Appendicitis
This page is for adult patients. For pediatric patients, see: appendicitis (peds)
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
- Rebound
- Rigidity
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
- GI
- Appendicitis
- Perforated appendicitis
- Peritonitis
- Crohn's disease (terminal ileitis)
- Diverticulitis (cecal, Asian patients)
- Inguinal hernia
- Mesenteric ischemia
- Ischemic colitis
- Meckel's diverticulum
- Neutropenic enterocolitis (typhlitis)
- Appendicitis
- GU
- Other
Evaluation
Dilated, non-compressible appendix with appendicolith and surrounding free fluid[1]
Labs
- CBC
- Normal WBC does not rule-out appendicitis
- Urine pregnancy
- Serum Lactate
- Does not necessarily define level of severity (if appendicitis is present.)
- Can aid in trending effective resuscitation once the diagnosis is made.
- CRP
- Normal CRP AND WBC makes appendicitis 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
- Imaging modalities
- Ultrasound
- First choice for pregnant women and children
- Limitations: operator-dependent, difficult to visualize with obesity, gravid uterus, bowel gas, guarding, lack of patient cooperation
- 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
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 500 mg IV q8hrs +
- Cefepime 50 mg/kg IV q12hrs OR
- Ciprofloxacin 400 mg IV q12hrs OR
- Levofloxacin 750 mg IV q24hrs OR
- Aztreonam 30 mg/kg IV q8hrs
- Imipenem/Cilastatin 25 mg/kg IV q6hrs (max 500mg)
- Meropenem 20 mg/kg IV q8hrs (max 1g)
- Piperacillin/Tazobactam 100 mg/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
Recurrent appendicitis
- Occurs in approximately 1:50,000 appendectomies [2]
- Typically caused by inflammation of the remaining appendiceal stump
- Can also be caused by a retained piece of the appendix not removed during surgery [3]
- Can present similar to primary appendicitis
- Treatment similar to that of primary appendicitis and likely requires surgical revision of the appendiceal stump or removal of retained tissue
- Delay in diagnosis and treatment can result in perforation and sepsis
See Also
External Links
References
- ↑ http://www.thepocusatlas.com/pediatrics/
- ↑ Hendahewa R. et al. The dilemma of stump appendicitis - a case report and literature review. Int J Surg Case Rep. 2015; 14: 101-3.
- ↑ Boardman T. et al. Recurrent appendicitis caused by a retained appendiceal tip: A case report. The Journal of Emergency Medicine. 2019; 57: 232-4.