Appendicitis

• Early on primarily malaise, indigestion, anorexia
  • Later patient develops abdominal pain
    • Initially vague, periumbilical (visceral innervation)
    • Later migrates to McBurney point (parietal innervation)
• Nausea, with or with out emesis, typically follows onset of pain
• Fever may or not occur
• Urinary symptoms common given proximity of appendix to urinary tract (sterile pyuria)
• Sudden improvement suggests perforation
• 33% of patients have atypical presentation
  • Retrocecal appendix can cause flank or pelvic pain
  • Gravid uterus sometimes displaces appendix superiorly → RUQ pain

• Rovsing sign (palpation of LLQ worsens RLQ pain)
• Psoas sign (extension of right leg at hip while patient lies on left side elicits abdominal pain)
• Obturator sign (internal and external rotation of thigh at hip elicits pain
• Peritonitis suggested by:
  • Right heel strike elicits pain
  • Guarding

• Appendicitis
• Abdominal aortic aneurysm
• Crohn's disease (terminal ileitis)
• Diverticulitis (cecal, Asian patients)
• Ectopic
• Endometriosis
• Epiploic appendagitis
• Herpes zoster
• Inguinal hernia
• Ischemic colitis
• Kidney stone
• Meckel's diverticulum
• Mesenteric lymphadenitis
• Mittelschmerz
• Neutropenic enterocolitis (typhlitis)
• Ovarian cyst
• Ovarian torsion
• PID
• Pyelonephritis
• Psoas abscess
• Testicular torsion

• CBC
  • Normal WBC does not rule-out appy
• Urinalysis
  • Sterile pyuria or hematuria consistent with appy
• Urine pregnancy
• CRP
  • Normal CRP AND WBC makes appy very unlikely

• Early surgical consultation should be obtained before imaging in straightforward cases
• Not universally necessary; consider in:
  • Women of reproductive age
  • Men with equivocal presentation
• Perforation may result in false negative study
• Imaging modalities
  • Ultrasound

Dilated, non-compressible appendix with appendicolith and surrounding free fluid[1]

• • • First choice for pregnant women and children
    • Limitations: operator-dependent, difficult to visualize with obesity, gravid uterus, bowel gas, guarding, lack of patient cooperation
    • Findings: noncompressible appendix >6mm in diameter, wall thickness greater or equal to 3 mm
    • Other supportive findings: aperistalsis, distinct wall layers, target appearance in axial view, appendicolith, periappendiceal fluid, prominent echogenic periappendiceal fat
  • CT
    • First choice for adult males and nonpregnant women with equivocal cases
    • Women derive the greatest benefit from preoperative imaging (lower neg appy rate)
    • Contrast (both PO and IV) is unnecessary but typically ordered
  • MRI
    • When unable to identify appendix in children or pregnant women

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).

1. NPO status
2. Fluid resuscitation
3. Analgesia/antiemetics

Coverage should extend to E. coli, Klebsiella, Proteus, and Bacteroides (an anaerobe)

Antibiotic prophylaxis should be coordinated with surgical consult

Options:

• Cefoxitin 2g IV q6 hours OR
• Cefotetan 2g IV q12 hours OR
• Moxifloxacin 400mg IV once daily OR
• Ertapenem 1g IV once daily

Options:

• Cefoxitin 40mg/kg IV q6 hours
• Cefotetan 40mg/kg IV q12 hours
• Gentamicin 2.5mg/kg IV q8hrs +
  • Metronidazole 7.5mg/kg IV 16hrs OR
  • Clindamycin 10mg/kg IV q8hrs

Defined as perforation, abscess, or phlegmon

Options:

• Metronidazole 500 mg IV q8hrs +
  • Cefepime 50 mg/kg IV q12hrs OR
  • Ciprofloxacin 400 mg IV q12hrs OR
  • Levofloxacin 750 mg IV q24hrs OR
  • Aztreonam 30 mg/kg IV q8hrs
• Imipenem/Cilastatin 25 mg/kg IV q6hrs (max 500mg)
• Meropenem 20 mg/kg IV q8hrs (max 1g)
• Piperacillin/Tazobactam 100 mg/kg (max 4.5g) IV q8hrs

Cautious use should be applied to use of fluoroquinolones in complicated pediatric appendicitis due to the risk of tendon injury

• Open laparotomy or laparoscopy
  • Patients who present <72 hours after the onset of symptoms usually undergo immediate appendectomy
  • Patients who present >72hrs and have perforated appendix may be treated initially with antibiotics, intravenous fluids, and bowel rest

• Either a simple wound infection or an intraabdominal abscess
  • Typically in patients with perforated appendicitis

• Occurs in approximately 1:50,000 appendectomies [2]
• Typically caused by inflammation of the remaining appendiceal stump
  • Can also be caused by a retained piece of the appendix not removed during surgery [3]
• Can present similar to primary appendicitis
• Treatment similar to that of primary appendicitis and likely requires surgical revision of the appendiceal stump or removal of retained tissue
• Delay in diagnosis and treatment can result in perforation and sepsis