Appendicitis

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

• Early on primarily malaise, indigestion, anorexia
  • Later pt develops abdominal pain
    • Initially vague, periumbilical (visceral innervation)
    • Later migrates to McBurney point (parietal innervation)
• Nausea, w/ or w/o 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 pts 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 R leg at hip while pt lies on L side elicits abd 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

• 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)
• GU
  • Ectopic
  • Endometriosis
  • Kidney stone
  • Mittelschmerz
  • Ovarian cyst
  • Ovarian torsion
  • PID
  • Pyelonephritis
• Other
  • Abdominal aortic aneurysm
  • Epiploic appendagitis
  • Mesenteric lymphadenitis
  • Herpes zoster
  • Psoas abscess
  • Testicular torsion

Diagnosis

1. Labs
   1. CBC
      1. Normal WBC does not rule-out appy
   2. UA
      1. Sterile pyuria or hematuria c/w appy
   3. Urine pregnancy
   4. CRP
      1. Normal CRP AND WBC makes appy very unlikely
2. Imaging
   1. Early sx consultation should be obtained before imaging in straightforward cases
   2. Not universally necessary; consider in:
      1. Women of reproductive age
      2. Men w/ equivocal presentation
   3. Perforation may result in false negative study
   4. Modality
      1. Ultrasound: Appendix
         1. First choice for pregnant women and children
         2. Findings: noncompressible appendix >6mm in diameter
      2. CT
         1. First choice for adult males and nonpregnant women w/ equivocal cases
            1. Women derive the greatest benefit from preoperative imaging (lower neg appy rate)
         2. Contrast (both PO and IV) is unncessary
      3. MRI
         1. When unable to identify appendix in children or pregnant women

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).

Treatment

1. NPO
2. Fluid resuscitation
3. Analgesia/antiemetics
4. Abx
   1. Must cover aerobic and anaerobic gran negatives
   2. Simple appendicitis
      1. Cefoxitin 2gm IV Q6hr OR
      2. Ampicillin-sulbactam 3gm IV QID OR
      3. Ciprofloxacin 400mg IV BID OR
      4. Metronidazole 500mg IV Q6hr + cefuroxime 1.5gm IV x1; then 750mg IV TID
   3. Complicated appendicitis (perforation, gangrene, abscess, immunocompromised)
      1. Piperacillin/tazobactam 4.5gm IV Q6hr OR
      2. Metronidazole 500mg IV Q6hr + aztreonam 2gm IV TID OR
      3. Cefepime 2gm IV BID OR
      4. Ciprofloxacin 400mg IV BID OR
      5. Imipenem 500mg IV Q6hr
5. Surgery
   1. Open laparotomy or laparoscopy
   2. Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy
   3. Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest

Disposition

Admission for surgery

Complications

1. Infection (either a simple wound infection or an intraabdominal abscess)
   1. Typically in patients with perforated appendicitis

See Also

Appendicitis (Peds)

Source

Tintinalli