Appendicitis


Article Author:
Mark Jones
Richard Lopez


Article Editor:
Jeffrey Deppen


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
8/23/2019 11:06:38 AM

Introduction

Appendicitis is inflammation of the vermiform appendix. This is a hollow organ located at the tip of the cecum, usually in the right lower quadrant of the abdomen. However, it can be located in almost any area of the abdomen depending on if there were any abnormal developmental issues or if there are any other concomitant conditions such as pregnancy or prior surgeries. The appendix develops embryonically in the fifth week. During this time there is a movement of the midgut to the external umbilical cord with the eventual return to the abdomen and rotation of the cecum. This results in the usual retrocecal location of the appendix. It is most often a disease of acute presentation, usually within 24 hours, but it can also present as a more chronic condition. If there has been a perforation with a contained abscess, then the presenting symptoms can be more indolent. The exact function of the appendix has been a debated topic. Today it is accepted that this organ may have an immunoprotective function and acts as a lymphoid organ especially in the younger person. Other theories contend that the appendix acts as a storage vessel for "good" colonic bacteria. Still, others argue that it is a mear developmental remnant and has no real function.[1][2][3]

Etiology

The cause of appendicitis is usually from an obstruction of the appendiceal lumen. This can be from an appendicolith (stone of the appendix), or from some other mechanical etiologies. Appendiceal tumors such as carcinoid tumors, intestinal parasites, and hypertrophied lymphatic tissue are all known causes of appendiceal obstruction and appendicitis. Often, the exact etiology of acute appendicitis is unknown. When the appendiceal lumen gets obstructed, bacteria will build up in the appendix and cause acute inflammation with perforation and abscess formation. One of the most popular misconceptions is the story of the death of Harry Houdini. After being unexpectedly punched in the abdomen, the rumor goes, his appendix ruptures causing immediate sepsis and death. The facts are that Houdini did die from sepsis and peritonitis from a ruptured appendix, but it had no connection to him being struck in the abdomen. It was more related to widespread peritonitis and the limited availability of effective antibiotics at the time.[4][5]

Epidemiology

Appendicitis occurs most often between the ages of 5 and 45 with a mean age of 28. The incidence is approximately 233/100,000 people. Males have a slightly higher predisposition of developing acute appendicitis compared to females, with a lifetime incidence of 8.6% for men and 6.7 % for women. There are approximately 300,000 hospital visits yearly in the United States for appendicitis-related issues.

Pathophysiology

The pathophysiology of appendicitis likely stems from obstruction of the appendiceal orifice. This results in inflammation, localized ischemia, perforation, and the development of a contained abscess or frank perforation with resultant peritonitis. This obstruction may be caused by lymphoid hyperplasia, infections (parasitic), fecaliths, or benign or malignant tumors. When an obstruction is the cause of appendicitis, it leads to an increase in intraluminal and intramural pressure, resulting in small vessel occlusion and lymphatic stasis. Once obstructed, the appendix fills with mucus and becomes distended, and as lymphatic and vascular compromise advances, the wall of the appendix becomes ischemic and necrotic. Bacterial overgrowth then occurs in the obstructed appendix, with aerobic organisms predominating in early appendicitis and mixed aerobes and anaerobes later in the course. Common organisms include Escherichia coli, Peptostreptococcus, Bacteroides, and Pseudomonas. Once significant inflammation and necrosis occur, the appendix is at risk of perforation leading to a localized abscess and sometimes frank peritonitis.[6]

The most common position of the appendix is retrocecal. While the anatomical position of the root of the appendix is mostly constant, tail positions can vary. Possible positions include retrocecal, subcecal, pre- and post-ileal, and pelvic.

Histopathology

Microscopic findings in acute appendicitis include the proliferation of neutrophils of the muscularis propria. The degree and extent of inflammation are directly proportionate to the severity of the infection and duration of the disease. As this condition progresses, extra appendiceal fat and surrounding tissues become involved in the inflammatory process. In severe situations, the cecum may be involved and may require resection at the time of surgery.

History and Physical

Classically, appendicitis presents as an initial generalized or periumbilical abdominal pain that then localizes to the right lower quadrant. Initially, as the visceral afferent nerve fibers at T8 through T10 are stimulated, and this leads to vague centralized pain. As the appendix becomes more inflamed and the adjacent parietal peritoneum is irritated, the pain becomes more localized to the right lower quadrant. Pain may or may not be accompanied by any of the following symptoms:

  • Anorexia
  • Nausea/vomiting
  • Fever (40% of patients)
  • Diarrhea
  • Generalize malaise
  • Urinary frequency or urgency

Uncommon presentation

Some patients may present with uncommon features such as pain localized to the right lower quadrant. In these patients, the pain may have woken the patient up from sleep. In addition, the rare patient may complain of pain while walking or coughing.

Pain upon passive extension of the right leg with the patient in the left lateral decubitus position is known as psoas sign. This maneuver stretches the psoas major muscle, which can be irritated by an inflamed retrocecal appendix. Patients often flex the hip to shorten the psoas major muscle and relieve pain.

Physical exam findings are often subtle, especially in early appendicitis.

As inflammation progresses, signs of peritoneal inflammation develop. Signs include:

  • Right lower quadrant guarding and rebound tenderness over McBurney's point (1.5 to 2 inches from the anterior superior iliac spine on a straight line from the ASIS to the umbilicus)
  • Rovsing's sign (right lower quadrant pain elicited by palpation of the left lower quadrant)
  • Dunphy's sign (increased abdominal pain with coughing)

Other associated signs such as psoas sign (pain on external rotation or passive extension of the right hip suggesting retrocecal appendicitis) or obturator sign (pain on internal rotation of the right hip suggesting pelvic appendicitis) are rare.

The time course of symptoms is variable but typically progresses from early appendicitis at 12 to 24 hours to perforation at greater than 48 hours. Seventy-five percent of patients present within 24 hours of the onset of symptoms.

The risk of rupture is variable but is about 2% at 36 hours and increases about 5% every 12 hours after that.

Evaluation

The emergency department physician must refrain from giving the patient any pain medication until the patient has been seen by the surgeon. The analgesics can mask the peritoneal signs and lead to a delay in diagnosis or even a ruptured appendix.

Lab Testing

Elevated white blood cells (WBC) with or without a left shift or bandemia is classically present, but up to one-third of patients with acute appendicitis will present with a normal WBC count. There are usually ketones found in the urine and the CRP may be elevated.

Imaging

Appendicitis is traditionally a clinical diagnosis. However, CT scan has greater than 95% accuracy for the diagnosis of appendicitis and is used with increasing frequency.[7][8][9]

CT criteria for appendicitis include an enlarged appendix (greater than 6 mm in diameter), appendiceal wall thickening (greater than 2 mm), peri-appendiceal fat stranding, appendiceal wall enhancement, the presence of appendicolith (approximately 25% of patients). It is unusual to see air or contrast in the lumen with appendicitis due to luminal distention and possible blockage in most cases of appendicitis. Nonvisualization of the appendix does not rule out appendicitis.

Ultrasound is less sensitive and specific than CT but may be useful to avoid ionizing radiation in children and pregnant women. MRI may also be useful for the pregnant patient with suspected appendicitis and an indeterminate ultrasound.

Classically the best way to diagnose acute appendicitis is with a good history and detailed physical exam performed by an experienced surgeon. Today, however, it is very easy to get a CT scan done in the emergency department. It has become common practice to rely mostly on the CT report to make the diagnosis of acute appendicitis. Occasionally appendicoliths are incidentally found on routine x-rays or CT scans. These patients are at a higher risk to develop appendicitis than the general population.

These patients should be considered for prophylactic appendectomies. Studies have also shown a 10% to 30% incidence of appendicoliths present in appendectomy specimens done for acute appendicitis.

Treatment / Management

While in the emergency department, the patient must be kept NPO and hydrated intravenously with crystalloid. Antibiotics should be administered intravenously as per the surgeon. The responsibility for the consent falls on the surgeon. 

The gold-standard treatment for acute appendicitis is to perform an appendectomy. Today the laparoscopic appendectomy is preferred over the open approach. Most uncomplicated appendectomies are performed laparoscopically. In cases where there is an abscess or advanced infection, the open approach may be needed. The laparoscopic approach affords less pain, quicker recovery, and the ability to explore most of the abdomen through small incisions. Situations, where there is a known abscess from a perforated appendix, may require a percutaneous drainage procedure usually done by an interventional radiologist. This stabilizes the patient and allows the inflammation to subside over time enabling a less difficult laparoscopic appendectomy to be performed at a later date. Practitioners also start patients on broad-spectrum antibiotics. There is some disagreement regarding preoperative antibiotic administration for uncomplicated appendicitis. Some surgeons feel routine antibiotics in these cases are not warranted, while others give them routinely. There have also been several studies promoting the treatment of uncomplicated appendicitis solely with antibiotics and avoiding surgery altogether.[1][10]

In patients with an appendiceal abscess, some surgeons continue antibiotics for several weeks and then perform an elective appendectomy. When the appendix has ruptured, the procedure can still be done laparoscopically but extensive irrigation of the abdomen and pelvis is necessary. In addition, the trocar sites may have to be left open.

Differential Diagnosis

The differential diagnosis includes Crohn ileitis, mesenteric adenitis, mittelschmerz, salpingitis, ruptured ovarian cyst, ectopic pregnancy, tubal-ovarian abscess, musculoskeletal disorders, endometriosis, pelvic inflammatory disease, gastroenteritis, right-sided colitis, renal colic, kidney stones, irritable bowel disease, testicular torsion, ovarian torsion, round ligament syndrome, epididymitis, and other nondescript gastroenterological issues.

Prognosis

If diagnosed and treated early, within 24 to 48 hours, the recovery and prognosis should be very good. Cases that present with advanced abscesses, sepsis, and peritonitis may have a more prolonged and complicated course, possibly requiring additional surgery or other interventions.

Complications

Postoperative abscesses, hematomas, and wound complications are all complications that can be seen after appendectomies. If the wound does get infected, one may grow Bacteroides. "Recurrent" appendicitis can occur if too much of the appendiceal stump is left after an appendectomy. This acts just like an appendix and can become occluded and infected just as with the initial episode. Therefore, it is important to ensure that there be very minimal and preferably no residual appendiceal stump after an appendectomy. If left untreated, appendicitis can lead to abscess formation with the development of an enterocutaneous fistula. Diffuse peritonitis and sepsis can also develop which may progress to significant morbidity and possible death.

Pearls and Other Issues

Special consideration should be given to the treatment of patients with perforated appendicitis with an abscess. Those who present with an abscess and do not exhibit peritonitis may benefit from CT or ultrasound-guided percutaneous drain placement as well as antibiotics. Interval appendectomy is classically performed 6 to 10 weeks after recovery. Historically, 20% to 40 % of patients treated medically for perforated appendicitis with an abscess had recurrent appendicitis in historical literature. More recent studies suggest these rates be much lower.

Complications of appendicitis and appendectomy include surgical site infections, intra-abdominal abscess formation (3% to 4% in open appendectomy and 9% to 24% in laparoscopic appendectomy), prolonged ileus, enterocutaneous fistula, and small bowel obstruction.

Occasionally the incorrect diagnosis of acute appendicitis is made when in reality the correct diagnosis is Crohn's disease of the cecum or terminal ileum. It is important to know that is this occurs that the appendix should be left in place if there is involvement at its base. Removal of the appendix in this situation has a high leak and fistula rate formation. On the other hand, if the base of the appendix is spared, then the appendix should be removed, even if it appears normal. This eliminates the future confusion of diagnosing acute Crohn's versus acute appendicitis.

In the past, it was commonplace to routinely remove the appendix at the time of other nonrelated surgeries to avoid developing appendicitis in the future. Today, however, most surgeons do not routinely remove a normal appendix at the time of other scheduled procedures. If a patient does go into surgery for an incorrect diagnosis of acute appendicitis, then it is advised to remove the appendix to avoid any future diagnostic issues.

Enhancing Healthcare Team Outcomes

Patients with appendicitis usually first present to the emergency department with abdominal pain. The triage nurse should be familiar with the signs and symptoms of appendicitis because these patients need urgent admission and treatment to prevent perforation. However, making a diagnosis of appendicitis is not always easy.

Several guidelines exist that can help healthcare workers make a diagnosis of appendicitis. While most physicians, nurse practitioners, and physician assistants rely on the physical exam, others may obtain an ultrasound. For questionable cases, a CT scan of the abdomen may be helpful. The American College of Radiology recommends an ultrasound in pregnant women and an MRI in inconclusive cases in the same patient population.[11][12]

While the patient is undergoing investigation, the nurse should start an IV, administer fluids and antibiotics as ordered. In women, a pregnancy test must be done to rule out an ectopic. The surgeon should be notified. Pain medications should typically only be administered after the patient has been seen by the surgeon. The nurse should monitor the patient for acute changes in pain or vital signs and report to the interdisciplinary team. Prior to surgery, the pharmacist should evaluate for potential drug-drug interactions and potential drug allergies reporting to the team any potential concerns.

Controversy also exists on how to best manage an appendiceal mass or phlegmon and when to undertake surgery. There is no longer any question that laparoscopic appendectomy is associated with minimal pain and faster recovery, but it is costly. Other studies indicate that a single small incision provides comparable results to a laparoscopic appendectomy and is cost-effective. In view of these controversies, an interprofessional team approach to diagnosis and management of appendicitis needs to be established in each institution to ensure that the patient has no morbidity and the management is cost-effective. [13](level III)

Outcomes

Many large series show that simple appendicitis treated either with an open or laparoscopic procedure has excellent outcomes. (Level III)  However, more severe and complicated appendicitis is known to be associated with worse outcomes and greater utilization of resources. Further, the atypical presentation of appendicitis in pregnancy and the elderly may also make diagnosis difficult and lead to a higher incidence of complications.  [14][15](Level III) In an era of managed care where quality care indices are monitored, it behooves healthcare workers to know the current standards of diagnosis and management of appendicitis or face denial of reimbursement.


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Appendicitis - Questions

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A patient undergoes an appendectomy that was perforated. The surgeon thoroughly cleanses the abdomen and a few days later the patient develops a red inflamed wound with a purulent discharge. What is the likely organism?



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Which two laboratory studies have the highest yield for making a diagnosis of appendicitis in a 16 year old patient?



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A general surgeon contacts you regarding preoperative clearance for an otherwise healthy 42-year-old scheduled for an appendectomy. The patient has no history of excessive bleeding, no family history of bleeding disorders, and is on no medications. He inquires about the need for coagulation studies, which have not been performed. Which of the following is a correct response to this inquiry?



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The wound made to remove a perforated appendix is classified as which of the following?



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A geriatric patient reports a poor appetite and mild bilateral lower abdominal pain that is described as crampy and is associated with a low-grade fever. What is the most probable diagnosis?



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A 25-year-old female is brought to the emergency room with a 6 hour history of abdominal pain with nausea and vomiting but no diarrhea. The pain started in the periumbilical region but now is at the right flank. She has no significant past medical history and reports she is not sexually active. Vital signs show temperature is 100.5 degrees C, blood pressure 135/90 mmHg, heart rate 105 beats/min. Exam shows no hepatosplenomegaly, positive bowel sounds, and mild diffuse tenderness without rebound or masses. There is no CVA tenderness. Pelvic exam is unremarkable without cervical motion tenderness. Urine HCG is negative and urinalysis shows 3 WBC/HPF and 3 RBC /HPF. WBC is 12,500/microL. Which of the following is the most likely diagnosis?



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A 78-year-old male has benign prostatic hyperplasia and chronic urinary retention. He develops abdominal pain and after 24 hours presents to the emergency department. CT of the pelvis shows a nonfilling and distended appendix, peri-appendiceal fluid collection, and thickening of the wall of the cecum. There is a filling defect of the bladder from the prostate. What is the most likely diagnosis?



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A 21-year-old female complains of a 16 hour history of right lower quadrant pain, nausea, and vomiting. She denies sexual activity and her last menstrual period was 14 days ago. She has no significant past medical history. Temperature is 39 degrees C and other vital signs are normal. There is rebound tenderness at the RLQ and bimanual exam is unremarkable. CBC shows WBC of 11,000/microliter with a left shift. Hemoglobin is 12.0 g/dL. Urinalysis and urine HCG is negative. What is the most likely diagnosis?



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A 60-year-old male with the past medical history of asthma and diabetes mellitus type II presented to the emergency department with right lower quadrant abdominal pain. The pain was throbbing in nature, 8/10 in severity, and constant, lasting for few hours at a time, and exacerbated with movement. Further questioning revealed he had ongoing abdominal pain for a week. His vital signs were BP 100/79 mmHg, pulse 96 per minute, respiratory rate 18 per minute, and temperature 101.6F. On examination, tenderness and rebound tenderness is present in the right iliac fossa (RIF). CBC demonstrates leukocytosis with left shift. Which of the following is true regarding the underlying diagnosis in the geriatric population?



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A 17-year-old male patient presents with anorexia and periumbilical pain followed by fever, nausea, vomiting, and right lower quadrant pain. What is the working diagnosis?



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What is the term for right lower quadrant pain with extension of the right hip or with flexion of the right hip against resistance?



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A 10 year old Caucasian male presents with complaints of periumbilical abdominal pain that is exacerbated with movement. He has 3 episodes of watery diarrhea in the last 24 hours and has not had an appetite in 12 hours. On abdominal exam, he has rebound tenderness and involuntary guarding. Which of the following should not be including in initial management?



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A 6 year old female presents with nausea, vomiting, anorexia, and right lower quadrant tenderness. On exam, she has rebound tenderness and guarding. What is the appropriate radiological study for this patient?



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Where should the inferior colic artery be ligated during an appendectomy?



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Which of the following clinical examination maneuvers is useful and positive in the diagnosis of appendicitis?



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A 38-year-old is in the emergency room with acute onset of abdominal pain and low-grade fever. The pain started at the umbilicus two hours ago and is now localized to the right lower quadrant. He has mild nausea and blood work reveals a normal white blood cell count. The surgeon has booked him for an urgent appendectomy as soon as possible because he has to take care of a patient with aortic dissection who is just being worked up in the intensive care unit. The patient with the appendectomy has no history of medical problems but has not had any coagulation studies done yet. What should the surgeon do?



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Which of the following CT scan findings on a study for abdominal pain on a patient with an equivocal history and physical would support that the appendix is not the cause?



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A 29-year-old female presents to the emergency department for abdominal pain that has been present for 12 hours. The pain began in the peri-umbilical region, and it has now migrated to the right lower quadrant. She reports decreased oral intake and nausea for the past day. Placing the patient in the left lateral decubitus position and passively extending the right leg produces marked tenderness. Given these physical exam findings, which of the following is the most likely position of the tail of the appendix?



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A patient with early appendicitis presents with vague periumbilical pain. Which of the following is true regarding this symptom?



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A 17-year-old white male develops severe right lower quadrant pain after a 12-hour history of mild, diffuse abdominal pain. He has associated nausea, vomiting, and fever. He is febrile with a temperature of 101.2 F. It is suspected that he has acute appendicitis. On physical exam of the abdomen, what would be expected?



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A client is complaining of pain in the location marked by the red line in the image below. What is correct about the location of pain and suspected diagnosis? Select all that apply.

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  • Image 6549 Not availableImage 6549 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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A 17-year-old female presented with a 2-day history of periumbilical pain which had localized to the right iliac fossa by the time she attended hospital. She describes the pain as sharp, constant, and aggravated by movement. She has no bowel or urinary symptoms and no previous abdominal problems. Her first-degree cousin died of colorectal carcinoma at a young age. Her vital signs were blood pressure 137/89 mmHg, pulse 96/min, respiratory rate 18/min, and temperature 100.6 F. Physical examination was unremarkable except for a mild tenderness in the right iliac fossa. Complete blood count (CBC) showed leukocytosis with left shift. Which of the following is the next best step in the management of this patient?

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  • Image 1707 Not availableImage 1707 Not available
    Contributed by Scott Dulebohn, MD
Attributed To: Contributed by Scott Dulebohn, MD



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A 16-year-old female presents to the hospital with a 3-day history of peri-umbilical pain, which localizes to the right iliac fossa by the time she came to the hospital. She describes the pain as dull, intermittent, and aggravated by movement. She also complains of burning micturition for the past few days. Her vital signs show a blood pressure of 137/89 mmHg, pulse 96/minute, respiratory rate 18/minute, and temperature 101.3 F. Physical examination is unremarkable for the most part apart from mild tenderness in the right iliac fossa. Complete blood count (CBC) shows leukocytosis with left shift. Ultrasound abdomen is unremarkable. She is retained overnight in the hospital and discharged the next day on oral antibiotics. Which of the following finding on the morning round most likely led to this decision?



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A 12-year-old female presents to the hospital with a 3-day history of peri-umbilical pain which had localized to the right iliac fossa by the time she came to the hospital. She describes the pain as sharp, constant, and aggravated by movement. She reports reduced hunger and nausea for the past 24 hours. She has had no bowel or urinary symptoms and no previous abdominal problems. She recalls recovering from a throat infection recently. Her vital signs show a blood pressure of 137/89 mmHg, pulse 96/minute, respiratory rate 18/minute, and temperature 101.6 F. Physical examination is remarkable for mild tenderness in the right iliac fossa and palpable abdominal lymph nodes. Complete blood count (CBC) shows leukocytosis with a left shift. Urine dipstick testing is positive for nitrites. A preliminary diagnosis is reached. Which of the following finding is most suggestive of an alternative diagnosis?



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A 60-year-old female with the past medical history of diabetes mellitus type 2 and uncontrolled hypertension presents to the emergency department with right lower quadrant abdominal pain. The pain is throbbing in nature, 8/10 in severity, and constant, lasting for few hours at a time, and exacerbated with movement. Further questioning reveals she has had ongoing abdominal pain for a week. Her vital signs show a blood pressure of 150/89 mmHg, pulse 96/minute, respiratory rate 18/minute, and temperature 101.6 F. On examination, a soft, non-tender mass with ill-defined margins measuring 6 x 4 cm is appreciated in the right iliac fossa. Complete blood count (CBC) shows leukocytosis. Contrast-enhanced CT abdomen reveals the mass to be of appendicular origin. Which of the following is the most appropriate management of this patient?



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A 60-year-old female with the past medical history of diabetes mellitus type 2 and uncontrolled hypertension presents to the emergency department with right lower quadrant abdominal pain. The pain is throbbing in nature, 10/10 in severity, and constant, lasting for few hours at a time, and exacerbated with movement. Further questioning reveals she had ongoing abdominal pain for a week. Her vital signs reveal a blood pressure of 150/89 mmHg, pulse 96/minute, respiratory rate 18/minute, and temperature 101.6 F. On examination, a soft, non-tender mass with ill-defined margins measuring 6 x 4 cm is appreciated in the right iliac fossa. CBC demonstrates leukocytosis. The patient is being managed conservatively using the Ochsner-Sherren regimen. Which of the following findings on a routine ward round would most likely warrant urgent exploration?



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A 34-year-old male presents with a 2-day history of peri-umbilical pain which had localized to the right iliac fossa by the time he came to the hospital. He describes the pain as sharp, constant, and aggravated by movement. He has had no bowel or urinary symptoms and no previous abdominal problems. His vital signs reveal a blood pressure of 127/79 mmHg, pulse 96/minute, respiratory rate 18/minute, and temperature 100.6 F. Physical examination is remarkable for mild tenderness in the right iliac fossa. Complete blood count (CBC) shows leukocytosis with a left shift. A preliminary diagnosis of acute appendicitis is made. Which of the following findings would most likely rule out this presumption?



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A 75-year-old male with hyperlipidemia and coronary artery disease presents to the emergency department with complaints of palpitations, transient wheezing and dyspnea, abdominal pain, and occasional diarrhea. His blood pressure is 142/70 mmHg, heart rate is 102/min, respiratory rate 18/min, and the temperature is 37 C (98.6 F). Physical exam reveals an elderly well-nourished male with tachycardia, facial flushing, bilateral expiratory wheezing, and isolated right lower quadrant abdominal pain. An electrocardiogram shows sinus tachycardia, and chest radiograph appears to be normal. Basic lab work is obtained which shows a white blood cell count of 14,000/microL, chloride 85 mmol/L, potassium 3.0 mmol/L, creatinine 1.2 mg/dL, lactic acid 2.5 mmol/L and urinalysis with large esterase and negative for nitrite or bacteria. Computed tomography of the abdomen and pelvis with oral and intravenous contrast is obtained and reveals right-sided liver lesions as well as appendiceal dilation, hypervascularity and adjacent fat stranding with what appears to be a 2.5 cm mass at its base. Which of the following is the most appropriate management of the patient's current condition?



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A 25-year-old male with no significant medical history presents to the emergency department with complaints of abdominal pain starting at his umbilicus for the past four days. The pain is now localized to his right lower quadrant for the last two days. His blood pressure is 130/80 mmHg, heart rate is 120/min, respiratory rate is 22/min, and the temperature is 38 C (100.4 F). Physical exam reveals a young well-nourished male with tachycardia, isolated right lower quadrant abdominal pain without peritoneal signs. An electrocardiogram shows sinus tachycardia, and chest radiograph appears to be normal. Basic lab work is obtained which shows a white blood cell count of 15,000/microL, chloride 85 mmol/L, potassium 3.0 mmol/L, creatinine 1.2 mg/dL, lactic acid 2.5 mmol/L and urinalysis with large esterase and negative for nitrite or bacteria. Computed tomography of the abdomen and pelvis with oral and intravenous contrast is obtained and reveals appendiceal tip dilation, hypervascularity and adjacent fat stranding with what appears to be a 1.5 cm mass at its tip. Which of the following is the most appropriate management of the patient's current condition?



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A 67-year-old female with hypertension and COPD presents to the emergency department with complaints of lower abdominal pain with associated nausea, vomiting, and anorexia over the last 48 hours. Her blood pressure is 148/90 mmHg, heart rate is 110/min, respiratory rate 18/min, and temperature 39 C (102.2 F). Physical exam reveals an elderly well-nourished female with tachycardia, bilateral expiratory wheezing, and isolated right lower quadrant abdominal pain. EKG shows sinus tachycardia, and chest radiograph appears to show hyperinflation of both lungs. Initial labs show a white blood cell count of 12,000/microL, chloride 82 mmol/L, potassium 3.0 mmol/L, creatinine 1.7 mg/dL, lactic acid 3.0 mmol/L and urinalysis with large esterase and negative for nitrite or bacteria. Computed tomography of the abdomen and pelvis with oral and intravenous contrast reveals appendiceal dilation, hypervascularity, and adjacent fat stranding consistent with acute appendicitis. The patient undergoes an uneventful appendectomy. The patient is discharged two days later, and the pathology report states there is a moderately differentiated adenocarcinoma in the tip of the appendix with signet cells. Which of the following is the next best step in the management of this patient?



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Appendicitis - References

References

Vaos G,Dimopoulou A,Gkioka E,Zavras N, Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. Journal of pediatric surgery. 2018 Jul 27     [PubMed]
Gignoux B,Blanchet MC,Lanz T,Vulliez A,Saffarini M,Bothorel H,Robert M,Frering V, Should ambulatory appendectomy become the standard treatment for acute appendicitis? World journal of emergency surgery : WJES. 2018     [PubMed]
Eng KA,Abadeh A,Ligocki C,Lee YK,Moineddin R,Adams-Webber T,Schuh S,Doria AS, Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology. 2018 Sep     [PubMed]
Khan MS,Chaudhry MBH,Shahzad N,Tariq M,Memon WA,Alvi AR, Risk of appendicitis in patients with incidentally discovered appendicoliths. The Journal of surgical research. 2018 Jan     [PubMed]
Stringer MD, Acute appendicitis. Journal of paediatrics and child health. 2017 Nov     [PubMed]
Hamilton AL,Kamm MA,Ng SC,Morrison M, Proteus spp. as Putative Gastrointestinal Pathogens. Clinical microbiology reviews. 2018 Jul     [PubMed]
Pooler BD,Repplinger MD,Reeder SB,Pickhardt PJ, MRI of the Nontraumatic Acute Abdomen: Description of Findings and Multimodality Correlation. Gastroenterology clinics of North America. 2018 Sep     [PubMed]
Swenson DW,Ayyala RS,Sams C,Lee EY, Practical Imaging Strategies for Acute Appendicitis in Children. AJR. American journal of roentgenology. 2018 Aug 14     [PubMed]
Kim DW,Suh CH,Yoon HM,Kim JR,Jung AY,Lee JS,Cho YA, Visibility of Normal Appendix on CT, MRI, and Sonography: A Systematic Review and Meta-Analysis. AJR. American journal of roentgenology. 2018 Sep     [PubMed]
Zani A,Hall NJ,Rahman A,Morini F,Pini Prato A,Friedmacher F,Koivusalo A,van Heurn E,Pierro A, European Paediatric Surgeons' Association Survey on the Management of Pediatric Appendicitis. European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie. 2018 Aug 15     [PubMed]
Gorter RR,Eker HH,Gorter-Stam MA,Abis GS,Acharya A,Ankersmit M,Antoniou SA,Arolfo S,Babic B,Boni L,Bruntink M,van Dam DA,Defoort B,Deijen CL,DeLacy FB,Go PM,Harmsen AM,van den Helder RS,Iordache F,Ket JC,Muysoms FE,Ozmen MM,Papoulas M,Rhodes M,Straatman J,Tenhagen M,Turrado V,Vereczkei A,Vilallonga R,Deelder JD,Bonjer J, Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surgical endoscopy. 2016 Nov     [PubMed]
Smith MP,Katz DS,Lalani T,Carucci LR,Cash BD,Kim DH,Piorkowski RJ,Small WC,Spottswood SE,Tulchinsky M,Yaghmai V,Yee J,Rosen MP, ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis. Ultrasound quarterly. 2015 Jun     [PubMed]
Schoel L,Maizlin II,Koppelmann T,Onwubiko C,Shroyer M,Douglas A,Russell RT, Improving imaging strategies in pediatric appendicitis: a quality improvement initiative. The Journal of surgical research. 2018 Oct     [PubMed]
Zosimas D,Lykoudis PM,Pilavas A,Burke J,Leung P,Strano G,Shatkar V, Open versus laparoscopic appendicectomy in acute appendicitis: results of a district general hospital. South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie. 2018 Jun     [PubMed]
Schneuer FJ,Adams SE,Bentley JP,Holland AJ,Huckel Schneider C,White L,Nassar N, A population-based comparison of the post-operative outcomes of open and laparoscopic appendicectomy in children. The Medical journal of Australia. 2018 Jul 16     [PubMed]

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