
- Testicular torsion
- Kidney stone
- Neutropenic enterocolitis (typhlitis)
Evaluation
Labs
- CBC
- Normal WBC does not rule-out appy
- Urinalysis
- Sterile pyuria or hematuria consistent with appy
- Urine pregnancy
- CRP
- Normal CRP AND WBC makes appy very unlikely
Imaging
- Early surgical consultation should be obtained before imaging in straightforward cases
- Not universally necessary; consider in:
- Women of reproductive age
- Men with equivocal presentation
- Perforation may result in false negative study
- Modalities
- Ultrasound
- First choice for pregnant women and children
- Findings: noncompressible appendix >6mm in diameter, wall thickness greater or equal to 3 mm
- Other supportive findings: aperistalsis, distinct wall layers, target appearance in axial view, appendicolith, periappendiceal fluid, prominent echogenic periappendiceal fat
- CT
- First choice for adult males and nonpregnant women with equivocal cases
- Women derive the greatest benefit from preoperative imaging (lower neg appy rate)
- Contrast (both PO and IV) is unnecessary but typically ordered
- MRI
- When unable to identify appendix in children or pregnant women
- Ultrasound
Clinical Scoring Systems
Alvarado score
| Right Lower Quadrant Tenderness | +2 |
| Elevated Temperature (37.3°C or 99.1°F) | +1 |
| Rebound Tenderness | +1 |
| Migration of Pain to the Right Lower Quadrant | +1 |
| Anorexia | +1 |
| Nausea or Vomiting | +1 |
| Leukocytosis > 10,000 | +2 |
| Leukocyte Left Shift | +1 |
Clinical scoring system, where a score (Total=10) is composed on presence/absence of 3 signs, 3 symptoms and 2 lab values to help guide in case management.
- ≤3 = Appendicitis unlikely
- ≥7 = Surgical consultation
- 4-6 = Consider CT
MANTRELS Mnemonic: Migration to the right iliac fossa, Anorexia, Nausea/Vomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever), Leukocytosis, and Shift of leukocytes to the left (factors listed in the same order as presented above).
Management
Supportive Management
- NPO status
- Fluid resuscitation
- Analgesia/antiemetics
Antibiotics
Coverage should extend to E. coli, Klebsiella, Proteus, and Bacteroides (an anaerobe)
Adult Simple Appendicitis
Antibiotic prophylaxis should be coordinated with surgical consult
Options:
- Cefoxitin 2g IV q6 hours OR
- Cefotetan 2g IV q12 hours OR
- Moxifloxacin 400mg IV once daily OR
- Ertapenem 1g IV once daily
Pediatric Simple Appendicitis
Options:
- Cefoxitin 40mg/kg IV q6 hours
- Cefotetan 40mg/kg IV q12 hours
- Gentamicin 2.5mg/kg IV q8hrs +
- Metronidazole 7.5mg/kg IV 16hrs OR
- Clindamycin 10mg/kg IV q8hrs
Complicated Appendicitis
Defined as perforation, abscess, or phlegmon
Options:
- Metronidazole 50mg IV q8hrs +
- Cefepime 50mg/kg IV q12hrs OR
- Ciprofloxacin 400mg IV q12hrs OR
- Levofloxacin 750mg IV q24hrs OR
- Aztreonam 30mg/kg IV q8hrs
- Imipenem/Cilastatin 25mg/kg IV q6hrs (max 500mg)
- Meropenem 20mg/kg IV q8hrs (max 1g)
- Piperacillin/Tazobactam 100mg/kg (max 4.5g) IV q8hrs
Cautious use should be applied to use of fluoroquinolones in complicated pediatric appendicitis due to the risk of tendon injury
Surgery
- Open laparotomy or laparoscopy
- Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy
- Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest
Disposition
Admission for surgery
Complications
- Infection (either a simple wound infection or an intraabdominal abscess)
- Typically in patients with perforated appendicitis
