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Harrison's Practice

Abdominal Pain

Definition

• Abdominal pain refers to the perceived location of pain not necessarily to its site of origin, which may be remote from
the abdominal cavity.
• Acute pain requires rapid, often emergent assessment of likely causes (e.g., a perforated viscus) and equally rapid
intervention.
• Subacute and chronic pain may reflect a wide range of disease processes, many anatomic, some functional, and generally
allowing for a more leisurely diagnostic and therapeutic approach.

Epidemiology

• Incidence
o One of the most common presenting problems in emergency medicine
o Accounts for ~10% of all emergency department visits
o Half of healthy adults have abdominal pain on questioning.
• Age and sex
o Dependent on cause of abdominal pain, for example:
 Acute cholecystitis is more common in women than in men.
 Ischemic colitis is more common in the elderly.
o Can affect anyone at any time

Mechanism

• Among the numerous mechanisms of abdominal pain are:


o Pain originating in the abdomen
 Inflammation of the parietal peritoneum, for example:
 Release of acid into the peritoneum from a perforated duodenal ulcer
 Obstruction of a hollow viscus, for example:
 Acute biliary obstruction by a gallstone
 Vascular disturbances, for example:
 Embolism to the superior mesenteric artery with resultant intestinal ischemia
 Injury to the abdominal wall, for example:
 Tear in the abdominal musculature from trauma
 Distension of visceral surfaces, for example:
 Splenomegaly occurring rapidly in a patient with acute hemolysis
o Pain referred from extraabdominal sources
 Common sites include:
 Thorax (for example, pleuritis)
 Spine (for example, a herniated disc)
 Pelvis (for example, epididymitis)
o Metabolic causes, for example:
 Hyperlipidemia causing acute pancreatitis
o Neurologic/psychiatric causes, for example:
 Herpes zoster (shingles)
o Functional causes, for example:
 Stress, anxiety
o Toxic causes, for example:
 Lead poisoning
o Still incompletely defined mechanisms, for example:
 Familial Mediterranean fever

Symptoms & Signs

• Signs and symptoms of abdominal pain reflect underlying pathophysiologic mechanism.

• Symptoms are best described by referring to quality, location, intensity, duration, and timing of the pain.
• Signs reflect the site of origin and, although critical to diagnosis, in many cases are nonspecific.
Pain of abdominal origin

• Inflammation of the parietal peritoneum


o Quality: steady and aching
o Location: directly over the inflamed area
o Intensity: dependent on the type and amount of material to which the peritoneal surfaces are exposed in a given
time period
 Sudden release into peritoneal cavity of a small quantity of sterile acid gastric juice causes much more
pain than the same amount of grossly contaminated neutral feces.
 Enzymatically active pancreatic juice causes more pain and inflammation than the same amount of
sterile bile containing no potent enzymes.
 Blood and urine are often so bland they are detected only if contact with the peritoneum is sudden or
massive.
 In bacterial contamination (e.g., pelvic inflammatory disease), pain is frequently of low intensity until
bacterial multiplication has caused elaboration of irritating substances.
o Rate at which irritating material is applied to the peritoneum is important.
 In perforated peptic ulcer, the clinical picture depends on the rapidity with which gastric juice enters
the peritoneal cavity.
o Pain is accentuated by pressure or changes in tension of the peritoneum.
 Produced by palpation or movement, such as coughing or sneezing
 Patient with peritonitis lies quietly in bed to avoid painful motion.
 Patient with colic may writhe incessantly.
o Tonic reflex spasm of the abdominal musculature may be present.
 Localized to the involved body segment
 Intensity of spasm is dependent on the location and rate of development of the inflammatory process
and the integrity of nervous system.
 Spasm over a perforated retrocecal appendix or a perforated ulcer into the lesser peritoneal sac may be
minimal or absent because of the protective effect of overlying viscera.
 A slowly evolving process often greatly attenuates the degree of spasm.
o There may be little or no detectable pain or spasm in obtunded, seriously ill, debilitated elderly or psychotic
patients, even in catastrophic abdominal emergencies.
• Obstruction of hollow viscera
o Classically described as intermittent or colicky
 Produces steady pain with occasional exacerbations
 Not nearly as well localized as pain of parietal peritoneal inflammation
o Obstruction of the small intestine
 Colicky pain
 Usually periumbilical or supraumbilical
 Poorly localized
 As the intestine becomes progressively dilated with loss of muscular tone, pain may become steadier
and less colicky.
 With superimposed strangulating obstruction, pain may spread to the lower lumbar region if there is
traction on the root of the mesentery.
o Colonic obstruction
 Colicky pain of lesser intensity than that of the small intestine
 Often located in infraumbilical area
 Lumbar radiation is common.
o Acute distention of the gallbladder (cholecystitis)
 Steady rather than colicky pain; the term biliary colic is misleading.
 Usually felt in the right upper quadrant with radiation to the right posterior region of the thorax or the
tip of right scapula
o Acute distention of the common bile duct (typically from choledocholithiasis)
 Often felt in the epigastrium with radiation to the upper part of the lumbar region
 Differentiation between common bile duct pain and acute distention of the gallbladder may be
impossible; in either condition, typical patterns of radiation are frequently absent.
o Gradual dilatation of the biliary tree (e.g., carcinoma of head of pancreas)
 May cause no pain or only a mild aching sensation in the epigastrium or right upper quadrant
o Acute inflammation of the biliary tree (acute cholangitis)
 Sharp, cutting, or gnawing right upper quadrant or epigastric pain, often radiating to the right shoulder
or interscapular region of the back
 Usually accompanied by fever (89%) and jaundice (60%); called Charcot’s triad
 In suppurative acute cholangitis, confusion and hypotension may be present as well as Charcot’s triad
(making Reynolds’s pentad).
o Distention of the pancreatic ducts
 Pain is similar to that of distention of the common bile duct.
 Very frequently accentuated by recumbency and relieved by upright position
o Obstruction of the urinary bladder
 Dull suprapubic pain, usually low in intensity
 Restlessness without specific complaint of pain may be the only sign of a distended bladder in an
obtunded patient.
o Acute obstruction of the intravesicular portion of ureter
 Severe suprapubic and flank pain that radiates to the penis, scrotum, or inner aspect of upper thigh
o Obstruction of the ureteropelvic junction
 Pain in costovertebral angle
o Obstruction of remainder of the ureter
 Flank pain that often extends into the same side of abdomen
• Vascular disturbances
o Pain is not always sudden or catastrophic.
o Embolism or thrombosis of the superior mesenteric artery or impending rupture of an abdominal aortic
aneurysm
 Pain may be severe and diffuse (poorly localized).
o Occlusion of the superior mesenteric artery
 Pain may be mild, continuous, and diffuse for 2 or 3 days before vascular collapse or findings of
peritoneal inflammation appear, or severe and diffuse.
 Early, insignificant discomfort is caused by hyperperistalsis rather than peritoneal inflammation.
 Absence of tenderness and rigidity in the presence of continuous, diffuse pain is characteristic of
vascular disease.
o Rupturing abdominal aortic aneurysm
 Abdominal pain with radiation to the sacral region, flank, or genitalia
 Pain may persist over several days before rupture and collapse occur.
• Abdominal wall pain
o Usually constant and aching
o Movement, prolonged standing, and pressure accentuate discomfort and muscle spasm.
o Hematoma of rectus sheath
 Occurs most often in patients on anticoagulant therapy
 A mass may be present in the lower quadrants of abdomen.
 Simultaneous involvement of muscles in other parts of body usually differentiates myositis of the
abdominal wall from an intraabdominal process.

Referred pain in abdominal diseases

• Referred pain of thoracic origin


o Frequently accompanied by splinting of the involved hemithorax with respiratory lag (i.e., defined as an
asymmetric expansion of the lungs on inspiration; it can signify splinting of muscles related to intrapleural or
intraabdominal pain or intrathoracic disease such as pneumothorax or massive atelectasis) and decrease in
excursion, often more marked than that seen in intraabdominal disease
o Diaphragmatic pleuritis from pneumonia or pulmonary infarction
 May cause pain in the right upper quadrant or supraclavicular area
 Apparent abdominal muscle spasm caused by referred pain
 When caused by referred pain, spasm diminishes during inspiration.
 Spasm is present during both inspiration and expiration when pain is of abdominal origin.
o Palpation over the area of referred pain in the abdomen rarely accentuates the pain; in some cases may relieve it.
• Referred pain from spine
o Usually involves compression or irritation of nerve roots
o Characteristically is intensified by certain motions (e.g., cough, sneeze, strain)
o Associated with hyperesthesia over involved dermatomes
• Referred pain from the testicles or seminal vesicles
o Dull aching pain
o Poorly localized
o Generally accentuated by the slightest pressure on the testicles or seminal vesicles

Metabolic abdominal crises


• May simulate almost any other type of intraabdominal disease
• In certain instances (e.g., hyperlipidemia), metabolic disease may be accompanied by an intraabdominal process such as
pancreatitis.
o Can lead to unnecessary laparotomy unless recognized
• C’1 esterase deficiency associated with angioneurotic edema is often associated with severe abdominal pain.
• The abdominal attacks of familial Mediterranean fever range from dull, aching pain with distension to severe generalized
pain with signs of peritonitis.
• Pain of porphyria and lead colic
o Severe hyperperistalsis is a prominent feature.
o Pain can be difficult to distinguish from that of intestinal obstruction.
• Uremia and diabetes
o Nonspecific pain
o Pain and tenderness frequently shift in location and intensity.
o Diabetic acidosis may be precipitated by an abdominal crisis, such as acute appendicitis or intestinal
obstruction.
 Failure of the pain to resolve when the diabetes is brought under control therefore necessitates a search
for other underlying pathology.
• Black widow spider bites
o Intense pain and rigidity of the abdominal muscles and back (the latter infrequently involved in intraabdominal
disease)

Neurogenic causes

• Abdominal pain may result from diseases that injure sensory nerves.
o Nature of the pain
 Burning
 Usually limited to distribution of given peripheral nerve
 Normal stimuli such as touch or change in temperature may be experienced as pain.
 May be precipitated by gentle palpation
 Frequently present in patient at rest
o Abdominal muscles are not rigid.
o Respirations are not disturbed.
o Distension of the abdomen is not common.
o Demonstration of irregularly spaced cutaneous pain spots may be the only indication of old nerve lesion
underlying causalgic pain.
• Pain arising from spinal nerves or roots
o Comes and goes suddenly
o Lancinating
o Not related to intake of food
o There is no distention of the abdomen or changes in respirations.
o May be caused by:
 Herpes zoster
 Impingement by arthritis
 Tumors
 Herniated nucleus pulposus
 Diabetes
 Syphilis
o Severe muscle spasm is common, but is either relieved or not accentuated by abdominal palpation.
o Pain is made worse by movement of the spine and is usually confined to a few dermatomes.
o Hyperesthesia is very common.

Functional causes

• Conforms to none of above patterns


• Irritable bowel syndrome (IBS)
o Characterized by abdominal pain and altered bowel habits
o Episodes of pain often brought on by stress.
o Pain varies considerably in type and location.
o Nausea and vomiting are rare.
o Localized tenderness and muscle spasm are inconsistent or absent.
Differential Diagnosis

• Two useful ways of approaching the diagnosis of abdominal pain are by mechanism and by location.

Differential diagnosis based on mechanism of pain

• See Table 14-1.


• Pain originating in the abdomen
o Parietal peritoneal inflammation
 Bacterial contamination (e.g., perforated appendix, pelvic inflammatory disease)
 Chemical irritation (e.g., perforated ulcer, pancreatitis, mittelschmerz)
o Mechanical obstruction of hollow viscera (e.g., blockage of the small or large intestine, biliary tree, or ureter)
o Vascular disturbances
 Embolism or thrombosis
 Vascular rupture
 Pressure or torsional occlusion
 Sickle cell anemia
o Abdominal wall
 Distortion or traction of the mesentery
 Trauma or infection of the abdominal muscles
o Distention of visceral surfaces (e.g., hepatic or renal capsules)
• Pain referred from an extra-abdominal source
o Thorax (e.g., myocardial or pulmonary infarction, pneumonia, pericarditis, esophageal disease)
o Spine (e.g., radiculitis from arthritis, herpes zoster)
o Genitalia (e.g., torsion of the testicle)
• Metabolic causes
o Uremia
o Diabetic ketoacidosis
o Porphyria
o Immunologic factors (C’1 esterase inhibitor deficiency)
• Neurologic/psychiatric causes
o Organic
 Tabes dorsalis
 Herpes zoster
 Causalgia and others
o Functional
 IBS: one of the most common causes of abdominal pain
• Toxic causes
o Lead poisoning and others
o Black widow spider bite
• Uncertain mechanisms
o Narcotic withdrawal
o Heat stroke

Differential diagnosis based on location of pain

• Right upper quadrant


o Cholecystitis
o Cholangitis
o Pancreatitis
o Pneumonia/empyema
o Pleurisy/pleurodynia
o Subdiaphragmatic abscess
o Hepatitis
o Budd-Chiari syndrome
• Right lower quadrant
o Appendicitis
o Salpingitis
o Inguinal hernia
o Ectopic pregnancy
o Nephrolithiasis
o Inflammatory bowel disease
o Mesenteric lymphadenitis
o Typhlitis
• Epigastric
o Peptic ulcer disease
o Gastritis
o Gastroesophageal reflux disease
o Pancreatitis
o Myocardial infarction
o Pericarditis
o Ruptured aortic aneurysm
o Esophagitis
• Periumbilical
o Early appendicitis
o Gastroenteritis
o Bowel obstruction
o Ruptured aortic aneurysm
• Left upper quadrant
o Splenic infarct
o Splenic rupture
o Splenic abscess
o Gastritis
o Gastric ulcer
o Pancreatitis
o Subdiaphragmatic abscess
• Left lower quadrant
o Diverticulitis
o Salpingitis
o Inguinal hernia
o Ectopic pregnancy
o Nephrolithiasis
o IBS
o Inflammatory bowel disease
• Diffuse nonlocalized pain
o Gastroenteritis
o Mesenteric ischemia
o Bowel obstruction
o IBS
o Peritonitis
o Diabetes
o Malaria
o Familial Mediterranean fever
o Metabolic diseases
o Psychiatric diseases

Diagnostic Approach

General considerations

• A diagnosis can almost always be achieved in patients with acute pain, unlike in patients with chronic pain.
• Definitive diagnosis cannot always be established on initial examination.
o Except in an emergent situation, watchful waiting with repeated questioning and examination will often:
 Elucidate the true nature of the illness
 Indicate the proper course of action
• Few abdominal conditions require abandonment of an orderly approach.
o Only patients with exsanguinating intraabdominal hemorrhage (e.g., a ruptured aneurysm) must be rushed to the
operating room immediately.
 This is relatively rare.
 Only a few minutes are required to assess critical nature of problem.
 Eliminate all obstacles, obtain adequate venous access for fluid replacement, begin operation.
 Many have died while awaiting unnecessary examinations (e.g., electrocardiograms, abdominal films).
 There are no contraindications to operation when massive intraabdominal hemorrhage is present.
o In most cases, GI hemorrhage can be managed more conservatively.
• IBS
o One of the most common causes of abdominal pain
o Must always be kept in mind
o Diagnosis based on clinical criteria after exclusion of demonstrable structural abnormalities
• Diseases of the upper abdominal cavity, such as acute cholecystitis or perforated ulcer, are frequently associated with
intrathoracic complications.
o The possibility of intrathoracic disease must be considered in every patient with abdominal pain, especially if
pain is in the upper part of abdomen.
o Thoracic and abdominal diseases frequently coexist and may be difficult to differentiate.
 Patients with known biliary tract disease often have epigastric pain during myocardial infarction.
 Biliary colic may be referred to the precordium or left shoulder in patient who has suffered previously
from angina pectoris.
 Patients with an inferior myocardial infarction often have abdominal symptoms; some have no
abdominal or chest pain.
• Consider a metabolic origin whenever the cause of abdominal pain is obscure.
o If prompt resolution of pain does not result from correction of metabolic abnormalities (e.g., DKA), suspect an
underlying organic problem.
• Diagnosis of the cause of abdominal pain in the elderly can be difficult.
o Coexistence of multiple chronic conditions and the use of multiple pharmaceutical agents may make the clinical
picture unclear.
o The physical examination may be benign even in the face of catastrophic illness.

History

• Far more valuable than any laboratory or radiographic examination


o A reasonably accurate diagnosis can usually be made on the basis of history alone.
o The chronological sequence of events is often more important than the location of pain.
o Key points of information include:
 Location of the pain
 Radiation of the pain
 Exacerbating and ameliorating factors
 Associated symptoms (fevers, chills, weight loss or gain, nausea, diarrhea, constipation, blood in the
stool, jaundice, change in color of urine or stool, change in diameter of stool)
 Family history of bowel disorders
 Alcohol intake
 Medication history
 Drugs may be causative; e.g., NSAIDs may cause ulcer disease and gastritis.
 Medications may suggest a diagnosis; e.g., an elderly patient taking antihypertensive and
cholesterol-lowering drugs may have generalized atherosclerotic disease and be at risk for
ischemic bowel disease.
 Accurate menstrual history in women
 Sexual history, contacts, risky behaviors, past sexually transmitted diseases
o Remember to consider extra-abdominal sources of pain.

Physical examination

• There is no substitute for sufficient time spent in examination.


• Simple inspection of the patient (e.g., the facial expression, position in bed, and respiratory activity) may provide
valuable clues to the severity of pain and urgency of the situation.
• Measurement of vital signs is the critical first step in examination.
o Fever, hypotension, tachycardia, and tachypnea, alone or in combination, are signs requiring urgent attention
and intervention.
o Orthostatic changes may indicate hypovolemia and/or hemorrhage.
• Examination of the skin and eyes for jaundice
• Auscultation and percussion of the chest
• Auscultation of the abdomen for bowel sounds
• Palpation of the abdomen for masses, tenderness, and peritoneal irritation
• Rectal examination and stool testing for occult blood
• Pelvic examination in a female, testicular and prostatic examination in a male
• The amount of information gleaned is directly proportional to gentleness and thoroughness of examiner.
o Once a patient with peritoneal inflammation has been examined brusquely, accurate assessment by the next
examiner becomes almost impossible.
• Eliciting rebound tenderness by sudden release of a deeply palpating hand in patient with suspected peritonitis is cruel
and unnecessary.
o Gentle percussion of abdomen (rebound tenderness on miniature scale) can be far more precise and localizing.
o Asking the patient to cough will elicit true rebound tenderness without the need to place a hand on the abdomen.
o Forceful demonstration of rebound tenderness will startle and induce protective spasm in nervous or worried
patient in whom true rebound tenderness is not present.
o A palpable gallbladder will be missed if palpation is so rough that voluntary muscle spasm becomes
superimposed on involuntary muscular rigidity.
• Abdominal signs
o May be minimal, but are still meaningful if accompanied by consistent symptoms
o May be virtually or totally absent in cases of pelvic peritonitis
 Thus, a rectal and/or pelvic exam are critical components of the assessment.
o Tenderness on pelvic or rectal examination in absence of other abdominal signs can be caused by operative
indications such as:
 Perforated appendicitis
 Diverticulitis
 Twisted ovarian cyst
• Auscultation
o The presence, absence, and quality of bowel sounds may be misleading and often over-rated as a diagnostic tool.
o A strangulating small intestinal obstruction or perforated appendicitis may occur in the presence of normal
peristaltic sounds.
o When proximal part of intestine above an obstruction becomes markedly distended and edematous, peristaltic
sounds may lose characteristics of borborygmi and become weak or absent, even when peritonitis is not present.
o Severe chemical peritonitis of sudden onset is usually associated with truly silent abdomen.
• Laboratory examinations (as indicated)
o May be of value, yet only infrequently establish a definitive diagnosis
o Tests that should be ordered include:
 Complete blood count
 Blood chemistries including blood urea nitrogen, glucose, bilirubin, amylase, and lipase
 Urinalysis
• Radiologic studies (as indicated)
o Plain and upright or lateral decubitus radiographs
o Contrast enema
o Ultrasonography
o CT with contrast
o Radioisotopic scans (HIDA)
o Barium or water-soluble contrast study of upper GI tract
 Useful in rare instances when the diagnosis is elusive
 Avoid oral administration of barium sulfate if there is any question of possible obstruction of the colon.
• Diagnostic procedures
o Upper and lower endoscopy
o Endoscopic retrograde cholangiopancreatography (ERCP)
o Laparoscopy

Laboratory Tests

• Urinalysis
o Helps reveal the patient’s state of hydration
o Helpful in assessing renal dysfunction, bleeding, or infection in the urinary tract, and the presence of
diabetes/DKA
• Complete blood count
o Leukocytosis
 Never the single deciding factor for surgical intervention
 Count >20,000/μL may be seen in perforation of a viscus, pancreatitis, acute cholecystitis, pelvic
inflammatory disease, and intestinal infarction.
 Note that other coexisting conditions may also elevate the white blood cell count, e.g., steroid therapy,
other inflammatory or infectious processes.
 A normal white blood cell count is not rare in perforation of abdominal viscera.
o Anemia
 When combined with an accurate history, the presence of anemia may be very helpful in the diagnosis.
 Iron deficiency anemia may indicate GI blood loss from an ulcer or intestinal lesion.
 In a patient with a GI bleed, if the red cells are microcytic and hypochromic, blood loss is
probably chronic; if not, the blood loss is likely more acute.
• Blood chemistries
o Blood urea nitrogen (BUN), glucose, and liver function studies will assess renal function, diabetes, and
underlying liver and biliary disease.
o Serum amylase may be elevated in pancreatitis, a perforated ulcer, strangulating intestinal obstruction, and acute
cholecystitis.
 Thus, an elevation of the amylase does not rule out the possibility of surgical disease.
 The amylase rises within 2–12 hours of the onset of acute pancreatitis.
o Serum lipase
 Rises less acutely than the amylase, but stays elevated longer
o β-human chorionic gonadotrophin levels will be elevated in pregnancy.
• Blood and urine cultures should be obtained in patients with fever or unstable vital signs.
o The elderly may not manifest fever despite infection, and the threshold for obtaining cultures should be low.
• HIV testing, if relevant

Imaging

• If the diagnosis is in doubt, then imaging studies can provide important information.
• Plain and upright or lateral decubitus radiographs may be of particular value in cases of:
o Intestinal obstruction (gas-filled bowel with cutoff at site of blockage)
o Perforated viscus (free air in the abdomen)
o Ischemic bowel disorders (thumbprinting of the bowel wall)
o Gallstones (visible in about 10–15% of cases)

• Barium or water-soluble contrast study of upper GI tract


o May demonstrate partial intestinal obstruction that may elude diagnosis by other means
o If there is any question of obstruction of colon, oral administration of barium sulfate should be avoided.
• Contrast enema may be diagnostic in suspected colonic obstruction (without perforation).
• Ultrasonography is useful in detecting:
o Enlarged gallbladder or pancreas
o Gallstones
o Enlarged ovary
o Tubal pregnancy
• Nuclear scan with hepatobiliary iminodiacetic acid (HIDA )
o A functional assessment of gallbladder function
o A positive test for acute cholecystitis is present when the dye enters the common bile duct but not the
gallbladder.
o Useful when cholecystitis is suspected but other imaging tests fail to demonstrate significant stone disease.
• CT scanning may demonstrate:
o An enlarged pancreas or other abdominal mass
o Gallstones
o Ruptured spleen
o Thickened colonic or appendiceal wall and streaking of the mesocolon or mesoappendix characteristic of
diverticulitis or appendicitis
o Lymphadenopathy suggestive of a chronic neoplastic or inflammatory process
o Vascular aneurysm

Diagnostic Procedures

• Upper and lower endoscopy


o Best method for detecting lesions within the lumen and mucosa of the GI tract
 Upper endoscopy will detect ulcer disease, gastritis and tumors, for example.
 Lower endoscopy (colonoscopy) will detect acute inflammatory bowel disease and tumors.
• ERCP
o Excellent way to visualize diseases of the common bile duct and pancreas when other imaging techniques have
failed.
• Laparoscopy
o Especially helpful in diagnosing pelvic conditions, such as:
 Ovarian cysts
 Tubal pregnancies
 Salpingitis
o Can also detect acute appendicitis
• Peritoneal lavage is used only in cases of trauma.
o Has been replaced as diagnostic tool by ultrasound, CT, and laparoscopy
• Exploratory laparotomy
o Less commonly needed with today’s improved imaging techniques

Treatment Approach

• The principles of managing the patient with acute abdominal pain are similar to those of any urgent clinical situation.
• As required by the circumstances, stabilize the patient.
o IV access is almost always advisable.
o Restoration of proper fluid and electrolyte balance should be carried out as quickly as tolerated.
• Ascertain if urgent surgical intervention is required.

• Provide pain relief.


o Narcotics or analgesics should not be withheld until a definitive diagnosis or definitive plan is formulated.
 The correct diagnosis is almost never hidden by the use of adequate analgesia.
• Prescribe empiric antibiotic therapy if intraabdominal infection is suspected.
• Provide other symptomatic relief (e.g., antiemetics, antispasmodics).
• Definitive treatment is dependent on etiology of pain.

Specific Treatments

Symptom relief

• Pain control
o Opioid analgesics (e.g., hydromorphone: 1–2 mg SC or IM; meperidine: 75–100 mg IM)
o Antacids or H2 receptor antagonists for burning pain caused by gastric acid (famotidine: 20 mg/50 mL IV;
ranitidine: 50 mg)
 H2 receptor blockers tend to provide quicker relief than proton pump inhibitors.
o Intravenous ketorolac (15–30 mg) may be used for renal or biliary colic.
• Control of intractable emesis
o Droperidol (2.5 mg IM)
o Prochlorperazine (5–10 mg IM)
o Promethazine (12.5–25 mg IM)
o Trimethobenzamide (200 mg IM)
o Any of these agents may cause mental status changes.
• Nasogastric tube with suction for suspected small-bowel obstruction

Empiric antibiotics

• Second-generation cephalosporins combined with metronidazole (unless local antibiotic resistance)


o Cefotetan (1–3 g IV q12h)
o Cefoxitin (2 g q4–8h or 3 g q6h IV)
o Metronidazole (loading dose: 15 mg/kg IV infusion over 1h; maintenance dose: 7.5 mg/kg IV infusion over 1h,
q6h)
 The combination of metronidazole with a fluoroquinolone (e.g., levofloxacin 750 mg qd IV) is
frequently used, with the addition of ampicillin 2g q6h IV) in severe, life-threatening disease.
 Alternatives: β-lactam agents with β-lactamase antagonists

o Ampicillin sulbactam (1.5–3 g q6h IV)
o Piperacillin/tazobactam (3.375 g q6h IV)
o Ticarcillin/clavulanate (200–300 mg/kg per d IV)
• Alternatives if patient recently took other antibiotics: carbapenem or cefepime
o Imipenem (500 mg q6h to 1 g q8h IV)
o Meropenem (1 g q8h IV)
• Antifungal agents may be necessary for immunocompromised patients.

Definitive treatment
• Dependent on etiology of pain

Monitoring

• Careful follow-up with frequent reexamination (by the same examiner, when possible) is recommended.
• Repeated studies may be necessary when a definitive diagnosis has not been made.

Complications

• Complications are dependent on the etiology of the pain but can include:
o Sepsis
o Peritonitis
o Ruptured viscus
o Ischemic bowel
o Intraabdominal hemorrhage
o Intestinal obstruction
o Urinary obstruction
o Splenic infarction

Prognosis

• Prognosis depends on:


o Etiology
o Timely diagnosis
o Appropriate treatment

Prevention

• Possible preventive measures depend on the underlying cause.

ICD-9-CM

• 789.00 Abdominal pain, unspecified site


• 789.0_ Abdominal pain, (anatomic site specified by fifth digit)

See Also

• Abdominal Abscesses
• Abdominal Aortic Aneurysm
• Acute Appendicitis
• Acute Cholecystitis
• Acute Intestinal Obstruction
• Acute Pancreatitis
• Chronic Pancreatitis
• Gallstones
• Gastritis
• Irritable Bowel Syndrome
• Pelvic Inflammatory Disease
• Peptic Ulcer Disease
• Peritonitis

Appendicitis

Introduction

Background
Appendicitis is acute inflammation and infection of the vermiform appendix, which is most commonly referred to simply as the
appendix. The appendix is a blind ending structure arising from the cecum. Acute appendicitis is one of the most common causes
of abdominal pain and the most frequent condition leading to emergent abdominal surgery in children.

Pathophysiology

Appendicitis is due to a closed-loop obstruction of the appendix. Most commonly, the obstruction is due to either lymphoid
hyperplasia within the appendix or impacted fecal matter, referred to as a fecalith. Obstruction of the appendix leads to bacterial
overgrowth and an increase in intraluminal pressure. The increased intraluminal pressure obstructs the venous blood flow in the
appendix and leads to congestion in the appendix. Over time, this congestion leads to ischemia in the appendix, allowing for
bacterial translocation and infection. The ischemia and the bacterial infection cause the inflammation of the appendix. As the
disease progresses, the inflammation progresses from a mild inflammation to a gangrenous appendix. When the appendix
becomes gangrenous, it may perforate. This process usually takes place over 72 hours. This is an important point when
considering the patient’s history.

When the appendix perforates, inflammatory fluid and bacterial contents are released into the abdominal cavity. This fluid may
infect the peritoneum, and the patient may develop generalized peritonitis. Concomitantly, the patient develops more intense and
generalized abdominal pain. However, the omentum and loops of small bowel may wall off the fluid and form an abscess. In this
case, the patient may continue to have localized abdominal pain in the area of the abscess.

Frequency

United States

Appendicitis occurs in all age groups but is rare in infants. If an infant has appendicitis, the diagnosis of Hirschsprung disease
should also be considered. The incidence in the United States is 4 cases per 1000 children. Overall, 7% of people in the United
States have their appendix removed during their life.

Mortality/Morbidity

At the time of diagnosis, the rate of perforation is 20-35%. Younger children have a higher rate of perforation, with reported rates
of 50-85%. The mortality rate for children with appendicitis is 0.1-1%. This is most commonly seen in neonates and infants. This
is due to 2 factors. First, appendicitis is rare in this age group; thus, unless the physician’s index of suspicion is high, appendicitis
is often low on the list of suspected differential diagnoses. Second, very young patients are unable to communicate the location
and nature of their pain. Some neonates may not even become febrile. Often, the patient’s only symptom is irritability or
inconsolability.

Sex

The male-to-female ratio is approximately 2:1.

Age

Appendicitis occurs in all age groups. The mean age in the pediatric population is 6-10 years. Appendicitis is rare in the neonate,
and the diagnosis is typically made after perforation for the reasons discussed above (see Mortality/Morbidity). Younger children
have a higher rate of perforation (50-85% reported).

Clinical

History

As with almost any clinical entity, the best place to start is with the patient’s history. The classic description of appendicitis is a
patient who develops vague periumbilical pain, followed by nausea, vomiting, and anorexia. Over time, the pain migrates to the
right lower quadrant. If the appendix perforates, an interval of pain relief is followed by development of generalized abdominal
pain and peritonitis. Although some patients progress in the classical fashion, some patients deviate from the classic
model. Fifteen percent of patients have a retrocecal appendix, and their signs and symptoms may not localize to the right lower
quadrant, localizing instead to the psoas muscle. Other patients may have the tip of their appendix deep in the pelvis, and their
signs and symptoms localize to the rectum or bladder.

• Pain: The initial symptom is poorly defined periumbilical pain. Acute onset of severe pain is not typically present in
acute appendicitis but is seen with acute ischemic conditions such as volvulus, testicular torsion, ovarian torsion, or
intussusception. If the pain is initially located in the right lower quadrant, severe constipation should be considered.
• Nausea and vomiting: Generally, vomiting that occurs prior to pain is unusual. However, in retrocecal appendices,
particularly those that extend cephalad along the posterior surface of the right colon, inflammation of the appendix
irritates the nearby duodenum, resulting in nausea and vomiting prior to the onset of right lower quadrant pain.
• Diarrhea: Likewise, significant diarrhea is atypical in appendicitis, and the physician should consider other diagnoses,
while not ruling out appendicitis. In patients with an appendix in a pelvic location, inflammation of the appendix
occasionally results in an irritative stimulation of the rectum. These patients often report diarrhea. However, upon closer
questioning, such patients relate symptoms of frequent, small-volume, soft stools and usually not true diarrhea.
• Shift to right lower quadrant pain: After a few hours, pain shifts to the right lower quadrant because of inflammation of
the parietal peritoneum. This pain is more intense, continuous, and localized.
• Fever: Most children with appendicitis are afebrile or have a low-grade fever and characteristic flushness of their cheeks.
Severe fever is not a common presenting feature unless perforation has occurred and may still be a rare finding.
According to one study, vomiting and fever are more frequent findings in children with appendicitis than in children with
other causes of abdominal pain.

Physical

The physical examination findings in children may vary depending on age. Irritability may be the only sign of appendicitis in a
neonate. Older children often seem uncomfortable or withdrawn. They may prefer to lie still because of peritoneal irritation.
Teenaged patients often present in a classic or near-classic fashion.

• General examination: Patient’s general state should be observed before interacting with them. The patient’s state of
activity or withdrawal may lend information into their state. A patient in obvious distress with abdominal pain gives the
impression of an infectious process; however, other causes must be ruled out.
• Cardiac and pulmonary examination: The evaluation of the heart and lungs of the patient reflects the overall state more
than suggests the appendix as a cause. Patients are often dehydrated or in pain and may be tachycardic or
tachypneic. Pediatric patients have great physiological reserve and may not show any general symptoms until they are
very ill.
• Abdominal examination
o The child's abdomen should be examined in the same way an adult's abdomen is examined. Full exposure of the
abdomen is key. Localization of the pain is also key but may depend on the position of the appendix.
o Observing the patient cough and asking them to localize their pain with one finger often localizes their
discomfort to the right lower quadrant. Typically, maximal tenderness can be found at the McBurney point in
the right lower quadrant. However, the appendix may lie in many positions.
 A medially positioned appendix may present as suprapubic tenderness.
 Patients with a laterally positioned appendix often have flank tenderness.
 Patients with a retrocecal appendix may not have any tenderness until it is advanced or perforated.
o Palpation of the abdomen should be performed with a gentle and light touch, searching for involuntary guarding
of the rectus or oblique muscles. Eliciting rebound tenderness is an unnecessary part of the abdominal
examination.
o The Rovsing sign is pain in the right lower quadrant in response to left-sided palpation or percussion and
strongly suggests peritoneal irritation.
o To perform the psoas sign, place the child on the left side and hyperextend the right leg at the hip. A positive
response suggests an inflammatory mass overlying the psoas muscle (retrocecal appendicitis).
o Perform the obturator sign by internally rotating the flexed right thigh. A positive response suggests an
inflammatory mass overlying the obturator space (pelvic appendicitis).
• Rectal examination
o A rectal examination is important and should be performed in all patients who are evaluated for appendicitis.
o The caliber of the patient's anus should be taken into consideration, and smaller digits should be used for
examining younger patients.
o The rectal examination in a young child may be completely objective because they may not be able to
communicate variations in tenderness or may have general discomfort from the examination.
o Objective information to ascertain includes impacted stool or an inflammatory mass.
o A patient able to communicate should be asked if they have tenderness in different areas of the rectum.
o Right-sided tenderness of the rectum is the classic finding in pelvic appendicitis or in pus that pools in the pelvis
from an inflamed appendix elsewhere in the abdomen.

Causes

• Appendicitis is caused by a closed-loop obstruction of the appendix. Most cases are caused either by impacted fecal
material, called a fecalith or appendicolith, or by hyperplasia of submucosal lymphoid follicles. Rarely, foreign objects or
nematodes may cause luminal obstruction.
• Obstruction leads to increasing intraluminal pressure from bacterial overgrowth. This increase in pressure leads to
vascular compression initially on the venous side. This causes congestion and decreased wall perfusion. This decreased
perfusion leads to necrosis and inflammation of the appendix.
• During this initial stage the patient feels only periumbilical pain due to the T10 innervation of the appendix. As the
inflammation continues, an exudate forms on the appendiceal serosal surface. When the exudate touches the parietal
peritoneum, a more intense and localized pain develops. The location of this pain has been described above (see History).
• As the obstruction continues, bacteria within the appendix proliferate and increase intraluminal pressure. The bacteria
then infiltrate the wall of the appendix. If the diagnosis is not made early, the obstruction progresses, and the wall of the
appendix stretches.
• Over time, the intraluminal pressure in the appendix increases and the strength of the appendiceal wall decreases due to
the necrosis, and perforation occurs. At this point, inflammatory fluid and bacterial contents release into the abdominal
cavity. This further inflames the peritoneal surface, and peritonitis develops. At this point, the location and extent of
peritonitis (diffuse or localized) depends on the degree to which the omentum and adjacent bowel loops can contain the
spillage of luminal contents.
• If the contents become walled off and form an abscess, the pain and tenderness may be very localized to the abscess. If
the contents are not walled off and the fluid is able to travel throughout the peritoneum, a general peritonitic state is
observed.

Differential Diagnoses

Constipation Pneumonia
Ectopic Pregnancy Pregnancy Diagnosis
Hemolytic-Uremic SyndromePyelonephritis
Henoch-Schoenlein Purpura Urinary Tract
Infection
Meckel Diverticulum
Ovarian Cysts
Pelvic Inflammatory Disease

Other Problems to Be Considered

Ovarian cyst
Ovarian torsion
Pelvic inflammatory disease (PID)
Pregnancy
Ectopic pregnancy
Renal calculi
Mesenteric lymphadenitis
Mittelschmerz
Pneumonia (right lower lobe)
Neutropenic typhilitis

Workup

Laboratory Studies

Laboratory findings may increase suspicion of appendicitis but are not diagnostic. The minimum laboratory workup for a patient
with possible appendicitis includes a WBC count with differential and urinalysis.

• CBC count
o The WBC count is elevated in approximately 70-90% of patients with acute appendicitis. However, remember
that this is elevated in many other abdominal conditions. Furthermore, the elevation is usually only mild and the
increase of the WBC count occurs only as the disease process progresses.
o The WBC count is often within the reference range within the first 24 hours of symptoms. Therefore, its
predictive value is limited.
o If the WBC count exceeds 15,000 cells/μL, the patient is more likely to have a perforation. However, one study
found no difference in the WBC counts of children with simple appendicitis and those with perforated
appendicitis.
o A WBC count within the reference range does not exclude appendicitis because this is typical in at least 10% of
patients with appendicitis.
o In the immunocompromised patient, a neutrophil count of less than 800 may suggest typhilitis.
• Urinalysis
o Urinalysis is useful for detecting urinary tract disease, including infection and renal stones. However, irritation
of the bladder or ureter by an inflamed appendix may result in a few urinary WBCs. The presence of 20 WBCs
suggests a urinary tract infection.
o Hematuria may be caused by renal stones, urinary tract infection, Henoch-Schönlein purpura, or hemolytic
uremic syndrome. However, small numbers of RBCs can also occur in appendicitis in as many as 20% of
patients when an overlying phlegmon or abscess lies adjacent to the ureter. Typically, RBCs are less than 20 per
high power field.
o Normal urinalysis results do not provide any diagnostic value for appendicitis, although a grossly abnormal
result may be suggestive of an alternative cause of abdominal pain
• Electrolytes: Electrolyte assessments and renal function tests are more helpful for management than diagnosis.
Indications include a significant history of vomiting or clinical suspicion of significant dehydration.
• Additional studies
o Liver function tests and amylase and lipase assessments are helpful when the etiology is unclear.
o A beta-human chorionic gonadotropin (beta-HCG) test should be performed to rule out pregnancy or ectopic
pregnancy in female patients.

Imaging Studies

• Abdominal radiography
o Abdominal radiography findings are normal in many individuals with appendicitis. However, plain films may be
helpful in the setting of severe constipation.
o A calcified appendiceal fecalith is present in less than 10% of persons with inflammation, but its presence
confirms the diagnosis.
o Radiographic signs suggestive of appendicitis include convex lumbar scoliosis, obliteration of right psoas
margin, right lower quadrant air-fluid levels, air in the appendix, or localized ileus. In rare incidents, a
perforated appendix may produce pneumoperitoneum.
o If no other imaging studies are to be performed, an abdominal series is strongly suggested.
• Ultrasonography
o Prior to the advent of CT scans, graded compression ultrasonography was the preferred imaging modality in the
evaluation of pediatric acute appendicitis. This technique involves locating the appendix using ultrasonography
and then attempting to compress the lumen of the appendix.
o The advantages of ultrasonography include its noninvasiveness, lack of radiation, no contrast medium, and
minimal pain.
o The downside of ultrasonography is that the examination is operator dependent. In experienced hands,
ultrasonography has an overall sensitivity of 85% and a specificity of 94% in pediatric patients.
o For ultrasonography to be diagnostic of appendicitis, it must locate and visualize the appendix. Ultrasonography
that does not visualize the appendix does little to rule in or out appendicitis.
o Specific ultrasonography findings can support the diagnosis of appendicitis.
o The finding of a noncompressible dilated appendix is a strong indicator of nonperforated appendicitis.
o After perforation, ultrasonography can reveal a periappendiceal phlegmon or abscess formation.
o Additional supportive findings include an appendicolith, fluid in the appendiceal lumen, focal tenderness over
the inflamed appendix (sonographic McBurney point), and a transverse diameter of 6 mm or larger.
o Ultrasonography is also useful in diagnosing alternate pathology (eg, tubo-ovarian abscess, ovarian torsion,
ovarian cyst, mesenteric adenitis).
• CT scanning
o CT scans have become the modality of choice for diagnosing appendicitis in children.
o Although radiation exposure is a concern, CT scans have been shown to have an accuracy of 97% in diagnosing
appendicitis.
o Other advantages include the ability to evaluate the entire abdomen and locate abscesses and phlegmon, lack of
dependence on operator skill, and physician familiarity with reading CT scans.
o Disadvantages include the aforementioned radiation exposure, the need for oral and intravenous contrast and its
related disadvantages, and the need for the patient to be still, which is often difficult for small children.
o Because of the advantages of CT scans, 62% of surveyed North American pediatric surgeons preferred it for
evaluation of appendicitis. Of note, less than 1% of pediatric surgeons favored CT scanning for every case of
suspected appendicitis. Most preferred CT scanning on a selected basis, with 51-58% of patients with suspected
appendicitis undergoing CT scanning.
o However, despite now widespread use of CT scanning for evaluation of appendicitis with its superior sensitivity
and specificity, the negative appendectomy rate in children has not shown a statistically significant reduction.
• Chest radiography: If the history, physical examination, laboratory tests, and imaging studies have failed to produce a
satisfactory differential diagnosis, anteroposterior (AP) and lateral chest radiography should be performed to look for
right lower lobe pneumonias.

Histologic Findings
Typically, histologic findings range from acute inflammatory infiltrate most apparent in the submucosal level in early appendicitis
to transmural infarction in perforated appendicitis.

• The finding of an apparently normal appendix at surgery requires careful follow-up of the histologic findings.
Occasionally, early appendicitis is histologically identified and clinically correlates with the resolution of preoperative
symptoms. Additionally, unsuspected findings of luminal nematodes should indicate further anthelmintic therapy (eg,
mebendazole [Vermox]).
• The authors have recently seen a small group of patients with “early appendicitis” based on history, physical examination
findings, and/or CT scans with minimal changes found in the appendix in the operating room or based on only
intraluminal inflammatory cells on histology; these patients have complete resolution of their signs and symptoms after
appendectomy. Whether this is because the appendectomy is performed at an earlier stage in the pathophysiologic
sequence of appendicitis or whether the patients' signs and symptoms resolve due to the placebo effect of the
appendectomy is unknown.

Staging

The clinical staging of appendicitis has important implications in the postoperative treatment of the child. Although somewhat
subjective at the time of surgery, appendicitis may be divided into 3 broad categories: acute (nongangrenous) appendicitis,
suppurative or gangrenous (nonperforated) appendicitis, and perforated appendicitis. Perforated appendicitis can be divided
further into cases with diffuse peritonitis and those with localized peritonitis.

• Acute (nongangrenous): This stage of appendicitis is referred to as early appendicitis. No mural gangrene or infarction is
present. This type requires no further antibiotic therapy in most settings. The child may be discharged home as soon as
diet and oral pain medications can be tolerated.
• Suppurative or gangrenous (nonperforated): Persons with exudative appendicitis, particularly in individuals with mural
gangrene, have an increased rate of postoperative intraabdominal and wound infections, even in the absence of
demonstrable perforations. Often, microperforations are present, as evident on routine cultures findings. However, if the
gram stain and culture findings are negative, the antibiotics can be stopped in approximately 24 hours, and the child may
be discharged home as soon as diet and oral pain medications can be tolerated.
• Perforated: Perforated appendicitis (either diagnosed by intraoperative findings or positive intraoperative cultures) is
associated with a postoperative infection rate in as many as 30% of patients. Children with perforated appendicitis
require antibiotic therapy for a minimum of 10 days. Often, the patient may develop intra-abdominal abscesses that
require drainage. A high index of suspicion for a postoperative abscess is required in the patient with
perforated appendicitis who has fevers of ileus that last more than 5 days.

Treatment

Medical Care

Making a timely diagnosis of appendicitis is a difficult challenge when evaluating children with abdominal pain. Classifying
patients with abdominal pain into the following 3 major categories may be helpful:

• Diagnosis not consistent with appendicitis


o This group includes patients whose history and physical examination findings are not consistent with
appendicitis or any significant abdominal process.
o Performing a complete physical examination, including rectal palpation and urinalysis, before discharge is
important.
o Few patients require sophisticated radiological evaluation. However, as discussed above, radiographic
evaluation of the kidney, ureters, bladder, and chest may assist in diagnosis (constipation or pneumonia) and
treatment.
• Classic history for appendicitis
o Patients with a classic history require prompt surgical consultation.
o Maintain nothing-by-mouth status in patients with suspected appendicitis and start intravenous fluids to restore
intravascular volume.
o Ensure adequate hydration for patients who present with suspected appendicitis.
o Even in early acute appendicitis, children frequently have not had sufficient oral intake and present with some
degree of intravascular dehydration.
o Antibiotic therapy is an important aspect of the preoperative treatment of appendicitis but should not be
administered until consulting with a surgeon.
o Direct antibiotic therapy against gram-negative and anaerobic organisms (eg, Escherichia coli, Bacteroides
species).
o Most of these patients do not require radiological evaluation if their history, physical, and laboratory evaluations
are convincing. However, some surgeons still prefer ultrasonography in female patients because of the
possibility of a gynecological etiology.
• Unclear diagnosis
o In these children, the history may be consistent with appendicitis; however, the examination is not supportive. In
other children, the inverse may be true.
o This is the main group who benefit from double-contrast abdominal CT scanning. Serial examinations and test
results may also help to clarify the diagnosis.
o Reevaluate the patient over a few hours to determine the need for surgical consultation. If uncertainty persists
after a period of observation, obtain surgical consultation.

Surgical Care

• Appendectomy
o The definitive treatment for appendicitis is appendectomy.
o Historically, appendectomy had a 10-20% false-positive rate, but the frequent use of radiologic imaging has
reduced this rate.
• Open versus laparoscopic appendectomy
o The classic operation for removing the appendix is an open appendectomy. This involves making a McBurney,
Rocke-Davis, or Fowler-Weir incision. Dissection then proceeds through the external oblique, internal oblique,
and transversalis in a muscle-spreading or muscle-splitting fashion. The peritoneum is entered. The appendix is
then brought out into the field, clamped, ligated, and divided. The exposed mucosa is then cauterized. Inversion
of the stump may be performed. The cecum is then returned to the abdomen, and the incision is closed.
o The use of laparoscopic appendectomy has now come into favor. In this procedure, port placement consists of
first putting the camera port in the umbilicus. Then, under direct visualization, two 5 mm ports are
placed. According to surgeon preference, one is placed in the right lower quadrant and one is placed in the left
lower quadrant or both are placed in the left lower quadrant. The cecum and appendix are laterally to medially
mobilized. Various methods (ie, electrocautery, endo-loops, stapling devices) are used to remove the appendix
and should be left to the discretion of the surgeon. The appendix is then removed from the abdomen using an
endobag.
o After an appropriate learning curve, the difference in operative time of open versus laparoscopic appendectomy
has shown no statistical significance.
o Potential advantages of laparoscopic appendectomy include reduced postoperative pain, lower wound infection
rate, and quicker return to normal activities.
o Length of stay has shown to be 0.6 days shorter with laparoscopic versus open appendectomy. Patients also
have a faster return to daily activities, including school and gym.
o The other advantage of laparoscopic appendectomy is the ability to evaluate the entire abdomen, which can be
useful or diagnostic in the adolescent female, in whom gynecological etiologies can often imitate appendicitis.
• Surgical treatment of perforated appendicitis
o Because of the short time from obstruction of the appendix to perforation, 20-35% of patients who present with
acute appendicitis have already perforated. In fact, estimates suggest that most patients perforate within 72
hours of symptom onset. If a patient presents beyond 72 hours from symptom onset, perforation is highly
suggested. However, if a patient presents with symptoms of appendicitis beyond 72 hours and has not
perforated, diagnoses other than appendicitis must be entertained.
o Controversy surrounds the ideal management of patients with perforated appendicitis, including laparoscopic
versus open appendectomy performed emergently or initial conservative management with appendectomy at a
later date when the acute inflammation has subsided. This delayed surgical treatment is referred to as interval
appendectomy and is generally performed 8-12 weeks after the initial episode.
 Interval appendectomy has gained popularity because of the perceived challenges in operating on
potentially distorted anatomy and difficulties in closing the inflamed appendiceal stump. These
challenges can result in ileocecal resection, right hemicolectomy, and/or temporary ileostomy.
 Recently, the need for interval appendectomy has been questioned because of the relatively small
recurrence rate of appendicitis after the initial episode.
 This area is a popular topic of current research; however, no large scale prospective randomized trials
have compared continued conservative management with interval laparoscopic appendectomy for
perforated appendicitis.
o Patients with perforated appendicitis can be divided into 2 cohorts; those who are discovered to be perforated in
the operating room during appendectomy and those with radiographic evidence of perforation, most commonly
seen on CT scan findings. The management of these two cohorts is different and the latter group has been the
focus of much research.
o Patients discovered to have perforated appendicitis in the operating room during appendectomy should be
treated in the same fashion as those with nonperforated appendicitis. The surgeon should complete the
appendectomy in a normal fashion. If a laparoscopic appendectomy is being performed, perforation alone is not
a reason for conversion to open appendectomy. However, if an abscess is encountered and drained, placement
of a drain in the abscess cavity should be considered. Also, when an open appendectomy is being performed
on a patient with a perforated appendix, the high incidence of wound infection should be considered in terms of
skin closure.
o Because CT scans are commonly used in the diagnosis of appendicitis, many patients are diagnosed with
perforated appendicitis prior to undergoing operative management. CT scan findings that suggest perforated
appendicitis include periappendiceal or pericecal air, abscess, phlegmon, and extensive free fluid. Because the
etiology of the disease is due to obstruction of the appendix and the inflammation occurs distal to the
obstruction, extravasation of contrast or extensive free air is rarely seen. If a patient is found to have free air
throughout the abdomen or under the diaphragm, other diagnoses should be entertained.
o Historically, a patient with perforated appendicitis was rushed to the operating room for appendectomy;
however this is no longer the case.
 Conservative management with interval appendectomy is now recommended. A patient found to have
perforated appendicitis on imaging study findings should be admitted to the hospital, be placed on a
nothing-by-mouth (NPO) diet, and given intravenous (IV) fluid resuscitation.
 If the patient is hemodynamically unstable or is unable to have their urine output measured, a Foley
catheter should be placed.
 The patient should be started on IV antibiotics. Generally, antibiotics for this condition are targeted at
enteric flora (eg, second-generation cephalosporin, gentamicin, metronidazole), and discharge from the
hospital is based on demonstration of lack of fever, tolerance of pain on oral medications, and adequate
oral intake.
 If the patient has an abscess that is accessible, percutaneous drainage is performed.
 Despite the use of conservative management, as many as 38% of children with perforated appendicitis
fail medical therapy. If the patient does not improve after admission and use of IV antibiotics, they
should undergo immediate appendectomy. Factors that suggest failure of conservative management
include bandemia on admission CBC count, fever of more than 38.3 º C after 24 hours of medical
therapy, and multisector involvement on CT scan findings. Medical therapy is deemed to have failed at
a median of 3 days.
 Most patients do well with this conservative approach alone, and recurrence rates range from 0-20%,
with a pooled rate of 8.9% found by one large meta-analysis.1 A much higher recurrence rate (72%) is
seen in pediatric patients with an appendicolith present during the initial acute episode. This overall
low recurrence rate in patients without appendicolith has caused many to advocate that interval
appendectomy is not needed. Recurrence is noted in most patients within the first 6 months; the longest
follow-up to date is 13 years. However, the status of future recurrence as adults in pediatric patients
with appendicitis is unknown. Because of this uncertainty, many pediatric surgeons prefer to perform
interval appendectomy.
o When a patient undergoes interval appendectomy, the laparoscopic approach is preferred because of the ability
to visualize a wider area of the abdomen, to lyse any postinflammatory adhesions that may be present, and to
avoid the need for extending an open incision in case of abnormal anatomy. However, the complication rate is
reported to be 12-23%, which is less than the 26% complication rate for emergent appendectomy in perforated
appendicitis. These numbers are based on relatively small studies with different protocols, which limits their
usefulness for direct comparison. However, a large meta-analysis did show a significantly greater morbidity
with immediate surgery versus conservative treatment with interval appendectomy (35.6% vs 13.5%).
o A recent study by Whyte et al suggested that interval laparoscopic appendectomy may be performed as an
outpatient procedure; 12 of 24 patients were discharged the evening of the procedure.2 Of the patients who
stayed, 9 stayed only one night. Although this report is encouraging, well-known complications of laparoscopic
appendectomy should not be forgotten, including wound infection, abscess, sepsis, and ileus.
o Delaying definitive surgery is associated with significant resource use, with increased imaging, drainage
procedures, and additional admissions. A potential drawback of conservative management with laparoscopic
appendectomy performed at a later date is the risk of misdiagnosis. The major differential diagnoses for acute
appendiceal abscess or mass include Crohn disease and malignancy. The increased use of CT scanning or
ultrasonography in the emergent setting has decreased this risk of misdiagnosis. This has helped to confirm the
diagnosis of appendiceal mass and also guides drainage interventions. The increased use of technology,
combined with improvements in antibiotics, makes conservative management a more attractive and less risky
choice from a misdiagnosis or treatment failure perspective.

Consultations

• Pediatrician
• General surgeon

Medication

Administer one dose preoperative antibiotics to children with suspected appendicitis and stop administration after surgery if no
perforation is noted. Patients who present with perforated appendicitis may be volume depleted and in need of aggressive fluid
resuscitation. Administer a combination of ampicillin, clindamycin (or metronidazole), and gentamicin to prevent infection from
aerobic and anaerobic organisms. Alternative regimens include ampicillin/sulbactam, cefoxitin, cefotetan, piperacillin/tazobactam,
ticarcillin/clavulanate, and imipenem/cilastatin. Fifteen percent of patients with a ruptured appendix may develop resistant
organisms and require a change in the antibiotics initially chosen.

Antibiotics

Antibiotic regimens should cover most commonly encountered organisms, including Escherichia coli and Bacteroides, Klebsiella,
Enterococcus, and Pseudomonas species.

Ampicillin (Marcillin, Omnipen, Polycillin, Principen)

Beta-lactam antibiotic with activity against some gram-positive and gram-negative organisms. Inhibits bacterial cell wall synthesis
during active multiplication.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1-2 g IV/IM q4-8h

Pediatric

100-200 mg/kg/d IV/IM divided q4-6h

• Dosing
• Interactions
• Contraindications
• Precautions

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease
effects of oral contraceptives

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Gentamicin (Garamycin, Gentacidin)

Aminoglycoside antibiotic with activity against gram-negative bacteria including Pseudomonas species. Synergistic with beta-
lactams against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing
regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1-1.5 mg/kg/dose IV/IM q8-24h; dose and frequency based on patient's age and renal function

Pediatric

1.5-2.5 mg/kg/dose IV/IM q8h; dose and frequency based on patient's age and renal function

• Dosing
• Interactions
• Contraindications
• Precautions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity;
aminoglycosides enhance effects of neuromuscular blocking agents (thus, prolonged respiratory depression may occur);
coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of
varying degrees may occur (monitor regularly)

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; nondialysis-dependent renal insufficiency

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis,
hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Clindamycin (Cleocin)

Lincosamide effective against gram-positive aerobic and anaerobic bacteria (except enterococci). Inhibits bacterial growth,
possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

• Dosing
• Interactions
• Contraindications
• Precautions
Adult

600-1200 mg/d IV/IM divided q6-8h

Pediatric

20-40 mg/kg/d IV/IM divided tid/qid

• Dosing
• Interactions
• Contraindications
• Precautions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects;
antidiarrheals may delay absorption

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly
fatal colitis

Ampicillin/sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Activity against some gram-positive organisms, gram-negative
organisms (nonpseudomonal species), and anaerobic bacteria.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h, not to exceed 4 g/d sulbactam or 8 g/d
ampicillin

Pediatric

3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h


>12 years: Administer as in adults, not to exceed 4 g/d sulbactam or 8 g/d ampicillin

• Dosing
• Interactions
• Contraindications
• Precautions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin
rash; may decrease effects of PO contraceptives

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Piperacillin/tazobactam (Zosyn)

Drug combination of beta-lactamase inhibitor with piperacillin. Activity against some gram-positive organisms, gram-negative
organisms, and anaerobic bacteria. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active
multiplication.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

3.375 g IV q6h

Pediatric

300-400 mg piperacillin/kg/d IV divided q6-8h

• Dosing
• Interactions
• Contraindications
• Precautions

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides
if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may
increase piperacillin levels

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not FDA approved for patients <12 y; dosage adjustment may be necessary with renal impairment

Cefoxitin (Mefoxin)

Second-generation cephalosporin with activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal
species), and anaerobic bacteria. Inhibits bacterial cell wall synthesis during active multiplication by binding 1 or more penicillin-
binding proteins.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1-2 g IV q6-8h

Pediatric

80-100 mg/kg/d IV divided q6-8h

• Dosing
• Interactions
• Contraindications
• Precautions

Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely
monitor renal function)

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Dosage adjustment may be necessary with renal impairment; caution with previously diagnosed colitis

Cefotetan (Cefotan)

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult

1-2 g IV q12h for 5-10 d

Pediatric

20-40 mg/kg/dose IV q12h for 5-10 d

• Dosing
• Interactions
• Contraindications
• Precautions

Consumption of alcohol within 72 h of administration may produce disulfiramlike reactions; may increase hypoprothrombinemic
effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase
nephrotoxicity

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer q24h if creatinine clearance 10-30 mL/min and q48h if <10 mL/min; (high doses may cause CNS toxicity); bacterial
or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus
beta-lactamase inhibitor that provides coverage against most gram-positive and gram-negative organisms and most anaerobes.
• Dosing
• Interactions
• Contraindications
• Precautions

Adult

3 g (based on ticarcillin component) IV q4-6h; not to exceed 18-24 g/d

Pediatric

Severe infections
<3 months: 200-300 mg/kg/d (based on ticarcillin component) IV divided q6-8h
>3 months: 300 mg/kg/d IV divided q4-6h; not to exceed 18 g/d

• Dosing
• Interactions
• Contraindications
• Precautions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if
administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may
increase penicillin levels

• Dosing
• Interactions
• Contraindications
• Precautions

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis
should not be treated with oral penicillin during acute stage

• Dosing
• Interactions
• Contraindications
• Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Obtain CBC count prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by
measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; monitor urinalysis,
BUN, and creatinine results during therapy and adjust dose if values become elevated

Imipenem and cilastatin (Primaxin)

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated
because of potential for toxicity.

• Dosing
• Interactions
• Contraindications
• Precautions

Adult
Base initial dose on severity of infection and administer in equally divided doses; dose may range from 250-500 mg (based on
imipenem component) q6h IV; not to exceed 3-4 g/d

Pediatric

Note: Dose is based on imipenem component


Neonates: 40-50 mg/kg/d IV divided q12h
Infants and children:
1-3 months: 100 mg/kg/d IV divided q6h
>3 months: 60-100 mg/kg/d IV divided q6h; not to exceed 4 g/d

Follow-up

Further Inpatient Care

After appendectomy, the main considerations include continued fluid resuscitation, use of antibiotics, possible percutaneous
drainage of intra-abdominal abscesses, and resumption of diet and bowel function.

• Fluid resuscitation
o Patients with appendicitis are dehydrated in most cases. These patients usually receive fluid boluses prior to
operation. However, continued fluid resuscitation appropriate to their fluid status and severity of appendicitis is
needed.
o The spectrum ranges from patients with early appendicitis who are started on clear fluids postoperatively and
can have intravenous (IV) fluids removed when advanced to regular diet to patients with perforated appendicitis
who require postoperative fluid boluses.
o If fluid status is unclear, urine output is the most common measure. The patients urine output should be no
lower than 0.5 mL/kg/h.
o If dehydration is suspected, Foley catheter placement, monitoring of urine output, and correct fluid replacement
are indicated.
• Antibiotics
o As described above (see Medication), patients who are diagnosed with appendicitis and are taken immediately
to the operating room receive 1 dose of preoperative antibiotics.
o If the appendix is not gangrenous or perforated, no postoperative antibiotics are indicated.
o A gangrenous appendix warrants antibiotics for 24-72 hours, depending on Gram stain and culture results.
o Perforated appendicitis requires intravenous antibiotics for an extended period. See Medication for a discussion
of antibiotic options.
• Percutaneous drainage
o Often, patients with gangrenous or perforated appendicitis develop intra-abdominal abscesses. These may be
present at the time of presentation or may develop after operation or during hospitalization if patient is planned
for an interval appendectomy.
o Commonly, a patient who has a prolonged ileus or fever for more than 5 days postoperatively has an intra-
abdominal abscess.
o The most common treatment is to perform a CT scan of the abdomen and pelvis with oral and intravenous
contrast to define the presence of an abscess.
o If present and in an accessible location, percutaneous drainage should be performed.
o A drain is commonly left in the abscess cavity, and continued drainage is monitored.
o Once drainage decreases and repeated CT scans show resolution of the abscess cavity and no fistulous tract to
the bowel, the drain can be removed.
• Diet and bowel function
o Patients with nonperforated appendicitis may be started on clear fluids postoperatively, and diet is advanced as
tolerated.
o Patients who can tolerate regular diet may be discharged home. These patients have minimal delay in the return
of bowel function and do not need to have a bowel movement prior to discharge.
o Patients with perforated appendicitis who have immediate appendectomy should remain on a diet of nothing by
mouth (NPO) until their bowel function returns. They should then be started on clear fluids, and the diet should
be advanced as tolerated.

Inpatient & Outpatient Medications

• Antibiotics: The patient may be discharged with antibiotics, according to the severity of the appendicitis.
• Pain medication
o If the patient has undergone an appendectomy, pain medication should be prescribed upon discharge.
o Liquid acetaminophen usually suffices in smaller children, with liquid acetaminophen with codeine
administered for breakthrough pain. The same medication combination can be used in older patients in a tablet
form, assuming they are able to swallow them.
o Patients who received inpatient narcotics or who are discharged on outpatient narcotics should be cautioned
about the possibility of becoming constipated and should be prescribed stool softeners.

Complications

• Intra-abdominal abscess
• Perforation
• Sepsis
• Shock

Prognosis

• Generally, prognosis is excellent.

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see
eMedicine's patient education articles Appendicitis and Abdominal Pain in Children.

Miscellaneous

Medicolegal Pitfalls

• Performing a complete examination, including examination of the genitals, is important. Testicular torsion and ectopic
pregnancy present similarly to appendicitis, and both have serious morbidity if not quickly diagnosed.
• Do not diagnose gastroenteritis in patients unless they have nausea, vomiting, and diarrhea.
o Even with the presence of vomiting and diarrhea, consider the unusual presentations of retrocecal or pelvic
appendicitis.
o Additionally, appendicitis can develop as a sequela of gastroenteritis associated with lymphoid hyperplasia.
• Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal symptoms.
• Instruct patients to be re-evaluated in 8-12 hours by their primary care physician or to return to the emergency
department.
• Keep patients with equivocal examination findings for observation and perform serial abdominal examinations or
consider performing a double-contrast abdominal CT scanning.
• Avoid treating vague abdominal pain with parenteral opiates and subsequent discharge.
• Avoid narcotics and potent nonsteroidals until after surgical consultation.
• Antibiotics are generally withheld until the decision is made for surgical intervention or another appropriate indication is
identified.
• If the constipation is diagnosed and treated with enemas and/or stool softeners with resolution of the signs and
symptoms, inform the patient and their family that recurrence of the abdominal pain in the future could be recurrent
constipation or acute appendicitis and to seek medical advice.