1.11.1 Appendicitis

Question 1

Describe appendicitis etiology & pathophys

Answer 1

• Obstruction of appendiceal lumen
  
  • Fecalith impaction
  • Stool impaction
  • Lymphoid hyperplasia
  • Lymphadenopathy
  • Tumors
  • Inflammation (IBD, Chrons)
• Increased mucus production and bacterial overgrowth
• Appendiceal wall tension
• May lead to necrosis and perforation

Question 2

Describe the “classic presentation” for appendicitis.

Describe atypical presentations

Answer 2

• 50% = classic
  
  • Periumbilical abd pain initially
  • Migratory pain to RLQ
  • Fever later, low grade < 101 F
  • Anorexia, n/v
    
    • Usually after pain begins
  • Presentation depends on location of apendix
    
    • UTI sx if near bladder/ureter
• Atypical
  
  • Diarrhea/bowel changes
  • Flatulence
  • Generalized malaise
  • Indigestion

Question 3

Describe key signs of appendicitis on your physical exam.

What about specific to retrocecal and pelvic appendix location?

Answer 3

• Rosvig’s sign
  
  • Palpate LLQ
  • Referred pain to RLQ
• McBurney Point Tenderness
  
  • RLQ tenderness
    
    • Rebound, abd guarding
  • Mostly associated with anterior appendices (anterior to cecum)
• Retrocecal appendix
  
  • Dull abd ache
  • (+) Psoas Sign
    
    • Lay pt on left side
    • Bring R leg back
    • Apply pressure to hip
    • Resistance to extension/pain - appendicitis
• Pelvic Appendix
  
  • Obturator sign
    
    • Pain on passive internal rotation of flexed thigh
  • Tenderness below McBurney’s Point
  • Rectal exam not useful
  • Pelvic exam: right adnexal tenderness may be present

Question 4

Describe diagnostic testing for c/f appendicitis

Answer 4

• CBC
  
  • Leukocytosis w left shift
• HCG
  
  • R/o ectopic pregnancy
• UA
  
  • Abnormal in 20-40% of appendicitis cases
  • Commonly mistaken for UTI
• CT abd/pelvis
  
  • Appendiceal wall thickening > 2mm
  • Enlarged appendiceal diameter > 6mm
    
    • Abd US can pick this up!
  • Occluded appendiceal lumen
  • Periappendiceal fat stranding
    *

Question 5

Describe the main scoring systems used in diagnosis.

Walk through risk stratification and management algorithm.

Answer 5

• Alvarado Score
  
  • Up to total of 10
  • Older, decent Sp and Se
• AIRS
  
  • Also takes into account CRP
  • 9-12 = surgical exploration
• Low Risk
  
  • Alv <4, AIR < 4
  • Outpatient Mgmt
• Moderate Risk
  
  • Alv 4-6, AIR 5-8
  • Consider RLQ abd US (+ RLQ pelvic US for female)
    
    • Low clinical suspicion + normal findings
      
      • Outpatient Mgmt
    • Moderate clinical suspicion, (-) or indeterminite findings
      
      • CT w IV/Oral contrast (vs MRI)
    • Positive Findings
      
      • Surgical consult, imaging, admission
• High Risk
  
  • Alv >7, AIR > 9
  • Emergency surgical consultation, imaging, admission

Question 6

Describe general treatment for appendicitis.

Answer 6

• General tx
  
  • NPO
  • IV hydration
  • Pain mgmt
    
    • Opioids
    • Ketorolac
  • Surgical consult
  • Empiric abx coverage
    
    • Gram (-) aerobes
      
      • E. coli, kelbsiella, proteus, PSA, strep, enterococci
    • Gram (-) anaerobes
      
      • B. fragilis, clostridium, prevotella
    • Community acquired, low risk
      
      • Monotherapy:
        
        • Ertapenem vs moxifloxacin
      • Combination:
        
        • 2nd/3rd Gen Cephalosporin + Flagyl
        • Cipro or levoflox + Flagyl
    • Healthcare Acquired or High Risk Community
      
      • Monotherapy:
        
        • Pip/Tazo
        • Imipenem
        • Meropenem
      • Combination:
        
        • Cefepime + Flagyl
        • Ceftazidime + Flagyl
        • Aztreonam + Flagyl + Vanc (serious beta-lactam allergies)
  • If d/c, f/u in 8-12h for re-exam

Question 7

Describe perforated appendicitis

Answer 7

• About 20-30% of patients with acute appendicitis
• Risk increases with delay in seeking tx
• Sepsis, peritonitis, abscess formation possible
• Most common etiology of perforated viscus