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Patient GG

42 y/o F
HPI:
5 day Hx of RLQ pain getting
progressively worse. Pain described as
sharp, 8/10 at worst, non-radiating
Subjective fever x4 days
Few episodes of diarrhea x3 days
Dark, brown urine x1 day
Decreased appetite but no n/v

Patient GG
PMHx: none
PSHx: lap cholecystectomy (2011),
removal/drainage of spinal cyst
Social Hx: denies smoking or drugs;
occasional use of alcohol (socially)
Home medications: none

Patient GG
Physical exam
General: AAOx3, mildly distressed due
to pain
Heart: RRR, normal S1/S2
Lungs: CTAB
Abdomen: soft, non-distended; bowel
sounds present; tender to deep
palpation mostly in RLQ; no rebound or
guarding; +Rovsing sign, - psoas sign, obturator sign

Patient GG
ED
WBC: 10.4
UA: RBC > 10
CT abdomen/pelvis: acute gangrenous
appendicitis with probable adjacent 1.9
cm abscess; no free air or ascites

Patient GG
Patient straight to OR for laparascopic appendectomy
and abdominal wash-out, with Blake drain placement
Findings: non-gangrenous; abscess noted and
drained
Treated with 3 days of Zosyn
Patient had repeated episodes of nausea/vomiting
post-operatively - was given scopolamine patch,
Zofran (ondansetron), and Vistaril (hydroxyzine)
Discharged on HD 2. Blake drain removed prior to
d/c, patient home on PO pain meds and low fat diet

Appendicitis
Pathophysiology
Obstruction by fecalith, calculi, lymphoid hyperplasia,
infectious process, or tumor
Young: lymphoid hyperplasia
Old: fibrosis, fecalith, tumor

Obstruction leads to increased intraluminal pressure and


lumen dilation, which causes thrombosis of blood vessels in
appendix wall and lymphatic stasis
Wall becomes ischemic/necrotic visceral nerves going to
T8-10 are stimulated, causing vague periumbilical pain
Bacteria grow and invade wall
Neutrophilic recruitment creates fibropurulent reaction on
outer surface irritation of parietal peritoneum with sharp
well-localized (somatic) pain

Appendicitis
Signs and Symptoms
RLQ pain or McBurneys point tenderness
May not be present if appendix is retrocecal. Pain may be
elicited on rectal and/or pelvic exam

Rovsings sign right side peritoneal irritation


Psoas sign retrocecal appendix
Obturator sign pelvic appendix
Anorexia
Nausea/vomiting
Fever: low-grade (early) or high-grade (late)
Indigestion, flatulence, bowel irregularity, diarrhea,
generalized malaise

Appendicitis

Appendicitis
Alvarado score
Migratory right ilia fossa pain (1)
Anorexia (1)
Nausea/vomiting (1)
Tenderness in right iliac fossa (1)
Rebound tenderness in right iliac fosse
(1)
Fever >37.5C
Leukocytosis (2)

Appendicitis
Labs
Mildly elevated WBC & left shift
Can be normal if early
Acute < Gangrenous < Perforated

Mildly elevated bilirubin if perforated

Imaging
CT enlarged appendix (>6mm), wall thickening
(>2mm), wall enhancement, periappendiceal fat
stranding, occluded lumen
MRI if pregnant
Ultrasound & plain film not frequently used

Appendicitis
CT with contrast

Appendicitis
DDx
Cecal or right-sided diverticulitis
Meckels diverticulitis
Acute ileitis
Crohns disease
Ob/Gyn diseases

Tubo-ovarian abscess
PID
Ovarian cyst
Mittelschmerz
Ovarian torsion
Endometriosis
Ovarian hyperstimulation syndrome
Ectopic pregnancy

GU disease
Renal colic
Testicular
torsion
Epididymitis

Appendicitis
Disease severity
Inflamed
Gangrenous
Perforated with localized free fluid
Perforated with regional abscess
Perforated with diffuse peritonitis

Appendicitis
Management
Medical vs. Surgical

Medical management in uncomplicated appendicitis in a trial of


243 patients (123 antibiotic group, 120 appendectomy group)
Amoxicillin/clavulanic acid for 8-15 days
Higher rate of post-intervention peritonitis in ABX group vs.
appendectomy (8% vs. 2%)
14 patients (12%) underwent appendectomy within 30 days of
treatment
Additional 30 patients underwent appendectomy within 1 year; 26 of
these had acute appendicitis

Other studies show high rate of recurrence or development of


complicated appendicitis
Non-surgical management can be considered for higher risk
populations

Appendicitis
Surgical management
Laparotomy vs. Laparoscopy

Laparoscopy
Better outcomes: decreased rate of wound
infection, less post-op pain, shorter hospital
stay, sooner return of bowel function
Worse outcomes: higher rate of intra-abdominal
abscess, longer operative time, higher rate of
intraoperative complications, higher costs
Preferred in: uncertain diagnosis, obese
patients, elderly

Appendicitis
Surgical management
Pre-op
Hydration
Correction of electrolytes
Perioperative antibiotics
Acute, non-perforated single pre-op dose for wound
prophylaxis. No post-op antibiotics needed
Perforated empiric broad-spectrum ABX, pending
culture/sensitivity results, for 5-7 days

Post-op
NPO clear liquids before discharge. Regular diet as
tolerated
No ABX if non-perforated

Appendicitis
Perforated appendicitis
Complications

Dehydration & electrolyte abnormalities


Generalize peritonitis
Retroperitoneal or liver abscess
Intraperitoneal abscess
Enterocutaneous fistula
SBO

Appendicitis
Perforated appendicitis
Management
Free perforation Ex lap to irrigate/drain
Contained perforation (abscess or phlegmon)
non-surgical (ABX, IVF, bowel rest) and/or
drainage of abscess (percutaneous or transrectal)
Pts with long duration of symptoms may have difficult
dissections due to adhesions & inflammation
Appendectomy if bowel obstruction, sepsis, or
persistent fever, pain, or leukocytosis
Interval appendectomy 6-8 weeks later to prevent
recurrence and exclude neoplasm